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

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Appropriations and Fund Transfers in the Patient Protection and Affordable Care Act (ACA) C. Stephen Redhead Specialist in Health Policy May 15, 2013 Congressional Research Service 7-5700 www.crs.gov R41301 CRS Report for Congress Prepared for Members and Committees of Congress Appropriations and Fund Transfers in the Patient Protection and Affordable Care Act Summary Among its many provisions, the Patient Protection and Affordable Care Act (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. ACA also expands eligibility for Medicaid; amends the Medicare program in ways that are intended to reduce the growth in spending; and makes other changes to the tax code, Medicare, Medicaid, and many other federal programs. In addition, ACA appropriates billions of dollars to support new or existing grant programs and other activities. These mandatory appropriations include funds for a temporary insurance program for individuals who have been uninsured for several months and have a preexisting condition, as well as funding for states to plan and establish exchanges. ACA provides funding for various Medicare and Medicaid demonstration programs, for the creation of a Center for Medicare and Medicaid Innovation to test and implement innovative payment and service delivery models, and for an independent board to provide Congress with proposals for reducing Medicare cost growth and improving quality of care for Medicare beneficiaries. ACA also appropriates amounts for four special funds. The first fund will provide a total of $11 billion over five years for community health centers and the National Health Service Corps. (A separate appropriation provides $1.5 billion for health center construction and renovation.) The second fund will support comparative effectiveness research through FY2019 with a mix of appropriations and transfers from the Medicare trust funds. The third fund, for which ACA provides a permanent annual appropriation, is intended to support prevention, wellness, and other public health-related programs authorized under the Public Health Service Act (PHSA). The fourth fund is helping cover the initial costs of ACA implementation. Finally, ACA provides funding for health workforce and for maternal and child health programs. Generally, the FY2013 mandatory appropriations in ACA are fully sequestrable at the rate applicable to nonexempt nondefense mandatory spending under the March 1, 2013, sequestration order triggered by the Budget Control Act. Lawmakers opposed to ACA introduced numerous bills in the 112th Congress, several of which saw legislative action. They included measures to repeal ACA and replace it with new law; repeal or amend specific ACA provisions; eliminate certain mandatory appropriations and rescind all unobligated funds; and block or otherwise delay ACA implementation. Some of these bills have been reintroduced in the 113th Congress. In addition to the mandatory appropriations discussed in this report, ACA authorizes new funding for numerous existing discretionary grant and other programs, primarily ones authorized under the PHSA. The law also creates a number of new discretionary grant programs and activities and provides for each an authorization of appropriations. Funding for all these discretionary programs and activities is subject to action by congressional appropriators. A companion product, CRS Report R41390, Discretionary Spending in the Patient Protection and Affordable Care Act (ACA), summarizes all the provisions in ACA that include an authorization of appropriations. Congressional Research Service Appropriations and Fund Transfers in the Patient Protection and Affordable Care Act Contents Introduction...................................................................................................................................... 1 Mandatory Appropriations and Fund Transfers in ACA .................................................................. 2 Discretionary Spending in ACA ...................................................................................................... 5 Automatic Annual Spending Reductions Under the Budget Control Act ........................................ 6 BCA’s Spending Reduction Procedures .................................................................................... 6 Direct Spending ................................................................................................................... 6 Discretionary Spending ....................................................................................................... 7 FY2013 Sequestration ............................................................................................................... 7 Tables Table 1. Summary of Mandatory Appropriations and Medicare Trust Fund Transfers in the Affordable Care Act ................................................................................................................ 9 Table 2. ACA Appropriations and Fund Transfers by Fiscal Year in Which Funds Are Available for Obligation ............................................................................................................. 20 Appendixes Appendix A. Acronyms Used in the Report................................................................................... 26 Appendix B. ACA-Related Authorizing Legislation in the 112th Congress................................... 27 Appendix C. ACA Provisions in Appropriations Bills (FY2011-FY2013).................................... 30 Contacts Author Contact Information........................................................................................................... 33 Acknowledgments ......................................................................................................................... 33 Congressional Research Service Appropriations and Fund Transfers in the Patient Protection and Affordable Care Act Introduction The Patient Protection and Affordable Care Act (ACA)1 made significant changes to the way health care is financed, organized, and delivered in the United States. Among its many provisions, ACA restructures the private health insurance market, sets minimum standards for health coverage, and, beginning in 2014, mandates that most U.S. residents obtain health insurance coverage or pay a penalty. The law provides for the establishment by 2014 of state-based health insurance exchanges for the purchase of private health insurance. Qualifying individuals and families will be able to receive federal subsidies to reduce the cost of purchasing coverage through the exchanges. In addition to expanding private health insurance coverage, ACA, as enacted, requires state Medicaid programs to expand coverage to all eligible nonelderly, non-pregnant individuals under age 65 with incomes up to 133% of the federal poverty level (FPL). States that elect not to expand their Medicaid programs risk losing their existing federal Medicaid matching funds. Under ACA, the federal government will initially cover 100% of the expansion costs, phasing down to 90% of the costs by 2020. On June 28, 2012, the U.S. Supreme Court, in National Federation of Independent Business v. Sebelius, found that the Medicaid expansion violated the Constitution by threatening states with the loss of their existing federal Medicaid matching funds.2 The Court precluded the Secretary of Health and Human Services (HHS) from penalizing states that choose not to participate in the Medicaid expansion (see text box below). ACA also amends the Medicare program in an effort to reduce the rate of its projected growth; imposes an excise tax on insurance plans found to have high premiums; and makes many other changes to the tax code, Medicare, Medicaid, the State Children’s Health Insurance Program (CHIP), and other federal programs. ACA included numerous appropriations that provide billions of dollars to support new and existing grant programs and other activities. Several other provisions require the HHS Secretary to transfer amounts from the Medicare Part A and Part B trust funds for specified purposes. This report summarizes all these mandatory spending provisions3 and, using publicly available information, provides details on the status of obligation of the funds. It also includes a brief discussion of ACA-related discretionary spending, which is provided in and controlled by annual appropriations acts. Finally, the report provides some analysis of the impact of the March 1, 2013, sequestration on ACA mandatory spending in FY2013. This report is periodically revised and updated to reflect important legislative and other developments. 1 ACA was signed into law on March 23, 2010 (P.L. 111-148, 124 Stat. 119). A week later, on March 30, 2010, the President signed the Health Care and Education Reconciliation Act (HCERA; P.L. 111-152, 124 Stat. 1029), which amended multiple health care and revenue provisions in ACA. Several other bills that were subsequently enacted during the 111th and 112th Congresses made more targeted changes to specific ACA provisions (see Appendixes B and C). All references to ACA in this report refer to the law as amended. Note that previous CRS reports on the Patient Protection and Affordable Care Act used the acronym PPACA to refer to the law. CRS is now using the more common acronym ACA. 2 NFIB v. Sebelius, No. 11-393, slip op. (June 28, 2012), available at http://www.supremecourt.gov/opinions/11pdf/11393c3a2.pdf. 3 Mandatory spending, also known as direct spending, refers to outlays from budget authority (i.e., the authority to incur financial obligations that result in government expenditures) that is provided in laws other than annual appropriations acts. Mandatory spending includes spending on entitlement programs. Congressional Research Service 1 Appropriations and Fund Transfers in the Patient Protection and Affordable Care Act U.S. Supreme Court Decision on ACA (June 28, 2012) In National Federation of Independent Business v. Sebelius (NFIB) the Court ruled on the constitutionality of both the individual mandate, which requires most U.S. residents (beginning in 2014) to carry health insurance or pay a penalty, and the Medicaid expansion. The Court upheld the individual mandate as a constitutional exercise of Congress’s authority to levy taxes. The penalty is to be paid by taxpayers when they file their tax returns and enforced by the Internal Revenue Service. In a separate opinion, the Court found that compelling states to participate in the ACA Medicaid expansion—which the Court determined to be essentially a new program—or risk losing their existing federal Medicaid matching funds was coercive and unconstitutional under the Spending Clause of the Constitution and the Tenth Amendment. The Court’s remedy for this constitutional violation was to prohibit HHS from penalizing states that choose not to participate in the expansion by withholding any federal matching funds for their existing Medicaid program. However, if a state accepts the new ACA expansion funds (initially a 100% federal match), it must abide by all the expansion coverage rules. Under NFIB v. Sebelius, all other provisions of ACA remain fully intact and operative. For more information, see CRS Report R42698, NFIB v. Sebelius: Constitutionality of the Individual Mandate, by Erika K. Lunder and Jennifer Staman; and CRS Report R42367, Medicaid and Federal Grant Conditions After NFIB v. Sebelius: Constitutional Issues and Analysis, by Kenneth R. Thomas. Mandatory Appropriations and Fund Transfers in ACA Table 1 summarizes all the ACA provisions that include an appropriation of funds, or a transfer of amounts from the Medicare trust funds. The provisions are grouped under the following headings: (1) Private Health Insurance; (2) Medicaid and the State Children’s Health Insurance Program (CHIP); (3) Medicare; (4) Fraud and Abuse; (5) Health Centers and the National Health Service Corps (NHSC); (6) Health Workforce; (7) Community-Based Prevention and Wellness; (8) Maternal and Child Health; (9) Long-Term Care; (10) Comparative Effectiveness Research; (11) Biomedical Research; and (12) ACA Implementation: Administrative Expenses. Each table row provides information on a specific ACA provision, organized across four columns. The first column shows the ACA section or subsection number. The second column indicates whether the provision is freestanding (i.e., new statutory authority that is not amending an existing statute) or amendatory (i.e., amends an existing statute such as the PHSA, either by adding a new program or amending an existing one). The third column gives a brief description of the program or activity, including details of the appropriation or fund transfer. The entry also includes the name of the administering HHS agency and, if applicable, the Catalog of Federal Domestic Assistance (CFDA) number for the grant program.4 The fourth column shows the amount of obligations to date, based on information in the HHS Tracking Accountability in Government Grants System (TAGGS), unless specified otherwise. The TAGGS database is a central repository for grants awarded by all the HHS operating divisions (agencies) and several offices within the Office of the Secretary. It is updated daily with new data provided by these entities.5 4 CFDA is a government-wide compendium of federal grant and other assistance programs. Each program is assigned a unique five-digit number, XX.XXX, where the first two digits represent the funding agency and the second three digits represent the program. Programs funded by the Department of Health and Human Services begin with the number 93. For more information, see https://www.cfda.gov. 5 To access and search the TAGGS database, go to http://www.taggs.hhs.gov/. Congressional Research Service 2 Appropriations and Fund Transfers in the Patient Protection and Affordable Care Act Readers are also encouraged to visit the website of the Center for Consumer Information and Insurance Oversight (CCIIO, within CMS),6 which is responsible for implementing ACA’s private health insurance provisions, as well as HealthCare.gov, which is tracking ACA implementation state-by-state. Both sites include factsheets, press releases, and other information on the ACA grant programs and activities summarized in this report. In many instances, ACA provides annual appropriations of specified amounts for one or more fiscal years. These funds must be obligated during the fiscal year in which the funds become available for obligation. A few provisions are multiple-year appropriations, in which the amount appropriated is available for obligation for a definite period of time in excess of one fiscal year (e.g., for the period FY2011 through FY2014). Often the provision includes additional language stating that the funds are to remain available “until expended” or “without fiscal year limitation.” One ACA provision (i.e., Section 1311) appropriates an unspecified amount—such sums as may be necessary, or SSAN—and authorizes the HHS Secretary to determine the amount necessary for the grant program.7 Generally, the ACA appropriations or fund transfers are for one or more fiscal years through FY2019. However, ACA includes four provisions (i.e., Sections 3021(a), 3403, 10323(b), and 4002) that continue to provide annual or multiple-year appropriations beyond FY2019. Table 2 provides additional details on each of the appropriations (and fund transfers) summarized in Table 1. It shows the amount available for obligation in each fiscal year (or multi-year period) over the 10-year period FY2010 through FY2019. Note that the provisions are organized and grouped under the same headings used in Table 1. The final column in Table 2 (“Total”) shows for each provision the cumulative amount of appropriations or fund transfers through FY2019. In several cases, that amount has yet to be determined (see table entries for ACA Sections 1311, 3403, 6301(d) & (e), 9023(e), and 10323(a)). For three of the provisions that provide appropriations beyond FY2019, the table shows the cumulative amount appropriated through FY2019 (see table entries for ACA Sections 3021(a), 4002, and 10323(b)). Unless otherwise stated, references to the Secretary in both tables refer to the HHS Secretary. A list of the acronyms used in this report is provided in Appendix A. As summarized in the tables, ACA appropriated billions of dollars for a number of short-term health care programs for targeted groups, including (1) $5 billion for the Pre-Existing Condition Insurance Plan (PCIP), a temporary insurance program to provide health insurance coverage for uninsured individuals with a preexisting condition; (2) $5 billion for a temporary reinsurance program to reimburse employers for a portion of the costs of providing health benefits to early retirees aged 55-64; and (3) $6 billion for the Consumer Operated and Oriented Plan (CO-OP) program, to establish temporary health insurance cooperatives. ACA also included money for states to plan and establish health insurance exchanges. The law created a Center for Medicare and Medicaid Innovation (CMI) within the Centers for Medicare and Medicaid Services (CMS), and appropriated $10 billion for the FY2011-FY2019 period—and $10 billion for each subsequent 10-year period—for CMI to test and implement innovative payment and service delivery models. It also established and funded an Independent 6 http://cciio.cms.gov. Two other ACA provisions (i.e., Sections 5508(c), and 9023(e)) also appropriate SSAN to carry out a program, but in each case there is an upper limit on the amount that may be appropriated. Another provision (i.e., Section 10323(a)) requires the HHS Secretary to transfer SSAN from the Medicare trust funds to carry out a pilot program. 7 Congressional Research Service 3 Appropriations and Fund Transfers in the Patient Protection and Affordable Care Act Payment Advisory Board (IPAB) to make recommendations to Congress for achieving specific Medicare spending reductions if costs exceed a target growth rate. IPAB’s recommendations are to take effect unless Congress overrides them, in which case Congress would be responsible for achieving the same level of savings. ACA also established four special funds and appropriated substantial amounts to each one: • The Community Health Center Fund (CHCF) will provide a total of $11 billion in annual appropriations over five years (FY2011-FY2015) for community health center operations and the National Health Service Corps. (A separate ACA appropriation provided $1.5 billion for health center construction and renovation.) While CHCF funding may have been intended to supplement annual discretionary appropriations for health centers and the NHSC program, the funds have partially supplanted discretionary health center funding and have become the sole source of funding for the NHSC program, which received no discretionary funds in FY2012.8 • The Patient-Centered Outcomes Research Trust Fund (PCORTF) will support comparative effectiveness research through FY2019 with a mix of annual appropriations—some of which are offset by revenues from a fee imposed on private health plans—and transfers from the Medicare Part A and Part B trust funds. • The Prevention and Public Health Fund (PPHF), for which ACA provided a permanent annual appropriation, is intended to support prevention, wellness, and other public health-related programs and activities authorized under the Public Health Service Act (PHSA).9 PPHF funds have been used to support several new discretionary grant programs authorized by ACA. The funds are also supplementing, and in some cases supplanting, annual discretionary appropriations for a number of established programs, including ones that were reauthorized by ACA (see discussion below under “Discretionary Spending in ACA”). • The Health Insurance Reform Implementation Fund (HIRIF), for which ACA appropriated $1 billion, was to help cover the initial administrative costs of implementing the law. In addition, ACA appropriated $2.4 billion for maternal and child health programs. Overall, the law included more than $100 billion in direct appropriations over the 10-year period FY2010FY2019, including $40 billion to provide two more years of funding for CHIP. Lawmakers opposed to specific provisions in ACA, or to the entire law, have introduced numerous bills to modify or repeal the law, including legislation to eliminate some of the mandatory appropriations discussed in this report. Appendix B summarizes the ACA-related authorizing legislation enacted during the 112th Congress, as well as the House-passed bills that 8 For more information, see CRS Report R42433, Federal Health Centers, by Elayne J. Heisler. Section 3205 of the Middle Class Tax Relief and Job Creation Act of 2012 (P.L. 112-96, 126 Stat. 156) reduced ACA’s appropriations to the PPHF over the period FY2013-FY2021 by a total of $6.25 billion. Under ACA, the PPHF would have received a total of $16.75 billion over that nine-year period; P.L. 112-96 reduced that amount to $10.50 billion. See Table 1 and Appendix B. 9 Congressional Research Service 4 Appropriations and Fund Transfers in the Patient Protection and Affordable Care Act would modify or repeal ACA. Appendix C summarizes the ACA-related provisions in annual appropriations acts for FY2011-FY2013. Discretionary Spending in ACA In addition to its impact on mandatory spending, implementation of ACA is having an effect on discretionary spending, which is provided in and controlled by annual appropriations acts. The law reauthorized appropriations for numerous existing discretionary grant programs and activities authorized under the PHSA. While the authorizations of appropriations for many of those programs expired prior to their reauthorization in ACA, most of them continued to receive an annual appropriation. ACA also created a number of new discretionary grant programs and provided for each an authorization of appropriations. Funding for all these discretionary programs will depend on future actions taken by congressional appropriators. With Congress now operating under enforceable discretionary spending limits, or caps, imposed by the BCA, it may prove difficult to secure funding for new programs and activities. Even maintaining current funding levels for existing programs with broad support and an established appropriations history can be a challenge when there is pressure to reduce federal discretionary spending. A companion product, CRS Report R41390, Discretionary Spending in the Patient Protection and Affordable Care Act (ACA), provides more detailed analysis of all the provisions in ACA that provide an authorization of appropriations for an existing or new program. In addition to discretionary spending on grant programs authorized (or reauthorized) by ACA, the Congressional Budget Office (CBO) estimates that both HHS and the Internal Revenue Service (IRS) will incur substantial administrative costs to implement the policies established by ACA. The IRS is responsible for implementing the eligibility determination, documentation, and verification processes for ACA’s health exchange subsidies, while HHS must implement numerous changes to Medicare, Medicaid, and CHIP, as well as some of the reforms to the private health insurance market. As already noted, ACA provided $1 billion to the HIRIF to help cover the initial administrative costs of implementation. Anticipating that all the HIRIF funds would be obligated by the end of FY2012, the President’s FY2013 budget requested more than $1 billion in new discretionary funding for CMS and the IRS to pay for ongoing ACA implementation costs. However, Congress did not provide any of these new funds. In FY2013, CMS reportedly will spend about $1.5 billion on ACA implementation, primarily to establish federally facilitated exchanges in states that choose not to run their own exchanges and to engage in consumer education and outreach. In the absence of any new FY2013 discretionary funding for ACA implementation, HHS plans to transfer funds from the PPHF and other HHS accounts. For more information on ACA administrative funding, see CRS Report R42051, Budget Control Act: Potential Impact of Sequestration on Health Reform Spending. Congressional Research Service 5 Appropriations and Fund Transfers in the Patient Protection and Affordable Care Act Automatic Annual Spending Reductions Under the Budget Control Act On March 1, 2013, President Obama ordered the sequestration (i.e., cancellation) of $85.33 billion in FY2013 budgetary resources from nonexempt budget accounts across the federal government. The FY2013 sequestration order was issued pursuant to the Balanced Budget and Emergency Deficit Control Act (BBEDCA), as amended by the Budget Control Act of 2011 (BCA).10 Under the BCA, the FY2013 sequestration was to be ordered on January 2, 2013. A provision in the American Taxpayer Relief Act of 2012 (ATRA)11 delayed the order by two months. The FY2013 sequestration is the first of a series of automatic spending reductions under the BCA, as amended by ATRA, that are required each year through FY2021. These annual spending reductions were triggered by the failure of the Joint Select Committee on Deficit Reduction to propose, and Congress and the President to enact, legislation to reduce the deficit by an amount greater than $1.2 trillion over the period FY2012-FY2021. BCA’s Spending Reduction Procedures Based on the formula in the BCA, the automatic spending reductions triggered by the failure of the Joint Committee must cut $109.33 billion in each fiscal year over the period FY2013FY2021. That amount is equally divided between defense and nondefense spending, each of which is subject to a $54.67 billion annual cut. Importantly, ATRA reduced the cuts for FY2013 by $24 billion, which means that both defense and nondefense spending are subject to $12 billion less in cuts in FY2013 (i.e., $42.67 billion, instead of $54.67 billion).12 The annual spending reduction in each spending category—defense and nondefense—is further divided proportionately between discretionary spending and nonexempt direct (i.e., mandatory) spending. Direct Spending Under the BCA, direct spending reductions are to be executed each year by an automatic acrossthe-board cancellation of budgetary resources—a process known as sequestration—for nonexempt accounts. The sequestration process is subject to exemptions and to certain rules, which are specified in Sections 255 and 256, respectively, of the BBEDCA.13 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 10 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. 11 P.L. 112-240, 126 Stat. 2313. 12 For more information, see CRS Report R42949, The American Taxpayer Relief Act of 2012: Modifications to the Budget Enforcement Procedures in the Budget Control Act, by Bill Heniff Jr. 13 For an overview of the BBEDCA exemptions and special rules, see CRS Report R42050, Budget “Sequestration” and Selected Program Exemptions and Special Rules, coordinated by Karen Spar. Congressional Research Service 6 Appropriations and Fund Transfers in the Patient Protection and Affordable Care Act spending programs, accounting for most of the government’s entitlement and other direct spending (excluding Medicare), are exempt from sequestration altogether.14 Discretionary Spending Discretionary spending reductions in FY2013 also are to be achieved through a sequestration of nonexempt discretionary appropriations. The sequestration rules exempt some discretionary spending, notably for veterans’ health care and Pell grants.15 For each of the remaining fiscal years (i.e., FY2014-FY2021), however, discretionary spending reductions will be achieved by lowering the enforceable discretionary spending limits (i.e., caps) established under the BCA, as amended by ATRA, by the total dollar amount of the reduction.16 Thus, policymakers will get to decide how to apportion the cuts within the lowered spending caps rather than having the cuts applied across-the-board to all nonexempt accounts through sequestration. FY2013 Sequestration On September 14, 2012, pursuant to the Sequestration Transparency Act of 2012 (STA),17 OMB released a report on the potential impact of a BCA-triggered FY2013 sequestration on direct and discretionary spending.18 The report provided a breakdown of exempt and nonexempt budget accounts, and included estimates of the FY2013 funding reductions in nonexempt accounts. The STA directed OMB to estimate the effects of sequestration based on FY2012 funding levels. The estimates, which OMB emphasized were preliminary and subject to revision, predated ATRA’s enactment and thus did not take into account the law’s $24 billion reduction in required spending cuts for FY2013. On March 1, 2013, the President ordered a sequestration of FY2013 budgetary resources in accordance with OMB’s final calculations of the dollar amounts of the reduction to each nonexempt budget account. Those calculations, which take into account ATRA’s $24 billion adjustment, were provided in a report submitted to Congress.19 OMB calculated that sequestration will reduce nonexempt nondefense discretionary spending by 5.0% and reduce spending on nonexempt nondefense mandatory programs by 5.1%. The mandatory appropriations in ACA are, in general, fully sequestrable at the rate applicable to nonexempt nondefense mandatory spending. However, for any given fiscal year in which sequestration is ordered, only new budget authority for that year (including advance appropriations that first become available for obligation in that year) is reduced. Unobligated 14 Ibid. Ibid. Note: All veterans programs, mandatory and discretionary, are exempt from sequestration. 16 The BCA established annual discretionary spending caps for each of FY2012 through FY2021. For more information, see CRS Report R42051, Budget Control Act: Potential Impact of Sequestration on Health Reform Spending, by C. Stephen Redhead. 17 P.L. 112-155, 126 Stat. 1210. 18 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. 19 U.S. Office of Management and Budget, OMB Report to the Congress on the Joint Committee Sequestration for Fiscal Year 2013, http://www.whitehouse.gov/sites/default/files/omb/assets/legislative_reports/ fy13ombjcsequestrationreport.pdf. 15 Congressional Research Service 7 Appropriations and Fund Transfers in the Patient Protection and Affordable Care Act balances (nondefense only) carried over from previous fiscal years are exempt from a sequestration order.20 Thus, the FY2013 sequestration order to reduce direct spending does not apply to unobligated ACA funds that were appropriated in a prior fiscal year (i.e., FY2010FY2012) and are still available for obligation. The exemption for unobligated balances carried over from prior fiscal years applies to a number of ACA appropriations. As already mentioned, the appropriation provision often specifies that the funds are to remain available “until expended” or “without fiscal year limitation.” One example is the PCIP program to provide health insurance coverage for eligible individuals who have been uninsured for six months and have a preexisting condition. The program terminates on January 1, 2014. ACA appropriated $5 billion in FY2010, to remain available without fiscal year limitation, to pay claims against the PCIP that are in excess of the premiums collected from enrollees. Any unobligated PCIP funds in FY2013 are exempt from sequestration. Another example is CMI, which received a $10 billion multiple-year appropriation in FY2011 to remain available for obligation through FY2019. The FY2013 appropriations for both PPHF and PCORTF are also fully sequestrable at the rate applicable to nonexempt nondefense mandatory spending. However, the reduction in CHCF funding is capped at 2%. For more discussion and analysis of the effect of BCA-triggered spending reductions on ACA mandatory (and discretionary) spending, see CRS Report R42051, Budget Control Act: Potential Impact of Sequestration on Health Reform Spending. 20 An exemption for nondefense unobligated balances is provided in BBEDCA Section 255(e). It reads as follows: “Unobligated balances of budget authority carried over from prior fiscal years, except balances in the defense category, shall be exempt from reduction under any order issued under this part.” 2 U.S.C. §905(e). Congressional Research Service 8 Table 1. Summary of Mandatory Appropriations and Medicare Trust Fund Transfers in the Affordable Care Act ACA Section Statutory Authority Program Obligations as of May 10, 2013, Based on TAGGS Unless Specified Otherwise Title I – Private Health Insurance 1002 1003 1101 1102 1311 CRS-9 New PHSA Sec. 2793 Consumer Assistance Program (CAP). Appropriates $30 million, to remain available without fiscal year limitation, for CAP grants to states to enable them (or the exchanges operating in such states) to establish, expand, or provide support for offices of health insurance consumer assistance, and health insurance ombudsman programs. [CMS/CCIIO; CFDA 93.519] $47 million New PHSA Sec. 2794 Review of health insurance premium rates. Appropriates $250 million for grants to states over the five-year period FY2010-FY2014 to support programs that review annual increases in health insurance premiums. No state may receive less than $1 million or more than $5 million in a grant year. Funds remaining unobligated at the end of FY2014 are to remain available for grants to states for planning and implementing ACA’s individual and group market reforms. [CMS/CCIIO; CFDA 93.511] $153 million New authority Pre-Existing Condition Insurance Plan (PCIP). Requires the Secretary to establish a temporary program—PCIP—to provide health insurance coverage for eligible individuals who have been uninsured for six months and have a pre-existing condition. The PCIP is federally administered in 23 states and DC; the remaining states administer their own PCIP programs. Appropriates $5 billion, to remain available without fiscal year limitation, to pay claims against (and administrative costs of) the PCIP that are in excess of premiums collected from enrollees. [CMS/CCIIO; CFDA 93.529] According to the most recent quarterly update, net PCIP outlays through December 2012 totaled $2.406 billion. Early Retiree Reinsurance Program (ERRP). Requires the Secretary to establish a temporary ERRP, ending on January 1, 2014, to provide reimbursement to participating employer-based plans for a portion of the cost of providing health benefits to early retirees age 55-64 and their families. Appropriates $5 billion, to remain available without fiscal year limitation, to carry out the ERRP. [CMS/CCIIO] According to the most recent program update, ERRP outlays through February 2012 totaled $4.73 billion. Health insurance exchange grants. Appropriates annually an amount (as determined by the Secretary) necessary to award exchange planning and establishment grants to states. No grants may be awarded after January 1, 2015, by which time exchanges must be self-sustaining. [CMS/CCIIO; CFDA 93.525] $3.869 billion New authority New authority [Total includes original funding plus awards made using additional funds. See http://cciio.cms.gov/programs/consumer/ capgrants/index.html.] [To date, two rounds of rate review grants have been awarded. CMS recently announced the availability of approx. $87 million for a third round of awards. See http://cciio.cms.gov/programs/marketreforms/rates/ index.html.] [PCIP has more than 110,000 enrollees to date. Note: The federally-run PCIP and the state-based PCIPs stopped accepting new enrollees on February 16, 2003, and March 2, 2013, respectively, because of the limited amount of funding. See http://cciio.cms.gov/programs/pcip/index.html; and https://www.pcip.gov.] [ERRP has provided payments to more than 2,800 employers and other sponsors of retiree plans. See http://cciio.cms.gov/ programs/errp/index.html.] [See http://cciio.cms.gov/programs/exchanges/index.html; and CRS Report R43066.] ACA Section 1322 1323 Statutory Authority New authority New authority Program Obligations as of May 10, 2013, Based on TAGGS Unless Specified Otherwise Consumer Operated and Oriented Plan (CO-OP). Requires the Secretary to establish the CO-OP program to provide low-interest loans until July 1, 2013, for the creation of nonprofit member-run health insurance issuers that offer qualified health plans in the individual and small group markets. Appropriates $6 billion to carry out the CO-OP program. Note: P.L. 112-10 and P.L. 112-74 together rescinded a total of $2.6 billion of the original appropriation, and P.L. 112-240 transferred 10% of the remaining unobligated funds to a new CO-OP contingency fund (to provide assistance and oversight to CO-OP loan recipients) and rescinded the other 90% of those funds. CMS no longer has the authority to make new loan awards. See Appendix C. [CMS/CCIIO; CFDA 93.545] According to a December 21, 2012 press release, the CO-OP program has awarded a total of $1.981 billion to 24 nonprofits offering coverage in 24 states. Funding for territories. Appropriates $1 billion, available for the period FY2014-FY2019, for U.S. territories that elect to establish a health insurance exchange. Funds must be used to provide premium and cost-sharing assistance to territory residents who obtain health insurance coverage through the exchange. No obligations. [See http://cciio.cms.gov/programs/coop/index.html.] Title II – Medicaid and State Children’s Health Insurance Program (CHIP) 2701 2707 2801 CRS-10 New SSA Sec. 1139B Medicaid adult health quality measures. Requires the Secretary to develop and, not later than January 1, 2012, publish an initial core set of quality measures for Medicaid-eligible adults. Appropriates $60 million for each of FY2010-FY2014, to remain available until expended. Total amount = $300 million. [CMS; CFDA 93.609] $26 million New authority Medicaid emergency psychiatric demonstration program. Appropriates $75 million for FY2011, to remain available for obligation through December 2015, for a three-year demonstration in which eligible states are required to reimburse certain institutions for mental disease (IMDs) for services provided to Medicaid beneficiaries aged 21 through 64 who are in need of medical assistance to stabilize an emergency psychiatric condition. [CMS/CMI; CFDA 93.537] Eleven states plus DC are participating in the demonstration, which began in July 2012. No public information located on funding obligations. Medicaid and CHIP Payment and Access Commission (MACPAC). Clarifies and expands MACPAC’s duties; for example, to include a review and assessment of payment policies under Medicaid and CHIP and how factors affecting expenditures and payment methodologies enable beneficiaries to obtain services, affect provider supply, and affect providers that serve a disproportionate share of low-income and other vulnerable populations. Appropriates $9 million and transfers from CHIP funding an additional $2 million for FY2010. Total amount = $11 million, to remain available until expended. ACA funding was obligated in FY2011 and FY2012. Amends SSA Sec. 1900 Initial core set of measures published in January 2012. [See http://innovations.cms.gov/initiatives/medicaidemergency-psychiatric-demo/.] [See http://www.macpac.gov/.] ACA Section 4108 4306 10203(d) Statutory Authority New authority Program Obligations as of May 10, 2013, Based on TAGGS Unless Specified Otherwise Medicaid Incentives for the Prevention of Chronic Diseases (MIPCD). Requires the Secretary to award five-year grants to states, subject to annual renewal of funding, to provide incentives for Medicaid beneficiaries to participate in evidence-based healthy lifestyle programs to prevent or help manage chronic disease. Appropriates $100 million for the five-year period beginning January 1, 2011, to remain available until expended. [CMS/CMI; CFDA 93.536] $30 million Amends SSA Sec. 1139A(e) CHIP childhood obesity demonstration program. Appropriates $25 million for the period FY2010 through FY2014 for a program authorized by the Children’s Health Insurance Program Reauthorization Act (CHIPRA; P.L. 111-3), which requires the Secretary to conduct a demonstration project to develop a model for reducing childhood obesity. [CDC; CFDA 93.535] $12 million Amends SSA Secs. 2104 & 2113 CHIP annual appropriations, and outreach and enrollment grants. Appropriates funding for the CHIP program for FY2014 ($19.147 billion) and FY2015 ($21.061 billion); the program previously had been funded through FY2013. Also, extends the time period for the Connecting Kids to Coverage Outreach and Enrollment grants through FY2015 and increases the existing appropriation for such grants from $100 million to $140 million. [CMS; CFDA 93.767] In September 2009, and again in August 2011, CMS awarded $40 million in two-year outreach and enrollment grants to states, local governments, and community organizations. In April 2010, CMS awarded $10 million in grants to tribal organizations. In January 2013, CMS announced the availability of another $40 million for a new round of awards. Medicare quality and efficiency measures. Expands the duties of the consensus-based entity under contract with CMS pursuant to SSA Sec. 1890 (currently the National Quality Forum). Requires the entity to convene multi-stakeholder groups to provide input on the national priorities for health care quality improvement (developed under ACA). In addition, the multi-stakeholder groups are required to provide input on the selection of quality measures for use in various specified Medicare payment systems for hospitals and other providers, as well as in other health care programs, and for use in reporting performance information to the public. Establishes a multi-step pre-rulemaking process and timeline for the adoption, dissemination, and review of measures by the Secretary. Requires the Secretary to transfer from the Medicare Part A and Part B trust funds $20 million for each of FY2010 through FY2014, to remain available until expended.a Total amount = $100 million. [CMS] No public information located on funding obligations. [MIPCD grants have been awarded to 10 states. See http://www.innovations.cms.gov/initiatives/MIPCD/ index.html.] [Funding has been awarded to three research facilities to identify effective childhood obesity prevention strategies, and to a fourth facility to evaluate the strategies and share successes. See http://www.cdc.gov/obesity/childhood/ researchproject.html.] [See http://www.grantsolutions.gov/preaward/ previewPublicAnnouncement.do?id=16205/ Medicare 3014 CRS-11 Amends SSA Sec. 1890(b). New SSA Sec. 1890A ACA Section 3021(a) 3024 3026 3027(b) CRS-12 Statutory Authority Program Obligations as of May 10, 2013, Based on TAGGS Unless Specified Otherwise Center for Medicare and Medicaid Innovation (CMI). Requires the Secretary, no later than January 1, 2011, to establish the CMI within CMS. The purpose of CMI is to test and evaluate innovative payment and service delivery models to reduce program expenditures under Medicare, Medicaid, and CHIP while preserving or enhancing the quality of care furnished under these programs. In selecting the models, the Secretary is also required to give preference to those that improve the coordination, quality, and efficiency of health care services. Appropriates (1) $5 million for FY2010 for the selection, testing, and evaluation of new payment and service delivery models; and (2) $10 billion for the period FY2011 through FY2019, plus $10 billion for each subsequent 10-year period, to continue such activities and for the expansion and nationwide implementation of successful models. Amounts are to remain available until expended.b [CMS] According to the President’s FY2014 budget: FY2011 obligations = $95 million; FY2012 obligations = $784 million; FY2013 obligations (est.) = $1.313 billion; FY2014 (est.) = $1.412 billion. New SSA Sec. 1866E Medicare independence at home demonstration program. Requires the Secretary to conduct a three-year Medicare demonstration program, beginning no later than January 1, 2012, to test a payment incentive and service delivery model that uses physician- and nurse practitioner-directed primary care teams to provide home-based services to chronically ill patients. The Secretary must submit a plan, no later than January 1, 2016, for expanding the program if it is determined that such expansion would improve the quality of care and reduce spending. Requires the Secretary to transfer from the Medicare Part A and Part B trust funds $5 million for each of FY2010 through FY2015 for administering and carrying out the demonstration, to remain available until expended.a Total amount = $30 million. [CMS] No public information located on funding obligations. New authority Community-based Care Transitions Program (CCTP). Requires the Secretary to establish a five-year program, beginning January 1, 2011, to provide funding to eligible hospitals and community-based organizations to test models for improving care transitions from the hospital to other settings for high-risk Medicare beneficiaries. Requires the Secretary to transfer from the Medicare Part A and Part B trust funds $500 million for the period FY2011 through FY2015, to remain available until expended.a Note: P.L. 113-6 rescinded $200 million of CCTP’s appropriation. See Appendix C. [CMS] No public information located on funding obligations. Medicare hospital gainsharing demonstration program. CMS is supporting two projects that allow hospitals to provide gainsharing payments to physicians that represent a share of the savings incurred as a result of collaborative efforts to improve overall quality and efficiency. ACA appropriates $1.6 million for FY2010, to remain available through FY2014 or until expended, for carrying out the demonstration. [CMS] No public information located on funding obligations. New SSA Sec. 1115A Amends DRA Sec. 5007 [For information on CMI’s programs, which include several of the initiatives summarized in this table, see http://www.innovations.cms.gov/.] [Fifteen independent practices and three consortia are participating in the independence at home demonstration, administered by CMI, see http://www.innovations.cms.gov/ initiatives/Independence-at-Home/index.html.] [There are currently 102 organizations participating in the CCTP, which is administered by CMI as part of its Partnership for Patients initiative. See http://www.innovations.cms.gov/ initiatives/CCTP/.] [There are two hospitals participating in the gainsharing demonstration, which is administered by CMI. See http://innovation.cms.gov/initiatives/Medicare-HospitalGainsharing/.] ACA Section 3113 Statutory Authority New authority Program Obligations as of May 10, 2013, Based on TAGGS Unless Specified Otherwise Diagnostic laboratory test demonstration program. Requires the Secretary to conduct a two-year demonstration program beginning July 1, 2011, with a subsequent report to Congress, to test the impact of direct payments for certain complex laboratory tests on Medicare costs and quality of care. Payments are to be made from the Part B trust fund and may not exceed $100 million. Transfers $5 million from the Medicare Part B trust fund, to remain available until expended, for carrying out the demonstration program and preparing the subsequent report. [CMS] Payments under the demonstration began in January 2012. [See http://www.cms.gov/Medicare/Demonstration-Projects/ DemoProjectsEvalRpts/Downloads/TCCDLT_FactSheet.pdf.] 3306 Amends MIPPA Sec. 119 Outreach and assistance for Medicare low-income programs. Transfers a total of $45 million from the Medicare Part A and Part B trust funds for the period FY2010 through FY2012 to extend funding for the following beneficiary outreach and education activities for Medicare lowincome programs: (1) State Health Insurance Counseling and Assistance Programs (SHIPs), $15 million; (2) Area Agencies on Aging (AAAs), $15 million; (3) Aging and Disability Resource Centers (ADRCs), $10 million; and (4) the National Center for Benefits Outreach and Enrollment (NCBOE), $5 million. Funds are to remain available until expended.c Note: P.L. 112-240 appropriates $25 million for FY2013 for these programs: (1) SHIPs, $7.5 million; (2) AAAs, $7.5 million; (3) ADRCs, $5 million; and (4) NCBOE, $5 million. [AoA, CMS; CFDA 93.518] HHS announced grant awards totaling $45 million in September 2010. 3403 New SSA Sec. 1899A Independent Payment Advisory Board (IPAB). Creates an independent, 15-member advisory board tasked with presenting Congress with comprehensive proposals to reduce excess cost growth and improve quality of care for Medicare beneficiaries. Appropriates $15 million for FY2012 to support the board’s activities. For each subsequent fiscal year, appropriates the amount from the previous fiscal year adjusted for inflation. Sixty percent of the appropriation is to be derived by transfer from the Medicare Part A trust fund, and 40% is to be derived by transfer from the Medicare Part B trust fund. Note: P.L. 112-74 and P.L. 113-6 each rescinded $10 million of IPAB’s FY2012 and FY2013 appropriations, respectively. See Appendix C. IPAB members have yet to be appointed. 4202(b) New authority Medicare prevention and wellness evaluation. Transfers $50 million from the Medicare Part A and Part B trust funds, to remain available until expended, to fund an evaluation of community-based prevention and wellness programs and, based on the findings, develop a plan to promote healthy lifestyles and chronic disease self-management among Medicare beneficiaries.a [CMS] No public information located on funding obligations. 4204(e) New authority Medicare vaccine coverage. Appropriates $1 million for FY2010 for a GAO report on the impact of Medicare Part D vaccine coverage on access to those vaccines among beneficiaries. Report released in December 2011 (GAO-12-61). CRS-13 ACA Section Statutory Authority 10323(a) New SSA Sec. 1881A Environmental health hazards. Extends Medicare eligibility to individuals with specified health conditions linked to environmental exposures, who have resided for specified times in an area subject to a Superfund public health emergency declaration. Requires the Secretary to establish a pilot program, with appropriate reimbursement methodologies, to provide comprehensive, coordinated, and cost-effective care to such individuals. Transfers such sums as may be necessary from the Medicare Part A and Part B trust funds to carry out the pilot program.a [CMS] No public information located on funding obligations. 10323(b) New SSA Sec. 2009 Environmental health hazards. Appropriates $23 million for the period FY2010 through FY2014, and $20 million for each five-year period thereafter, for grants to state and local government agencies, health care facilities, and other entities to (1) provide screening for specified lung diseases and other environmental health conditions to individuals who have resided for specified times in an area subject to a Superfund public health emergency declaration; and (2) disseminate public information about the availability of screening, the detection and treatment of environmental health conditions, and the availability of Medicare benefits to certain individuals diagnosed with such conditions, pursuant to new SSA Sec. 1881A (as added by ACA Sec. 10323(a)). [CMS; CFDA 93.534] $5 million Health Care Fraud and Abuse Control (HCFAC) Account. Applies a permanent inflation adjustment to the annual appropriation (provided under SSA Sec. 1817(k)) for the HCFAC account. Appropriates from the Medicare Part A trust fund the following supplemental amounts for the HCFAC account: $10 million for each of FY2011 through FY2020; plus an additional $95 million for FY2011, $55 million for FY2012, $30 million for each of FY2013 and FY2014, and $20 million for each of FY2015 and FY2016. Funds are to remain available until expended. Total amount = $350 million. [CMS] No public information located on ACA funding obligations. Program Obligations as of May 10, 2013, Based on TAGGS Unless Specified Otherwise [Funding provided for an asbestos health screening program in Libby, Montana.] Fraud and Abuse 6402(i) & HCERA Sec. 1303(a) Amends SSA Sec. 1817(k) Health Centers and the National Health Service Corps 4101(a) 10503(b)(1) CRS-14 New authority New authority School-based health centers (SBHCs). Appropriates $50 million for each of FY2010 through FY2013, to remain available until expended, for a grant program to fund the construction and renovation of school-based health centers. Total amount = $200 million. [HRSA; CFDA 93.501] $142 million Community Health Center Fund (CHCF). Transfers from the CHCF the following amounts for health center operations, to remain available until expended: FY2011 = $1 billion; FY2012 = $1.2 billion; FY2013 = $1.5 billion; FY2014 = $2.2 billion; and FY2015 = $3.6 billion. Total amount = $9.5 billion. [HRSA; CFDA 93.527] In FY2011 and FY2012, HRSA awarded a total of approximately $1.2 billion in ACA grants to support health center operations and related activities. [See http://bphc.hrsa.gov/about/schoolbased/index.html.] [See http://bphc.hrsa.gov/about/healthcenterfactsheet.pdf.] ACA Section Statutory Authority Program Obligations as of May 10, 2013, Based on TAGGS Unless Specified Otherwise 10503(b)(2) New authority National Health Service Corps (NHSC). Transfers from the CHCF the following amounts for NHSC operations, scholarships, and loan repayments, to remain available until expended: FY2011 = $290 million; FY2012 = $295 million; FY2013 = $300 million; FY2014 = $305 million; and FY2015 = $310 million. Total amount = $1.5 billion. [HRSA; CFDA 93.547] According to the President’s FY2014 budget: FY2011 obligations = $289 million; FY2012 obligations = $297 million; FY2013 obligations (est.) = $300 million; FY2014 obligations (est.) = $305 million. 10503(c) New authority Health center construction and renovation. Appropriates $1.5 billion, to be available for the period FY2011 through FY2015, and to remain available until expended, for health center construction and renovation. [HRSA; CFDA 93.526] $1.498 billion Health workforce demonstration programs. Requires the Secretary to establish two demonstration projects. The first is to award health profession opportunity grants to states, Indian tribes, institutions of higher education, and local workforce investment boards to help low-income individuals obtain education and training in health care jobs that pay well and are in high demand. Funds may be used to provide financial aid and other supportive services. The second project is to provide states with grants to develop core training competencies and certification programs for personal and home care aides. Appropriates $85 million for each of FY2010 through FY2014, of which $5 million in each of FY2010 through FY2012 is to be used for the second project. Total amount = $425 million. [ACF, HRSA; CFDA 93.093, 93.512] $195 million: Health Profession Opportunity Grant (HPOG) Amends SSA Sec. 501(c) Family-to-family health information centers. Renews funding for the family-to-family information centers, which assist families of children with disabilities or special health care needs and the professionals who serve them, by appropriating $5 million for each of FY2010 through FY2012, to remain available until expended. Total amount = $15 million. Note: P.L. 112240 appropriated $5 million for FY2013. [HRSA; CFDA 93.504] $5 million (FY2012) New PHSA Sec. 340H Teaching health centers. Appropriates such sums as may be necessary, not to exceed $230 million, for the period FY2011 through FY2015 to make payments for direct and indirect graduate medical education (GME) costs to qualified teaching health centers (THCs). [HRSA; CFDA 93.530] $30 million New authority Medicare graduate nurse education demonstration program. Appropriates $50 million for each of FY2012 through FY2015, to remain available until expended, for a Medicare demonstration program under which up to five eligible hospitals will receive reimbursement for providing advanced practice nurses with clinical training in primary care, preventive care, transitional care, and chronic care management. Total amount = $200 million. [CMS/CMI] CMI, which is administering this program, has selected the five participating hospitals and begun making reimbursement payments. Health Workforce 5507(a) 5507(b) 5508(c) 5509 CRS-15 New SSA Sec. 2008 $13 million: Personal and Home Care Aide State Training (PHCAST) program [See http://www.acf.hhs.gov/programs/ofa/programs/hpog and http://bhpr.hrsa.gov/nursing/grants/phcast.html.] [See http://mchb.hrsa.gov/programs/familytofamily/ index.html.] [See http://bhpr.hrsa.gov/grants/teachinghealthcenters/.] [See http://innovations.cms.gov/initiatives/GNE/index.html.] ACA Section 10502 Statutory Authority New authority Program Health care facility construction. Appropriates $100 million for FY2010, to remain available for obligation until Sept. 30, 2011, for debt service on, or construction or renovation of, a hospital affiliated with a state’s sole public medical and dental school. [HRSA; CFDA 93.502] Obligations as of May 10, 2013, Based on TAGGS Unless Specified Otherwise $100 million [Funding awarded to Ohio State University.] Community-Based Prevention and Wellness 4002 New authority Prevention and Public Health Fund (PPHF). Establishes a PPHF and originally provided a permanent annual appropriation to the fund, as follows: FY2010 = $500 million; FY2011 = $750 million; FY2012 = $1 billion; FY2013 = $1.25 billion; FY2014 = $1.5 billion; FY2015 and each year thereafter = $2 billion. Requires the Secretary to transfer amounts from the fund to HHS accounts to increase funding, over the FY2008 level, for PHSA-authorized prevention, wellness, and public health activities, including prevention research and health screenings. Authorizes House and Senate appropriators to transfer monies from the PPHF to eligible activities. Note: P.L. 112-96 subsequently reduced the annual appropriations to the PPHF over the period FY2013-FY2021, as follows: FY2013 through FY2017 = $1 billion; FY2018 and FY2019 = $1.25 billion; FY2020 and FY2021 = $1.5 billion; FY2022 and each year thereafter = $2 billion. [OS, CDC, HRSA, SAMHSA, ACL; CFDA 93.507, 93.521, 93.522, 93.523, 93.524, 93.531, 93.533, 93.538, 93.539, 93.540, 93.542.] PPHF funds are annual appropriations that must be obligated during the fiscal year in which they are made available. For an analysis and complete list of all PPHF awards for FY2010 and FY2011, see the GAO report, Prevention and Public Health Fund: Activities Funded in Fiscal Years 2010 and 2011 (GAO-12788), at http://www.gao.gov/assets/650/648310.pdf. Maternal, infant, and early childhood home visiting program. Appropriates the following amounts for grants to states, U.S. territories, and Indian tribes to develop and implement early childhood home visiting programs that adhere to evidence-based models of service delivery: FY2010 = $100 million; FY2011 = $250 million, FY2012 = $350 million; FY2013 = $400 million; FY2014 = $400 million. Total amount = $1.5 billion. Programs must establish benchmarks to measure improvements for the participating families in maternal and newborn health; prevention of child abuse or neglect or child injuries; school readiness and achievement; reductions in crime or domestic violence; family economic self-sufficiency; and coordination and referrals for other community resources and supports. [HRSA, ACF; CFDA 93.505, 93.508] $719 million For a summary of the allocation of PPHF funds for FY2012 and FY2013, by agency and program, see http://www.hhs.gov/ open/recordsandreports/prevention/index.html. [This website was mandated by P.L. 112-74 and continued by P.L. 113-6; see Appendix C.] Note: The listed CFDA programs do not capture all the uses of PPHF funding. PPHF funds have also been integrated into existing programs that do not mention PPHF. Maternal and Child Health 2951 CRS-16 New SSA Sec. 511 [See http://mchb.hrsa.gov/programs/homevisiting/.] ACA Section 2953 2954 1021110214 Statutory Authority Program Obligations as of May 10, 2013, Based on TAGGS Unless Specified Otherwise New SSA Sec. 513 Personal Responsibility Education Program (PREP). Establishes a state formula grant program to support evidence-based PREPs designed to educate adolescents about abstinence, contraception, and adulthood. Also, requires the Secretary to award grants to implement innovative youth pregnancy prevention strategies and to target services at high-risk populations. Appropriates $75 million for each of FY2010 through FY2014, of which $10 million each year is to be reserved for the youth pregnancy prevention grants. Funds are to remain available until expended. Total amount = $375 million. [ACF; CFDA 93.092] $231 million Amends SSA Sec. 510 Abstinence education grants. Renews funding for the state formula grant program to support abstinence education programs by appropriating $50 million for each of FY2010 through FY2014. Total amount = $250 million. Funds are awarded to states based on the proportion of low-income children in each state compared to the national total, and may only be used for teaching abstinence. [ACF, CDC; CFDA 93.235] $121 million (FY2010-FY2013) New authority Pregnancy assistance grants. Appropriates $25 million for each of FY2010 through FY2019 (total amount = $250 million) to establish a Pregnancy Assistance Fund for the purpose of awarding grants to states to assist pregnant and parenting teens and women. State grantees have the flexibility to make funds available to institutions of higher education, high schools and community service centers, and to the state attorneys general to improve services for pregnant women who are victims of domestic violence, sexual assault, or stalking. [OS; CFDA 93.500] $72 million Medicaid Money Follows the Person (MFP) demonstration program. Extends funding for the MFP demonstration through FY2016. The program authorizes the Secretary to award competitive grants to states to reduce their reliance on institutional care for people needing long-term care, and expand options for elderly people and individuals with disabilities to receive home and community-based long-term care services. Appropriates $450 million for each of FY2012 through FY2016, to remain available through FY2016. Total amount = $2.25 billion. [CMS; CFDA 93.791] $340 million (FY2012-FY2013) [See http://www.acf.hhs.gov/programs/fysb/programs/ adolescent-pregnancy-prevention/programs/prepcompetitive.] [See http://www.acf.hhs.gov/programs/fysb/resource/aegpfact-sheet.] [See http://www.hhs.gov/ash/oah/oah-initiatives/paf/ home.html.] Long-Term Care 2403 CRS-17 Amends DRA Sec. 6071(h) [See http://www.medicaid.gov/Medicaid-CHIP-ProgramInformation/By-Topics/Long-Term-Services-and-Support/ Balancing/Money-Follows-the-Person.html.] ACA Section 2405 Statutory Authority New authority Program Obligations as of May 10, 2013, Based on TAGGS Unless Specified Otherwise State Aging and Disability Resource Centers (ADRCs). Appropriates $10 million for each of FY2010 through FY2014 (total amount = $50 million) for ADRCs, authorized under OAA Sec. 202. ADRCs serve as a single, coordinated resource for consumer information on the range of long-term care options in community and institutional settings. Some ADRCs also serve as the entry point to publicly administered long-term care programs (e.g., Medicaid, OAA services, state assistance programs). AoA and CMS have invested more than $100 million in the ADRC program since 2003. ADRCs currently operate in over 350 community sites across 54 states and territories. See also the entry for ACA Sec. 3306, above. [AoA; CFDA 93.517] $15 million [See http://www.aoa.gov/AoA_programs/HCLTC/ADRC/ index.aspx.] 6201 New authority Background checks of long-term care providers. Requires the Secretary to establish a nationwide program for background checks on direct patient access employees of long-term care facilities or providers, and to provide federal matching funds to states to conduct these activities. Requires the Treasury Secretary to transfer to HHS an amount, not to exceed $160 million, that is specified by the HHS Secretary as necessary to carry out the program for the period FY2010 through FY2012. Funds are to remain available until expended. [CMS; CFDA 93.506] $52 million 8002(d) Amends DRA Sec. 6021(d) National Clearinghouse for Long-Term Care Information. Appropriates $3 million for each of FY2011 through FY2015 for the National Clearinghouse for Long-Term Care Information, and requires the Clearinghouse to include information on the Community Living Assistance Services and Supports (CLASS) program, established under ACA Sec. 8002(a). Note: P.L. 112-240 repealed the CLASS program; see Appendix B. Total amount = $15 million. [AoA] No public information located on funding obligations. However, these are annual appropriations that must be obligated during the fiscal year in which they are made available. [See http://www.longtermcare.gov/LTC/Main_Site/ index.aspx.] Comparative Effectiveness Research 6301(d)-(e) CRS-18 New IRC Secs. 9511, 4375, & 4376. New SSA Sec. 1183 Patient-Centered Outcomes Research Trust Fund (PCORTF). Establishes a PCORTF to fund the new Patient-Centered Outcomes Research Institute (PCORI) and its comparative effectiveness research activities. Appropriates to the PCORTF $10 million for FY2010, $50 million for FY2011, and $150 million for each of FY2012 through FY2019, for a total of $1.26 billion over that 10-year period. For each of FY2013 through FY2019, the PCORTF is to receive additional appropriations equal to the net revenues from a new health insurance policy/plan fee,d as well as Medicare trust fund transfers.e Each fiscal year, 20% of the funds in the PCORTF are to be transferred to the Secretary, to remain available until expended. Of those transferred funds, 80% are to be provided to AHRQ. [OS, AHRQ] In May 2013, PCORI announced grant awards totaling $89 million, which brings the total amount awarded to fund PCORI’s research agenda to $129 million. PCORI has also awarded $30 million for a series of pilot projects. [See http://www.pcori.org/.] ACA Section Statutory Authority Program Obligations as of May 10, 2013, Based on TAGGS Unless Specified Otherwise Biomedical Research 9023 New IRC Sec. 48D Therapeutic research and development tax credits and grants. Creates a two-year tax credit program, subject to an overall cap of $1 billion, for small companies (250 or fewer employees) that invest in new therapies to prevent, diagnose, and treat cancer and other diseases. Companies may apply for one or more tax credits, each covering up to 50% of the cost of qualifying research investments made in 2009 and 2010. However, the total amount of tax credits any one company receives for the two years may not exceed $5 million. Companies may elect to receive one or more grants in lieu of tax credits, subject to the same restrictions (i.e., grants may cover up to 50% of the cost of qualifying investments made in 2009 and 2010; the total amount of grants any one company receives for the two years may not exceed $5 million). Appropriates such sums as may be necessary to carry out the grant program. [IRS] According to the IRS: total grant awards = $970 million; total tax credits = $17 million. [See http://www.irs.gov/Businesses/Small-Businesses-&-SelfEmployed/Qualifying-Therapeutic-Discovery-Project-Creditsand-Grants.] ACA Implementation: Administrative Expenses HCERA Sec. 1005 New authority Health Insurance Reform Implementation Fund (HIRIF). Appropriates $1 billion to the HIRIF for federal administrative expenses to carry out ACA. [OS; CFDA 93.528] According to the President’s FY2014 Budget, there was an unobligated balance of $241 million at the beginning of FY2013. Source: Prepared by the Congressional Research Service based on the text of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148), as amended. a. Transfers from the two trust funds are in such proportion as the Secretary determines appropriate. b. Of the amounts appropriated for the period FY2011-FY2019, and for each subsequent 10-year period, at least $25 million must be made available each fiscal year for the selection, testing, and evaluation of new payment and service delivery models. c. Transfers from the two trust funds are in the same proportion as the Secretary determines under SSA Sec. 1853(f). d. The health insurance fee is to equal $2 multiplied by the average number of covered lives in a policy/plan year ($1 in the case of a policy/plan year ending during FY2013), updated annually by the rate of medical inflation beginning in FY2015. e. The trust fund transfers are to equal $2 ($1 in FY2013) multiplied by the average number of individuals entitled to benefits under Part A or enrolled under Part B in a given fiscal year, updated annually by the rate of medical inflation beginning in FY2015. CRS-19 Table 2. ACA Appropriations and Fund Transfers by Fiscal Year in Which Funds Are Available for Obligation FY2010-FY2019 Appropriation (or Fund Transfer) in $ millions ACA Section Program FY2010 FY2011 FY2012 FY2013 FY2014 FY2015 FY2016 FY2017 FY2018 FY2019 Totala Private Health Insurance 1002 Health insurance consumer information 30b 1003 Review of health insurance premium rates 250 — — — — — — — — — 250 1101 Temporary high-risk health insurance pools 5,000b — — — — — — — — — 5,000 1102 Early retiree reinsurance program 5,000b — — — — — — — — — 5,000 1311 Health insurance exchange planning and establishment Appropriates amounts necessary for grants each fiscal year, as determined by the Secretary; no grant awards after Jan. 1, 2015 — — — — TBDc 1322 Consumer operated and oriented plans (CO-OPs) 6,000d — — — — — — — 6,000 1323 Health insurance exchange subsides (U.S. territories) — — — — (Note: This section also authorizes to be appropriated SSAN for FY2011 and each fiscal year thereafter.) — — $1 billion total for CY2014 through CY2109e 30 1,000 Medicaid and Children’s Health Insurance Program (CHIP) 2701 Medicaid adult health quality measures 60 60 60 60 60 — — — — — 300f 2707 Medicaid emergency psychiatric demonstration — 75g — — — — — — — — 75 2801 Medicaid and CHIP Payment and Access Commission 4108 Medicaid prevention and wellness incentives — 4306 CHIP childhood obesity demonstration $25 million total for FY2010 through FY2014 10203(d) CHIP annual appropriationi — 10203(d) CHIP outreach and enrollment grants CRS-20 11h (Note: This section also authorizes to be appropriated SSAN for FY2011 and each fiscal year thereafter.) $100 million total for CY2011 through CY2015f 11 — — — — 100 — — — — — 25 21,061 — — — — 40,208 Increases total funding from $100 million to $140 million and extends funding period through FY2015 — — — — 40 — — — 19,147 Appropriation (or Fund Transfer) in $ millions ACA Section Program FY2010 FY2011 FY2012 FY2013 FY2014 FY2015 FY2016 FY2017 FY2018 20j 20 20 20 20 — — — — FY2019 Totala Medicare 3014 Medicare quality and efficiency measures 3021(a) Center for Medicare and Medicaid Innovation 5 3024 Medicare independence at home demonstration 5j 3026 Community-based care transition services 3027(b) Medicare gainsharing demonstration 2 — — — — 3113 Diagnostic laboratory test demonstration 5l — — — 3306 Outreach and assistance for low-income beneficiaries 25m 3403 Independent Payment Advisory Board — — 15n 4202(b) Prevention and wellness evaluation 50j — — — — — — — — — 50 4204(e) GAO study of Medicare vaccine coverage 1 — — — — — — — — — 1 10323(a) Environmental health pilot program 10323(b) Environmental health screening and education — — plus $10 billion total for FY2011 through FY2019, and $10 billion for each subsequent 10-year period 5 5 5 5 5 10,005f — — — — 30 — — — — 500 — — — — — 2f — — — — — — 5 — — — — — — 70 For FY2013 and each subsequent fiscal year, appropriates previous year’s amount adjusted for inflation; funds derived from the Medicare trust funds. TBDc $500 million total for FY2011 through FY2015k $45 million total for FY2010 through FY2012m 100 SSANj TBDc $20 million total for FY2015 though FY2019, and for each 5-year period thereafter $23 million total for FY2010 through FY2014 43f Fraud and Abuse 6402(i) & HCERA 1303(a) Health Care Fraud and Abuse Control (HCFAC) Account — 105 65 40 40 30 30 10 10 10 350o 50 50 — — — — — — 200f Health Centers and the National Health Service Corps (NHSC) 4101(a) CRS-21 School-based health center establishment grants 50 50 Appropriation (or Fund Transfer) in $ millions ACA Section Program FY2010 FY2011 FY2012 FY2013 FY2014 FY2015 FY2016 FY2017 FY2018 FY2019 Totala 10503(b)(1) Community Health Centers Fund, patient services — 1,000 1,200 1,500 2,200 3,600 — — — — 9,500f 10503(b)(2) Community Health Centers Fund, NHSC — 290 295 300 305 310 — — — — 1,500f 10503(c) Community health center construction and renovation — $1.5 billion total for FY2011 through FY2015 — — — — 1,500f Health Workforce 5507(a) Health workforce demonstration grants 85 85 85 85 85 — — — — — 425 5507(b) Family-to-family health information centers 5 5 5 5p — — — — — — 20f 5508(c) Teaching health centers, GME payments — SSAN for FY2011 through FY2015, not to exceed $230 million — — — — ≤230 5509 Medicare graduate nurse education demonstration — — 50 50 50 50 — — — — 200f 10502 Health care facility construction 100 — — — — — — — — — 100q 500 750 1,000 1,000 1,000 1,000 1,000 1,000 1,250 1,250 9,750r Community-Based Prevention and Wellness 4002 Prevention and Public Health Fund Maternal and Child Health 2951 Maternal, infant, and early childhood home visitation 100 250 350 400 400 — — — — — 1,500 2953 Personal responsibility education program grants 75 75 75 75 75 — — — — — 375f 2954 Abstinence education state grants 50 50 50 50 50 — — — — — 250 10214 Pregnancy assistance grants 25 25 25 25 25 25 25 25 25 25 250 — 450 450 450 450 450 450 — — — 2,700 Long-Term Care 2403 CRS-22 Medicaid money follows the person demonstration Appropriation (or Fund Transfer) in $ millions ACA Section Program 2405 State Aging and Disability Resource Centers 6201 Background checks of longterm care providers 8002(d) National Clearinghouse for Long-Term Care Information FY2010 FY2011 FY2012 FY2013 FY2014 FY2015 FY2016 FY2017 FY2018 10 10 10 10 10 — — — — — 50 — — — — — — — ≤160s 3 3 3 — — — — 15 Up to $160 million total for FY2010 through FY2012 FY2019 Totala — 3 3 Patient-Centered Outcomes Research Trust Fund, Medicare transfers — — — For each of FY2013-FY2019, transfers amounts from the Medicare trust funds as determined by a formula TBDt Patient-Centered Outcomes Research Trust Fund, appropriations 10 50 150 For each of FY2013-FY2019, appropriates $150 million plus an amount equal to the net revenue from a fee levied on insurance policies and health plans TBDu SSAN — — — — — — — — — ≤1v 1,000 — — — — — — — — — 1,000 Comparative Effectiveness Research 6301(d) 6301(e) Biomedical Research 9023(e) Grants for investment in new therapeutics PPACA Implementation HCERA 1005 Health Insurance Reform Implementation Fund Source: Prepared by the Congressional Research Service based on the text of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148), as amended. Notes: Funds are provided from the Treasury unless otherwise noted. A dash means that ACA does not appropriate or transfer funds for the fiscal year(s) noted. a. Total represents the cumulative amount of appropriations or fund transfers over the 10-year period FY2010-FY2019. Note that in several instances the 10-year total is yet to be determined (TBD); see table entries for ACA Secs. 1311, 3403, 6301(d) & (e), 9023(e), and 10323(a). In addition, four provisions provide annual or multipleyear appropriations beyond FY2019. The total shown in the table for three of these provisions represents the cumulative amount appropriated through FY2019; see table entries for ACA Secs. 3021(a), 4002 (discussed in table note “q” below), and 10323(b). Finally, the total for ACA Sec. 6402(i) includes an amount appropriated in FY2020 (see table note “n” below). b. Funds are to remain available without fiscal year limitation. c. To be determined. d. ACA Sec. 1322 appropriated $6 billion for the CO-OP program. Subsequently, Division B, Title VIII, Sec. 1857 of P.L. 112-10 canceled $2.2 billion of that appropriation; Division F, Title V, Sec. 524 of P.L. 112-74 rescinded an additional $400 million; and Sec. 644 of P.L. 112-240 transferred 10% of the remaining unobligated funds to a new CO-OP contingency fund (to provide assistance and oversight to CO-OP loan recipients) and rescinded the other 90% of those funds. CMS no longer has the authority to make new loan awards. See Appendix C. CRS-23 e. Of this total amount, $925 million is for Puerto Rico, and the remaining $75 million is for the other U.S. territories in amounts as specified by the Secretary. f. Funds are to remain available until expended. g. Funds are to remain available for obligation through Dec. 31, 2015. h. Of this total amount, $9 million is appropriated, and the remaining $2 million is a transfer from CHIP funding for FY2010. Funds are to remain available until expended. i. Prior to enactment of ACA, the CHIP program was funded through FY2013. j. The Secretary is required to transfer amounts from the Medicare Part A and Part B trust funds each fiscal year in such proportion as the Secretary determines appropriate. Funds are to remain available until expended. k. The Secretary is required to transfer amounts from the Medicare Part A and Part B trust funds each fiscal year in such proportion as the Secretary determines appropriate. Funds are to remain available until expended. Note: Division F, Title V, Sec. 1520 of P.L. 113-6 rescinded $200 million of CCTP’s appropriation. See Appendix C. l. The Secretary is required to transfer the $5 million from the Medicare Part B trust fund, to remain available until expended. m. The Secretary is required to transfer amounts from the Medicare Part A and Part B trust funds in the same proportion as the Secretary determines under SSA Sec. 1853(f). Funds are to remain available until expended. Note: Sec. 610 of P.L. 112-240 appropriated $25 million for FY2013 for the four outreach and assistance programs funded under ACA Sec. 3306. See Table 1 and Appendix C. n. Division F, Title V, Sec. 525 of P.L. 112-74 rescinded $10 million of IPAB’s appropriation for FY2012. Division F, Title V, Sec. 1521 rescinded $10 million of IPAB’s appropriation for FY2013. See Appendix C. o. Funds are to be appropriated from the Medicare Part A trust fund. Note: the total amount appropriated (i.e., $350 million) includes a final appropriation of $10 million for FY2020. p. Sec. 624 of P.L. 112-240 appropriated $5 million for FY2013 for this program. q. Funds are to remain available for obligation until Sept. 30, 2011. r. ACA Sec. 4002 originally provided a permanent annual appropriation to the Prevention and Public Health Fund, as follows: FY2010 = $500 million; FY2011 = $750 million; FY2012 = $1 billion; FY2013 = $1.25 billion; FY2014 = $1.5 billion; FY2015 and each year thereafter = $2 billion. Subsequently, P.L. 112-96 reduced the annual appropriations to the PPHF over the period FY2013-FY2021, as follows: FY2013 through FY2017 = $1 billion; FY2018 and FY2019 = $1.25 billion; FY2020 and FY2021 = $1.5 billion; FY2022 and each year thereafter = $2 billion. Thus, appropriations to the fund now total $9.750 billion over the period FY2010-FY2019. s. The HHS Secretary is required to notify the Treasury Secretary of the amount necessary to carry out activities under this section for the period of FY2010 through FY2012, but not to exceed $160 million. The Treasury Secretary must then transfer the amount specified from the Treasury to the HHS Secretary. Funds are to remain available until expended. t. To be determined. ACA Sec. 6301(d) provided the following formula for the transfer of funds from the Medicare Part A and Part B trust funds to the Patient-Centered Outcomes Research Trust Fund: (1) for FY2013, an amount from each respective Medicare trust fund equal to $1 multiplied by the average number of individuals entitled to Part A benefits, or enrolled in Part B during that period; and (2) for each of FY2014-FY2019, an amount from each respective Medicare trust fund equal to $2 multiplied by the average number of individuals entitled to Part A benefits, or enrolled in Part B during that fiscal year. Beginning in FY2015, amounts are subject to adjustment for increases in health care spending. u. To be determined. In addition to the amounts transferred to the Patient-Centered Outcomes Research Trust Fund under ACA Sec. 6301(d), described in the preceding table note, ACA Sec. 6301(e) appropriated to the Fund a specified amount for each of FY2010-FY2019, plus an additional amount for each of FY2013 through FY2019 equal to the net revenues received from a fee imposed on health insurance policies and self-insured plans. The fee equals $2 multiplied by the average number of covered lives in a policy/plan year ($1 in the case of policy/plan years ending during FY2013). Beginning in FY2015, amounts are subject to adjustment for increases in health care spending. CRS-24 v. CRS-25 To be determined. ACA Sec. 9023(e) created a two-year tax credit program, subject to an overall cap of $1 billion, for small companies that invest in new therapies to prevent, diagnose and treat cancer and other diseases. The total amount of tax credits any one company can receive for the two years may not exceed $5 million. Companies may elect to receive one or more grants—for which SSAN are appropriated—in lieu of tax credits. Grant applications must be received before Jan. 1, 2013. Appropriations and Fund Transfers in the Patient Protection and Affordable Care Act Appendix A. Acronyms Used in the Report The following laws and federal agencies are referred to in this report by their acronym: AoA Administration on Aging ACF Administration for Children and Families AHRQ Agency for Healthcare Research and Quality BBEDCA Balanced Budget and Emergency Deficit Control Act of 1985 (P.L. 99-177) CCIIO Center for Consumer Information and Insurance Oversight CDC Centers for Disease Control and Prevention CHIP Children’s Health Insurance Program CMS Centers for Medicare & Medicaid Services DRA Deficit Reduction Act of 2005 (P.L. 109-171) HCERA Health Care and Education Reconciliation Act of 2010 (P.L. 111-152) HRSA Health Resources and Services Administration OS HHS Office of the Secretary IRC Internal Revenue Code IRS Internal Revenue Service MIPPA Medicare Improvements for Patients and Providers Act of 2008 (P.L. 110-275) OAA Older Americans Act PHSA Public Health Service Act PPACA Patient Protection and Affordable Care Act (P.L. 111-148) SSA Social Security Act Congressional Research Service 26 Appropriations and Fund Transfers in the Patient Protection and Affordable Care Act Appendix B. ACA-Related Authorizing Legislation in the 112th Congress Lawmakers opposed to specific provisions in ACA, or to the entire law, introduced numerous bills in the 112th Congress to modify or repeal the law. Most of the legislative activity on these bills took place in the House. The ACA-related legislation included bills that would have (1) repealed the law in its entirety and, in some instances, replaced it with new law; (2) repealed or amended specific provisions in the law; (3) eliminated certain mandatory appropriations in ACA (discussed in this report) and rescinded all unobligated funds;21 (4) replaced the mandatory appropriations for one or more ACA programs with authorizations of appropriations, and rescinded all unobligated funds; and (5) blocked or otherwise delayed ACA implementation. A few provisions, with sufficiently broad and bipartisan support were approved in both the House and the Senate and signed into law. This appendix summarizes the ACA-related provisions in authorization legislation enacted during the 112th Congress. It also provides a brief overview of each of the ACA-related bills that were passed by the House, but which were not approved by the Senate. Appendix C summarizes the ACA-related provisions in annual appropriations acts for the period FY2011-FY2013. Enacted Legislation P.L. 112-9 (April 14, 2011; H.R. 4), Comprehensive 1099 Taxpayer Protection and Repayment of Exchange Subsidy Overpayments Act of 2011. P.L. 112-9 repealed the ACA requirement that businesses file an information report (IRS Form 1099) whenever they pay a vendor more than $600 for goods in a single year. To pay for the 1099 repeal, P.L. 112-9 raised the limits on the amount of excess premium tax credits that individuals would have to repay. [Note: Under ACA, the amount received in premium credits is based on income as reported on tax returns. These amounts are reconciled the following year, which could result in an overpayment of credits if income increases. ACA placed limits on the amount of any premium credit overpayment that had to be repaid to the government.] P.L. 112-56 (November 21, 2011; H.R. 674), 3% Withholding Repeal and Job Creation Act. Among its many provisions, P.L. 112-56 amended the calculation of Modified Adjusted Gross Income (MAGI) to include Social Security benefits. MAGI will be used to determine eligibility for health insurance exchange subsidies and Medicaid, beginning in 2014. P.L. 112-96 (February 22, 2012; H.R. 3630), Middle Class Tax Relief and Job Creation Act of 2012. Among its many provisions, P.L. 112-96: (1) reduced ACA’s annual appropriations to the PPHF over the period FY2013-FY2021 by a total of $6.25 billion to help offset the costs of the law’s extension of the payroll tax cut; (2) extended by one year the disproportionate share hospital (DSH) allotment reduction imposed by ACA; and (3) corrected the formula to phase down ACA’s Medicaid disaster-recovery FMAP adjustment as originally intended. [Note: The purpose of the adjustment was to help Louisiana avoid a significant reduction in its federal Medicaid match (i.e., Federal Medical Assistance Percentage, or FMAP) in the aftermath of 21 Of the total amount of funding available for obligation, the unobligated balance represents the funds that an agency has not yet awarded or otherwise made a legal commitment to provide as payment for goods or services. Congressional Research Service 27 Appropriations and Fund Transfers in the Patient Protection and Affordable Care Act Hurricane Katrina. As written in ACA, the formula for the disaster-recovery FMAP adjustment unintentionally caused the FMAP adjustment to increase, rather than phase down, each year the state qualifies for the adjustment.] P.L. 112-141 (July 6, 2012; H.R. 4348), Moving Ahead for Progress in the 21st Century Act, or “MAP-21”. Among its many provisions, P.L. 112-141 included a further adjustment to ACA’s Medicaid disaster-recovery provision (see entry for P.L. 112-96, above). P.L. 112-240 (January 2, 2013; H.R. 8), American Taxpayer Relief Act of 2012. Among its many provisions, P.L. 112-240: (1) provided $25 million for FY2013 for the four outreach and assistance programs that were funded by ACA Sec. 3306 through FY2012; (2) provided $5 million for FY2013 for the family-to-family information centers, which ACA Sec. 5507(b) funded through FY2012; (3) transferred 10% of the remaining unobligated CO-OP funds to a new COOP contingency fund (to provide assistance and oversight to CO-OP loan recipients) and rescinded the other 90% of those funds; and (4) repealed the Community Living Assistance Services and Supports (CLASS) program. House-Passed Bills H.R. 2, Repealing the Job-Killing Health Care Law Act. Passed the House by a vote of 245189 on January 19, 2011; offered as an amendment during Senate floor debate on an unrelated bill (S. 223) and rejected on a procedural motion by a vote of 47-51. H.R. 2 would have repealed ACA in its entirety and restored the provisions of law amended or repealed by ACA as if it had not been enacted. H.R. 5, Protecting Access to Healthcare Act. Passed the House by a vote of 223-181 on March 22, 2012. Title II of H.R. 5 would have repealed the authority and appropriations for the Independent Payment Advisory Board (IPAB). H.R. 358, Protect Life Act. Passed the House by a vote of 251-172 on October 13, 2011. H.R. 358 would have prohibited using any funds authorized or appropriated by ACA to pay for an abortion or to pay for any part of the costs of a health plan that covers abortions, except if the pregnancy is the result of rape or incest, or the life of the pregnant female is at risk unless an abortion is performed. It would have required insurers that offer plans through the exchanges that cover abortion services to offer identical plans that do not cover abortion services. It also would have prohibited federal, state or local government programs that receive ACA funding from discriminating against health care entities that refuse to provide abortion services or abortion training. H.R. 436, Health Care Cost Reduction Act of 2012. Passed the House by a vote of 270-146 on June 7, 2012. H.R. 436 would have (1) repealed ACA’s 2.3% excise tax on medical devices; (2) repealed the law’s restrictions on using tax-preferred accounts to pay for over-the-counter drugs; (3) allowed individuals to recoup up to $500 of unused funds remaining in their flexible spending account (FSA) after the end of the plan year; and (4) eliminated all limits on repayment of any premium credit overpayment, making individuals liable for the full amount. H.R. 1173, Fiscal Responsibility and Retirement Security Act of 2012. Passed the House by a vote of 267-159 on February 1, 2012. H.R. 1173 would have repealed the Community Living Assistance Services and Supports (CLASS) program. Congressional Research Service 28 Appropriations and Fund Transfers in the Patient Protection and Affordable Care Act H.R. 1213, A bill to repeal ACA funding for health insurance exchanges. Passed the House by a vote of 238-183 on May 3, 2011. H.R. 1213 would have repealed the authority and appropriations for state exchange planning and establishment grants and rescinded all unobligated funds. H.R. 1214, A bill to repeal ACA funding for school-based health center (SBHC) construction. Passed the House by a vote of 235-191 on May 4, 2011. H.R. 1214 would have repealed the authority and appropriations for SBHC construction grants and rescinded all unobligated funds. H.R. 1216, A bill to convert funding for graduate medical education (GME) in qualified teaching health centers (THCs) to an authorization of appropriations. Passed the House by a vote of 234-185 on May 25, 2011. H.R. 1216 would have replaced the appropriation for GME payments to THCs with an authorization of appropriations for each of FY2012 through FY2015, and rescinded all unobligated funds. It would have prohibited the GME funds from being used to provide abortions, except in cases of rape or incest or when the woman’s life is in danger. H.R. 1217, A bill to repeal the Prevention and Public Health Fund (PPHF). Passed the House by a vote of 236-183 on April 13, 2011. H.R. 1217 would have repealed the authority and appropriations for the PPHF and rescinded all unobligated funds. H.R. 4628, Interest Rate Reduction Act. Passed the House by a vote of 215-195 on April 27, 2012. H.R. 4628 would have postponed by one year a scheduled increase in Stafford education loan rates and, to offset the costs of that adjustment, repealed the authority and appropriations for the PPHF and rescinded all unobligated funds. [Note: The one-year Stafford loan rate extension was incorporated as Division F, Title III of MAP-21, the surface transportation reauthorization bill (see entry for P.L. 112-141, above). The provision in H.R. 4628 to repeal PPHF and rescind all unobligated funds was not included in MAP-21.] H.R. 5652, Sequester Replacement Reconciliation Act of 2012. Passed the House by a vote of 218-199 on May 10, 2012. H.R. 5652, which was introduced pursuant to the reconciliation instructions in the House FY2013 budget resolution (H.Con.Res. 112), would have replaced the FY2013 sequestration of discretionary spending (as required under the Budget Control Act of 2011) with a $19 billion reduction in the FY2013 discretionary cap, and would have implemented a series of mandatory program savings recommended by six House committees. Among its many provisions, H.R. 5652 would have (1) eliminated all limits on repayment of any premium credit overpayment, making individuals liable for the full amount; (2) repealed the authority and appropriations for the exchange planning and establishment grants and rescinded all unobligated funds; (3) repealed the authority and appropriations for the PPHF and rescinded all unobligated funds; (4) rescinded all remaining unobligated funds for the Consumer Operated and Oriented Plan (CO-OP) program; (5) extended by one year the DSH allotment reduction imposed by ACA; and (6) repealed ACA’s Medicaid maintenance of effort requirements. H.R. 6079, Repeal of Obamacare Act. Passed the House by a vote of 244-185 on July 11, 2012. H.R. 6079 would have repealed ACA in its entirety and restored the provisions of law amended or repealed by ACA as if it had not been enacted. Congressional Research Service 29 Appropriations and Fund Transfers in the Patient Protection and Affordable Care Act Appendix C. ACA Provisions in Appropriations Bills (FY2011-FY2013) Numerous ACA-related provisions have been included in appropriations legislation introduced and enacted since passage of the health reform law. These provisions, often referred to as appropriations riders, generally are of two types: (1) appropriations restrictions that prohibit the use of discretionary funds provided in the bill to implement specific ACA provisions or the entire law; and (2) legislative language that amends or repeals specific ACA provisions.22 This appendix summarizes the ACA provisions that were included in the enacted appropriations legislation for FY2011, FY2012, and FY2013. It also provides for each of those years a brief overview of the ACA-related provisions that were added to both the Labor-HHS-Education and the Financial Services and General Government appropriations acts introduced and, in most cases, reported by the House and Senate Appropriations Committees. Only a few of those provisions were incorporated in the final omnibus appropriations legislation that was signed into law. FY2011 Appropriations On April 15, 2011, the Department of Defense and Full-Year Continuing Appropriations Act, 2011 (P.L. 112-10, H.R. 1473), was signed into law, marking the completion of the FY2011 appropriations process more than six months after the beginning of the fiscal year. Prior to the enactment of P.L. 112-10, the President signed seven FY2011 interim continuing resolutions to fund the federal government. P.L. 112-10 included the FY2011 Department of Defense regular appropriations act and extended funding for the remaining 11 regular appropriations acts through the end of FY2011, generally at the annualized rate provided in FY2010, but with spending adjustments for numerous specified programs and activities. Division B, Title VIII of P.L. 112-10 (Labor-HHS-Education) included the following ACA-related provisions: (1) canceled $2.2 billion of the original $6 billion appropriation for the CO-OP program; (2) repealed the free choice voucher program that would have required certain employers to provide vouchers to qualified employees for purchasing coverage through a health insurance exchange; (3) prohibited transfers from the Public Health and Social Services Emergency Fund to pay for the new U.S. Public Health Sciences Track; (4) removed the maintenance of effort requirement for use of the CHCF funds; and (5) mandated a GAO study of the costs and processes of ACA implementation, and a Medicare actuarial analysis of the impact of ACA’s private insurance reforms on employer-sponsored health insurance premiums. [Note: The House passed but the Senate rejected an enrollment correction to H.R. 1473 (H.Con.Res. 35) that would have prohibited using any of the funds provided in P.L. 112-10 or in any previous act to implement ACA.] 22 House rules prohibit legislative language that establishes new law, or that amends or repeals current law, in regular appropriations bills and supplemental appropriations measures. However, they do not prohibit such provisions in continuing resolutions. These rules may be waived in a special rule adopted by the Rules Committee prior to floor consideration of the appropriations bill or conference report. A comparable rule in the Senate prohibits legislative language in both Senate Appropriations Committee amendments and non-committee amendments. For more information, see CRS Report R42388, The Congressional Appropriations Process: An Introduction, by Jessica Tollestrup. Congressional Research Service 30 Appropriations and Fund Transfers in the Patient Protection and Affordable Care Act Several months prior to the enactment of P.L. 112-10, on August 2, 2010, the Senate Appropriations Committee reported its version of the FY2011 Labor-HHS-Education appropriations bill (S. 3686). The measure instructed the HHS Secretary to allocate the PPHF funds for FY2011 (i.e., $750 million) to the programs specified, and in the amounts specified, in a table included in the accompanying committee report (S.Rept. 111-243). The House Appropriations Subcommittee on Labor-HHS-Education also approved a draft FY2011 bill, but the full committee took no further action on it. On February 19, 2011, the House by a vote of 235189 passed its version of a full-year continuing resolution for FY2011 (H.R. 1). The bill included nine separate but overlapping provisions that would have prohibited using any of the discretionary funds provided in the bill to implement specific ACA provisions or the entire law. The Senate subsequently rejected H.R. 1 by a vote of 44-56 on March 9, 2011. FY2012 Appropriations The Consolidated Appropriations Act, 2012 (P.L. 112-74, H.R. 2055), which included nine FY2012 appropriations acts, was signed into law on December 23, 2011. Division F of P.L. 11274 (Labor-HHS-Education) included the following ACA-related provisions: (1) rescinded $400 million of the remaining $3.8 billion for the CO-OP program; see P.L. 112-10, above; (2) rescinded $10 million of IPAB’s $15 million appropriation for FY2012; (3) instructed the HHS Secretary to establish a website with detailed information on the allocation and use of FY2012 PPHF funds; and (4) prohibited the use of PPHF funds for lobbying, publicity, or propaganda purposes. Prior to the enactment of P.L. 112-74, the House and Senate Appropriations Committees took the following actions on the FY2012 Labor-HHS-Education and the FY2012 Financial Services and General Government appropriations acts: • The chairman of the House Appropriations Subcommittee on Labor-HHSEducation introduced a chairman’s bill (H.R. 3070) on September 29, 2011, but the subcommittee did not mark up or report the measure to the full committee. The bill received no full committee action. H.R. 3070, as introduced, included the following ACA-related provisions: (1) rescinded the entire FY2012 appropriations for CHCF, PPHF, IPAB, the pregnancy assistance grants, the home visitation program, state ADRCs, and the health workforce demonstration grants; (2) rescinded all the remaining CO-OP funds (i.e., $3.8 billion); (3) rescinded $1.862 billion of the $10 billion appropriation for CMI for the period FY2011-FY2019; and (4) prohibited using any of the discretionary funds provided in the bill to implement and administer ACA until 90 days after all ACA legal challenges are complete. • The House Appropriations Committee reported the Financial Services and General Government Appropriations Act, 2012 (H.R. 2434, H.Rept. 112-136) on July 7, 2011. The measure included the following two ACA-related provisions: (1) prohibited the IRS from using any of the discretionary funds provided in the bill to implement the ACA individual mandate; and (2) prohibited the transfer of any ACA funds to the IRS. • The Senate Appropriations Committee reported the Departments of Labor, Health and Human Services, and Education, and Related Agencies Appropriations Act, 2012 (S. 1599) on September 22, 2011. Similar to the previous year’s bill, S. 1599, as reported, instructed the HHS Secretary to allocate the PPHF funds for Congressional Research Service 31 Appropriations and Fund Transfers in the Patient Protection and Affordable Care Act FY2012 (i.e., $1 billion) to the programs specified, and in the amounts specified, in a table included in the accompanying committee report (S.Rept. 112-84). In addition, S.Rept. 112-84 included language directing the HHS Secretary to submit a detailed report on all the recipients of PPHF funding. • The Senate Appropriations Committee reported the Financial Services and General Government Appropriations Act, 2012 (S. 1573) on September 15, 2011. The measure did not include any ACA provisions. However, the accompanying committee report (S.Rept. 112-79) directed the IRS to submit a detailed table itemizing each fund transfer from HHS to the IRS for the purpose of ACA implementation. FY2013 Appropriations The Consolidated and Further Continuing Appropriations Act, 2013 (P.L. 113-6, 127 Stat. 198), which funds seven of the 12 regular appropriations—including Labor-HHS-Education— through a full-year continuing resolution, was signed into law on March 26, 2013, almost six months after the beginning of the fiscal year. This law funds most (with some anomalies) HHS discretionary programs that receive funding through the Labor-HHS-Education appropriations act at their FY2012 levels minus an across-the-board rescission of 0.2%. Division F, Title V of P.L. 113-6 (Labor-HHS-Education) included the following ACA-related provisions: (1) rescinded $200 million of CCTP’s $500 million appropriation; and (2) rescinded $10 million of IPAB’s FY2013 appropriation. In addition, the PPHF website and the prohibition on using PPHF funds for lobbying, publicity, or propaganda purposes, which were included in P.L. 112-74, remain in effect under P.L. 113-6. Finally, P.L. 113-6 did not provide any new funds for ACA implementation. Prior to the enactment of P.L. 113-6, the House and Senate Appropriations Committees took the following actions on the FY2013 Labor-HHS-Education and the FY2013 Financial Services and General Government appropriations acts: • The House Appropriations Subcommittee on Labor-HHS-Education approved a draft bill for FY2013 on July 18, 2012, but no further action was taken. The measure did not include any of the new CMS funds requested in the President’s FY2013 budget for ACA implementation, and it prohibited using any of the discretionary funding provided in the bill to support CMS’s Center for Consumer Information and Insurance Oversight (CCIIO). The draft bill also included the following ACA-related provisions: (1) rescinded the entire FY2013 appropriations for PPHF and IPAB, and rescinded the FY2013 base appropriation of $150 million for PCORTF; (2) rescinded $3 billion of the remaining $3.4 billion for the CO-OP funds (see P.L. 112-74, above); (3) rescinded $1.590 billion of the $10 billion appropriation for CMI for the period FY2011-FY2019; (4) rescinded $300 million of the $1.5 billion CHCF appropriation in FY2013 for community health centers; (5) prohibited using any of the discretionary funds provided in the bill to implement and administer ACA; (6) instructed the HHS Secretary to establish a website with detailed information on the allocation and use of FY2013 PPHF funds; and (7) prohibited the use of PPHF funds for lobbying, publicity, or propaganda purposes. • The House Appropriations Committee reported the Financial Services and General Government Appropriations Act, 2013 (H.R. 6020, H.Rept. 112-550) on Congressional Research Service 32 Appropriations and Fund Transfers in the Patient Protection and Affordable Care Act June 26, 2012. The measure did not include any of the new IRS funds requested in the President’s FY2013 budget for ACA implementation. H.R. 6020 prohibited the IRS from using any of the discretionary funds provided in the bill to carry out the transfer of ACA funds to the agency. • The Senate Appropriations Committee reported the Departments of Labor, Health and Human Services, and Education, and Related Agencies Appropriations Act, 2013 (S. 3295) on June 14, 2012. Again, similar to the bills for the previous two fiscal years, S. 3295, as reported, instructed the HHS Secretary to allocate the PPHF funds for FY2013 (i.e., $1 billion, reflecting the rescission in P.L. 112-96) to the programs specified, and in the amounts specified, in a table included in the accompanying committee report (S.Rept. 112-176). In addition, the bill directed the HHS Secretary to establish a website with detailed information on the allocation and use of PPHF funds. • The Senate Appropriations Committee reported the Financial Services and General Government Appropriations Act, 2013 (S. 3301) on June 14, 2012. The measure did not include any ACA provisions. However, the accompanying committee report (S.Rept. 112-177) directed the IRS to submit a detailed table itemizing each HIRIF fund transfer to the IRS for the purpose of ACA implementation. Author Contact Information C. Stephen Redhead Specialist in Health Policy credhead@crs.loc.gov, 7-2261 Acknowledgments The following analysts have contributed to earlier versions of this report: Kirsten Colello, Patricia Davis, Gary Guenther, Elayne Heisler, Lisa Herz, Janet Kinzer, Sarah Lister, Alison Mitchell, Bernice Reyes, Amanda Sarata, Pamela Smith, Carmen Solomon-Fears, Emilie Stoltzfus, and Susan Thaul. Congressional Research Service 33August 1, 2014 Congressional Research Service 7-5700 www.crs.gov R41301 Appropriations and Fund Transfers in the Affordable Care Act (ACA) Summary Implementation of the Patient Protection and Affordable Care Act (Affordable Care Act, or ACA) is having a significant impact on federal mandatory—also known as direct—spending. Most of the projected spending under the law is for expanding health insurance coverage. This spending includes premium tax credits and other subsidies for individuals and families that purchase private insurance coverage through the health insurance exchanges established under the ACA, as well as enhanced federal funding to expand state Medicaid programs and tax credits for small employers. In addition, the ACA included numerous appropriations that are providing billions of dollars in mandatory funds to support new and existing grant programs and other activities. Other ACA provisions require the Secretary of Health and Human Services (HHS) to transfer amounts from the Medicare Part A and Part B trust funds for specified purposes. The law appropriated significant amounts to support short-term health care programs for targeted groups prior to the health insurance exchanges becoming operational in 2014. It also created a Center for Medicare and Medicaid Innovation (CMMI) within the Centers for Medicare and Medicaid Services (CMS) and appropriated $10 billion for the FY2011-FY2019 period—and $10 billion for each subsequent 10-year period—for CMMI to test and implement innovative payment and service delivery models. The ACA established four special funds and appropriated substantial amounts to each one. First, the Community Health Center Fund, to which the ACA appropriated a total of $11 billion in annual appropriations over the five-year period FY2011-FY2015, is helping support the federal health centers program and the National Health Service Corps. Second, the Prevention and Public Health Fund, for which the ACA provided a permanent annual appropriation, is intended to support prevention, wellness, and other public health-related programs authorized under the Public Health Service Act. Third, the Patient-Centered Outcomes Research Trust Fund is supporting comparative effectiveness research through FY2019 with a mix of annual appropriations, fees assessed on private health insurance, and Medicare trust fund transfers. Finally, the Health Insurance Reform Implementation Fund, to which the ACA appropriated $1 billion, is helping cover the administrative costs of implementing the law. Overall, the ACA included more than $100 billion in appropriations over the 10-year period FY2010-FY2019, including $40 billion to provide funding for the State Children’s Health Insurance Program for FY2014 and FY2015. Federal outlays on insurance expansion coverage under the ACA, which constitutes most of the law’s mandatory spending, are almost entirely exempt from sequestration. However, the mandatory appropriations in the ACA are, in general, fully sequestrable at the percentage rate applicable to nonexempt nondefense mandatory spending. Besides the mandatory appropriations discussed in this report, the ACA also is having an effect on federal discretionary spending, which is controlled by the annual appropriations acts. A companion report, CRS Report R41390, Discretionary Spending Under the Affordable Care Act (ACA), discusses the law’s impact on discretionary spending. Congressional Research Service Appropriations and Fund Transfers in the Affordable Care Act (ACA) Contents Introduction...................................................................................................................................... 1 ACA Appropriations and Fund Transfers ........................................................................................ 2 Appropriations Vary by Duration and Amount .......................................................................... 2 Numerous Programs Have Received ACA Funding.................................................................. 3 Congress Has Extended and Rescinded Some ACA Funding ................................................... 4 Impact of Sequestration on ACA Mandatory Spending ................................................................... 5 Tables Table 1. Mandatory Appropriations and Medicare Trust Fund Transfers in the Affordable Care Act ........................................................................................................................................ 7 Table 2. ACA Appropriations and Fund Transfers by Fiscal Year in Which Funds Are Available for Obligation ............................................................................................................. 19 Appendixes Appendix A. Acronyms Used in the Report................................................................................... 25 Appendix B. Annual Spending Reductions Under the Budget Control Act .................................. 26 Contacts Author Contact Information........................................................................................................... 27 Acknowledgments ......................................................................................................................... 27 Congressional Research Service Appropriations and Fund Transfers in the Affordable Care Act (ACA) Introduction Implementation of the Patient Protection and Affordable Care Act (Affordable Care Act, or ACA)1 is having a significant impact on federal mandatory—also known as direct—spending.2 Most of the projected spending under the law is for expanding health insurance coverage. This spending includes premium tax credits and other subsidies for individuals and families that purchase private insurance coverage through the health insurance exchanges established under the ACA, as well as enhanced federal funding to expand state Medicaid programs and tax credits for small employers.3 The Congressional Budget Office (CBO) and the Joint Committee on Taxation (JCT) estimate that the gross costs for insurance coverage expansion will total $1,839 billion over the 10-year period FY2015-FY2024. CBO and the JCT project that those costs will be offset by revenues from the ACA’s new taxes and fees, and by savings from the law’s changes to the Medicare program that are designed to slow the rate of growth of Medicare payments to certain health care providers.4 The ACA also included numerous appropriations that are providing billions of dollars in mandatory funds to support new and existing grant programs and other activities. Several other provisions in the law require the Secretary of Health and Human Services (HHS) to transfer amounts from the Medicare Part A and Part B trust funds for specified purposes. This report summarizes all the mandatory appropriations and Medicare trust fund transfers in the ACA and provides details on the status of obligation of these funds. The information is presented in two tables. The report also includes a brief discussion of the impact that sequestration is having on ACA mandatory spending. This report is periodically revised and updated to reflect important legislative and other developments. Besides its impact on mandatory spending, the ACA also is having an effect on federal discretionary spending, which is controlled by the annual appropriations acts. Discretionary spending under the ACA falls into two broad categories. First, there are the amounts provided in 1 The 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 numerous health care and revenue provisions in the ACA and added multiple new stand-alone provisions. Congress and the President have since enacted several other bills that have made targeted changes to specific ACA provisions. All references to the ACA in this report refer collectively to the law as amended and to other related HCERA provisions. 2 Mandatory, or direct, spending generally refers to outlays from budget authority (i.e., the authority to incur financial obligations that result in government expenditures such as paying salaries, purchasing services, or awarding grants) that is provided in authorizing laws, as opposed to annual appropriations acts. Mandatory spending includes spending on entitlement programs (e.g., Medicare, Social Security). 3 While a detailed examination of the ACA is beyond the scope of this report, numerous CRS products that provide more in-depth information on the many new programs and activities authorized and funded by the law are available at http://www.crs.loc.gov (see under “Issues Before Congress: Health”). 4 CBO, Updated Estimates of the Effects of the Insurance Coverage Provisions of the Affordable Care Act, April 2014, http://www.cbo.gov/sites/default/files/cbofiles/attachments/45231-ACA_Estimates.pdf. For more information on the ACA’s projected impact on federal direct spending and revenues, see CRS Report R42051, Budget Control Act: Potential Impact of Sequestration on Health Reform Spending, by C. Stephen Redhead. Congressional Research Service 1 Appropriations and Fund Transfers in the Affordable Care Act (ACA) appropriations acts for specific grant and other programs pursuant to explicit authorizations of appropriations in the ACA. Second, there are the costs incurred by federal agencies to administer and enforce the health insurance reforms and other core requirements of the law. A companion CRS report discusses the ACA’s impact on discretionary spending.5 ACA Appropriations and Fund Transfers Table 1 summarizes all the ACA provisions that include an appropriation of funds or a transfer of amounts from the Medicare trust funds. The provisions are grouped under the following headings: (1) Private Health Insurance; (2) Medicaid and the State Children’s Health Insurance Program (CHIP); (3) Medicare; (4) Fraud and Abuse; (5) Health Centers; (6) Health Workforce and the National Health Service Corps; (7) Community-Based Prevention and Wellness; (8) Maternal and Child Health; (9) Long-Term Care; (10) Comparative Effectiveness Research; (11) Biomedical Research; and (12) ACA Implementation: Administrative Expenses. Each table row gives 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, typically the Social Security Act). Amendatory provisions either add a new program to the statute or modify an existing one. The third column gives a brief description of the program or activity, including details of the appropriation or fund transfer. The entry also includes the name of the administering agency within HHS and, if applicable, the Catalog of Federal Domestic Assistance (CFDA) number for the grant program.6 The fourth column shows the amount of obligations to date, based on information in the HHS Tracking Accountability in Government Grants System (TAGGS), unless specified otherwise. The TAGGS database is a central repository for grants awarded by all the HHS operating divisions (agencies) and several offices within the Office of the Secretary. It is updated daily with new data provided by these entities.7 Appropriations Vary by Duration and Amount In many instances the ACA provided annual appropriations of specified amounts for one or more fiscal years. These funds must be obligated during the fiscal year in which the funds become available for obligation. A few provisions are multiple-year appropriations, in which the amount appropriated is available for obligation for a period of time in excess of one fiscal year (e.g., for the period FY2011 through FY2014). Often the provision includes additional language stating that the funds are to remain available “until expended” or “without fiscal year limitation.” Most ACA appropriations and fund transfers are for a limited time period. Some programs received a single annual appropriation, often with the stipulation that the funds remain available 5 CRS Report R41390, Discretionary Spending Under the Affordable Care Act (ACA), coordinated by C. Stephen Redhead. 6 CFDA is a government-wide compendium of federal grant and other assistance programs. Each program is assigned a unique five-digit number, XX.XXX, where the first two digits represent the funding agency and the second three digits represent the program. Programs funded by the Department of Health and Human Services begin with the number 93. For more information, see https://www.cfda.gov. 7 To access and search the TAGGS database, go to http://www.taggs.hhs.gov/. Congressional Research Service 2 Appropriations and Fund Transfers in the Affordable Care Act (ACA) until expended. Others were provided funding through FY2014 or FY2015, or in some cases through FY2019. The ACA included four provisions (i.e., Sections 3021(a), 3403, 10323(b), and 4002) that continue to provide annual or multiple-year appropriations beyond FY2019 in perpetuity. The ACA also included three indefinite appropriations that provide an unspecified amount of funding as indicated by the phrase “such sums as may be necessary,” or SSAN. One such provision (i.e., Section 1311) appropriated SSAN and authorized the HHS Secretary to determine the specific amount necessary for the grant program.8 Table 2 provides additional details on each of the appropriations (and fund transfers) summarized in Table 1. It shows the amount available for obligation in each fiscal year (or multi-year period) over the 10-year period FY2010 through FY2019. Note that the provisions are organized and grouped under the same headings used in Table 1. The final column in Table 2 (“Total”) shows for each provision the total amount of appropriations or fund transfers. Note that in several cases the total amount has yet to be determined (see table entries for Sections 1311, 3403, 6301(d) & (e), 9023(e), and 10323(a)). For three of the provisions that continue to provide funding beyond FY2019, the amount in the total column represents the cumulative amount appropriated through FY2019 (see table entries for Sections 3021(a), 4002, and 10323(b)). Unless otherwise stated, references to the Secretary in both tables refer to the HHS Secretary. A list of the federal laws and agencies referred to in this report by their acronym is provided in Appendix A. Numerous Programs Have Received ACA Funding As summarized in the tables, the ACA funded a broad range of new and existing programs. The law appropriated significant amounts to support the following short-term health care programs for targeted groups prior to the health insurance exchanges becoming operational in 2014: (1) $5 billion for the Pre-Existing Condition Insurance Plan (PCIP), a temporary insurance program to provide health insurance coverage for uninsured individuals with a pre-existing condition; (2) $5 billion for a temporary reinsurance program to reimburse employers for a portion of the costs of providing health benefits to early retirees aged 55-64; and (3) $6 billion for the Consumer Operated and Oriented Plan (CO-OP) program, to support temporary health insurance cooperatives. The ACA appropriated $2.4 billion for maternal and child health programs and provided an unspecified amount of funding for state grants to plan and establish health insurance exchanges.9 The law established the Center for Medicare and Medicaid Innovation (CMMI) within the Centers for Medicare and Medicaid Services (CMS) and appropriated $10 billion for the FY2011FY2019 period—and $10 billion for each subsequent 10-year period—for CMMI to test and implement innovative payment and service delivery models. It also established and funded an Independent Payment Advisory Board (IPAB) to make recommendations to Congress for achieving specific Medicare spending reductions if costs exceed a target growth rate. IPAB’s 8 The two other indefinite appropriations (i.e., Sections 5508(c), and 9023(e)) provide SSAN to carry out a program, but in each case there is an upper limit on the amount that may be appropriated. Note that a fourth provision (i.e., Section 10323(a)) requires the HHS Secretary to transfer SSAN from the Medicare trust funds to carry out a pilot program. 9 For a state-by-state breakdown of ACA exchange planning and establishment grants, see CRS Report R43066, Federal Funding for Health Insurance Exchanges, by Annie L. Mach and C. Stephen Redhead. Congressional Research Service 3 Appropriations and Fund Transfers in the Affordable Care Act (ACA) recommendations are to take effect unless Congress overrides them, in which case Congress would be responsible for achieving the same level of savings. The ACA created four special funds and appropriated substantial amounts to each one: • The Community Health Center Fund (CHCF), to which the ACA appropriated a total of $11 billion in annual appropriations over the five-year period FY2011FY2015), is helping support the federal health centers program and the National Health Service Corps (NHSC). [Note: A separate ACA appropriation provided $1.5 billion for health center construction and renovation.] While CHCF funding may have been intended to supplement annual discretionary appropriations for the health centers program and the NHSC, the funds have partially supplanted (i.e., replaced) discretionary health center funding and have become the sole source of funding for the NHSC program, which received no discretionary funds in FY2012, FY2013, or FY2014.10 • The Prevention and Public Health Fund (PPHF), for which the ACA provided a permanent annual appropriation, is intended to support prevention, wellness, and other public health-related programs and activities authorized under the Public Health Service Act (PHSA).11 PPHF funds have been used to support several new discretionary grant programs authorized by the ACA. The funds are also supplementing, and in some cases supplanting, annual discretionary appropriations for a number of established programs, including ones that were reauthorized by the ACA. In FY2013, almost half of the PPHF funds were used to help pay for CMS’s administrative costs associated with exchange operations.12 • The Patient-Centered Outcomes Research Trust Fund (PCORTF) is supporting comparative effectiveness research with a mix of annual appropriations—some of which are offset by revenues from a fee imposed on private health plans—and transfers from the Medicare Part A and Part B trust funds through FY2019. • The Health Insurance Reform Implementation Fund (HIRIF), to which the ACA appropriated $1 billion, is helping cover the administrative costs of implementing the law. Overall, the law included more than $100 billion in direct appropriations over the 10-year period FY2010-FY2019, including $40 billion to provide CHIP funding for FY2014 and FY2015. Congress Has Extended and Rescinded Some ACA Funding As already noted, most of the ACA funding is for a limited period of time. Three laws enacted since 2012 have extended funding for some programs whose ACA funding was (or is) about to 10 For more information, see CRS Report R42433, Federal Health Centers, by Elayne J. Heisler; and CRS Report R41390, Discretionary Spending Under the Affordable Care Act (ACA), coordinated by C. Stephen Redhead. 11 Section 3205 of the Middle Class Tax Relief and Job Creation Act of 2012 (P.L. 112-96, 126 Stat. 156) reduced the ACA’s annual appropriations to the PPHF over the period FY2013-FY2021 by a total of $6.25 billion. See Table 1. 12 For more information, see CRS Report R41390, Discretionary Spending Under the Affordable Care Act (ACA), coordinated by C. Stephen Redhead. Congressional Research Service 4 Appropriations and Fund Transfers in the Affordable Care Act (ACA) lapse. Those laws are the American Taxpayer Relief Act of 2012 (ATRA),13 the Pathway for SGR Reform Act of 2013 (PSGRRA),14 and the Protecting Access to Medicare Act of 2014 (PAMA).15 Lawmakers opposed to specific ACA provisions have also succeeded in getting some ACA funding rescinded. ATRA, the Middle Class Tax Relief and Job Creation Act of 2012, and enacted appropriations acts for each of the past four fiscal years (i.e., FY2011, FY2012, FY2013, and FY2014) have all included ACA funding rescissions.16 All the ACA funding extensions and rescissions are summarized in the tables. Impact of Sequestration on ACA Mandatory Spending Federal outlays on insurance expansion coverage under the ACA, which constitute most of the mandatory spending under the ACA, are almost entirely exempt from the annual sequestration triggered by the Budget Control Act of 2011 (BCA).17 However, the mandatory appropriations in the ACA are, in general, fully sequestrable at the percentage rate applicable to nonexempt nondefense mandatory spending. For more background on the BCA’s annual spending reductions, see Appendix B. The FY2013 sequestration order reduced spending on nonexempt nondefense mandatory programs by 5.1%. [Note: This percentage reflects adjustments made by ATRA, which reduced the overall dollar amount that needed to be cut from FY2013 defense and nondefense spending.] The FY2014 sequestration order reduced spending on nonexempt nondefense mandatory programs by 7.2%. Finally, the FY2015 sequestration order, issued on March 10, 2014, will reduce spending on nonexempt nondefense mandatory programs by 7.3%. For technical reasons, OMB concluded that cuts in CHCF funding for community health centers and migrant health centers are capped at 2%. Importantly, only new budget authority for nondefense programs is sequestrable in any given fiscal year. That includes advance appropriations that first become available for obligation in that year. Unobligated balances carried over from previous fiscal years are exempt from sequestration.18 13 P.L. 112-240, 126 Stat. 2313. P.L. 113-67, Division B, 127 Stat. 1195. 15 P.L. 113-93, 128 Stat. 1040. 16 For more information on all the legislative actions taken to amend the ACA since its enactment, including actions taken through the annual appropriations process, see CRS Report R43289, Legislative Actions to Repeal, Defund, or Delay the Affordable Care Act, by C. Stephen Redhead and Janet Kinzer. 17 P.L. 112-25, 125 Stat. 240. 18 The exemption for nondefense unobligated balances is provided in BBEDCA Section 255(e). It reads as follows: “Unobligated balances of budget authority carried over from prior fiscal years, except balances in the defense category, shall be exempt from reduction under any order issued under this part.” 2 U.S.C. § 905(e). 14 Congressional Research Service 5 Appropriations and Fund Transfers in the Affordable Care Act (ACA) The exemption for unobligated balances carried over from prior fiscal years applies to a number of ACA appropriations. As already mentioned, the appropriations provision often specifies that the funds are to remain available “until expended” or “without fiscal year limitation.” One example is the PCIP program to provide temporary health insurance coverage for eligible individuals who have been uninsured for six months and have a pre-existing condition. The ACA appropriated $5 billion in FY2010, to remain available without fiscal year limitation, to pay claims against the PCIP that are in excess of the premiums collected from enrollees. Unobligated PCIP funds carried over to FY2013 or FY2014 were exempt from sequestration. Another example is CMMI, which received a $10 billion multiple-year appropriation in FY2011 to remain available for obligation through FY2019. Congressional Research Service 6 Table 1. Mandatory Appropriations and Medicare Trust Fund Transfers in the Affordable Care Act ACA Section Statutory Authority Summary of Provision Obligations as of July 22, 2014, Based on TAGGS Unless Specified Otherwise Private Health Insurance 1002 1003 1101 1102 CRS-7 New PHSA Sec. 2793 Consumer Assistance Program (CAP). Appropriated $30 million, to remain available without fiscal year limitation, for CAP grants to states to enable them (or the exchanges operating in such states) to establish, expand, or provide support for offices of health insurance consumer assistance, and health insurance ombudsman programs. [CMS/CCIIO; CFDA 93.519] $40 million New PHSA Sec. 2794 Review of health insurance premium rates. Appropriated $250 million for grants to states over the five-year period FY2010-FY2014 to support programs that review annual increases in health insurance premiums. No state may receive less than $1 million or more than $5 million in a grant year. Unobligated funds the end of FY2014 are to remain available for grants to states for planning and implementing ACA’s individual and group market reforms. [CMS/CCIIO; CFDA 93.511] $215 million New freestanding authority Pre-Existing Condition Insurance Plan (PCIP). Required the Secretary to establish a temporary program—PCIP—to provide health insurance coverage for eligible individuals who have been uninsured for six months and have a pre-existing condition. Appropriated $5 billion, to remain available without fiscal year limitation, to pay claims against (and administrative costs of) the PCIP program that are in excess of premiums collected from enrollees. Note: Until June 2013, 27 states administered their own PCIP programs; the remaining 23 states and DC elected to have their PCIP program federally administered. Seventeen state-run PCIP programs then transferred administration to the federal program. [CMS/CCIIO; CFDA 93.529] According to the most recent quarterly update, net PCIP outlays through September 2013 totaled $3.956 billion. New freestanding authority Early Retiree Reinsurance Program (ERRP). Required the Secretary to establish a temporary ERRP to provide reimbursement to participating employer-based plans for a portion of the cost of providing health benefits to early retirees age 55-64 and their families. Appropriated $5 billion, to remain available without fiscal year limitation, to carry out the ERRP. [CMS/CCIIO] According to the most recent program update, ERRP outlays through February 2012 totaled $4.725 billion. Total includes original funding plus awards made using additional funds. See http://www.cms.gov/CCIIO/Programsand-Initiatives/Consumer-Support-and-Information/ Consumer-Assistance-Program-Grants.html. To date, three rounds of rate review grants have been awarded. See http://www.cms.gov/CCIIO/Programs-andInitiatives/Health-Insurance-Market-Reforms/Review-ofInsurance-Rates.html. More than 134,000 individuals have received coverage under PCIP. Originally scheduled to end on January 1, 2014, the program was extended through March 31, 2014. However, the federally-run PCIP and the state-based PCIPs stopped accepting new enrollees on February 16, 2013, and March 2, 2013, respectively, because of the limited amount of funding. See http://www.cms.gov/CCIIO/Programs-and-Initiatives/ Insurance-Programs/Pre-Existing-Condition-InsurancePlan.html; and https://www.pcip.gov. ERRP has provided payments to more than 2,800 employers and other sponsors of retiree plans. The program ended on January 1, 2014; however, HHS stopped accepting new ERRP applications on May 5, 2011, because of limited funding. See http://www.cms.gov/CCIIO/Programs-and-Initiatives/ Insurance-Programs/Early-Retiree-Reinsurance-Program.html; and http://www.errp.gov. ACA Section 1311 1322 1323 Statutory Authority Summary of Provision Obligations as of July 22, 2014, Based on TAGGS Unless Specified Otherwise New freestanding authority Health insurance exchange grants. Appropriated to the Secretary an amount necessary to award exchange planning and establishment grants to states. Instructs the Secretary each fiscal year to determine the total amount to be made available. No grants may be awarded after January 1, 2015, by which time exchanges must be self-sustaining. [CMS/CCIIO; CFDA 93.525] $4.755 billion New freestanding authority Consumer Operated and Oriented Plan (CO-OP). Required the Secretary to establish the CO-OP program to provide low-interest loans until July 1, 2013, for the creation of nonprofit member-run health insurance issuers that offer qualified health plans in the individual and small group markets. Appropriated $6 billion to carry out the CO-OP program. Note: The FY2011 and FY2012 Labor-HHS-Education appropriations acts (P.L. 112-10 and P.L. 112-74, respectively) together rescinded a total of $2.6 billion of the original appropriation. The American Taxpayer Relief Act of 2012 (ATRA; P.L. 112-240) rescinded 90% of the program’s unobligated balance as of January 2, 2013, and transferred the remaining unobligated funds to a new CO-OP contingency fund to provide assistance and oversight to CO-OP loan recipients, ending CMS’s authority to make new loans. Overall, Congress rescinded a total of $4.879 billion, leaving $1.121 billion of the original $6 billion CO-OP program appropriation. [CMS/CCIIO] According to a December 13, 2013, fact sheet, the CO-OP program has awarded a total of $2.103 billion in loans to 23 nonprofits that plan to offer coverage in a total of 26 states. Funding for territories. Appropriated $1 billion, available for the period FY2014-FY2019, for U.S. territories that elect to establish a health insurance exchange. Funds must be used to provide premium and cost-sharing assistance to territory residents who obtain health insurance coverage through the exchange. No public information located on funding obligations. New freestanding authority For more information on federal funding for health insurance exchanges, see CRS Report R43066, Federal Funding for Health Insurance Exchanges. See http://www.cms.gov/CCIIO/Programs-and-Initiatives/ Insurance-Programs/Consumer-Operated-and-Oriented-PlanProgram.html. Medicaid and State Children’s Health Insurance Program (CHIP) 2701 2707 CRS-8 New SSA Sec. 1139B Medicaid adult health quality measures. Required the Secretary to develop and, not later than January 1, 2012, publish an initial core set of quality measures for Medicaid-eligible adults. Appropriated $60 million for each of FY2010-FY2014, to remain available until expended. Total amount = $300 million. Note: The Protecting Access to Medicare Act of 2014 (PAMA; P.L. 113-93) requires $15 million of these funds to be used for the development of quality measures for children enrolled in Medicaid and CHIP, pursuant to SSA Sec. 1139A. [CMS; CFDA 93.609] $49 million New freestanding authority Medicaid emergency psychiatric demonstration program. Appropriated $75 million for FY2011, to remain available for obligation through December 2015, for a three-year demonstration in which eligible states are required to reimburse certain institutions for mental disease (IMDs) for services provided to Medicaid beneficiaries aged 21 through 64 who are in need of medical assistance to stabilize an emergency psychiatric condition. [CMS/CMI; CFDA 93.537] Eleven states plus DC are participating in the demonstration, which began in July 2012. No public information located on funding obligations. See http://www.medicaid.gov/Medicaid-CHIP-ProgramInformation/By-Topics/Quality-of-Care/Adult-Health-CareQuality-Measures.html. See http://innovation.cms.gov/initiatives/Medicaid-EmergencyPsychiatric-Demo/. ACA Section 2801 4108 4306 10203(d) CRS-9 Statutory Authority Summary of Provision Obligations as of July 22, 2014, Based on TAGGS Unless Specified Otherwise Amends SSA Sec. 1900 Medicaid and CHIP Payment and Access Commission (MACPAC). Clarified and expanded MACPAC’s duties; for example, to include a review and assessment of payment policies under Medicaid and CHIP and how factors affecting expenditures and payment methodologies enable beneficiaries to obtain services, affect provider supply, and affect providers that serve a disproportionate share of low-income and other vulnerable populations. Appropriated $9 million and transferred from CHIP funding an additional $2 million for FY2010. Total amount = $11 million, to remain available until expended. ACA funding was obligated in FY2011 and FY2012. New freestanding authority Medicaid Incentives for the Prevention of Chronic Diseases (MIPCD). Required the Secretary to award five-year grants to states, subject to annual renewal of funding, to provide incentives for Medicaid beneficiaries to participate in evidence-based healthy lifestyle programs to prevent or help manage chronic disease. Appropriated $100 million for the five-year period beginning January 1, 2011, to remain available until expended. [CMS/CMI; CFDA 93.536] $51 million Amends SSA Sec. 1139A(e) CHIP childhood obesity demonstration program. Appropriated $25 million for the period FY2010 through FY2014 for a program authorized by the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA; P.L. 111-3), which requires the Secretary to conduct a demonstration project to develop a model for reducing childhood obesity. [CDC; CFDA 93.535] $24 million Amends SSA Secs. 2104 & 2113 CHIP annual appropriations, and outreach and enrollment grants. Appropriated funding for the CHIP program for FY2014 ($19.147 billion) and FY2015 ($21.061 billion); the program previously had been funded through FY2013. Also, extended the time period for the Connecting Kids to Coverage Outreach and Enrollment grants through FY2015 and increased the existing appropriation for such grants from $100 million to $140 million. [CMS; CFDA 93.767] Since 2009, CMS has awarded three cycles of outreach and enrollment grants totaling $122 million to states, local governments, community organizations, and tribal organizations. See http://www.macpac.gov/. MIPCD grants have been awarded to 10 states. See http://www.innovations.cms.gov/initiatives/MIPCD/index.html. Funding has been awarded to three research facilities to identify effective childhood obesity prevention strategies, and to a fourth facility to evaluate the strategies and share successes. See http://www.cdc.gov/obesity/childhood/ researchproject.html. See http://www.insurekidsnow.gov/professionals/outreach/ grantees/index.html. ACA Section Statutory Authority Summary of Provision Obligations as of July 22, 2014, Based on TAGGS Unless Specified Otherwise Medicare 3014 Amends SSA Sec. 1890(b). New SSA Sec. 1890A Medicare quality and efficiency measures. Expanded the duties of the consensus-based entity under contract with CMS pursuant to SSA Sec. 1890 (currently the National Quality Forum). Required the entity to convene multi-stakeholder groups to provide input on the national priorities for health care quality improvement (developed under the ACA). In addition, the multi-stakeholder groups are required to provide input on the selection of quality measures for use in various specified Medicare payment systems for hospitals and other providers, as well as in other health care programs, and for use in reporting performance information to the public. Established a multi-step pre-rulemaking process and timeline for the adoption, dissemination, and review of measures by the Secretary. Required the Secretary to transfer from the Medicare Part A and Part B trust funds $20 million for each of FY2010 through FY2014, to remain available until expended.a Total amount = $100 million. [CMS] No public information located on funding obligations. 3021(a) New SSA Sec. 1115A Center for Medicare and Medicaid Innovation (CMMI). Required the Secretary, no later than January 1, 2011, to establish the CMMI within CMS. The purpose of CMMI is to test and evaluate innovative payment and service delivery models to reduce program expenditures under Medicare, Medicaid, and CHIP while preserving or enhancing the quality of care furnished under these programs. In selecting the models, the Secretary is also required to give preference to those that improve the coordination, quality, and efficiency of health care services. Appropriated (1) $5 million for FY2010 for the selection, testing, and evaluation of new payment and service delivery models; and (2) $10 billion for the period FY2011 through FY2019, plus $10 billion for each subsequent 10-year period, to continue such activities and for the expansion and nationwide implementation of successful models. Amounts are to remain available until expended.b [CMS] According to CMS’s budget documents (FY2013-FY2015), CMMI’s obligations are as follows: FY2011 (actual) = $95 million; FY2012 (actual) = $781 million; FY2013 (actual) = $953 million; FY2014 (current law) = $1.637 billion; FY2015 (estimate) = $1.522 billion. Medicare independence at home demonstration program. Required the Secretary to conduct a three-year Medicare demonstration program, beginning no later than January 1, 2012, to test a payment incentive and service delivery model that uses physician- and nurse practitioner-directed primary care teams to provide home-based services to chronically ill patients. The Secretary must submit a plan, no later than January 1, 2016, for expanding the program if it is determined that such expansion would improve the quality of care and reduce spending. Required the Secretary to transfer from the Medicare Part A and Part B trust funds $5 million for each of FY2010 through FY2015 for administering and carrying out the demonstration, to remain available until expended.a Total amount = $30 million. [CMS] Fourteen independent practices and three consortia are participating in the independence at home demonstration, administered by CMMI. No public information located on funding obligations. 3024 CRS-10 New SSA Sec. 1866E For information on CMI’s programs, which include several of the initiatives summarized in this table, see http://www.innovations.cms.gov/. See http://innovation.cms.gov/initiatives/Independence-atHome/index.html. ACA Section 3026 3027(b) 3113 3306 CRS-11 Statutory Authority Summary of Provision Obligations as of July 22, 2014, Based on TAGGS Unless Specified Otherwise Community-based Care Transitions Program (CCTP). Required the Secretary to establish a five-year program, beginning January 1, 2011, to provide funding to eligible hospitals and community-based organizations to test models for improving care transitions from the hospital to other settings for high-risk Medicare beneficiaries. Required the Secretary to transfer from the Medicare Part A and Part B trust funds $500 million for the period FY2011 through FY2015, to remain available until expended.a Note: The FY2013 Labor-HHS-Education appropriations act (P.L. 113-6) rescinded $200 million of CCTP’s transfer. [CMS] There are currently 102 organizations participating in the CCTP, which is administered by CMMI as part of the Partnership for Patients initiative. No public information located on funding obligations. Medicare hospital gainsharing demonstration program. CMS is supporting two projects that allow hospitals to provide gainsharing payments to physicians that represent a share of the savings incurred as a result of collaborative efforts to improve overall quality and efficiency. The ACA appropriated $1.6 million for FY2010, to remain available through FY2014 or until expended, for carrying out the demonstration. [CMS] There are two hospitals participating in the gainsharing demonstration, which is administered by CMMI. No public information located on funding obligations. New freestanding authority Diagnostic laboratory test demonstration program. Required the Secretary to conduct a two-year demonstration program beginning July 1, 2011, with a subsequent report to Congress, to test the impact of direct payments for certain complex laboratory tests on Medicare costs and quality of care. Payments are to be made from the Part B trust fund and may not exceed $100 million. Transferred $5 million from the Medicare Part B trust fund, to remain available until expended, for carrying out the demonstration program and preparing the subsequent report. [CMS] Payments under the demonstration began in January 2012. Amends MIPPA Sec. 119 Outreach and assistance for Medicare low-income programs. Transferred a total of $45 million from the Medicare Part A and Part B trust funds for the period FY2010 through FY2012 to extend funding for the following beneficiary outreach and education activities for Medicare lowincome programs that were funded by the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA; P.L. 110-275): (1) State Health Insurance Counseling and Assistance Programs (SHIPs), $15 million; (2) Area Agencies on Aging (AAAs), $15 million; (3) Aging and Disability Resource Centers (ADRCs), $10 million; and (4) the National Center for Benefits Outreach and Enrollment (NCBOE), $5 million. Note: ATRA (P.L. 112-240) transferred $25 million for FY2013 for these programs: (1) SHIPs, $7.5 million; (2) AAAs, $7.5 million; (3) ADRCs, $5 million; and (4) NCBOE, $5 million. The Pathway for SGR Reform Act of 2013 (PSGRRA; P.L. 113-67, Division B) transferred $12.5 million to provide prorated funding for the first half of FY2014. PAMA (P.L. 113-93) amended PSGRRA by transferring $25 million for FY2014 (same as FY2013) and by transferring $12.5 million for the first half of FY2015. Funds are to remain available until expended.c [ACL, CMS; CFDA 93.071] $41 million (FY2009-FY2014) New freestanding authority Amends DRA Sec. 5007 See http://www.innovations.cms.gov/initiatives/CCTP/. See http://innovation.cms.gov/initiatives/Medicare-HospitalGainsharing/. See http://www.cms.gov/Medicare/Demonstration-Projects/ DemoProjectsEvalRpts/Downloads/TCCDLT_FactSheet.pdf. ACA Section Statutory Authority Summary of Provision Obligations as of July 22, 2014, Based on TAGGS Unless Specified Otherwise 3403 New SSA Sec. 1899A Independent Payment Advisory Board (IPAB). Established an independent, 15-member advisory board tasked with presenting Congress with comprehensive proposals to reduce excess cost growth and improve quality of care for Medicare beneficiaries. Appropriated $15 million for FY2012 to support the board’s activities. For each subsequent fiscal year, appropriates the amount from the previous fiscal year adjusted for inflation. Sixty percent of the appropriation is to be derived by transfer from the Medicare Part A trust fund, and 40% is to be derived by transfer from the Medicare Part B trust fund. Note: The Labor-HHS-Education appropriations acts for FY2012, FY2013 and FY2014 (P.L. 112-74, P.L. 113-6, and P.L. 11376, respectively) each rescinded $10 million of IPAB’s appropriation for that fiscal year. The President has not appointed, nor has the Senate approved, any IPAB members. 4202(b) New freestanding authority Medicare prevention and wellness evaluation. Transferred $50 million from the Medicare Part A and Part B trust funds, to remain available until expended, to fund an evaluation of community-based prevention and wellness programs and, based on the findings, develop a plan to promote healthy lifestyles and chronic disease self-management among Medicare beneficiaries.a [CMS] No public information located on funding obligations. 4204(e) New freestanding authority Medicare vaccine coverage. Appropriated $1 million for FY2010 for a GAO report on the impact of Medicare Part D vaccine coverage on access to those vaccines among beneficiaries. Report released in December 2011 (GAO-12-61). 10323(a) New SSA Sec. 1881A Environmental health hazards. Extended Medicare eligibility to individuals with specified health conditions linked to environmental exposures, who have resided for specified times in an area subject to a Superfund public health emergency declaration. Required the Secretary to establish a pilot program, with appropriate reimbursement methodologies, to provide comprehensive, coordinated, and cost-effective care to such individuals. Transferred such sums as may be necessary from the Medicare Part A and Part B trust funds to carry out the pilot program.a [CMS] No public information located on funding obligations. 10323(b) New SSA Sec. 2009 Environmental health hazards. Appropriated $23 million for the period FY2010 through FY2014, and $20 million for each five-year period thereafter, for grants to state and local government agencies, health care facilities, and other entities to (1) provide screening for specified lung diseases and other environmental health conditions to individuals who have resided for specified times in an area subject to a Superfund public health emergency declaration; and (2) disseminate public information about the availability of screening, the detection and treatment of environmental health conditions, and the availability of Medicare benefits to certain individuals diagnosed with such conditions, pursuant to new SSA Sec. 1881A (as added by ACA Sec. 10323(a)). [CMS; CFDA 93.534] $10 million CRS-12 Funding provided for an asbestos health screening program in Libby, Montana. ACA Section Statutory Authority Summary of Provision Obligations as of July 22, 2014, Based on TAGGS Unless Specified Otherwise Fraud and Abuse 6402(i) & HCERA Sec. 1303(a) Amends SSA Sec. 1817(k) Health Care Fraud and Abuse Control (HCFAC) Account. Applied a permanent inflation adjustment to the annual appropriation (provided under SSA Sec. 1817(k)) for the HCFAC account. Appropriated from the Medicare Part A trust fund the following supplemental amounts for the HCFAC account: $10 million for each of FY2011 through FY2020; plus an additional $95 million for FY2011, $55 million for FY2012, $30 million for each of FY2013 and FY2014, and $20 million for each of FY2015 and FY2016. Total amount = $350 million. Funds are to remain available until expended. [CMS] No public information located on ACA funding obligations. New freestanding authority School-based health centers (SBHCs). Appropriated $50 million for each of FY2010 through FY2013, to remain available until expended, for a grant program to fund the construction and renovation of school-based health centers. Total amount = $200 million. [HRSA; CFDA 93.501] $140 million New freestanding authority Community-based health centers. Transferred from the CHCF the following amounts for health center operations, to remain available until expended: FY2011 = $1 billion; FY2012 = $1.2 billion; FY2013 = $1.5 billion; FY2014 = $2.2 billion; and FY2015 = $3.6 billion. Total amount = $9.5 billion. [HRSA; CFDA 93.527] According to the Budget Appendices for FY2013-FY2015, the obligations of ACA funds for health centers are as follows: FY2011 (actual) = $998 million; FY2012 (actual) = $1.171 billion; FY2013 (actual) = $1.491 billion; FY2014 (actual) = $2.145 billion; FY2015 (estimate) = $3.600 billion. Health Centers 4101(a) 10503(b)(1) See http://bphc.hrsa.gov/about/schoolbased/index.html. See http://bphc.hrsa.gov/about/healthcenterfactsheet.pdf. 10503(c) New freestanding authority Health center construction and renovation. Appropriated $1.5 billion, to be available for the period FY2011 through FY2015, and to remain available until expended, for health center construction and renovation. [HRSA; CFDA 93.526] $1.486 billion Health Workforce and the National Health Service Corps 10503(b)(2) CRS-13 New freestanding authority National Health Service Corps (NHSC). Transfers from the CHCF the following amounts for NHSC operations, scholarships, and loan repayments, to remain available until expended: FY2011 = $290 million; FY2012 = $295 million; FY2013 = $300 million; FY2014 = $305 million; and FY2015 = $310 million. Total amount = $1.5 billion. [HRSA; CFDA 93.547] According to the Budget Appendices for FY2013-FY2015, the obligations of ACA funds for the NHSC are as follows: FY2011 (actual) = $289 million; FY2012 (actual) = $297 million; FY2013 (actual) = $286 million; FY2014 (estimate) = $283 million; FY2015 (estimate) = $310 million. ACA Section 5507(a) 5507(b) 5508(c) 5509 10502 CRS-14 Statutory Authority New SSA Sec. 2008 Summary of Provision Obligations as of July 22, 2014, Based on TAGGS Unless Specified Otherwise Health workforce demonstration programs. Required the Secretary to establish two demonstration projects. The first is to award health profession opportunity grants to states, Indian tribes, institutions of higher education, and local workforce investment boards to help low-income individuals obtain education and training in health care jobs that pay well and are in high demand. Funds may be used to provide financial aid and other supportive services. The second project is to provide states with grants to develop core training competencies and certification programs for personal and home care aides. Appropriated $85 million for each of FY2010 through FY2014, of which $5 million in each of FY2010 through FY2012 is to be used for the second project. Total amount = $425 million. Note: PAMA (P.L. 11393) provided an additional year of funding (i.e., $85 million for FY2015). [ACF, HRSA; CFDA 93.093, 93.512] $264 million: Health Profession Opportunity Grant (HPOG) Amends SSA Sec. 501(c) Family-to-family health information centers. Renewed funding for the family-to-family information centers, which assist families of children with disabilities or special health care needs and the professionals who serve them, by appropriating $5 million for each of FY2010 through FY2012, to remain available until expended. Total amount = $15 million. Note: ATRA (P.L. 112-240) appropriated $5 million for FY2013; PSGRRA (P.L. 113-67, Division B) appropriated $2.5 million for the first half of FY2014; and PAMA (P.L. 113-93) appropriated $2.5 million for the second half of FY2014 and $2.5 million for the first half of FY2015. [HRSA; CFDA 93.504] $11 million (FY2012-FY2014) New PHSA Sec. 340H Teaching health centers. Appropriated such sums as may be necessary, not to exceed $230 million, for the period FY2011 through FY2015 to make payments for direct and indirect graduate medical education (GME) costs to qualified teaching health centers (THCs). [HRSA; CFDA 93.530] $99 million New freestanding authority Medicare graduate nurse education demonstration program. Appropriated $50 million for each of FY2012 through FY2015, to remain available until expended, for a Medicare demonstration program under which up to five eligible hospitals will receive reimbursement for providing advanced practice nurses with clinical training in primary care, preventive care, transitional care, and chronic care management. Total amount = $200 million. [CMS/CMI] CMMI, which is administering this program, selected five participating hospitals and has begun making reimbursement payments. Health care facility construction. Appropriated $100 million for FY2010, to remain available for obligation until Sept. 30, 2011, for debt service on, or construction or renovation of, a hospital affiliated with a state’s sole public medical and dental school. [HRSA; CFDA 93.502] $100 million New freestanding authority $13 million: Personal and Home Care Aide State Training (PHCAST) program See http://www.acf.hhs.gov/programs/ofa/programs/hpog; and http://bhpr.hrsa.gov/nursing/grants/phcast.html. See http://mchb.hrsa.gov/programs/familytofamily/index.html. See http://bhpr.hrsa.gov/grants/teachinghealthcenters/. See http://innovations.cms.gov/initiatives/GNE/index.html. Funding awarded to Ohio State University. ACA Section Statutory Authority Summary of Provision Obligations as of July 22, 2014, Based on TAGGS Unless Specified Otherwise Community-Based Prevention and Wellness 4002 New freestanding authority Prevention and Public Health Fund (PPHF). Established a PPHF and originally provided a permanent annual appropriation to the fund, as follows: FY2010 = $500 million; FY2011 = $750 million; FY2012 = $1 billion; FY2013 = $1.25 billion; FY2014 = $1.5 billion; FY2015 and each year thereafter = $2 billion. Required the Secretary to transfer amounts from the fund to HHS accounts to increase funding, over the FY2008 level, for PHSA-authorized prevention, wellness, and public health activities, including prevention research and health screenings. Provided House and Senate appropriators with the authority to transfer monies from the PPHF to eligible activities. Note: The Middle Class Tax Relief and Job Creation Act of 2012 (P.L. 11296) reduced the annual appropriations to the PPHF over the period FY2013FY2021 as follows: FY2013 through FY2017 = $1 billion; FY2018 and FY2019 = $1.25 billion; FY2020 and FY2021 = $1.5 billion; FY2022 and each year thereafter = $2 billion. [OS, CDC, HRSA, SAMHSA, ACL; CFDA 93.507, 93.521, 93.522, 93.523, 93.524, 93.531, 93.533, 93.538, 93.539, 93.540, 93.542.] PPHF funds are annual appropriations that must be obligated during the fiscal year in which they are made available. For an analysis and complete list of all PPHF awards for FY2010 and FY2011, see the GAO report, Prevention and Public Health Fund: Activities Funded in Fiscal Years 2010 and 2011 (GAO-12788), at http://www.gao.gov/assets/650/648310.pdf. Maternal, infant, and early childhood home visiting program. Appropriated the following amounts for grants to states, U.S. territories, and Indian tribes to develop and implement early childhood home visiting programs that adhere to evidence-based models of service delivery: FY2010 = $100 million; FY2011 = $250 million, FY2012 = $350 million; FY2013 = $400 million; FY2014 = $400 million. Total amount = $1.5 billion. Programs must establish benchmarks to measure improvements for the participating families in maternal and newborn health; prevention of child abuse or neglect or child injuries; school readiness and achievement; reductions in crime or domestic violence; family economic self-sufficiency; and coordination and referrals for other community resources and supports. Note: PAMA (P.L. 113-93) appropriated $400 million for the first half of FY2015. [HRSA, ACF; CFDA 93.505, 93.508] $1.071 billion For a summary of the allocation of PPHF funds for FY2012, FY2013 and FY2014, by agency and program, see http://www.hhs.gov/open/recordsandreports/prevention/ index.html. The listed CFDA programs do not capture all the uses of PPHF funding. PPHF funds have also been integrated into existing programs that do not mention PPHF. Maternal and Child Health 2951 CRS-15 New SSA Sec. 511 See http://mchb.hrsa.gov/programs/homevisiting/. ACA Section 2953 2954 1021110214 Statutory Authority Summary of Provision Obligations as of July 22, 2014, Based on TAGGS Unless Specified Otherwise New SSA Sec. 513 Personal Responsibility Education Program (PREP). Established a state formula grant program to support evidence-based PREPs designed to educate adolescents about abstinence, contraception, and adulthood. Also, required the Secretary to award grants to implement innovative youth pregnancy prevention strategies and to target services at high-risk populations. Appropriated $75 million for each of FY2010 through FY2014, of which $10 million each year is to be reserved for the youth pregnancy prevention grants. Total amount = $375 million. Funds are to remain available until expended. Note: PAMA (P.L. 113-93) appropriated $75 million for FY2015. [ACF; CFDA 93.092] $303 million Amends SSA Sec. 510 Abstinence education grants. Renewed funding for the state formula grant program to support abstinence education programs by appropriating $50 million for each of FY2010 through FY2014. Total amount = $250 million. Funds are awarded to states based on the proportion of low-income children in each state compared to the national total, and may only be used for teaching abstinence. Note: PAMA (P.L. 113-93) appropriated $50 million for FY2015. [ACF, CDC; CFDA 93.235] $156 million (FY2010-FY2014) New freestanding authority Pregnancy assistance grants. Appropriated $25 million for each of FY2010 through FY2019 (total amount = $250 million) to establish a Pregnancy Assistance Fund for the purpose of awarding grants to states to assist pregnant and parenting teens and women. State grantees have the flexibility to make funds available to institutions of higher education, high schools and community service centers, and to the state attorneys general to improve services for pregnant women who are victims of domestic violence, sexual assault, or stalking. [OS; CFDA 93.500] $89 million Medicaid Money Follows the Person (MFP) demonstration program. Extended funding for the MFP demonstration through FY2016. The program authorizes the Secretary to award competitive grants to states to reduce their reliance on institutional care for people needing long-term care, and expand options for elderly people and individuals with disabilities to receive home and community-based long-term care services. Appropriated $450 million for each of FY2012 through FY2016, to remain available through FY2016. Total amount = $2.25 billion. [CMS; CFDA 93.791] $1.563 billion (FY2007-FY2014) See http://www.acf.hhs.gov/programs/fysb/programs/ adolescent-pregnancy-prevention/programs/prep-competitive. See http://www.acf.hhs.gov/programs/fysb/resource/aegp-factsheet. See http://www.hhs.gov/ash/oah/oah-initiatives/paf/home.html. Long-Term Care 2403 CRS-16 Amends DRA Sec. 6071(h) See http://www.medicaid.gov/Medicaid-CHIP-ProgramInformation/By-Topics/Long-Term-Services-and-Supports/ Balancing/Money-Follows-the-Person.html. ACA Section 2405 Statutory Authority Summary of Provision Obligations as of July 22, 2014, Based on TAGGS Unless Specified Otherwise New freestanding authority State Aging and Disability Resource Centers (ADRCs). Appropriated $10 million for each of FY2010 through FY2014 (total amount = $50 million) for ADRCs, authorized under OAA Sec. 202. ADRCs serve as a single, coordinated resource for consumer information on the range of long-term care options in community and institutional settings. Some ADRCs also serve as the entry point to publicly administered long-term care programs (e.g., Medicaid, OAA services, state assistance programs). Over 500 ADRC sites have been established across 50 states, DC, and two territories. See also the entry for ACA Sec. 3306, above. [ACL; CFDA 93.517] $21 million (FY2010-FY2014; includes ACA mandatory + discretionary funds) 6201 New freestanding authority Background checks of long-term care providers. Required the Secretary to establish a nationwide program for background checks on direct patient access employees of long-term care facilities or providers, and to provide federal matching funds to states to conduct these activities. Required the Treasury Secretary to transfer to HHS an amount, not to exceed $160 million, specified by the HHS Secretary as necessary to carry out the program for the period FY2010 through FY2012. Funds are to remain available until expended. [CMS; CFDA 93.506] $57 million 8002(d) Amends DRA Sec. 6021(d) National Clearinghouse for Long-Term Care Information. Appropriated $3 million for each of FY2011 through FY2015 for the National Clearinghouse for Long-Term Care Information, and required the Clearinghouse to include information on the Community Living Assistance Services and Supports (CLASS) program, established under ACA Sec. 8002(a). Total amount = $15 million. Note: ATRA (P.L. 112-240) repealed the appropriations for the National Clearinghouse and rescinded all unobligated FY2013 funds (as of January 3, 2013), and repealed the CLASS program. [ACL] $6 million (FY2011-FY2014) See http://www.acl.gov/Programs/CDAP/OIP/ADRC/ index.aspx. See http://longtermcare.gov/. Comparative Effectiveness Research 6301(d)-(e) CRS-17 New IRC Secs. 9511, 4375, & 4376. New SSA Sec. 1183 Patient-Centered Outcomes Research Trust Fund (PCORTF). Established the PCORTF to fund the new Patient-Centered Outcomes Research Institute (PCORI) and its comparative effectiveness research activities. Appropriated to the PCORTF $10 million for FY2010, $50 million for FY2011, and $150 million for each of FY2012 through FY2019, for a total of $1.26 billion over that 10-year period. For each of FY2013 through FY2019, the PCORTF is to receive additional appropriations equal to the net revenues from a new fee on health insurance policies and self-insured plans,d as well as Medicare trust fund transfers.e Each fiscal year, 20% of the funds in the PCORTF are to be transferred to the Secretary, to remain available until expended. Of those transferred funds, 80% are to be provided to AHRQ. [OS, AHRQ] Details of all the PCORI research awards are available at http://www.pcori.org/. ACA Section Statutory Authority Summary of Provision Obligations as of July 22, 2014, Based on TAGGS Unless Specified Otherwise Biomedical Research 9023 New IRC Sec. 48D Therapeutic research and development tax credits and grants. Created a two-year tax credit program, subject to an overall cap of $1 billion, for small companies (250 or fewer employees) that invest in new therapies to prevent, diagnose, and treat cancer and other diseases. Companies could apply for one or more tax credits, each covering up to 50% of the cost of qualifying research investments made in 2009 and 2010. However, the total amount of tax credits any one company receives for the two years could not exceed $5 million. Companies could elect to receive one or more grants in lieu of tax credits, subject to the same restrictions (i.e., grants could cover up to 50% of the cost of qualifying investments made in 2009 and 2010; the total amount of grants any one company receives for the two years could not exceed $5 million). Appropriated such sums as may be necessary to carry out the grant program. [IRS] According to the IRS: total grant awards = $970 million; total tax credits = $17 million. See http://www.irs.gov/Businesses/Small-Businesses-&-SelfEmployed/Qualifying-Therapeutic-Discovery-Project-Creditsand-Grants. ACA Implementation: Administrative Expenses HCERA Sec. 1005 New freestanding authority Health Insurance Reform Implementation Fund (HIRIF). Appropriated $1 billion to the HIRIF for federal administrative expenses to carry out the ACA. [OS] According to the FY2015 Budget, there was an unobligated balance of $87 million at the beginning of FY2014. Source: Prepared by the Congressional Research Service based on the text of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148), as amended. a. Transfers from the two trust funds are in such proportion as the Secretary determines appropriate. b. Of the amounts appropriated for the period FY2011-FY2019, and for each subsequent 10-year period, at least $25 million must be made available each fiscal year for the selection, testing, and evaluation of new payment and service delivery models. c. Transfers from the two trust funds are in the same proportion as the Secretary determines under SSA Sec. 1853(f). d. The health insurance fee is to equal $2 multiplied by the average number of covered lives in a policy/plan year ($1 in the case of a policy/plan year ending during FY2013), updated annually by the rate of medical inflation beginning in FY2015. e. The trust fund transfers are to equal $2 ($1 in FY2013) multiplied by the average number of individuals entitled to benefits under Part A or enrolled under Part B in a given fiscal year, updated annually by the rate of medical inflation beginning in FY2015. CRS-18 Table 2. ACA Appropriations and Fund Transfers by Fiscal Year in Which Funds Are Available for Obligation Dollars in Millions, Includes Funding Extensions and Rescissions Fiscal Year ACA Section Program 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 Totala (Note: This section also authorizes to be appropriated SSAN for FY2011 and each fiscal year thereafter.) 30 Private Health Insurance 1002 Health insurance consumer information 30b 1003 Review of health insurance premium rates 250 — — — — — — — — — 250 1101 Temporary high-risk health insurance pools 5,000b — — — — — — — — — 5,000 1102 Early retiree reinsurance program 5,000b — — — — — — — — — 5,000 1311 Health insurance exchange planning and establishment Appropriates amounts necessary for grants each fiscal year, as determined by the Secretary; no grant awards after Jan. 1, 2015. — — — — TBDc 1322 Consumer operated and oriented plans (CO-OPs) 1,121d — — — — — — — 1,121d 1323 Health insurance exchange subsides (U.S. territories) — — — — — — $1 billion total for CY2014 through CY2109e 1,000 Medicaid and Children’s Health Insurance Program (CHIP) 2701 Medicaid adult health quality measures 60 60 60 60 60 — — — — — 300f 2707 Medicaid emergency psychiatric demonstration — 75g — — — — — — — — 75 2801 Medicaid and CHIP Payment and Access Commission 4108 Medicaid prevention and wellness incentives — 4306 CHIP childhood obesity demonstration $25 million total for FY2010 through FY2014 10203(d) CHIP annual appropriationi — 10203(d) CHIP outreach and enrollment grants CRS-19 11h (Note: This section also authorizes to be appropriated SSAN for FY2011 and each fiscal year thereafter.) $100 million total for CY2011 through CY2015f 11 — — — — 100 — — — — — 25 21,061 — — — — 40,208 Increases total funding from $100 million to $140 million and extends funding period through FY2015. — — — — 40 — — — 19,147 Fiscal Year ACA Section Program 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 Totala Medicare 3014 Medicare quality and efficiency measures 3021(a) Center for Medicare and Medicaid Innovation 5 3024 Medicare independence at home demonstration 5j 3026 Community-based care transition services 3027(b) Medicare gainsharing demonstration 2 — — — — 3113 Diagnostic laboratory test demonstration 5l — — — 3306 Outreach and assistance for low-income beneficiaries 25m 3403 Independent Payment Advisory Board — — 5n 4202(b) Prevention and wellness evaluation 50j — — — — — — — — — 50 4204(e) GAO study of Medicare vaccine coverage 1 — — — — — — — — — 1 10323(a) Environmental health pilot program 10323(b) Environmental health screening and education 20j — 20 20 20 20 — — — — — $10 billion total for FY2011 through FY2019, and $10 billion for each subsequent 10-year period. 5 5 5 5 5 10,005f — — — — 30 — — — — 300k — — — — — 2f — — — — — — 5 25m 12.5m — — — — 107.5 $300 million total for FY2011 through FY2015k $45 million total for FY2010 through FY2012m 100 For FY2013 and each subsequent fiscal year, appropriates previous year’s amount adjusted for inflation; funds derived from the Medicare trust funds.n TBDc SSANj TBDc $20 million total for FY2015 though FY2019, and for each 5-year period thereafter $23 million total for FY2010 through FY2014 43f Fraud and Abuse 6402(i) & HCERA 1303(a) Health Care Fraud and Abuse Control (HCFAC) Account — 105 65 40 40 30 30 10 10 10 350o 50 50 50 50 — — — — — — 200f Health Centers 4101(a) CRS-20 School-based health center establishment grants Fiscal Year ACA Section Program 2010 2011 10503(b)(1) Community-based health center operations (CHCF) — 10503(c) Health center construction and renovation — 2012 1,000 2013 1,200 1,500 2014 2015 2,200 3,600 $1.5 billion total for FY2011 through FY2015 2016 2017 2018 2019 Totala — — — — 9,500f — — — — 1,500f Health Workforce and the National Health Service Corps 10503(b)(2) National Health Service Corps (CHCF) — 290 295 300 305 310 — — — — 1,500f 5507(a) Health workforce demonstration grants 85 85 85 85 85 85p — — — — 510 5507(b) Family-to-family health information centers 5 5 5 5q 5q 2.5q — — — — 27.5f 5508(c) Teaching health centers, GME payments — SSAN for FY2011 through FY2015, not to exceed $230 million — — — — ≤230 5509 Medicare graduate nurse education demonstration — — 50 50 50 50 — — — — 200f 10502 Health care facility construction 100 — — — — — — — — — 100r 500 750 1,000 1,000 1,000 1,000 1,000 1,000 1,250 1,250 9,750s Community-Based Prevention and Wellness 4002 Prevention and Public Health Fund Maternal and Child Health 2951 Maternal, infant, and early childhood home visitation 100 250 350 400 400 400t — — — — 1,900 2953 Personal responsibility education program grants 75 75 75 75 75 75u — — — — 450f 2954 Abstinence education state grants 50 50 50 50 50 50v — — — — 300 10214 Pregnancy assistance grants 25 25 25 25 25 25 25 25 25 25 250 — 450 450 450 450 450 450 — — — 2,700 Long-Term Care 2403 CRS-21 Medicaid money follows the person demonstration Fiscal Year ACA Section Program 2405 State Aging and Disability Resource Centers 6201 Background checks of longterm care providers 8002(d) National Clearinghouse for Long-Term Care Information 2010 10 2011 2012 10 2013 10 Up to $160 million total for FY2010 through FY2012 — 3 3 2014 2015 2016 2017 2018 2019 Totala 10 10 — — — — — 50 — — — — — — — ≤160w 0x 0x 0x — — — — 6 Comparative Effectiveness Research 6301(d) Medicare trust fund transfers (PCORTF) — — — For each of FY2013-FY2019, transfers amounts from the Medicare trust funds as determined by a formula.y TBDc 6301(e) Appropriations and fees (PCORTF) 10 50 150 For each of FY2013-FY2019, appropriates $150 million plus an amount equal to the net revenue from a fee levied on health insurance and self-insured plans.z TBDc SSAN — — — — — — — — — ≤1aa — — — — — — — — — 1,000 Biomedical Research 9023(e) Grants for investment in new therapeutics ACA Implementation: Administrative Expenses HCERA 1005 Health Insurance Reform Implementation Fund 1,000 Source: Prepared by the Congressional Research Service based on the text of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148), as amended. Notes: Funds are provided from the Treasury unless otherwise noted. A dash means that ACA does not appropriate or transfer funds for the fiscal year(s) noted. a. Total represents the cumulative amount of appropriations or fund transfers over the 10-year period FY2010-FY2019. Note that in several instances the 10-year total is yet to be determined (TBD); see table entries for ACA Secs. 1311, 3403, 6301(d) & (e), 9023(e), and 10323(a). In addition, four provisions provide annual or multipleyear appropriations beyond FY2019. The total shown in the table for three of these provisions represents the cumulative amount appropriated through FY2019; see table entries for ACA Secs. 3021(a), 4002 (discussed in table note “s” below), and 10323(b). Finally, the total for ACA Sec. 6402(i) includes an amount appropriated in FY2020 (see table note “o” below). b. Funds are to remain available without fiscal year limitation. c. To be determined. d. ACA Sec. 1322 appropriated $6 billion for the CO-OP program. P.L. 112-10 rescinded $2.2 billion of that amount, and then P.L. 112-74 rescinded an additional $400 million. Finally, P.L. 112-240 rescinded 90% of the program’s unobligated balance as of January 2, 2013, and transferred the remaining unobligated funds to a new COOP contingency fund to provide assistance and oversight to CO-OP loan recipients. This effectively terminated CMS’s authority to make new loan awards. Overall, Congress rescinded a total of $4.879 billion, leaving $1.121 billion of the original $6 billion CO-OP program appropriation. e. Of this total amount, $925 million is for Puerto Rico, and the remaining $75 million is for the other U.S. territories in amounts as specified by the Secretary. f. Funds are to remain available until expended. CRS-22 g. Funds are to remain available for obligation through December 31, 2015. h. Of this total amount, $9 million is appropriated, and the remaining $2 million is a transfer from CHIP funding for FY2010. Funds are to remain available until expended. i. Prior to enactment of ACA, the CHIP program was funded through FY2013. j. The Secretary is required to transfer amounts from the Medicare Part A and Part B trust funds each fiscal year in such proportion as the Secretary determines appropriate. Funds are to remain available until expended. k. The Secretary is required to transfer amounts from the Medicare Part A and Part B trust funds each fiscal year in such proportion as the Secretary determines appropriate. Funds are to remain available until expended. P.L. 113-6 rescinded $200 million of the ACA’s original transfer of $500 million for CCTP. l. The Secretary is required to transfer the $5 million from the Medicare Part B trust fund, to remain available until expended. m. The Secretary is required to transfer amounts from the Medicare Part A and Part B trust funds in the same proportion as the Secretary determines under SSA Sec. 1853(f). P.L. 112-240 extended funding for an additional year by transferring $25 million for FY2013 for the four outreach and assistance programs funded by ACA through FY2012. P.L. 113-93 further extended funding for the programs by transferring $25 million for FY2014 and $12.5 million for the first half of FY2015. Funds are to remain available until expended. See Table 1. n. P.L. 112-74 rescinded $10 million of IPAB’s $15 million appropriation for FY2012; P.L. 113-6 rescinded $10 million of IPAB’s appropriation for FY2013; and P.L. 113-76 rescinded $10 million of IPAB’s appropriation for FY2014. o. Funds are to be appropriated from the Medicare Part A trust fund. Note: the total amount appropriated (i.e., $350 million) includes a final appropriation of $10 million for FY2020. p. P.L. 113-93 provided an additional year of funding for health workforce demonstration grants. q. P.L. 112-240 appropriated $5 million for FY2013 for family-to-family health information centers. P.L. 113-67 and P.L. 113-93 provided an additional $5 million for FY2014 and a prorated amount for the first half of FY2015. See Table 1. r. Funds are to remain available for obligation until September 30, 2011. s. ACA Sec. 4002 originally provided a permanent annual appropriation to the Prevention and Public Health Fund, as follows: FY2010 = $500 million; FY2011 = $750 million; FY2012 = $1 billion; FY2013 = $1.25 billion; FY2014 = $1.5 billion; FY2015 and each year thereafter = $2 billion. P.L. 112-96 reduced the annual appropriations to the PPHF over the period FY2013-FY2021, as follows: FY2013 through FY2017 = $1 billion; FY2018 and FY2019 = $1.25 billion; FY2020 and FY2021 = $1.5 billion; FY2022 and each year thereafter = $2 billion. Thus, appropriations to the fund now total $9.750 billion over the period FY2010-FY2019. t. P.L. 113-93 appropriated $400 million for the first half of FY2015. u. P.L. 113-93 provided an additional year of funding for PREP grants. v. P.L. 113-93 provided an additional year of funding for abstinence education grants. w. The HHS Secretary is required to notify the Treasury Secretary of the amount necessary to carry out activities under this section for the period of FY2010 through FY2012, but not to exceed $160 million. The Treasury Secretary must then transfer the amount specified from the Treasury to the HHS Secretary. Funds are to remain available until expended. x. P.L. 112-240 repealed the appropriations for the National Clearinghouse and rescinded all unobligated FY2013 funds (as of January 3, 2013). y. ACA Sec. 6301(d) provided the following formula for the transfer of funds from the Medicare Part A and Part B trust funds to the PCORTF: (1) for FY2013, an amount from each respective Medicare trust fund equal to $1 multiplied by the average number of individuals entitled to Part A benefits, or enrolled in Part B during that period; and (2) for each of FY2014-FY2019, an amount from each respective Medicare trust fund equal to $2 multiplied by the average number of individuals entitled to Part A benefits, or enrolled in Part B during that fiscal year. Beginning in FY2015, amounts are subject to adjustment for increases in health care spending. CRS-23 The FY2015 Budget includes the following transfer amounts from the Medicare trust funds to the PCORTF: FY2013 actual = $52 million; FY2014 estimate = $107 million; FY2015 estimate = $117 million. z. The fee is equal to $2 multiplied by the average number of covered lives in a policy/plan year ($1 in the case of policy/plan years ending during FY2013). Beginning in FY2015, amounts are subject to adjustment for increases in health care spending. The FY2015 Budget includes the following fee revenue: FY2013 actual = $277 million; FY2014 estimate = $347 million; FY2015 estimate = $392 million. aa. To be determined. ACA Sec. 9023(e) created a two-year tax credit program, subject to an overall cap of $1 billion, for small companies that invest in new therapies to prevent, diagnose and treat cancer and other diseases. The total amount of tax credits any one company can receive for the two years may not exceed $5 million. Companies may elect to receive one or more grants—for which SSAN are appropriated—in lieu of tax credits. Grant applications must be received before January 1, 2013. CRS-24 Appropriations and Fund Transfers in the Affordable Care Act (ACA) Appendix A. Acronyms Used in the Report The following laws and federal agencies are referred to in this report by their acronym: ACA Patient Protection and Affordable Care Act (P.L. 111-148) ACF Administration for Children and Families ACL Administration for Community Living AHRQ Agency for Healthcare Research and Quality ATRA American Taxpayer Relief Act of 2012 (P.L. 112-240) BBEDCA Balanced Budget and Emergency Deficit Control Act of 1985 (P.L. 99-177) CBO Congressional Budget Office CCIIO Center for Consumer Information and Insurance Oversight CDC Centers for Disease Control and Prevention CMI Center for Medicare & Medicaid Innovation CMS Centers for Medicare & Medicaid Services DRA Deficit Reduction Act of 2005 (P.L. 109-171) HCERA Health Care and Education Reconciliation Act of 2010 (P.L. 111-152) HHS (Department of) Health and Human Services HRSA Health Resources and Services Administration OS Office of the Secretary (HHS) IRC Internal Revenue Code IRS Internal Revenue Service MIPPA Medicare Improvements for Patients and Providers Act of 2008 (P.L. 110-275) OAA Older Americans Act OMB Office of Management and Budget PAMA Protecting Access to Medicare Act of 2014 (P.L. 113-93) PHSA Public Health Service Act PSGRRA Pathway for SGR Reform Act of 2013 (P.L. 113-67, Division B) SSA Social Security Act Congressional Research Service 25 Appropriations and Fund Transfers in the Affordable Care Act (ACA) Appendix B. Annual Spending Reductions Under the Budget Control Act The Budget Control Act of 2011 (BCA)19 amended the Balanced Budget and Emergency Deficit Control Act of 1985 (BBEDCA) by establishing two budget enforcement mechanisms to reduce federal spending by at least $2.1 trillion over the 10-year period FY2012 through FY2021. First, the BCA established enforceable limits, or caps, on discretionary spending for each of those years. Second, the BCA created a Joint Committee on Deficit Reduction to develop legislation to further limit federal spending. The failure of the Joint Committee to agree on deficit-reduction legislation triggered automatic annual spending reductions for each of FY2013 through FY2021. The BCA specified that a total of $109 billion must be cut each year from nonexempt budget accounts. That amount is equally divided between defense and nondefense spending. Within each category—defense and nondefense—the spending cuts are divided proportionately between discretionary spending and nonexempt mandatory (i.e., direct) spending. Under the BCA, the spending reductions are achieved through a combination of sequestration (i.e., an across-theboard cancellation of budgetary resources) and lowering the BCA-imposed discretionary spending caps. The BCA requires that the mandatory spending reductions in each category—defense and nondefense—must be executed each year by a sequestration of all nonexempt accounts, subject to the BBEDCA sequestration rules. Discretionary spending in each category is also subject to sequestration, but only in FY2013. For each of the remaining fiscal years (i.e., FY2014 through FY2021), discretionary spending reductions are to be achieved by lowering the discretionary spending caps for defense and nondefense spending by the total dollar amount of the reduction. Thus, congressional appropriators get to decide how to apportion the cuts within the lowered spending caps rather than having the cuts applied across-the-board to all nonexempt discretionary spending accounts through sequestration. The Office of Management and Budget (OMB) is responsible for calculating the percentages and amounts by which mandatory and discretionary spending are required to be reduced each year, and for applying the BBEDCA’s sequestration exemptions and rules. The American Taxpayer Relief of 2012 (ATRA)20 revised the discretionary spending caps for FY2013 and FY2014 and reduced the overall dollar amount that needed to be sequestered from FY2013 defense and nondefense spending. The Bipartisan Budget Act of 201321 further revised the spending caps for FY2014 and FY2015 and eliminated the requirements that these caps be lowered pursuant to the BCA’s annual spending reductions.22 19 P.L. 112-25, 125 Stat. 240. P.L. 112-240, 126 Stat. 2313. 21 P.L. 113-67, Division A, 127 Stat. 1165. 22 For a more complete analysis of the Budget Control Act of 2011 and the amendments that were made to it by the American Taxpayer Relief Act of 2012, see CRS Report R41965, The Budget Control Act of 2011, by Bill Heniff Jr., Elizabeth Rybicki, and Shannon M. Mahan; and CRS Report R42949, The American Taxpayer Relief Act of 2012: Modifications to the Budget Enforcement Procedures in the Budget Control Act, by Bill Heniff Jr. 20 Congressional Research Service 26 Appropriations and Fund Transfers in the Affordable Care Act (ACA) Author Contact Information C. Stephen Redhead Specialist in Health Policy credhead@crs.loc.gov, 7-2261 Acknowledgments The following CRS analysts contributed to earlier versions of this report: Kirsten Colello, Patricia Davis, Gary Guenther, Elayne Heisler, Lisa Herz, Janet Kinzer, Sarah Lister, Alison Mitchell, Bernice Reyes, Amanda Sarata, Carmen Solomon-Fears, Emilie Stoltzfus, and Susan Thaul. Congressional Research Service 27