.
Discretionary Spending Under the Affordable
Care Act (ACA)
C. Stephen Redhead, Coordinator
Specialist in Health Policy
Kirsten J. Colello
Specialist in Health and Aging Policy
Elayne J. Heisler
Specialist in Health Services
Sarah A. Lister
Specialist in Public Health and Epidemiology
Amanda K. Sarata
Specialist in Health Policy
October 28, 2014March 11, 2015
Congressional Research Service
7-5700
www.crs.gov
R41390
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Summary
The Patient Protection and Affordable Care Act (Affordable Care Act, or ACA) reauthorized
funding for numerous existing discretionary grant programs administered by the Department of
Health and Human Services (HHS). The ACA also created many new discretionary grant
programs and provided for each an authorization of appropriations. Generally, the law authorized
(or reauthorized) appropriations through FY2014 or FY2015. This report summarizes all the
discretionary spending provisions in the ACA. A companion product, CRS Report R41301,
Appropriations and Fund Transfers in the Affordable Care Act (ACA), summarizes all the
mandatory appropriations in the law.
Among the provisions that are intended to strengthen the nation’s health care safety net and
improve access to care, the ACA permanently reauthorized the federal health centerscenter program and
the National Health Service Corps (NHSC). The NHSC provides scholarships and student loan
repayments to individuals who agree to a period of service as a primary care provider in a
federally designated Health Professional Shortage Area. In addition, the ACA addressed concerns
about the current size, specialty mix, and geographic distribution of the health care workforce. It
reauthorized and expanded existing health workforce education and training programs under
Titles VII and VIII of the Public Health Service Act (PHSA). Title VII supports the education and
training of physicians, dentists, physician assistants, and public health workers through grants,
scholarships, and loan repayment. The ACA created several new programs to increase training
experiences in primary care, in rural areas, and in community-based settings, and provided
training opportunities to increase the supply of pediatric subspecialists and geriatricians. It also
expanded the nursing workforce development programs authorized under PHSA Title VIII.
As part of a comprehensive framework for federal community-based public health activities,
including a national strategy and a national education and outreach campaign, the ACA
authorized several new grant programs with a focus on preventable or modifiable risk factors for
disease (e.g., sedentary lifestyle, tobacco use). The new law also leveraged a number of
mechanisms to improve health care quality, including new requirements for quality measure
development, collection, analysis, and public reporting; programs to develop and disseminate
innovative strategies for improving the quality of health care delivery; and support for care
coordination programs such as medical homes and the co-location of primary health care and
mental health services. Additionally, the ACA authorized funding for programs to prevent elder
abuse, neglect, and exploitation; grants to expand trauma care services and improve regional
coordination of emergency services; and demonstration projects to implement alternatives to
current tort litigation for resolving medical malpractice claims, among other provisions.
The Congressional Budget Office estimated that the ACA’s discretionary spending provisions, if
fully funded by appropriations acts, would result in appropriations of approximately $100 billion
over the 10-year period FY2012-FY2021. Much of that funding would be for discretionary
programs that existed prior to, and whose funding was reauthorized by, the ACA. While most of
those existing discretionary programs continue to receive an annual discretionary appropriation,
albeit at levels below the amounts authorized by the law, few of the new grant programs
authorized under the ACA have received any discretionary funding. However, several of the new
programs have received mandatory funds from the ACA. This report is periodically revised and
updated to reflect important legislative and other developments.
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Contents
Introduction...................................................................................................................................... 1
Discretionary Spending Under the ACA.......................................................................................... 2
Authorizations of Appropriations for Grant Programs ..................ACA Authorizations of Appropriations for Grant and Other Programs............................................ 2
Expired or Expiring Authorizations of Appropriations .. 2
Discretionary Appropriation Amounts To Date ..................................................... 5
Administrative Spending on Health Insurance Exchanges ........................................................ 5
Recent Actions to Reduce Discretionary Spending ..................... 4
Expired or Expiring Authorizations of Appropriations ........................................................................ 7
Trends in Nondefense Discretionary Spending ............. 5
Administrative Spending on the ACA’s Insurance Coverage Provisions .................................................................. 7 5
Tables
Table 1. CMS Administrative Funding for Exchange Operations ................................................... 6
Table 2. ACA Discretionary Spending: Health Centers and Clinics ................................................ 98
Table 3. ACA Discretionary Spending: Health Care Workforce.................................................... 1110
Table 4. ACA Discretionary Spending: Prevention and Wellness ................................................. 2523
Table 5. ACA Discretionary Spending: Maternal and Child Health .............................................. 3129
Table 6. ACA Discretionary Spending: Health Care Quality......................................................... 3129
Table 7. ACA Discretionary Spending: Nursing Homes................................................................ 3633
Table 8. ACA Discretionary Spending: Health Disparities Data Collection.................................. 3734
Table 9. ACA Discretionary Spending: Emergency Care and Trauma Services............................ 3835
Table 10. ACA Discretionary Spending: Elder Justice .................................................................. 3936
Table 11. ACA Discretionary Spending: Biomedical Research ..................................................... 4138
Table 12. ACA Discretionary Spending: Biologics ....................................................................... 4239
Table 13. ACA Discretionary Spending: 340B Drug Pricing ........................................................ 4239
Table 14. ACA Discretionary Spending: Medical Malpractice...................................................... 4340
Table 15. ACA Discretionary Spending: Pain Care Management ................................................. 4340
Table 16. ACA Discretionary Spending: Medicaid........................................................................ 4441
Table 17. ACA Discretionary Spending: Medicare........................................................................ 4441
Table 18. ACA Discretionary Spending: Private Health Insurance ............................................... 4542
Table AB-1. Programs with Expired Authorizations of Appropriations ........................................... 4645
Table AB-2. Programs Whose Authorizations of Appropriations Expire at the End of
FY2015 ....................................................................................................................................... 4746
Appendixes
Appendix. Expired and Expiring Authorizations of Appropriations A. Discretionary Spending and the Budget Control Act of 2011 .................................. 43
Appendix B. Expired and Expiring Authorizations of Appropriations .......................................... 45
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Contacts
Author Contact Information........................................................................................................... 4847
Acknowledgments ......................................................................................................................... 4847
Key Policy Staff ............................................................................................................................. 4847
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Introduction
Implementation of the Patient Protection and Affordable Care Act (Affordable Care Act, or
ACA),1 the health reform law enacted in March 2010, is having a significant impact on federal
mandatory—also known as direct—spending.2 The ACA provided subsidies to help offset the cost
To help achieve its goal of increasing access to
affordable health care, the ACA authorized premium tax credits and cost-sharing subsidies to help
offset the cost of purchasing private insurance coverage through the health insurance exchanges established under
the law and included ;
enhanced federal funding to expand state Medicaid programs; and provided tax credits for small
employers. The ACA also authorized a variety of new spending under the Medicare program.
In addition, the ACA included numerous appropriations that are providing billions of dollars of
mandatory funds for new and existing programs. For example, the law funded temporary
insurance programs for targeted groups prior to the exchanges becoming operational, and
provided funding for grants to states to plan and establish exchanges. It provided a permanent
appropriation, available for 10-year periods, for a new Center for Medicare & Medicaid
Innovation to test and implement innovative health care payment and service delivery models.
And it established four special funds—and appropriated amounts to each one—to support primary
care, public health, comparative effectiveness research, and the administrative costs of the ACA’s
implementation (see text box).3
Special Funds Established by the ACA
The Community Health Center Fund (CHCF), to which the ACA appropriated a total of $11 billion over the
five-year period FY2011-FY2015, is providing supplementary funding for the federal health center program and the
National Health Service Corps (NHSC). Both programs are administered by the HHS Health Resources and Services
Administration (HRSA). For more information, see CRS Report R43911, The Community Health Center Fund: In Brief, by
Elayne J. Heisler.
The Prevention and Public Health Fund (PPHF), to which the ACA provided a permanent annual
appropriation, is intended to support prevention, wellness, and other public health programs and activities
administered by the Centers for Disease Control and Prevention (CDC) and other HHS agencies.
The Patient-Centered Outcomes Research Trust Fund (PCORTF) is supporting patient-centered
comparative clinical effectiveness research over a 10-year period (FY2010-FY2019) with a mix of appropriations,
some of which are offset by revenue from a fee imposed on health plans, as well as transfers from the Medicare Part
A and Part B trust funds.
The Health Insurance Reform Implementation Fund (HIRIF), to which the ACA appropriated $1 billion, is
helping cover the administrative costs of implementing the law. The law also
included numerous mandatory appropriations to fund temporary programs that increase access to
health care for targeted groups, provide funding to states to plan and establish health insurance
exchanges, and support many other research and demonstration programs.3
In addition, the ACA is having an impact on federal discretionary spending, which is subject to
the annual appropriations process.4 The law included many discretionary spending provisions that
authorize the appropriation of funds to support new and existing grant programs and other
activities. Moreover, the two federal agencies that are primarily responsible for the ACA’s
implementation—the Centers for Medicare & Medicaid Services (CMS) within the Department
of Health and Human Services (HHS), and the Internal Revenue Service (IRS) within the
Department of the Treasury—are incurring substantial costs to administer and enforce the law.
Both agencies have requested additional discretionary funding in recent budget cycles to cover
those costs.
This report focuses on the ACA’s effects on discretionary spending. The information is
summarized in a series of spending tables. The report begins with a discussion of the types of
discretionary spending provisions in the ACA, and an explanation of the format and content of the
tables. It also discusses recent actions taken by Congress and the President to reduce the federal
deficit, including enactment of the Budget Control Act of 2011 (and its subsequent amendments).
The impact of these actions on nondefense discretionary spending is briefly summarized.
This report is periodically revised and updated to reflect important legislative and administrative
developments.
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 more targeted changes to specific
ACA provisions. All references to the ACA in this report refer collectively to the ACA, as amended, and to other
related provisions in HCERA.
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
Discretionary spending refers to outlays from budget authority that is provided in and controlled by annual
appropriations acts. It typically covers the routine costs of running federal agencies, including wages and salaries.
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Discretionary Spending Under the ACA
Discretionary spending under the ACA falls into one of two broad categories. First, there are the
amounts provided in appropriations
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Besides its impact on mandatory spending, the ACA also is having an effect on discretionary
spending, which is subject to the annual appropriations process.4 Discretionary spending under
the ACA falls into two broad categories. First, there are the amounts provided in appropriations
acts for specific grant and other programs pursuant to explicit
authorizations of appropriations in
the ACA. Second, there are the substantial costs incurred by federal
agencies to administer and
enforce the health insurance reforms and other core requirements of
the law.
Authorizations of Appropriations for Grant the law. The two agencies
primarily responsible for the ACA’s implementation are the Centers for Medicare & Medicaid
Services (CMS), within the Department of Health and Human Services (HHS), and the Internal
Revenue Service (IRS), within the Department of the Treasury. Both agencies have requested
additional discretionary funding in recent years to cover the costs of implementing the law.
This report examines the ACA’s effects on discretionary spending. It first discusses all the ACA
authorizations (and reauthorizations) of appropriations for grant and other programs. This
information, along with actual funding amounts, is summarized in a series of tables. The report
then reviews the ACA administrative costs borne by CMS and the IRS. Appendix A provides an
overview of the enforceable discretionary spending limits (caps) and the annual spending
reductions under the Budget Control Act of 2011. It also briefly summarizes the trends in
nondefense discretionary spending since 1962.
This report is periodically revised and updated to reflect important legislative and administrative
developments. A companion CRS report summarizes all the ACA’s mandatory appropriations and
the obligation of these funds.5
ACA Authorizations of Appropriations for Grant
and Other Programs
The ACA authorized numerous new discretionary grant programs and provided for each an
authorization of appropriations, generally through FY2014 or FY2015. Many of these provisions
authorize annual appropriations of specified amounts for one or more fiscal years to carry out the
program. Other provisions authorize the appropriation of specified amounts for FY2010 or
FY2011, and unspecified amounts—such sums as may be necessary, or SSAN—for later years. A
few provisions authorize multi-year appropriations, available for obligation for a period in excess
of one fiscal year (e.g., for the period FY2011 through FY2014). Numerous other provisions
simply authorize the appropriation of SSAN, in a few cases without specifying any fiscal years.
In addition, the ACA reauthorized funding—in most instances through FY2014 or FY2015—for
many existing discretionary grant programs, primarily ones authorized under the Public Health
Service Act (PHSA). They include most, but not all, of the federal health workforce programs
administered by Health Resources and Services Administration (HRSA). Funding authorizations
for many of these established programs had expired prior to their reauthorization by the ACA.
However, the programs continued to receive an annual appropriation. Importantly, the ACA
permanently reauthorized appropriations for the federal health centers program, the National
Health Service Corp (NHSC), and many programs and services provided by the Indian Health
Service (IHS).5
The actual funding levels for the discretionary grant programs authorized (or reauthorized) by the
ACA depend on decisions made by the congressional appropriators. That process may lead to
greater or smaller amounts than the sums authorized by the law. With Congress operating under
enforceable discretionary spending limits (see discussion below under “Recent Actions to Reduce
Discretionary Spending”), it can be a challenge to maintain funding levels for long-standing
programs with an established appropriations history, let alone secure initial funding to implement
new programs.
4
Discretionary spending refers to outlays from budget authority that is provided in and controlled by annual
appropriations acts. It typically covers the routine costs of running federal agencies, including wages and salaries.
5
CRS Report R41301, Appropriations and Fund Transfers in the Affordable Care Act (ACA), by C. Stephen Redhead.
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Health Service Corp (NHSC), and many programs and services provided by the Indian Health
Service (IHS).6
All the ACA’s discretionary spending provisions that include authorizations of appropriations are
summarized in a series of tables below. The provisions are organized by general topic under the
following headings: Health Centers and
Clinics (Table 2); Health Care Workforce (Table 3);
Acronyms Used in the Tables in
(Table 3); Prevention and Wellness (Table 4);
This Report
Maternal and Child Health (Table 5); Health Care Quality
(Table 6); Nursing Homes (Table 7); Health Disparities Data Collection (Table 8); Emergency
5
ACA reauthorized the Indian Health Care Improvement Act (IHCIA), which includes many discretionary Indian
Health Service (IHS) programs and services, and it extended indefinitely the authorizations of appropriations for these
programs and services. For more information on ACA’s Indian health provisions, which are not included in this report,
see CRS Report R41630, The Indian Health Care Improvement Act Reauthorization and Extension as Enacted by the
ACA: Detailed Summary and Timeline, by Elayne J. Heisler.
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Care (Table 9); Elder Justice (Table 10); Biomedical Research (Table 11); Biologics (Table 12);
340B Drug Pricing (Table 13); Medical Malpractice (Table 14); Pain Care Management (Table
15); Medicaid (Table 16); Medicare (Table 17); and Private Health Insurance (Table 18).
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
Acronyms Used in the Tables in
an existing statute such as the PHSA).
This Report
Amendatory provisions either add a new
program to the statute or modify an existing
Agency for Healthcare Research and Quality (AHRQ)
one. The name of the administering agency or
Centers for Disease Control and Prevention (CDC)
office within HHS is also included, if known.
Centers for Medicare and Medicaid Services (CMS)
The third column provides a brief description
of the program, including the types of entities
Community Health Center Fund (CHCF)
6
and/or individuals eligible for funding, and
Federal Food, Drug, and Cosmetic Act (FFDCA)
gives details of the authorization of
Food and Drug Administration (FDA)
appropriations.
Health Resources and Services Administration (HRSA)
Finally, the fourth column shows the
Indian Health Service (IHS)
program’s actual funding levels for FY2010
National Institutes of Health (NIH)
through FY2014 if it received any
discretionary appropriations (or other funding) Office of Personnel Management (OPM)
during that period. The FY2015 funding
Office of the Secretary (OS)
request, if applicable, is also provided.7
Prevention and Public Health Fund (PPHF)
Funding from sources other than annual
Public Health Service Act (PHSA)
discretionary appropriations (e.g., ACA
mandatory funds) is shown in parentheses. All
Substance Abuse and Mental Health Services
the discretionary funding listed in the tables in Administration (SAMHSA)
this report is provided by the Departments of
Social Security Act (SSA)
Labor, Health and Human Services,
Education, and Related Agencies (L-HHSED) annual appropriations act. If CRS was unable to identify specific appropriations for a
program, then that is indicated by the phrase “No appropriations identified.” In some instances a
program may be
Agency for Healthcare Research and Quality (AHRQ)
Care Quality (Table 6); Nursing Homes
Centers for Disease Control and Prevention (CDC)
(Table 7); Health Disparities Data Collection
Centers for Medicare and Medicaid Services (CMS)
Community Health Center Fund (CHCF)
(Table 8); Emergency Care (Table 9); Elder
Federal Food, Drug, and Cosmetic Act (FFDCA)
Justice (Table 10); Biomedical Research
Food and Drug Administration (FDA)
(Table 11); Biologics (Table 12); 340B Drug
Health Resources and Services Administration (HRSA)
Pricing (Table 13); Medical Malpractice
Indian Health Service (IHS)
(Table 14); Pain Care Management (Table
National Institutes of Health (NIH)
Office of Personnel Management (OPM)
15); Medicaid (Table 16); Medicare (Table
Office of the Secretary (OS)
17); and Private Health Insurance (Table 18).
Prevention and Public Health Fund (PPHF)
Public Health Service Act (PHSA)
Substance Abuse and Mental Health Services
Administration (SAMHSA)
Social Security Act (SSA)
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).
Amendatory provisions either add a new program to the statute or modify an existing one. The
name of the administering agency or office within HHS is also included, if known. The third
column provides a brief description of the program, including the types of entities and/or
individuals eligible for funding,7 and gives details of the authorization of appropriations.
Finally, the fourth column shows the program’s actual funding levels for FY2010 through
FY2015 if it received any discretionary appropriations (or other funding) during that period.8 The
FY2016 funding request, if applicable, is also provided.9 Funding from sources other than annual
discretionary appropriations (e.g., ACA mandatory funds) is shown in parentheses. Unless
otherwise noted, the funding figures represent final amounts reflecting sequestration and other
adjustments. Many of the programs have seen their discretionary funding remain flat or decrease
since FY2010.
All the discretionary funding listed in the tables in this report is provided by the Departments of
Labor, Health and Human Services, Education, and Related Agencies (L-HHS-ED) annual
6
The ACA reauthorized the Indian Health Care Improvement Act (IHCIA), which includes many discretionary Indian
Health Service (IHS) programs and services, and it extended indefinitely the authorizations of appropriations for these
programs and services. For more information on ACA’s Indian health provisions, which are not included in this report,
see CRS Report R41630, The Indian Health Care Improvement Act Reauthorization and Extension as Enacted by the
ACA: Detailed Summary and Timeline, by Elayne J. Heisler.
7
Not applicable if the funding is to support programs and activities carried out by the federal agency.
8
The funding amounts in the tables are taken from HHS agency budget documents available at http://www.hhs.gov/
budget/.
9
The President released the FY2016 Budget on February 2, 2015, http://www.whitehouse.gov/omb/budget/Overview.
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appropriations act. If CRS was unable to identify specific appropriations for a program, then that
is indicated by the phrase “No appropriations identified.” In some instances a program may be
supported with funds from another budget account.
In each of the larger tables with multiple entries (i.e., Tables 2, 3, 4, 6 and 9), the ACA provisions
are grouped based on whether they reauthorize funding for existing programs or authorize
funding for new programs. Where available, the table entry includes the Catalog of Federal
Domestic Assistance (CFDA) number for the grant program.8 Unless otherwise stated, all
references in the tables to the Secretary refer to the HHS Secretary.
6
Not applicable if the funding is to support programs and activities carried out by the federal agency.
The funding amounts in the tables are taken from HHS agency budget documents available at http://www.hhs.gov/
budget/. Congress has yet to complete work on any of the regular appropriations bills for FY2015, which began on
October 1, 2014. The President signed the Continuing Appropriations Resolution, 2015 (P.L. 113-164), on September
19, 2014. P.L. 113-164 provides continuing appropriations through December 11, 2014.
8
CFDA is a government-wide compendium of federal grant and other assistance programs. Each program is assigned a
unique five-digit number, XX.XXX, where the first two digits represent the funding agency and the second three digits
represent the program. Programs funded by the Department of Health and Human Services begin with the number 93.
(continued...)
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10 Unless otherwise stated, all
references in the tables to the Secretary refer to the HHS Secretary.
Discretionary Appropriation Amounts To Date
The Congressional Budget Office (CBO) estimated that fully funding the ACA’s discretionary
spending provisions would result in appropriations of almost $100 billion over the period
FY2012-FY2021.11 However, that figure is somewhat misleading because three programs—the
health centers program, the NHSC, and the IHS—account for about $85 billion of the total
amount. These programs were in existence prior to the ACA and were permanently reauthorized
by the law.
Most, though not all, of the existing grant programs that were reauthorized underby the ACA
continue continue
to receive annual discretionary appropriations. However, these programs typically are
generally are funded at
levels below the amounts authorized by the law. The federal health centerscenter program
(see Table 2)
and the NHSC (see Table 3) are particularly noteworthy in this regard. Both
programs have seen
a significant decrease in their discretionary funding since FY2010 and,
increasingly, are being supported by mandatory ACA funds from the Community Health Center
Fund (CHCF; see text box below) have been supported by the
CHCF. Indeed, CHCF funds have become the sole source of funding
for the NHSC, which has
not received an annual discretionary appropriation since FY2011. In
addition, mandatory ACA funds from the Prevention and Public Health Fund (PPHF; see text box
below) have addition, PPHF funds have
supplemented, and in some cases supplanted, annual discretionary appropriations for
a number of established programs, including ones that were reauthorized by the ACA.9
ACA Mandatory Spending
Most of the mandatory (i.e., direct) spending under the ACA is for expanding health insurance coverage. This
spending includes the premium tax credits and cost-sharing subsidies, the federal government’s share of the costs of
Medicaid expansion, and tax credits for small employers. The ACA also included numerous appropriations that
provide billions of dollars of mandatory funds for new and existing programs. For example, the law provided funding
for several temporary insurance programs and for grants to states to plan and establish health insurance exchanges. It
also provided a permanent appropriation, available for 10-year periods, for a new Center for Medicare & Medicaid
Innovation within CMS to test and implement innovative health care payment and service delivery models.
Finally, the ACA created four special funds and appropriated amounts to each one:
•
The Community Health Center Fund (CHCF), to which the ACA appropriated a total of $11 billion over
the five-year period FY2011-FY2015, is providing supplementary funding for the federal health centers program
and the National Health Service Corps (NHSC). Both programs are administered by the HHS Health Resources
and Services Administration (HRSA).
•
The Prevention and Public Health Fund (PPHF), to which the ACA provided a permanent annual
appropriation, is intended to support prevention, wellness, and other public health programs and activities
administered by the Centers for Disease Control and Prevention (CDC) and other HHS agencies.
•
The Patient-Centered Outcomes Research Trust Fund (PCORTF) is supporting patient-centered
comparative clinical effectiveness research over a 10-year period (FY2010-FY2019) with a mix of appropriations,
some of which are offset by revenue from a fee imposed on health plans, as well as transfers from the Medicare
Part A and Part B trust funds.
•
The Health Insurance Reform Implementation Fund (HIRIF), to which the ACA appropriated $1 billion,
is helping cover the administrative costs of implementing the law.
For details on all the ACA’s mandatory appropriations and the status of obligation of these funds, see CRS Report
R41301, Appropriations and Fund Transfers in the Affordable Care Act (ACA), by C. Stephen Redhead. Congress also has
rescinded some of the mandatory funds provided by the ACA; see CRS Report R43289, Legislative Actions to Repeal,
Defund, or Delay the Affordable Care Act, by C. Stephen Redhead and Janet Kinzer.
Few of the new grant programs authorized by the ACA have received any discretionary funding.10
Several of these new programs, however, have received PPHF funds.11
(...continued)
For more information, see https://www.cfda.gov.
9
established programs, including ones that were reauthorized by the ACA.12
An examination of the tables in this report also reveals that few of the new grant programs
authorized by the ACA have received any discretionary funding,13 though a handful have received
10
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.
11
U.S. Congress, House Committee on Energy and Commerce, Subcommittee on Health, “CBO’s Analysis of the
Major Health Care Legislation Enacted in March 2010,” Statement of Douglas W. Elmendorf, Director, 112th Cong., 1st
sess., March 30, 2011. Available at http://www.cbo.gov/ftpdocs/121xx/doc12119/03-30-HealthCareLegislation.pdf.
See p. 16. Note: CBO’s estimate of ACA discretionary spending includes (1) amounts specified in ACA, plus estimated
amounts for subsequent years (adjusted for anticipated inflation) where ACA specified an amount for the first year
(FY2010 or FY2011) and authorized SSAN for subsequent years; and (2) estimated amounts for subsequent years
(adjusted for anticipated inflation) where there is an appropriation for FY2010 under prior law and ACA authorized the
appropriation of SSAN for later years. The CBO estimate does not include new ACA programs for which the law
provided only an authorization for the appropriation of SSAN.
12
These programs include (1) Sec. 5301, Primary Care Training and Enhancement Program, see Table 3; (2) Sec.
10501(m)(2), Public Health and Preventive Medicine Programs, see Table 3; (3) Sec. 4003, Clinical and Community
Preventive Services Task Forces, see Table 4; and (4) Sec. 4204, Immunizations Programs, see Table 4.
1013
Examples of programs that have received discretionary funding include CDC’s congenital heart disease and breast
health awareness programs (see Table 4) and the Cures Acceleration Network (CAN) program at NIH (see Table 11).
11
These programs include (1) Sec. 5208, Nurse-Managed Health Clinics, see Table 2; (2) Sec. 5306, Mental and
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CBO estimated that the ACA’s discretionary spending provisions, if fully funded by future
appropriations acts, would result in appropriations of almost $100 billion over the period
FY2012-FY2021.12 However, much of that funding—about $85 billion—would be for three
programs that were in existence prior to, and whose funding was reauthorized by, the ACA;
namely, the federal health centers program, the NHSC, and the IHS
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.
PPHF funds.14 In most instances, the Administration has not requested funding for these programs
in its annual budget, nor have the appropriators chosen to provide any funds. Under the current
discretionary spending limits (see Appendix A), appropriators face challenges in maintaining
funding levels for longstanding programs with an established funding history, let alone finding
funds to implement new programs.
Expired or Expiring Authorizations of Appropriations
It was noted earlier that the ACA generally authorized (or reauthorized) discretionary
appropriations through FY2014 or FY2015. Indeed, a majority of the discretionary grant
programs summarized in the tables in this report have funding authorizations that have expired or
will expire at the end of the current fiscal year. These programs are listed in a pair of tables in the
Appendix B. Table AB-1 shows the programs with expired authorizations of appropriations. Table
AB-2 shows the programs whose authorizations of appropriations expire at the end of FY2015.
Administrative Spending on Health Insurance Exchanges
In addition to funding the discretionary grant programs and other activities that were authorized
(or reauthorized) by the ACA, both CMS and the IRS are incurring significant administrative
costs to implement the law. Table 1 summarizes the sources and amounts of CMS’s
administrative funding for health insurance exchange operations to date. Congress instructed
CMS to provide this information in the agency’s FY2015 budget submission. There is no
comparable ACA funding information publicly available for the IRS, which is administering the
law’s tax provisions including the premium tax credit and other subsidies.
During the period FY2010 through FY2012, CMS obligated a total of $456 million to support
exchange operations. Of that amount, $331 million came from annual discretionary
appropriations that cover the routine costs of running federal agencies, including salaries and
expenses: $307 million from CMS’s Program Management account, and an additional $24
million from the HHS Departmental Management account. The remaining $125 million came
from the HIRIF.
CMS’s administrative costs to support exchange operations totaled $1,545 million in FY2013. In
the FY2013 budget CMS requested an increase of $1,001 million for its Program Management
account for ACA implementation and other activities. However, Congress did not provide any
(...continued)the ACA’s Insurance
Coverage Provisions
CMS and the IRS are incurring significant administrative costs to implement the ACA. Congress
instructed CMS to provide a breakdown of funding for the federally facilitated exchange (FFE) in
the agency’s FY2016 budget submission. Table 1 summarizes CMS’s administrative funding for
FFE development and operations from FY2010 through FY2016. Overall, FFE funding during
this period will total an estimated $8.367 billion.
CMS has relied on funding from a variety of sources to support FFE development and operations,
in part because Congress denied the agency’s request for an increase in its annual appropriations
in each of the past three years (i.e., FY2013-FY2015). Prior to FY2013, CMS used discretionary
funding from its Program Management account—supplemented by a small amount of
discretionary funding from the HHS Departmental Management account—for FFE development.
The agency also used mandatory funds from the Health Insurance Reform Implementation Fund
(HIRIF), which is administered by the HHS Secretary. The ACA established the HIRIF and
appropriated $1 billion to it to help pay for administration of the law (see earlier text box).15
In the FY2013 budget, CMS requested an increase of $1.001 billion for its Program Management
account for FFE operations and other activities. However, Congress did not provide the agency
any additional discretionary funding for FY2013. CMS instead used funds from other sources to
help pay for ongoing administrative costs associated with FFE operations.16 Those funds included
14
These programs include (1) Sec. 5208, Nurse-Managed Health Clinics, see Table 2; (2) Sec. 5306, Mental and
Behavioral Health Education and Training Grants, see Table 3; (3) Sec. 5102, State Health Care Workforce
Development Grants, see Table 3; (4) Sec. 4201, Community Transformation Grants, see Table 4; (5) Sec. 10408,
Small Business Workplace Wellness Grants, see Table 4; and (6) Sec. 10501(g), National Diabetes Prevention
Program, see Table 4.
12
U.S. Congress, House Committee on Energy and Commerce, Subcommittee on Health, “CBO’s Analysis of the
Major Health Care Legislation Enacted in March 2010,” Statement of Douglas W. Elmendorf, Director, 112th Cong., 1st
sess., March 30, 2011. Available at http://www.cbo.gov/ftpdocs/121xx/doc12119/03-30-HealthCareLegislation.pdf.
See p. 16. Note: CBO’s estimate of ACA discretionary spending includes (1) amounts specified in ACA, plus estimated
amounts for subsequent years (adjusted for anticipated inflation) where ACA specified an amount for the first year
(FY2010 or FY2011) and authorized SSAN for subsequent years; and (2) estimated amounts for subsequent years
(adjusted for anticipated inflation) where there is an appropriation for FY2010 under prior law and ACA authorized the
appropriation of SSAN for later years. The CBO estimate does not include new ACA programs for which the law
provided only an authorization for the appropriation of SSAN.
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Discretionary Spending Under the Affordable Care Act (ACA)
additional discretionary funds for ACA implementation in FY2013. CMS instead used funds from
other sources to help pay for ongoing administrative costs associated with exchange operations.
Those funds included 15
CMS provided a table showing the various sources of funding for FFE operations, by fiscal year, in its Justification
of Estimates for Appropriations Committees, FY2015, at http://www.cms.gov/About-CMS/Agency-Information/
PerformanceBudget/Downloads/FY2015-CJ-Final.pdf; see page 349.
16
Ibid.
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.
(1) discretionary funds transferred from other HHS accounts under the
Secretary’s transfer
authority;1317 (2) expired discretionary funds from the Nonrecurring Expenses
Fund (NEF);1418 (3)
mandatory funds from the HIRIF; and (4) mandatory funds from the PPHF (see
Table 1Prevention and Public
Health Fund (PPHF).
Table 1. CMS Administrative Funding for Exchange Operations
Dollars in Millions, by Fiscal Year
Funding Source
2010-2012
Actual
2013
Actual
2014
Estimate
2015
Request
Discretionary Appropriations
CMS Program Management
307
520
711a
629
HHS Departmental Management
24
—
—
—
Secretary’s Transfer Authority
—
114
109
—
Nonrecurring Expenses Fund (NEF)
—
300
350
—
125
158
20
—
Prevention and Public Health Fund (PPHF)
—
454
—
—
Federally facilitated exchange (FFE) User Fees
—
—
200
1,159
456
1,545
1,390
1,788
Mandatory and Other Funds
Health Insurance Reform Implementation Fund (HIRIF)
Total
Source: Table prepared by the Congressional Research Service based on data provided in the Centers for
Medicare & Medicaid Services’ FY2015 congressional budget justification document, available at
http://www.cms.gov/About-CMS/Agency-Information/PerformanceBudget/Downloads/FY2015-CJ-Final.pdf.
Notes: Figures in each column may not add to total due to rounding.
a.
Includes $100 million in budget authority that was made available by using NEF funds for non-FFE activities.
In FY2014, CMS’s administrative costs for exchange operations will total an estimated $1,390
million. The agency requested an increase of $1,397 million for its Program Management account
in the FY2014 budget for ACA implementation and other activities. But as in the previous fiscal
year Congress did not give CMS any additional funding. Once again, the agency is relying on
transferred departmental funds as well as NEF and HIRIF funding to help support exchange
operations in FY2014. In addition, CMS will collect an estimated $200 million in exchange user
fees (see Table 1).
The President’s FY2015 budget includes a total of $1,788 for exchange operations. Of that
amount, $629 million is from CMS’s Program Management account, and the remaining $1,159
13
Source of Funding
All Sources (Discretionary and
Mandatory)
Health Insurance Reform Implementation
Fund; HIRIF (non-add)
2016
Est.
Total
20102016
8,367
2010
2011
2012
2013
2014
2015
Est.
5
125
325
1,543
2,032
2,147
2,189
850
1,514
Total 5-year funding (FY2010-FY2014) = 437
Prevention and Public Health Fund; PPHF
(non-add)
Federally Facilitated Exchange (FFE) User
Fees (non-add)
454
252
Source: Table prepared by CRS based on data presented in CMS’s Justification of Estimates for Appropriations
Committees, FY2016, p. 345, available at http://www.cms.gov/About-CMS/Agency-Information/
PerformanceBudget/Downloads/FY2016-CJ-Final.pdf.
Note: The HIRIF amount was provided by the HHS budget office.
In the FY2014 budget, CMS requested an increase of $1.397 billion for its Program Management
account for FFE operations and other activities. But, as in the previous fiscal year, Congress did
not give CMS any additional funding. The agency relied in FY2014 on transferred departmental
funds as well as NEF and HIRIF funding to help support the FFE.19 However, Congress blocked
the use of PPHF funds by CMS that year. FY2014 also was the first year in which CMS collected
FFE user fees, a total of $252 million (see Table 1). Under the ACA, exchanges are permitted to
charge participating insurance companies an assessment or user fee to generate funds to support
their operations.
In the FY2015 budget, CMS requested an increase of $227 million for its Program Management
account to fund FFE operations and other activities. Once again Congress denied the agency’s
request for additional funding. CMS will collect an estimated $850 million in FFE user fees in
FY2015 (see Table 1) to help support FFE operations. But with most of the HIRIF funds already
obligated, and a continued block on the use of PPHF funding, CMS this year will have to rely on
discretionary funding sources for FFE operations, in addition to the user fees.
17
The L-HHS-ED Appropriations Act provides the HHS Secretary with limited authority to transfer funds between
appropriations accounts. No more than 1% of the funds in any given account may be transferred, and recipient accounts
may not be increased by more than 3%. Congressional appropriators must be notified in advance of any transfer.
1418
The Nonrecurring Expenses Fund is an account within the Department of the Treasury. The HHS Secretary is
authorized to transfer to the NEF unobligated balances of expired discretionary funds. NEF funds are available until
expended for use by the HHS Secretary for capital acquisitions including facility and information technology
infrastructure. Congressional appropriators must be notified in advance of any planned use of NEF funds.
19
See footnote 15.
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Discretionary Spending Under the Affordable Care Act (ACA)
million is projected to come from exchange user fees. The FY2015 budget does not identify any
other sources of funding to support exchange operations (see Table 1). CMS has requested an
increase of $227 million for its Program Management account in FY2015 to help support ACA
implementation and other activities.
Recent Actions to Reduce Discretionary Spending
Since FY2010, Congress has taken a number of steps to curb federal discretionary spending.
During negotiations to complete the FY2011 appropriations process and avert a government
shutdown in early 2011, lawmakers agreed to cuts in discretionary spending for a broad range of
agencies and programs. Congress and the President then enacted the Budget Control Act (BCA)
of 2011,15 which established enforceable discretionary spending limits, or caps, for each of
FY2012 through FY2021. Operating under BCA-imposed discretionary spending caps, Congress
further reduced funding for many programs during the FY2012, FY2013, and FY2014
appropriations cycles.
The BCA also triggered annual spending reductions beginning in FY2013 for both defense and
nondefense spending. All the spending on programs and activities summarized in this report falls
within the nondefense category. The BCA spending reductions involve a combination of
automatic across-the-board spending cuts to nonexempt programs through a process known as
sequestration, as well as lowering the BCA-imposed discretionary spending caps. More details on
the BCA annual spending reductions are provided in the text box below.
Unless otherwise noted, the FY2010-FY2014 funding figures in the tables in this report represent
final amounts reflecting sequestration and other adjustments. Many of the grant programs listed in
the tables that have received annual appropriations since FY2010 have seen their discretionary
funding decline. As noted earlier, some of these programs are being supported by mandatory
funds provided by the ACA.
Trends in Nondefense Discretionary Spending
According to CBO, nondefense discretionary (NDD) spending has generally ranged between
about 3% and 4% of gross domestic product (GDP) since 1962, the first year for which there are
comparable data. The two exceptions to this trend are the period 1975-1981, when NDD spending
averaged almost 5% of GDP, and the period 2009-2011, when stimulus spending increased NDD
outlays above 4% of GDP. NDD spending as a share of GDP is now declining and fell to 3.5% in
2013, CBO estimates. Under the current deficit-reduction policies, CBO projects that NDD
spending in 2016 will fall to its lowest level as a share of GDP since 1962 and will continue to
decline thereafter.16
15
P.L. 112-25, 125 Stat. 240.
CBO, “Options for Reducing the Deficit: Discretionary Spending,” blog post, December 12, 2013,
http://www.cbo.gov/publication/44958.
16
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Discretionary Spending Under the Affordable Care Act (ACA)
Annual Spending Reductions Under the Budget Control Act
The BCA amended the Balanced Budget and Emergency Deficit Control Act of 1985 (BBEDCA) by establishing two
budget enforcement mechanisms to reduce federal spending over the 10-year period FY2012 through FY2021. First, it
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-the-board cancellation of budgetary resources) and lowering the BCAimposed 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 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 FY2013 sequestration order reduced spending on nonexempt nondefense mandatory programs by 5.1% and
reduced nonexempt nondefense discretionary (NDD) spending by about 5.0% [Note: These amounts reflect
adjustments made by the American Taxpayer Relief Act of 2012 (ATRA), which reduced the overall dollar amount
that needed to be cut from FY2013 defense and nondefense spending.] For technical reasons, OMB concluded that
cuts in mandatory (i.e., CHCF) funding for community health centers and migrant health centers are capped at 2%.
The FY2014 sequestration order reduced spending on nonexempt nondefense mandatory programs by 7.2%. OMB
also lowered the FY2014 NDD spending cap by $37 billion. However, the Bipartisan Budget Act of 2013 (BBA)
subsequently amended the BCA by establishing new discretionary spending caps for FY2014 and FY2015 and
eliminating the requirement that these caps be lowered pursuant to the BCA’s annual spending reductions. As a
result, the new FY2014 NDD cap is more than $22 billion above the BCA-lowered FY2014 cap that it replaces, and
almost $24 billion above the FY2013 post-sequestration NDD funding level.
The FY2015 sequestration order reduces spending on nonexempt nondefense mandatory programs by 7.3%.
Pursuant to the BBA, the FY2015 NDD spending cap is virtually unchanged from the final FY2014 level.
Congressional Research Service
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Table 2. ACA Discretionary Spending: Health Centers and Clinics
ACA
Section
Statutory
Authority
(Agency)
Summary of Provision
Funding (FY2010-FY2015.
In FY2016, CMS estimates that it will spend $2.189 billion on FFE operations, of which $1.514
billion (69%) is projected to come from user fees (see Table 1). The agency is requesting an
increase of $270 million in its Program Management funding.
There is no comparable ACA funding information for the IRS, which is administering the law’s
tax provisions, including the premium tax credit and other subsidies. The IRS has not provided
(or been instructed by Congress to provide) a breakdown of its spending on ACA implementation.
Like CMS, the IRS requested additional funding for ACA implementation in each of the past
three years: $360 million for FY2013, $440 million for FY2014, and $436 million for FY2015.20
But, as with CMS, Congress has not provided the IRS with any new funding. In fact, Congress
cut the IRS’s funding for FY2015 by $346 million (3%). According to the HHS budget office, the
department transferred to the IRS a total of $526 million in HIRIF funds over the FY2010FY2014 period to help support ACA implementation.21 HHS has transferred much smaller
amounts from the HIRIF to the Department of Labor ($5 million) and the Office of Personal
Management ($6 million).22
In FY2016, the IRS is requesting an increase of $474 million for ACA implementation.23
20
Details of the IRS’s funding requests for ACA implementation are provided in the agency’s budget documents for
FY2013-FY2015 at http://www.treasury.gov/about/budget-performance/Pages/cj-index.aspx.
21
E-mail from Nicholas Minter, Office of the Secretary, HHS, February 6, 2015.
22
Ibid.
23
Internal Revenue Service, Budget in Brief, FY2016, p. 20, http://www.treasury.gov/about/budget-performance/
budget-in-brief/Documents/15.%20IRS%20FY%202016%20BIB%20Final.pdf.
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.
Table 2. ACA Discretionary Spending: Health Centers and Clinics
ACA
Section
Statutory
Authority
(Agency)
Summary of Provision
Funding (FY2010-FY2016)
Health Centers: Existing Program
5601
Reauthorizes
PHSA Sec. 330
(HRSA)
Health centers. Permanently reauthorizes funding for the program that provides
operating grants to health centers serving federally designated medically underserved
populations and furnishing comprehensive primary care services, referrals, and other
services needed to facilitate access to such care, regardless of ability to pay. Eligible
grantees include community, migrant, public housing, and homeless health centers
that meet the statutory requirements of PHSA Sec. 330. Authorizes the appropriation
of $2,989 million for FY2010, $3,862 million for FY2011, $4,991 million for FY2012,
$6,449 million for FY2013, $7,333 million for FY2014, $8,333 million for FY2015, and,
for each subsequent fiscal year, an amount equal to the previous year’s funding
adjusted for any increase in the number of patients served and the per-patient costs.
[CFDA 93.224, 93.527]
FY2010 = $2,185 milliona
FY2011 = $1,581 millionmilliona (+ $1,000 million CHCF)a
FY2012 = $1,567 millionmilliona (+ $1,200 million CHCF)a
FY2013 = $1,479 millionmilliona (+ $1,465 million CHCF)a
FY2014 = $1,495 million492 milliona (+ $2,145 million CHCF)a
FY2015 request = $1,000 million (+ $3,600 million
CHCF)a
[
FY2015 = $1,492 milliona (+ $3,509 million CHCFb)
FY2016 request = $1,492 milliona (+ $2,700 million
proposed new mandatory funds)
Note: In addition to appropriating mandatory funds for
health center operations for FY2011-FY2015 through the
CHCF, the ACA also appropriated $1.5 billion for health
center construction and renovation. For more
information on the ACA’s mandatory appropriations, see
CRS Report R41301.]
Health Centers and Clinics: New Programs
4101(b)
5208
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CRS-8CRS-9
New PHSA Sec.
399Z-1 (HRSA)
School-based health centers (SBHCs). Requires the Secretary to award grants
to fund the management and operation of SBHCs that provide comprehensive
physical and behavioral health services to children and adolescents, subject to parental
consent. SBHCs that meet certain specified criteria and match 20% of the grant
amount with non-federal funds (unless waived). Preference may be given to SBHCs
serving children and adolescents who have limited access to or difficulty accessing
health care. Authorizes the appropriation of SSAN for each of FY2010 through
FY2014.
No appropriations identified.
New PHSA Sec.
330A-1 (HRSA)
Nurse-managed health clinics (NMHCs). Requires the Secretary to award
grants to fund the operation of NMHCs—associated with schools, colleges, federally
qualified health centers (FQHCs), or nonprofit health/social services agencies—that
provide comprehensive primary health care and wellness services to vulnerable or
underserved populations regardless of income or insurance status. At least one
advanced practice nurse must hold an executive management position in the NMHC.
Authorizes the appropriation of $50 million for FY2010, and SSAN for each of
FY2011 through FY2014. [CFDA 93.515]
FY2010 = $15 million (all PPHF)
[Note: The ACA appropriated a total of $200 million for
SBHC construction and renovation. For more
information on the ACA’s mandatory appropriations, see
CRS Report R41301.]
No appropriations identified for FY2011-FY2014.
FY2016.
.
Statutory
Authority
(Agency)
ACA
Section
10504
New freestanding
authority (HRSA)
Summary of Provision
Access to affordable care demonstration program. Within six months of
enactment, requires the Secretary to establish a three-year demonstration project in
up to 10 states—each state may receive up to $2 million—to provide access to
comprehensive health care services to the uninsured. Eligible grantees must be statebased, nonprofit, public-private partnerships that provide access to comprehensive
health care services to the uninsured at reduced fees. Authorizes the appropriation of
SSAN (no years specified).
Funding (FY2010-FY2015FY2016)
No appropriations identified.
Sources: Table prepared by the Congressional Research ServiceCRS based on the text of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended).
Funding amounts are taken
from HRSA’s budget documents, including the FY2014 operating plan, available at http://www.hrsa.gov/about/budget/index.html.
Note: For more information on health centers, see CRS Report R42433, Federal Health Centers, by Elayne J. Heisler.
a.
CRS-10
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a.
Annual appropriations for health centers include the following amounts for the Federal Tort Claims Act (FTCA) program: FY2010 = $44 million; FY2011 = $100
million; FY2012 = $95 million; FY2013 = $89 million; FY2014 = $95 million; FY2015 = $100 million; FY2016 request = $89100 million. Under the FTCA, health center
employees and
contractors are considered federal employees and are immune from medical malpractice lawsuits while acting within the scope of their employment.
The federal
government assumes responsibility for such malpractice claims.
b.
HRSA proposes to reserve $541 million of these funds for FY2016-FY2018 to offset anticipated funding reductions in the health center program.
CRS-9
.
Table 3. ACA Discretionary Spending: Health Care Workforce
ACA
Section
Statutory
Authority
(Agency)
Summary of Provision
Funding (FY2010-FY2015FY2016)
NHSC scholarships and loan repayments. Permanently reauthorizes funding for
the NHSC program. In exchange for a commitment to work in a federally designated
Health Professional Shortage Area (HPSA), the program provides (1) scholarships to
students training in a primary care discipline to cover tuition, fees, other educational
costs, and a stipend; and (2) student loan repayments of up to $50,000 a year to
primary care and mental health clinicians. To be eligible for a scholarship, a student
must be accepted or enrolled in a training program for medicine, dentistry, family
nurse practitioner, nurse midwife, or physician assistant, and agree to two to four
years of service in an NHSC-approved site in a HPSA. Loan repayments are for
primary care, dental, and mental health clinicians who agree to at least two years of
service in an NHSC-approved site in a HPSA. Authorizes the appropriation of $320
million for FY2010, $414 million for FY2011, $535 million for FY2012, $691 million
for FY2013, $893 million for FY2014, and $1,155 billion for FY2015; amounts in
subsequent years based on previous year’s funding, subject to adjustment. [CFDA
93.162, 93.288, 93.547]
FY2010 = $141 million
FY2011 = $25 million (+ $290 million CHCF)
FY2012 = $295 million (all CHCF)
FY2013 = $285 million (all CHCF)
FY2014 = $283 million (all CHCF)
FY2015 request = $810 million (i.e., $100 million
discretionary funds + $310 million CHCF + $400 million
proposed new mandatory funds)
National Health Service Corps (NHSC)
5207
CRS-11
Reauthorizes
PHSA Title III,
Part D, Subpart
III (HRSA)
ACA
Section
Statutory
Authority
(Agency)
Summary of Provision
Funding (FY2010-FY2015)
Physicians: Existing Program
5301
Amends and
reauthorizes
PHSA Sec. 747
(HRSA= $287 million (all CHCF)
FY2016 request = $287 million (+ $523 million proposed
new mandatory funds)
Primary care training and enhancement program. (1) Authorizes five-year
grants to public and nonprofit private hospitals, medical schools, academically affiliated
physician assistant training programs, and other public and nonprofit private entities
to support training programs in primary care. Funds are to be used to plan, develop,
and operate accredited training programs, including residency and internship
programs, in family medicine, general internal medicine, and general pediatrics and to
provide financial assistance (e.g., traineeships). (2) Authorizes five-year grants to
medical schools for primary care capacity building. Funds are to be used to create
academic units or programs that improve clinical teaching in the primary care fields,
and (in a separate authorization) to integrate academic units to enhance
interdisciplinary recruitment, training, and faculty development. Funding priority given
to entities proposing innovative approaches to primary care training and with a
record of training primary care providers, among other things. For both grant
programs, authorizes the appropriation of $125 million for FY2010, and SSAN for
each of FY2011 through FY2014. Note: 15% of the amount appropriated must be
used for physician assistant training programs. Separately, authorizes the
appropriation of $750,000 for each of FY2010 through FY2014 for capacity building
grants to integrate academic units. [CFDA 93.510, 93.514, 93.884]
FY2010 = $39 million (+ $198 million PPHF)
FY2011 = $39 million
FY2012 = $39 million
FY2013 = $37 million
FY2014 = $37 million
FY2015 = $39 million
FY2016 request = $37 million
39 million
National Health Service Corps (NHSC)
5207
Reauthorizes
PHSA Title III,
Part D, Subpart
III (HRSA)
Physicians: Existing Program
5301
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Amends and
reauthorizes
PHSA Sec. 747
(HRSA)
.
ACA
Section
Statutory
Authority
(Agency)
Summary of Provision
Funding (FY2010-FY2016)
Physicians: New Programs
5203
New PHSA Sec.
775 (HRSA)
Pediatric specialist loan repayment program. Requires the Secretary to
implement a loan repayment program that pays up to $35,000 for each year of service
(for a maximum of three years) to practicing or in-training pediatric specialists and
surgeons, as well as child and adolescent mental health specialists, who agree to at
least two years of service in a HPSA. Authorizes the appropriation of $30 million for
each of FY2010 through FY2014 for loan repayments to pediatric specialists and
surgeons, and $20 million for each of FY2010 through FY2013 for loan repayments to
mental health providers.
No appropriations identified.
5508(a)
New PHSA Sec.
749A (HRSA)
Teaching health centers development grants. Authorizes three-year grants of
up to $500,000 to FQHCs, rural health clinics, Indian health centers, and entities
receiving PHSA Title X (family planning) funds that establish or expand a primary care
residency training program. Authorizes the appropriation of $25 million for FY2010,
$50 million for each of FY2011 and FY2012, and SSAN for each fiscal year thereafter.
No appropriations identified.
CRS-12
ACA
Section
10501(l)
Statutory
Authority
(Agency)
New PHSA Sec.
749B (HRSA)
Summary of Provision
Funding (FY2010-FY201510501(l)
New PHSA Sec.
749B (HRSA)
Rural physician training grants. Requires the Secretary to (1) award grants to
medical schools for recruiting students most likely to practice in underserved rural
communities and for providing rural-focused training and experience; and (2) within
60 days of enactment, by regulation, define underserved rural communities. Priority is
given to entities that train students to practice in rural communities, that have
established partnerships with rural community health centers, or who submit a longterm plan for tracking where graduates practice. Note: HRSA published an interim
final rule on May 26, 2010 (75 Federal Register 29447). Authorizes the appropriation of
$4 million for each of FY2010 through FY2013.
No appropriations identified.
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CRS-11
FY2016 request = $4 million
.
ACA
Section
Statutory
Authority
(Agency)
Summary of Provision
Funding (FY2010-FY2016)
Dentistry: Existing Program
5303
New PHSA Sec.
748; authority
previously part of
Sec. 747 (HRSA)
General, pediatric, and public health dentistry training. Authorizes grants or
contracts to dental and dental hygiene schools, as well as approved residency or
advanced education programs in general, pediatric, or public health dentistry, for
dental training activities including faculty development, financial assistance, faculty loan
repayment programs, technical assistance for pediatric dental programs, and pre- and
post-doctoral training programs in dental primary care. Gives priority to entities that
train individuals from disadvantaged backgrounds, who have a record of placing
graduates in facilities that provide care to the underserved, or whose programs focus
on providing care to the underserved through demonstrated partnerships with
FQHCs, rural health clinics, or through having programs focused on specific topics,
such as HIV/AIDs. Authorizes the appropriation of $30 million for FY2010, and SSAN
for each of FY2011 through FY2015. Permits grantees to carry over funds for up to
three fiscal years. [CFDA 93.059, 93.884]
FY2010 = $15 million
FY2011 = $17 million
FY2012 = $20 million
FY2013 = $20 million
FY2014 = $21 million
FY2015 = $21 million
FY2016 request = $21 million
Alternative dental health care provider demonstration program. Authorizes
the Secretary to award 15 five-year grants of not less than $4 million to train or
employ alternative dental health care providers (e.g., community dental health
coordinators, dental health aides) to increase access to dental health care services in
rural and other underserved communities. Eligible grantees include institutions of
higher education; public-private entities; FQHCs; facilities operated by the IHS or by
Indian tribes or organizations; state or county public health clinics; public hospitals or
health systems; and accredited dental education programs. Authorizes the
appropriation of SSAN (no years specified).
No appropriations identified.
Dentistry: Existing Program
5303
New PHSA Sec.
748; authority
previously part of
Sec. 747 (HRSA)
[Note: HRSA also administers a state oral health
workforce grant program (PHSA Sec. 340G): FY2010 =
$17 million; FY2011 = $16 million; FY2012 = $12 million;
FY2013 = $11 million; FY2014 = $11 million; FY2015
=
$13 million; FY2016 request = $1113 million. CFDA 93.236]
Dentistry: New Program
5304
c11173008
CRS-12
CRS-13
New PHSA Sec.
340G-1 (HRSA)
[Note: A provision in the L-HHS-ED appropriations act
for each of the fourfive most recent fiscal years (i.e.,
FY2011-FY2014 FY2011FY2015) prohibits HRSA from funding this new
demonstration program.]
.
ACA
Section
Statutory
Authority
(Agency)
Summary of Provision
Funding (FY2010-FY2015FY2016)
Nursing: Existing Programs
5309(a)
5311(a)
c11173008
CRS-13
Amends and
reauthorizes
PHSA Sec. 831
(HRSA)
Amends and
reauthorizes
PHSA Sec. 846A
(HRSA)
Nurse education, practice, quality, and retention program. Authorizes grants
or contracts to expand enrollment in baccalaureate nursing programs; provide
training in new technologies; develop cultural competencies; expand nursing practice
arrangements in non-institutional settings; and support nurse retention programs that
offer career advancement for nursing personnel, enhance collaboration among nurses
and other health professionals, and promote nurse involvement in clinical decision
making. Eligible grantees include nursing schools, health care facilities (including
NMHCs), or partnerships of the two. Authorizes the appropriation of SSAN for each
of FY2010 through FY2014. See also ACA Sec. 5312 below, which authorizes
appropriations for several Title VIII nursing education programs including Sec. 831.
[CFDA 93.359, 93.503]
FY2010 = $40 million
FY2011 = $40 million
FY2012 = $40 million
FY2013 = $37 million
FY2014 = $38 million
FY2015 request = $38 million
5311(a)
Amends and
reauthorizes
PHSA Sec. 846A
(HRSA)= $40 million
FY2016 request = $40 million
Nursing faculty loan program. Authorizes loans to nursing school students
pursuing advanced degrees to become qualified nursing faculty. Sets the annual loan
limit at $35,500 for FY2010 and FY2011; for subsequent fiscal years, the loan limit is
subject to a cost-of-attendance adjustment. Students who go on to serve as nursing
school faculty may have up to 85% of their loan repayment cancelled. Authorizes the
appropriation of SSAN for each of FY2010 through FY2014. [CFDA 93.264]
FY2010 = $25 million
FY2011 = $25 million
FY2012 = $25 million
FY2013 = $23 million
FY2014 = $25 million
FY2015 = $27 million
FY2016 request = $2527 million
CRS-14
Note: See entry below under “Mental and Behavioral
Health: New Programs”
.
ACA
Section
5312
Statutory
Authority
(Agency)
Amends PHSA
Sec. 871;
previously Sec.
841 (HRSA)
Summary of Provision
Authorization of appropriations. Authorizes the appropriation of $338 million
for FY2010, and SSAN for each of FY2011 through FY2016, for the nursing workforce
programs authorized under PHSA Secs. 811, 821, 831, and new 831A (see ACA Sec.
5309(b) below:
•
Sec. 811: Advanced nursing education – grants to accredited programs for
advanced nurse education including combined registered nurse mastersmaster’s degree
programs, authorized nurse practitioner programs, accredited nurse midwifery
programs, and accredited nurse anesthesia programs. [CFDA 93.124, 93.247,
93.358, 93.513]
Funding (FY2010-FY2015)
Funding for Sec. 811:
FY2010 = $64 million
FY2011 = $64 million
FY2012 = $63 million
FY2013 = $60 million
FY2014 = $62 million
FY2015 request = $62 million
•
Sec. 821: Nursing workforce diversity – grants to nursing schools, academic
health centers, state or local governments, and other appropriate public or
private nonprofit entities for stipends and scholarships so as to increase nursing
education opportunities for disadvantaged individuals. [CFDA 93.178]
•
Sec. 831: Nurse education, practice, quality, and retention – see ACA Sec.
5309(a) above.
Funding (FY2010-FY2016)
Funding for Sec. 811Funding for Sec. 821:
FY2010 = $1664 million
FY2011 = $1664 million
FY2012 = $1663 million
FY2013 = $1560 million
FY2014 = $1561 million
FY2015 = $64 million
FY2016 request = $15 million
•
Sec. 831: Nurse education, practice, quality, and retention – see ACA Sec.
5309(a) above.
See ACA Sec. 5309(a) above for funding for the Sec. 831
program.64 million
Funding for Sec. 821:
FY2010 = $16 million
FY2011 = $16 million
FY2012 = $16 million
FY2013 = $15 million
FY2014 = $16 million
FY2015 = $15 million
FY2016 request = $15 million
Note: ACA did not reauthorize funding for the nursing education loan repayment and
scholarship programs authorized under PHSA Sec. 846.a
See ACA Sec. 5309(a) above for funding for the Sec. 831
program.
Nursing: New Programs
5309(b)
New PHSA Sec.
831A (HRSA)
Nurse retention program. New authority that largely duplicates the nurse
retention grant program authorized under PHSA Sec. 831; see ACA Sec. 5309(a)
above. Authorizes the appropriation of SSAN for each of FY2010 through FY2012.
Note: ACA Sec. 5312 also authorizes appropriations for this new program; see
above.
No appropriations identified.
5311(b)
New PHSA Sec.
847 (HRSA)
Nursing faculty loan repayment program. Authorizes a loan repayment
program for qualified nursing students or graduates who agree to serve as nursing
faculty for four to six years. Sets the annual loan limit for FY2010 and FY2011 at
$10,000 for individuals with a master’s or equivalent degree in nursing ($20,000 for
those with a doctorate or equivalent degree in nursing), and an aggregate loan limit of
$40,000 for individuals with a master’s or equivalent degree in nursing ($80,000 for
those with a doctorate or equivalent degree in nursing). Thereafter, the annual and
aggregate loan limits are subject to a cost-of-attendance adjustment. Authorizes the
appropriation of SSAN for each of FY2010 through FY2014.
No appropriations identified.
CRS-15
c11173008
CRS-14
.
ACA
Section
5316
Statutory
Authority
(Agency)
New freestanding
authority
Summary of Provision
Family nurse practitioner demonstration program. Requires the Secretary to
award three-year demonstration grants to FQHCs and NMHCs, not to exceed
$600,000 a year, for programs to train nurse practitioners as primary care providers
(as defined in ACA Sec. 5208). Preference given to bilingual individuals. Authorizes
the appropriation of SSAN for each of FY2011 through FY2014.
Funding (FY2010-FY2015FY2016)
No appropriations identified.
Geriatrics and Long-Term Care: Existing Program
5305(c)
Amends and
reauthorizes
PHSA Sec. 865;
previously Sec.
855 (HRSA)
Geriatric nursing education and training. Provides grants for traineeships for
individuals preparing for advanced degrees in geriatric nursing or other nursing areas
that specialize in elder care. Eligible grantees include nursing schools, health care
facilities, programs leading to certification as a certified nurse assistant, and
partnerships of such schools, facilities, and programs. Authorizes the appropriation of
SSAN for each of FY2010 through FY2014. [CFDA 93.265]
FY2010 = $5 million
FY2011 = $5 million
FY2012 = $4 million
FY2013 = $4 million
FY2014 = $4 million
FY2015 = $5 million
FY2016 request = $45 million
Geriatrics and Long-Term Care (LTC): New Programs
5302
c11173008
CRS-15CRS-16
New PHSA Sec.
747A (HRSA)
Direct care worker training. Requires the Secretary to establish a grant program
to provide new training opportunities, such as tuition and fee assistance, for direct
care workers employed in LTC settings. Individuals who receive assistance are
required to work in the field of geriatrics, disability services, LTC services and
supports, or chronic care management for a minimum of two years. Eligible grantees
include institutions of higher education that have an established partnership with an
LTC entity, as specified. Authorizes the appropriation of $10 million for the period
FY2011 through FY2013.
No appropriations identified.
.
ACA
Section
5305(a)
Statutory
Authority
(Agency)
Amends PHSA
Sec. 753 by
adding new
subsections (d)(e) (HRSA)
Summary of Provision
Funding (FY2010-FY2015FY2016)
Geriatric workforce development; geriatric career incentive awards. Sec.
753(d) requires the Secretary to award no more than 24 grants or contracts for
$150,000 to entities that operate geriatric education centers to support short-term
intensive courses on geriatrics and LTC, and support training for family caregivers and
direct care workers. Eligible grantees include accredited schools of allied health,
medicine, nursing, dentistry, osteopathic medicine, optometry, podiatric medicine,
veterinary medicine, public health, or chiropractic care; accredited graduate programs
in clinical psychology, clinical social work, health administration, marriage and family
therapy, and counseling; and physician assistant programs. Sec. 753(e) requires the
Secretary to award grants or contracts to advance practice nurses, clinical social
workers, pharmacists, and psychologists pursuing an advanced degree in geriatrics or
a related field, in return for agreeing to teach or practice in the field of geriatrics,
LTC, or chronic care management for a minimum of five years upon completion of
the degree. Authorizes the appropriation of $10.8 million for the period FY2011
through FY2014 for Sec. 753(d), and $10 million for the period FY2011 through
FY2013 for Sec. 753(e). [CFDA 93.156, 93.250, 93.969]
No appropriations identified.
Education and training in pain care. Authorizes a grant program to train health
professionals in pain care. Eligible grantees include health professions schools,
hospices, and other public and private entities. Applicants must agree to include
training and education on recognizing the signs and symptoms of pain; applicable laws
and policies on controlled substances; interdisciplinary approaches to pain care
delivery; barriers to care in underserved populations; and recent developments in
pain care. Authorizes the appropriation of SSAN for each of FY2010 through FY2012,
to remain available until expended. [See also Table 15.]
No appropriations identified.
[Note: The three existing geriatric education and training
programs authorized under PHSA Sec. 753(a)-(c), which
support activities that are broadly comparable to the
new programs authorized by the ACA, have received the
following amounts: FY2010 = $34 million; FY2011 = $34
million; FY2012 = $31 million, (+ $2 million PPHF ),
FY2013 = $29 million (+
$2 million PPHF); FY2014 = $33
million; FY2015 request
= $33 million.]= $34 million; FY2016 request = $34
million. In FY2015, HRSA combined these three
programs into one new program, the Geriatric
Workforce Enhancement Program.
Pain Care: New Program
4305(c)
CRS-17
New PHSA Sec.
759 (HRSA)
ACA
Section
Statutory
Authority
(Agency)
Summary of Provision
Funding (FY2010-FY2015)
Public Health: Existing Programs
10501(m)(2)
c11173008
CRS-16
Amends PHSA
Sec. 770 (HRSA)
Public health and preventive medicine programs. Reauthorizes funding for the
public health workforce programs authorized under PHSA Secs. 765-769. They
include grants for public health training centers; tuition, fees, and stipends for
traineeships in public health and in health administration; and residency programs in
preventive medicine and dental public health. Several programs mention preference
for underserved communities or underrepresented minorities. Eligible grantees
include accredited academic institutions, as well as state, local, and tribal public health
departments. Authorizes the appropriation of $43 million for FY2011, and SSAN for
each of FY2012 through FY2015. [CFDA 93.117, 93.249, 93.516, 93.964]
FY2010 = $10 million (+ $15 million PPHF)
FY2011 = $10 million (+ $20 million PPHF)
FY2012 = $8 million (+ $25 million PPHF)
FY2013 = $8 million
FY2014 = $18 million
FY2015 = $21 million
FY2016 request = $18 million17 million
.
ACA
Section
Statutory
Authority
(Agency)
Summary of Provision
Funding (FY2010-FY2016)
Public Health: New Programs
5204
New PHSA Sec.
776 (HRSA)
Public health workforce loan repayment program. Requires the Secretary to
establish a student loan repayment program that pays up to $35,000 a year, or onethird of total debt, whichever is less, to increase the supply of public health
professionals. Eligible individuals must agree to work for at last three years in a public
health agency or related training fellowship. Authorizes the appropriation of $195
million for FY2010, and SSAN for each of FY2011 through FY2015.
No appropriations identified.
5206(b)
New PHSA Sec.
777 (HRSA)
Public health and allied health scholarship program. Authorizes grants to
accredited institutions for scholarships to help support the training of mid-career
professionals in public health and allied health. Available grant funds are to be divided
50:50 between supporting public health and allied health professionals. Authorizes the
appropriation of $60 million for FY2010, and SSAN for each of FY2011 through
FY2015.
No appropriations identified.
5313
New PHSA Sec.
399V (CDC)
Community health worker (CHW) program. Requires CDC to award grants
to promote healthy behaviors and outcomes for populations in medically underserved
communities through programs of training and supervision of CHWs. Eligible grantees
include states and subdivisions, health departments, free clinics, hospitals, and FQHCs.
Priority is to be given to applicants that target areas with a high proportion of
uninsured or underinsured individuals, or with high rates of chronic illness or infant
mortality. Authorizes the appropriation of SSAN for each of FY2010 through FY2014.
No appropriations identified.
CRS-18
ACA
Section
Statutory
Authority
(Agency)
Summary of Provision
Funding (FY2010-FY2015)
5314
New PHSA Sec.
778 (CDC)
CDC training fellowships. Authorizes the Secretary to expand existing CDC
training fellowships in epidemiology, laboratory science, and informatics; the Epidemic
Intelligence Service (EIS); and other training programs that meet similar objectives.
Participants may be placed in state and local health agencies, and states can receive
federal assistance for loan repayment programs for such participants. Authorizes the
appropriation of $39.5 million for each of FY2010 through FY2013 ($24.5 million for
EIS, and $5 million each for epidemiology, laboratory science, and informatics).
[CFDA 93.065]
Funding for CDC’s public health workforce and career
development programs:
FY2010 = $38 million (+ $7 million PPHF)
FY2011 = $36 million (+ $25 million PPHF)
FY2012 = $36 million (+ $25 million PPHF)
FY2013 = $48 million (+ $16 million PPHF)
FY2014 = $52 million
FY2015 = $52 million
FY2016 request = $5231 million (+ $15 million PPHF)
36 million PPHF)
c11173008
CRS-17
.
ACA
Section
Statutory
Authority
(Agency)
Summary of Provision
Funding (FY2010-FY2016)
5315
New PHSA Title
II, Part D – Secs.
271-274 (U.S.
Surgeon General)
United States Public Health Sciences Track. Authorizes the establishment of a
science track at academic sites selected by the Secretary to award degrees that
emphasize team-based service, public health, epidemiology, and emergency
preparedness/response. Funds may be used for program development and for tuition
and stipends for students who meet a service obligation, including in the United States
Public Health Service (USPHS) Commissioned Corps. Requires the Secretary to
transfer SSAN from the Public Health and Social Services Emergency Fund for FY2010
and each fiscal year thereafter. Note: P.L. 112-10 prohibited any such transfer of
funds.b
No appropriations identified.
5210
Amends PHSA
Sec. 203 (U.S.
Surgeon General)
USPHS Commissioned Corps. Establishes a Ready Reserve Corps of officers who
are subject to involuntary call to active duty (and training) by the Surgeon General, in
order to bolster the available workforce for both routine and emergency public
health missions. Authorizes the appropriation of $17.5 million for each of FY2010
through FY2014 ($5 million for recruitment and training, $12.5 million for the Ready
Reserve Corps).
No appropriations identified.
CRS-19
ACA
Section
Statutory
Authority
(Agency)
Summary of Provision
Funding (FY2010-FY2015)
Workforce Diversity, Health Disparities, Cultural Competency: Existing Programs
5307(a)
Amends and
reauthorizes
PHSA Sec. 741
(HRSA)
Cultural competency, prevention, public health, disparities, and individuals
with disability training. Authorizes grants, contracts, or cooperative agreements
for the development and evaluation of research, demonstration projects, and model
curricula that provide training in cultural competency, prevention, public health
proficiency, reducing health disparities, and aptitude for working with individuals with
disabilities. Requires the Secretary to coordinate this program with the one
authorized under PHSA Sec. 807 (see below). Authorizes the appropriation of SSAN
for each of FY2010 through FY2015.
No appropriations identified.
5307(b)
Amends and
reauthorizes
PHSA Sec. 807
(HRSA)
Cultural competency, prevention, public health, disparities, and individuals
with disability training. Authorizes grants, contracts, or cooperative agreements
for the development and evaluation of research, demonstration projects, and model
curricula that provide training in cultural competency, prevention, public health
proficiency, reducing health disparities, and aptitude for working with individuals with
disabilities. The Secretary is required to coordinate this program with the one
authorized under PHSA Sec. 741 (see above). Authorizes the appropriation of SSAN
for each of FY2010 through FY2015.
No appropriations identified.
c11173008
CRS-18
.
ACA
Section
Statutory
Authority
(Agency)
Summary of Provision
Funding (FY2010-FY2016)
5401
Amends and
reauthorizes
PHSA Sec. 736
(HRSA)
Centers of excellence (COE). Requires the Secretary to fund COEs at health
professions schools that recruit, enroll, and graduate underrepresented minorities or
that recruit underrepresented minorities serving in faculty or administrative positions.
Authorizes the appropriation of $50 million for each of FY2010 through FY2015, and
SSAN for each subsequent fiscal year. [CFDA 93.157]
FY2010 = $25 million
FY2011 = $24 million
FY2012 = $23 million
FY2013 = $21 million
FY2014 = $22 million
FY2015 = $22 million
FY2016 request = $22 million
CRS-20
ACA
Section
5402
5403(a)
CRS-21
Statutory
Authority
(Agency)
Amends PHSA
Sec. 740 (HRSA)
Amends and
reauthorizes
PHSA Sec. 751
(HRSA)
Summary of Provision
Authorization of appropriations. Authorizes appropriations for the workforce
diversity programs authorized under PHSA Secs. 737, 738, and 739:
25 million
5402
Amends PHSA
Sec. 740 (HRSA)
Authorization of appropriations. Authorizes appropriations for the workforce
diversity programs authorized under PHSA Secs. 737, 738, and 739:
Funding for Sec. 737:
FY2010 = $49 million
FY2011 = $49 million
FY2012 = $47 million
FY2013 = $44 million
FY2014 = $45 million
FY2015 = $46 million
FY2016 request = $46 million
•
Authorizes the appropriation of $51 million for FY2010, and SSAN for each of
FY2011 through FY2014, for Sec. 737, Scholarships for Disadvantaged Students,
which provides grants to health professions schools for awarding scholarships to
students from disadvantaged backgrounds with financial need. [CFDA 93.925]
•
Authorizes the appropriation of $5 million for each of FY2010 through FY2014
for Sec. 738, Faculty Loan Repayment Program, which helps repay loans for
health profession graduates from disadvantaged backgrounds who serve as
faculty at an eligible health professions college for at least two years. [CFDA
93.923]
•
c11173008
CRS-19
Authorizes the appropriation of $60 million for FY2010, and SSAN for each of
FY2011 through FY2014 for Sec. 739, Health Careers Opportunity Program,
which provides grants to health professions schools and other educational
institutions to improve recruitment and academic preparation of students from
disadvantaged backgrounds. [CFDA 93.822]
Funding for Sec. 738:
FY2010 = $1 million
FY2011 = $1 million
FY2012 = $1 million
FY2013 = $1 million
FY2014 = $1 million
FY2015 = $1 million
FY2016 request = $1 million
Funding for Sec. 739:
FY2010 = $22 million
FY2011 = $22 million
FY2012 = $15 million
FY2013 = $14 million
FY2014 = $14 million
FY2015 = $14 million
FY2016 request = $14 millionc
.
ACA
Section
5403(a)
Statutory
Authority
(Agency)
Amends and
reauthorizes
PHSA Sec. 751
(HRSA)
Summary of Provision
Area Health Education Centers (AHECs). Requires the Secretary to award
grants (with a matching requirement) to medical and nursing schools of at least
$250,000 to (1) plan, develop, and operate AHEC programs; and (2) to maintain and
improve the effectiveness of existing AHEC programs. AHECs recruit, train, and
prepare individuals from minority populations or from disadvantaged or rural
backgrounds to work in medically underserved areas. Authorizes the appropriation of
$125 million for each of FY2010 through FY2014; funds may be carried over for up to
three fiscal years. [CFDA 93.107, 93.824]
Funding (FY2010-FY2015)
Funding for Sec. 737:
FY2010 = $49 million
FY2011 = $49 million
FY2012 = $47 million
FY2013 = $44 million
FY2014 = $45 million
FY2015 request = $45 million
Funding for Sec. 738:
FY2010 = $1 million
FY2011 = $1 million
FY2012 = $1 million
FY2013 = $1 million
FY2014 = $1 million
FY2015 request = $1 million
Funding for Sec. 739FY2016)
Funding for AHECs:
FY2010 = $2233 million
FY2011 = $2233 million
FY2012 = $1527 million
FY2013 = $1428 million
FY2014 = $14 million
FY2015 request = $0
Funding for AHECs:
FY2010 = $33 million
FY2011 = $33 million
FY2012 = $27 million
FY2013 = $28 million
FY2014 30 million
FY2015 = $30 million
FY2015 request = $0
ACA
Section
Statutory
Authority
(Agency)
Summary of Provision
Funding (FY2010-FY2015)FY2016 request = $0
Workforce Diversity, Health Disparities, Cultural Competency: New Program
5403(b)
New PHSA Sec.
752 (HRSA)
Continuing educational support for health professionals serving in
underserved communities. Requires the Secretary to award grants to enhance
education through distance learning, continuing education, collaborative conferences,
and telehealth, with a focus on primary care. Eligible grantees include health
professions schools, academic health centers, state or local governments, or other
public or nonprofit entities participating in training activities. Authorizes the
appropriation of $5 million for each of FY2010 through FY2014, and SSAN for each
subsequent fiscal year. [CFDA 93.189]
No appropriations identified.
Mental and Behavioral Health: New Program
5306
c11173008
CRS-20CRS-22
Redesignates
PHSA Sec. 756 as
Sec. 757, and
adds a new Sec.
756 (HRSA)
Mental and behavioral health education and training grants. Authorizes
grants for the recruitment and education of students in social work, interdisciplinary
psychology training, and internships or other field placement programs related to
child and adolescent mental health. Priority for social work grants given to schools of
social work meeting certain criteria such as recruiting from and placing graduates into
areas with a high-need and high-demand population. Priority for psychology grants
given to institutions focusing on the needs of specified vulnerable groups. Priority for
grants to train professional and paraprofessional child and adolescent mental health
workers given to applicants that can, among other things, assess workforce needs and
that have programs designed to increase the number of child and adolescent mental
health workers serving high-priority populations. Authorizes the appropriation of $35
million for the period of FY2010 through FY2013 (i.e., $8 million for training in social
work, $12 million for training in graduate psychology, $10 million for training in
professional child and adolescent mental health, and $5 million for training in
paraprofessional child and adolescent mental health). [CFDA 93.732]
FY2012 = $10 million (all PPHF)
No appropriations identified since FY2012.
[Note: (1) HRSA’s graduate psychology education
program, which predatesmental and behavioral health education
and training programs (PHSA Sec. 755), which predate
the ACA, received the following
amounts: FY2010 = $3
million; FY2011 = $3 million;
FY2012 = $3 million;
FY2013 = $3 million; FY2014 = $8
million; FY2015 = $9
million; FY2016 request = $89 million.
(2) SAMHSA
received $35 million in FY2014 and in
FY2015 to expand the mental and
behavioral health
workforce, through a partnership with
HRSA. SAMHSA requested the same amount for FY2015
requested $56 million for FY2016 to continue the
program.]
(3) Citing PHSA Secs. 755, 756, and 831, the FY2016
budget includes $10 million for a new Clinical Training in
Interprofessional Practice Program (CTIPP).
.
Statutory
Authority
(Agency)
ACA
Section
Summary of Provision
Funding (FY2010-FY2015FY2016)
Policy and Planning: Existing Program
5103
Amends and
reauthorizes
PHSA Sec. 761
(HRSA)
Health care workforce program assessment. Requires the Secretary to
establish a National Center for Health Care Workforce Analysis, award grants to
support state and regional centers for health workforce analysis, and increase funding
for longitudinal evaluations of specified individuals who have received education,
training, or financial assistance from programs under PHSA Title VII. Authorizes the
appropriation of the following amounts: $7.5 million for each of FY2010 through
FY2014 for the National Center; $4.5 million for each of FY2010 through FY2014 for
state and regional centers; and SSAN for FY2010 through FY2014 for the longitudinal
evaluations. [CFDA 93.300]
FY2010 = $3 million
FY2011 = $3 million
FY2012 = $3 million
FY2013 = $3 million
FY2014 = $5 million
FY2015 = $5 million
FY2016 request = $5 million
[Note: These amounts also include funding for PHSA
Sec.
792 (health professions data) and Sec. 806 (nursing
grant grant
program data).]
Policy and Planning: New Programs
5101
New freestanding
authority
National Health Care Workforce Commission. Establishes a 15-member
commission focused on evaluating and meeting the need for health care workers in
the United States. The commission is required to conduct studies, produce annual
reports beginning in 2011, and make recommendations on high-priority topics related
to the health care workforce. Authorizes the appropriation of SSAN (no years
specified).
No appropriations identified.
5102
New freestanding
authority (HRSA)
State health care workforce development grants. Establishes a matching grants
program for state partnerships to plan and implement activities leading to coherent
and comprehensive health care workforce development strategies at the state and
local levels. Planning grants of up to $150,000 are for up to one year and require a
15% match. Implementation grants are for up to two years (with up to one additional
year of funding) and require a 25% match. Authorizes the appropriation of $8 million
for FY2010, and SSAN for each subsequent fiscal year, for planning grants; and $150
million for FY2010, and SSAN for each subsequent fiscal year, for implementation
grants. [CFDA 93.509]
FY2010 = $6 million (all PPHF)
No appropriations identified since FY2012.
Sources: Table prepared by the Congressional Research ServiceCRS based on the text of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended).
Funding amounts are taken
from HRSA’s budget documents, including the FY2014 operating plan, available at http://www.hrsa.gov/about/budget/index.html.
a.
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The nursing education loan repayment program repays 60% of a registered nurse’s educational loans in return for a two-year commitment to work in a health care
facility with a critical shortage of nurses. Participants may have an additional 25% of their loan repaid in exchange for one more year of service. The nurse
scholarship program offers scholarships to individuals attending nursing school in exchange for at least two years working in a health care facility with a critical
shortage of nurses. Together the two programs, which are authorized under PHSA Sec. 846 and collectively known as NURSE Corps, received $94 million in
.
FY2010, $93 million in FY2011, $83 million in FY2012, and $78 million in FY2013, $80 million in FY2014, and $82 million in FY2015. The FY2016. The FY2014 request is for $83 82
million. The authorization of appropriations for
Sec. 846 expired at the end of FY2007 and was not reauthorized by ACA.
b.
CRS-24
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b.
The Department of Defense and Full-Year Continuing Appropriations Act, 2011 (P.L. 112-10, Div. B, Sec. 1828) prohibited the transfer of funds from the Public
Health and Social Services Emergency Fund (PHSSEF) to support the U.S. Public Health Sciences Track. The PHSSEF is an HHS account administered by the
Secretary. Congress has historically used the PHSSEF to provide one-time funding for non-routine activities. Each fiscal year, Congress appropriates amounts to the
PHSSEF for specified purposes. ACA did not authorize or appropriate funds to the PHSSEF.
c.
This funding request is for a new Health Workforce Diversity Program to replace the Health Careers Opportunity Program.
CRS-22
.
Table 4. ACA Discretionary Spending: Prevention and Wellness
ACA
Section
Statutory
Authority
(Agency)
Summary of Provision
Funding (FY2010-FY2015FY2016)
Community-Based Prevention: Existing Programs
3509/3511
New PHSA Secs.
229 (OS), 310A
(CDC), 925
(AHRQ); new
SSA Sec. 713
(HRSA); and new
FFDCA Sec. 1011
(FDA). Amends
PHSA Secs.
486(a) (NIH) and
501(f)
(SAMHSA).
Offices on Women’s Health. Establishes within OS an Office on Women’s Health,
headed by a Deputy Assistant Secretary for Women’s Health, and transfers all
functions and personnel from the existing Office on Women’s Health of the Public
Health Service to the new office. Requires the OS Office on Women’s Health to
establish an HHS Coordinating Committee on Women’s Health and a National
Women’s Health Information Center, among other things. Authorizes the
appropriation of SSAN for each of FY2010 through FY2014.
Funding for OS Office on Women’s Health:
FY2010 = $34 million
FY2011 = $34 million
FY2012 = $34 million
FY2013 = $33 million
FY2014 = $34 million
FY2015 request = $30 million
Amends the existing authorities for NIH’s Office of Research on Women’s Health
(ORWH) and SAMHSA’s Associate Administrator for Women’s Services by specifying
that the ORWH director and the Associate Administrator are to report directly to
the NIH Director and the SAMHSA Administrator, respectively. Authorizes the
appropriation of SSAN (no years specified).
Funding for NIH Office of Research on Women’s Health:
FY2010 = $43 million
FY2011 = $42 million
FY2012 = $42 million
FY2013 = $40 million
FY2014 = $41 million
FY2015 request = $41 million
Establishes Offices of Women’s Health at CDC, AHRQ, HRSA, and FDA to make
recommendations regarding grant-making through other agency accounts. Authorizes
the appropriation of SSAN for each of FY2010 through FY2014.
4003
Amends PHSA
Sec. 915(a)
(AHRQ). New
PHSA Sec. 399U
(CDC).
Clinical and community preventive services task forces. Reauthorizes and
expands the authority for the U.S. Preventive Services Task Force (USPSTF) to review
and recommend effective clinical preventive services. Provides explicit statutory
authority for the existing Task Force on Community Preventive Services (TFCPS) to
review and recommend effective community-based interventions. Authorizes the
appropriation of SSAN for each fiscal year to carry out the activities of the USPSTF
and the TFCPS.
Funding for OS Office on Women’s Health:
FY2010 = $34 million
FY2011 = $34 million
FY2012 = $34 million
FY2013 = $33 million
FY2014 = $34 million
FY2015 = $32 million
FY2016 request = $32 million
Funding for NIH Office of Research on Women’s Health:
FY2010 = $43 million
FY2011 = $42 million
FY2012 = $42 million
FY2013 = $40 million
FY2014 = $41 million
FY2015 = $41 million
FY2016 request = $41 million
AHRQ funding for USPSTF:
FY2010 = $4 million (+ $5 million PPHF)
FY2011 = $4 million (+ $7 million PPHF)
FY2012 = $4 million (+ $7 million PPHF)
FY2013 = $5 million (+ $6 million PPHF)
FY2014 = $4 million (+ $7 million PPHF)
FY2015 = $12 million
FY2016 request = $1112 million
CDC funding for TFCPS:
FY2010 = $5 million (all PPHF)
FY2011 = $7 million (all PPHF)
FY2012 = $10 million (all PPHF)
FY2013 = $7 million (all PPHF)
FY2014 = $0
FY2015 = $0
FY2016 request = $8 million (all PPHF)
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.
CRS-25
ACA
Section
Statutory
Authority
(Agency)
Summary of Provision
Funding (FY2010-FY2015FY2016)
4102(b)
Amends PHSA
Sec. 317M(c)
(CDC, HRSA)
School-based dental sealant program. Amends the existing school-based dental
sealant grant program, which was discretionary, by requiring the Secretary to award
grants to the 50 states and to Indian tribes for school-based dental sealant programs.
Note: The authorization of appropriations for the school-based dental sealant
program expired at the end of FY2005. ACA did not reauthorize appropriations for
the program.
Funding for all of CDC’s existing oral health programs
under PHSA Sec. 317M:
FY2010 = $15 million
FY2011 = $15 million
FY2012 = $16 million
FY2013 = $15 million
FY2014 = $16 million
FY2015 = $16 million
FY2016 request = $16 million
[Note: Amounts below the line reflect realignment for
the CDC Working Capital Fund (WCF) and are not
comparable to amounts above the line.]
4204
Amends PHSA
Sec. 317 and adds
a new subsection
(m) (CDC)
Immunization programs. Provides explicit authority for states to purchase
vaccines at prices negotiated by Secretary. Authorizes the appropriation of SSAN (no
years specified) for state immunization grants. Establishes a new immunization
demonstration grant, for which is authorized the appropriation of SSAN for each of
FY2010 through FY2014. [CFDA 93.185, 93.268, 93.533, 93.539]
Funding for the Sec. 317 immunization program
(including program implementation and accountability):
FY2010 = $561 million
FY2011 = $361 million (+ $100 million PPHF)
FY2012 = $452 million (+ $190 million PPHF)
FY2013 = $461 million (+ $91 million PPHF)
FY2014 = $452451 million (+ $160 million PPHF)
FY2015 = $401 million (+ $210 million PPHF)
FY2016 request = $350request = $433 million (+ $127210 million PPHF)
[Note: Amounts below the line reflect realignment for
the CDC WCF and are not comparable to amounts
above the line.]
CRS-26
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CRS-24
.
ACA
Section
10334
Statutory
Authority
(Agency)
Amends PHSA
Sec. 1707 (OS)
and PHSA Title
IV (NIH), and
adds new PHSA
Sec. 1707A
(AHRQ, CDC,
CMS, FDA,
HRSA, SAMHSA)
Summary of Provision
Offices of Minority Health. Establishes within OS an Office of Minority Health,
headed by a Deputy Assistant Secretary for Minority Health, and transfers all
functions and personnel from the existing Office of Minority Health of the Public
Health Service to the new office. Authorizes the appropriation of SSAN for each of
FY2011 through FY2016.
Renames NIH’s National Center on Minority Health and Health Disparities
(NCMHD) as the National Institute on Minority Health and Health Disparities
(NIMHD). Specifies that the NIMHD Director is responsible for the coordination of
all NIH research on minority health and health disparities.
Establishes an Office of Minority Health in AHRQ, CDC, CMS, FDA, HRSA, and
SAMHSA. Requires the Secretary to designate an appropriate amount of each
agency’s funding to support the activities of its Office of Minority Health.
10412
Reauthorizes
PHSA Sec. 312
(HRSA)
Rural access to emergency devices. Authorizes the appropriation of $25 million
for each of FY2003 through FY2014 for a program of grants to community
partnerships to purchase and distribute automatic external defibrillators (AEDs) in
rural communities, and to provide AED training for first responders. [CFDA 93.259]
Funding (FY2010-FY2015FY2016)
Funding for OS Office of Minority Health:
FY2010 = $56 million
FY2011 = $56 million
FY2012 = $56 million
FY2013 = $40 million
FY2014 = $57 million
FY2015 = $57 million
FY2016 request = $3657 million
Funding for NIH/NIMHD:
FY2010 = $211212 million
FY2011 = $276210 million
FY2012 = $276 million
FY2013 = $260262 million
FY2014 = $268 million
FY2015 = $269 million
FY2016 request = $268282 million
FY2010 = $3 million
FY2011 = $0.2 million
FY2012 = $1 million
FY2013 = $2 million
FY2014 = $3 million
FY2015 = $5 million
FY2016 request = $0
Community-Based Prevention: New Programs
4004
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CRS-25
CRS-27
New freestanding
authority
Education and outreach regarding prevention. Requires the Secretary to carry
out various specified communications activities regarding health promotion and
disease prevention, for common and serious chronic health problems. They include
establishing, within one year of enactment, a national media campaign on health
promotion and disease prevention. Authorizes the appropriation of SSAN for each
fiscal year; no more than $500 million total.
Note: Education and outreach for health promotion are
core public health activities and a part of many HHS
programs, authorized in broad language in the PHSA.
Thus, it is not possible to identify total funding for Sec.
4004 implementation. However, HHS has reported using
a portion of PPHF funds each year for various
prevention, education and outreach activities, such as
tobacco prevention media activities, and education and
outreach regarding Alzheimer’s disease.
.
reported using $30
million in FY2012 PPHF funds for tobacco prevention
media activities and prevention education and outreach,
and continues to use a portion of annual PPHF funds for
education, awareness, and outreach activities for various
other disease prevention and health promotion
purposes.
Statutory
Authority
(Agency)
Summary of Provision
4102(a)
New PHSA Secs.
399LL, 399LL-1,
and 399LL-2
(CDC)
Oral health activities. Requires CDC, subject to appropriations, to fund a five-year
national oral health education campaign, and award grants to community-based
providers of dental services for dental caries disease management programs, among
other things. Authorizes the appropriation of SSAN (no years specified).
No appropriations identified.
4102(c)
Amends PHSA
Sec. 317M by
adding a new
subsection (d)
(CDC)
Oral health infrastructure. Requires the Secretary to enter into cooperative
agreements with states and tribal entities to establish oral health leadership and
programs to improve oral health. Authorizes the appropriation of SSAN for FY2010
through FY2014.
No appropriations identified.
4102(d)
New freestanding
authority (CDC,
AHRQ)
Oral health surveillance. Requires the Secretary to expand the following
surveillance systems to include more information on oral health: Pregnancy Risk
Assessment Monitoring System (PRAMS); National Health and Nutrition Examination
Survey (NHANES); National Oral Health Surveillance System (NOHSS); and Medical
Expenditure Panel Survey (MEPS). Authorizes the appropriation of SSAN (no years
specified) for PRAMS, and SSAN for each of FY2010 through FY2014 for NOHSS; no
explicit authorization of appropriations for NHANES/MEPS expansion.
No appropriations identified.
4201
New freestanding
authority (CDC)
Community transformation grants. Requires CDC to fund competitive grants
for the implementation, evaluation, and dissemination of evidence-based community
preventive health activities. Authorizes the appropriation of SSAN for each of FY2010
through FY2014. [CFDA 93.531]
FY2011 = $145 million (all PPHF)
FY2012 = $226 million (all PPHF)
FY2013 = $146 million (all PPHF)
FY2014 = $0
FY2015 = $0
FY2016 request = $0
4202(a)
New freestanding
authority (CDC)
Community wellness pilot program. Requires CDC to award grants to state and
local health departments, and to Indian tribes, for five-year pilot programs to provide
community prevention interventions, screenings, and clinical referrals for individuals
between 55 and 64 years of age. Authorizes the appropriation of SSAN for each of
FY2010 through FY2014.
No appropriations identified.
4206
Amends PHSA
Sec. 330 by
adding a new
subsection (s)
Individualized wellness plan demonstration program. Requires the Secretary
to establish a pilot program in not more than 10 community health centers to test the
impact of providing at-risk individuals who use the centers with individualized wellness
plans. Authorizes the appropriation of SSAN (no years specified).
No appropriations identified.
ACA
Section
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Funding (FY2010-FY2015)
FY2016)
.
ACA
Section
Statutory
Authority
(Agency)
Summary of Provision
Funding (FY2010-FY2015FY2016)
4304
New PHSA Sec.
2821 (CDC)
Epidemiology and laboratory capacity grants. Codifies existing grant programs
to strengthen national epidemiology, laboratory, and information management
capacity for the response to infectious diseases and other conditions of public health
importance. Authorizes the appropriation of $190 million for each of FY2010 through
FY2013. [Note: ACA requires a specific distribution of funds among epidemiology,
information management, and laboratory grants. A provision in annual appropriations
acts nullifies this distribution directive.]
Funding for CDC’s Epidemiology and Laboratory
Capacity (ELC) program and Emerging Infections
Program (EIP) grants:
FY2010 = $20 million (all PPHF)
FY2011 = $40 million (all PPHF)
FY2012 = $40 million (all PPHF)
FY2013 = $40 million (PPHF + transfers)
FY2014 = $40 million (all PPHF)
FY2015 = $40 million (all PPHF)
FY2016 request = $40 million (all PPHF)
10407
New freestanding
authority (CDC)
Diabetes activities. Requires CDC to conduct several diabetes prevention activities
including state assessments, vital statistics, physician education, and funding of an
various diabetes prevention
activities and fund an Institute of Medicine (IOM) report. Authorizes the
appropriation of SSAN (no years
specified).
No appropriations identified.
10411
New PHSA Secs.
399V-2 (CDC)
and 425 (NIH)
Congenital heart disease programs. Authorizes CDC to establish a National
Congenital Heart Disease Surveillance System (NCHDSS), or to award one grant to
establish such a system. Authorizes NIH to expand and coordinate research on
congenital heart disease. Authorizes the appropriation of SSAN for each of FY2011
through FY2015 for both the surveillance system and the expanded research
program.
Funding for CDC’s congenital heart disease program:
FY2012 = $2 million
FY2013 = $2 million
FY2014 = $3 million
FY2015 = $4 million
FY2016 request = $34 million (all PPHF)
10413
New PHSA Sec.
399NN (OS,
CDC)
Young women’s breast health awareness. Among other things, requires CDC
to conduct an education campaign and award grants for a media campaign regarding
breast health in young women, and to conduct prevention research; requires the
Secretary to award grants to provide education and assistance to young women
diagnosed with breast disease. Authorizes the appropriation of $9 million for each of
FY2010 through FY2014.
FY2010 = $5 million
FY2011 = $5 million
FY2012 = $5 million
FY2013 = $5 million
FY2014 = $5 million
FY2015 request amount not specified
CRS-29
= $5 million
FY2016 request amount not specified
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.
Statutory
Authority
(Agency)
ACA
Section
10501(g)
New PHSA Sec.
399V-3 (CDC)
Summary of Provision
National diabetes prevention program (NDPP). Among other things, requires
the Secretary to award grants for community-based diabetes prevention program
model sites. Authorizes the appropriation of SSAN for each of FY2010 through
FY2014. [Note: NDPP is a component of CDC’s broader diabetes prevention
activities.]
Funding (FY2010-FY2015FY2016)
FY2010 = $0
FY2011 = $0
FY2012 = $10 million (all PPHF)
FY2013 = $3 million*
FY2014 = $10 million
FY2015 = $10 million
FY2016 request = $10 million
*NDPP did not receive dedicated funding for FY2013.
CDC used internal transfers to continue program
activities.
Workplace Wellness: New Program
10408
New freestanding
authority (CDC)
Small business wellness program. Requires the Secretary to award grants to
employers to provide their employees with access to comprehensive workplace
wellness programs. Eligible employers are those with fewer than 100 employees, who
work at least 25 hours per week. Authorizes the appropriation of $200 million for
the period of FY2011 through FY2015, to remain available until expended.
FY2010 = $0
FY2011 = $10 million (all PPHF)
FY2012 = $10 million (all PPHF)
FY2013 = $0
FY2014 = $10 (all PPHF)
FY2015 = $10 (all PPHF)
FY2016 request = $0
Sources: Table prepared by the Congressional Research ServiceCRS based on the text of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended).
Funding amounts are taken
from agency budget documents, including operating plans for certain fiscal years, available at http://www.hhs.gov/budget/, and communications
with the CDC Washington
Office.
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.
CRS-30
Table 5. ACA Discretionary Spending: Maternal and Child Health
Statutory
Authority
(Agency)
New SSA Sec.
512 (HRSA)
ACA
Section
2952(b)
Summary of Provision
Services to individuals with a postpartum condition. Authorizes grants to
establish, operate and coordinate effective and cost-efficient systems for the delivery
of essential services to individuals with, or at risk of, postpartum depression and their
families. Eligible grantees include public or nonprofit private entities, state or local
government public-private partnerships, recipients of Healthy Start grants, public or
nonprofit private hospitals, community-based organizations, hospices, ambulatory care
facilities, community health centers, and primary care centers. Authorizes the
appropriation of $3 million for FY2010, and SSAN for each of FY2011 and FY2012.
Funding (FY2010-FY2015FY2016)
No appropriations identified.
Source: Table prepared by the Congressional Research ServiceCRS based on the text of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended).
Table 6. ACA Discretionary Spending: Health Care Quality
ACA
Section
Statutory
Authority
(Agency)
Summary of Provision
Funding (FY2010-FY2015FY2016)
Quality Measure Development, Analysis, and Public Reporting: New Programs
3013(a)&(c)
CRS-31
New PHSA 931
(AHRQ)
Quality measure development. Requires the Secretary, in consultation with
AHRQ and CMS, to (1) identify gaps where no quality measures exist or where
existing measures need improvement, updating or expansion consistent with the
National Strategy for Quality Improvement; and (2) fund or enter into agreements
with eligible entities that have demonstrated expertise in measure development to
develop, improve, update, or expand quality measures in areas identified as gap areas.
Authorizes the appropriation of $75 million for each of FY2010 through FY2014, to
remain available until expended. At least 50% of the amounts appropriated must be
used pursuant to SSA Sec. 1890A(e), as added by ACA Sec. 3013(b). See below.
No appropriations identified.
ACA
Section
Statutory
Authority
(Agency)
Summary of Provision
Funding (FY2010-FY2015)Although no appropriations have been made pursuant to
this authorization, quality measure development is being
carried out with other programmatic and agency funding.
3013(b)
Amends new SSA
Sec. 1890A, as
added by ACA
Sec. 3014(b), by
adding a new
subsection (e)
(CMS)
Quality and efficiency measures development. Requires CMS, in consultation
with AHRQ, through contracts, to develop quality and efficiency measures as
determined appropriate for use under the SSA.
See ACA Sec. 3013(a)&(c) above.Although no appropriations have been made pursuant to
this authorization, quality measure development is being
carried out with other programmatic and agency funding.
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.
ACA
Section
Statutory
Authority
(Agency)
Summary of Provision
Funding (FY2010-FY2016)
3015
New PHSA Sec.
399II
Collection and analysis of data for quality and resource use measures.
Requires the Secretary to establish and implement an overall strategic framework to
carry out the public reporting of performance information. Requires the Secretary to
collect and aggregate consistent data on quality and resource use measures, and
authorizes the Secretary to award grants or contracts for this purpose. Authorizes
the Secretary to award grants or contracts to multi-stakeholder entities to support
new, or improve existing, efforts to collect and aggregate quality and resource use
measures. Authorizes the appropriation of SSAN for each of FY2010 through FY2014.
No appropriations identified.
3015
New PHSA Sec.
399JJ
Public reporting of performance information. Requires the Secretary to make
available to the public, through standardized websites, performance information
summarizing data on quality measures. The information must include clinical
conditions to the extent such data are available and, where appropriate, be providerspecific and sufficiently disaggregated and specific to meet the needs of patients with
different clinical conditions. Authorizes the appropriation of SSAN for each of FY2010
through FY2014.
No appropriations identified.
Quality Improvement Research, Training, and Implementation: New Programs
3501
CRS-32
New PHSA Sec.
933 (AHRQ)
Health care delivery system research. Requires AHRQ to (1) identify, develop,
evaluate, and disseminate innovative strategies for quality improvement practices in
the delivery of health care services that represent best practice; (2) support research
on health care delivery improvement and facilitate adoption of best practices; and (3)
make the research findings available to the public; among other specified functions.
Authorizes the appropriation of $20 million for FY2010 through FY2014.
FY2014 = $5 million
No appropriations identified prior to FY2014.
ACA
Section
Statutory
Authority
(Agency)
Summary of Provision
Funding (FY2010-FY2015)
3501/3511
New PHSA Sec.
934 (AHRQ)
Quality improvement technical assistance and implementation. Requires
AHRQ to award grants (with a matching requirement) to eligible entities for
providing technical support to health care providers in order to help them
understand, adapt, and implement the models and practices identified by the research
conducted by the agency. Grantees must have demonstrated expertise in providing
information and technical support and assistance to health care providers regarding
quality improvement. Authorizes the appropriation of SSAN (no years specified).
No appropriations identified.
3508/3511
New freestanding
authority
Quality and patient safety training. Authorizes the Secretary to award
demonstration grants (with a matching requirement) to eligible health professions
schools or consortia to develop and implement academic curricula that integrate
quality improvement and patient safety into clinical education of health professionals.
Authorizes the appropriation of SSAN (no years specified).
No appropriations identified.
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No appropriations identified prior to FY2014.
.
ACA
Section
Statutory
Authority
(Agency)
Summary of Provision
Funding (FY2010-FY2016)
Health Care Coordination: Existing Program
3510
CRS-33
Amends and
reauthorizes
PHSA Sec. 340A
(HRSA)
Patient navigator program. Prohibits the Secretary from awarding a grant to an
entity under this section unless the entity provides assurances that patient navigators
recruited, assigned, trained, or employed using these grant funds meet certain
minimum core proficiencies. Eligible grantees include public or nonprofit private
health centers (including FQHCs), IHS facilities, hospitals, cancer centers, rural health
clinics, academic health centers, and nonprofit entities that partner or coordinate
referrals with such a facility to provide patient navigator services. Authorizes the
appropriation of $3.5 million for FY2010, and SSAN for each of FY2011 through
FY2015. [CFDA 93.191]
FY2010 = $5 million
FY2011 = $5 million
No appropriations identified since FY2011.
ACA
Section
Statutory
Authority
(Agency)
Summary of Provision
Funding (FY2010-FY2015)
Health Care Coordination: New Programs
3502/3511
New freestanding
authority
Community health team grants to support medical homes. Requires the
Secretary to award grants to or enter into contracts with states, state-designated
entities, and tribal organizations to support community-based interdisciplinary,
interprofessional health teams in assisting primary care practices. Funding must be
used to establish the health teams and to provide capitated payments to the
providers. Authorizes the appropriation of SSAN (no years specified).
No appropriations identified.
3503/3511
New PHSA Sec.
935 (AHRQ)
Medication therapy management (MTM) grants. Requires the Secretary, not
later than May 1, 2010, to provide grants to support MTM services provided by
licensed pharmacists that are targeted at patients who take four or more prescribed
medications, take high-risk medications, have two or more chronic diseases, or have
undergone a transition of care or other factors that are likely to create a high risk for
medication-related problems. Authorizes the appropriation of SSAN (no years
specified).
No appropriations identified.
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.
ACA
Section
Statutory
Authority
(Agency)
Summary of Provision
Funding (FY2010-FY2016)
3506
New PHSA Sec.
936 (AHRQ)
Program to facilitate shared decision making. Requires the Secretary, through
a contract, to develop and identify standards for patient decision aids, to review
patient decision aids, and develop a certification process for determining whether
patient decision aids meet those standards. The contract is to be awarded to the
entity that holds the contract under SSA Sec. 1890 (currently the National Quality
Forum). Further requires the Secretary to (1) award grants or contracts to develop,
update, and produce patient decision aids, to test such materials to ensure they are
balanced and evidence-based, and to educate providers on their use; and (2) to award
grants for establishing Shared Decision Making Resource Centers to develop and
disseminate best practices to speed adoption and effective use of patient decision aids
and shared decision making. Also requires the Secretary to award grants to providers
for the development and implementation of shared decision-making techniques.
Authorizes the appropriation of SSAN for FY2010 and each subsequent fiscal year.
No appropriations identified.
CRS-34
Statutory
Authority
(Agency)
ACA
Section
Summary of Provision
Funding (FY2010-FY2015)
5405
New PHSA Sec.
399V-1 (AHRQ)
Primary care extension program. Requires the Secretary to establish a Primary
Care Extension Program to award state planning and implementation grants for
Primary Care Extension Program State Hubs, consisting of the state health
department and other specified entities. State hubs must contract with and provide
grant funds to county and local entities to serve as Primary Care Extension Agencies
that assist primary care providers in implementing patient-centered medical homes
and develop and support primary care learning communities, among other functions.
Authorizes the appropriation of $120 million for each of FY2011 and FY2012, and
SSAN for each of FY2013 and FY2014.
No appropriations identified.
5604
New PHSA Sec.
520K (SAMHSA)
Co-locating primary and specialty care in community-based mental health
settings. Requires the Secretary to fund demonstration projects for providing
coordinated and integrated services to individuals with mental illness and co-occurring
chronic diseases through the co-location of primary and specialty care services in
community-based mental and behavioral health settings. Authorizes the appropriation
of $50 million for FY2010, and SSAN for each of FY2011 through FY2014.
Note: SAMHSA’s Primary & Behavioral Health Care
Integration (PBHCI) program, authorized under PHSA
Sec. 520A, predates ACA and has received the following
amounts: FY2011 = $28 million (+ $35 million PPHF);
FY2012 = $31 million (+ $35 million PPHF); FY2013 =
$29 million; FY2014 = $5052 million; FY2015 request =
$26 million (+ $8 million = $52 million;
FY2016 request = $28 million (all PPHF).
10333
New PHSA Sec.
340H
Community-based collaborative care network program. Authorizes the
Secretary to award grants to support community-based collaborative care networks
(CCN). An eligible CCN is a consortium of health care providers with a joint
governance structure that provides comprehensive coordinated and integrated health
care services (as defined by the Secretary) for low-income populations. CCNs must
include a safety net hospital and all FQHCs in the community, as specified. Authorizes
the appropriation of SSAN for each of FY2011 through FY2015.
No appropriations identified.
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.
Statutory
Authority
(Agency)
ACA
Section
10410
New PHSA Sec.
520B (SAMHSA)
Summary of Provision
Centers of excellence for depression. Requires SAMHSA to award five-year
grants (with a matching requirement) on a competitive basis to eligible institutions of
higher education or research institutions to establish national centers of excellence
for depression. One grantee is to be designated as the coordinating center and
required to establish and maintain a national database. Centers of excellence may
receive a grant of up to $5 million; the coordinating center may receive a grant of up
to $10 million. Authorizes the appropriation of $100 million for each of FY2011
through FY2015, and $150 million for each of FY2016 through FY2020.
Funding (FY2010-FY2016)
No appropriations identified.
Sources: Table prepared by the Congressional Research ServiceCRS based on the text of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended).
Funding amounts are taken
from agency budget documents, including the FY2014 operating plans, available at http://www.hhs.gov/budget/.
CRS-35
Table 7. ACA Discretionary Spending: Nursing Homes
Statutory
Authority
(Agency)
ACA
Section
Summary of Provision
Funding (FY2010-FY2015FY2016)
6112
New freestanding
authority
National independent monitor demonstration program. Requires the
Secretary, within one year of enactment, to implement a two-year demonstration to
develop, test, and implement an independent monitoring program to oversee
interstate and large intrastate chains of skilled nursing facilities (SNFs) and nursing
facilities (NFs). Authorizes the appropriation of SSAN (no years specified); a
monitored chain must contribute a portion of costs of the demonstration, as
determined by the Secretary.
No appropriations identified.
6114
New freestanding
authority
Culture change and information technology demonstration programs.
Requires the Secretary, within one year of enactment, to award one or more
competitive grants to support each of the following three-year demonstration
projects for SNFs and NFs: (1) develop best practices for culture change (i.e., patientcentric models of care); and (2) develop best practices for the use of health
information technology. Authorizes the appropriation of SSAN (no years specified).
No appropriations identified.
Source: Table prepared by the Congressional Research ServiceCRS based on the text of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended).
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.
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Table 8. ACA Discretionary Spending: Health Disparities Data Collection
Statutory
Authority
(Agency)
ACA
Section
Summary of Provision
Funding (FY2010-FY2015FY2016)
4302(a)
New PHSA Title
XXXI; new Sec.
3101
Health disparities data collection and analysis. Not later than two years after
enactment, requires federally conducted and supported health programs and surveys,
to the extent practicable, to collect and report data on race, ethnicity, sex, primary
language, and disability status, as well as other demographic data on health disparities
as deemed appropriate by the Secretary. Requires the Secretary to adopt standards for
the measurement and collection of such data. Requires the Secretary to analyze the
data collected on health disparities; provide for the public reporting and dissemination
of the data and analyses; and safeguard the privacy of the information. Authorizes the
appropriation of SSAN for each of FY2010 through FY2014; however, data may not be
collected unless funds are directly appropriated for such purpose. [Note: On October
31, 2011, HHS published final standards for collecting and reporting health disparities
data. See http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlid=208.]
No appropriations identified.
5605
New freestanding
authority
Key national indicators. Establishes a Commission on Key National Indicators
composed of eight members appointed by Congress. [Note: The commission members
were appointed in Dec. 2010. See http://www.stateoftheusa.org/content/commissionon-key-national-ind.php.] Requires the commission to contract with the National
Academy of Sciences to review available public and private sector research on key
national indicator set selection and determine how best to establish a key national
indicator system, among other things. Mandates a Government Accountability Office
(GAO) study of previous efforts by public, private, or foreign entities to develop best
practices for a key national indicator system. Authorizes the appropriation of $10
million for FY2010, and $7.5 million for each of FY2011 through FY2018, with amounts
appropriated to remain available until expended. [Note: GAO released its study in
March 2011. See http://www.gao.gov/new.items/d11396.pdf.]
No appropriations identified.
Source: Table prepared by the Congressional Research ServiceCRS based on the text of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended).
CRS-37
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.
Table 9. ACA Discretionary Spending: Emergency Care and Trauma Services
Statutory
ACA
Authority
Summary of Provision
Section
(Agency)
Emergency Care and Trauma Services: Existing Programs
3505(a)
Amends and
Trauma care centers. Requires the Secretary to establish separate grant programs
reauthorizes
for IHS and tribal trauma care centers to (1) help defray substantial uncompensated
PHSA Secs. 1241- care costs, (2) further the core missions of trauma care centers, and (3) provide
emergency relief to ensure the continued availability of trauma services. Authorizes
1245 (HRSA)
the appropriation of $100 million for FY2009, and SSAN for each of FY2010 through
FY2015.
5603
Amends and
Children’s emergency medical services demonstration grants. Expands
reauthorizes
emergency services for children who need treatment for trauma or critical care by
PHSA Sec. 1910
lengthening the period for demonstration grants to four years (with an optional fifth
year). Authorizes the appropriation of $25 million for FY2010, $26.3 million for
(HRSA)
FY2011, $27.6 million for FY2012, $28.9 million for FY2013, and $30.4 million for
FY2014. Note: The Emergency Medical Services for Children Reauthorization Act of
2014 (P.L. 113-180) authorizes the appropriation of $20.2 million for each of FY2015
through FY2019. [CFDA 93.127]
Emergency Care and Trauma Services: New Programs
3504(a)
New PHSA Sec.
Regional systems for emergency care. Requires the Assistant Secretary for
Preparedness and Response to award at least four multi-year contracts or grants
1204 (OS)
(with matching requirement) to states and Indian tribes for pilot projects to improve
regional coordination of emergency services. Priority given to entities serving a
medically underserved population. Authorizes the appropriation of $24 million for
each of FY2010 through FY2014.
3504(b)
New PHSA Sec.
Emergency medicine research. Requires the Secretary to expand and accelerate
498D (NIH,
basic, translational, and service delivery research on emergency medical care systemsmedicine and care
AHRQ, HRSA,
and emergency medicinesystems, including pediatric emergency medical care. Also requires
the Secretary to
support research on the economic impact of coordinated emergency
CDC)
care systems. care systems.
CDC)
Authorizes the appropriation of SSAN for each of FY2010 through
FY2014.
3505(b)
New PHSA Secs.
Trauma service availability grants. Requires the Secretary to award grants to
states for the purpose of supporting trauma-related physician specialties and
1281-1282
broadening access to and availability of trauma care services. States must use at least
40% of the funds for grants to safety net trauma centers. Authorizes the
appropriation of $100 million for each of FY2010 through FY2015.
ACA
Section
Funding (FY2010-FY2015FY2016)
No appropriations identified.
FY2010 = $21 million
FY2011 = $21 million
FY2012 = $21 million
FY2013 = $20 million
FY2014 = $20 million
FY2015 = $20 million
FY2016 request = $20 million
Note: In addition to authorizing funding for the new
program, this ACA provision reauthorized funding for
several existing trauma care grant programs in PHSA
Title XII Parts A and B (i.e., Secs. 1202, 1203, and 12111222). No appropriations identified for any of the
programs.
No appropriations identified.
No appropriations identified.
Sources: Table prepared by the Congressional Research ServiceCRS based on the text of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended).
Funding amounts are taken from HRSA’s budget documents, including the FY2014 operating plan
from HRSA’s and OS’s budget documents, available at http://www.hrsa.gov/about/budget/index.html.
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.
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Table 10. ACA Discretionary Spending: Elder Justice
ACA
Section
Statutory
Authority
(Agency)
6703(a)
New SSA Sec.
2021 (OS)
6703(a)
New SSA Sec.
2022
6703(a)
New SSA Sec.
2024
6703(a)
New SSA Sec.
2031
6703(a)
New SSA Sec.
2041(a)
6703(a)
New SSA Sec.
2041(b)
6703(a)
New SSA Sec.
2041(c)
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Summary of Provision
Elder Justice Coordinating Council. Establishes an Elder Justice Coordinating
Council to include the Secretary as chair and the U.S. Attorney General, as well as
the head of each federal department or agency, identified by the chair, as having
administrative responsibility or administering programs related to elder abuse,
neglect, and exploitation. Authorizes the appropriation of SSAN (no years specified).
See also new SSA Sec. 2024 below.
Advisory Board on Elder Abuse, Neglect, and Exploitation. Establishes an
advisory board to create a short- and long-term multidisciplinary plan for
development of the field of elder justice and to make recommendations to the Elder
Justice Coordinating Council. Authorizes the appropriation of SSAN (no years
specified). See also new SSA Sec. 2024 below.
Authorization of appropriations. Authorizes funding for new SSA Secs. 2021
(Coordinating Council), 2022 (Advisory Board), and 2023 (human subject protection
guidelines for researchers). Authorizes the appropriation of $6.5 million for FY2011,
and $7.0 million for each of FY2012 through FY2014.
Forensic centers and expertise. Requires the Secretary to award grants to eligible
entities to establish and operate stationary and mobile forensic centers and to
develop forensic expertise pertaining to elder abuse, neglect, and exploitation.
Authorizes the appropriation of $4 million for FY2011, $6 million for FY2012, and $8
million for each of FY2013 and FY2014.
Incentives for LTC staffing. Requires the Secretary to award grants to LTC
facilities for them to offer continuing training and varying levels of certification to
employees providing direct care to residents and to improve management practices
so as to promote retention of direct care workers. Authorizes the appropriation of
$20 million for FY2011, $17.5 million for FY2012, and $15 million for each of FY2013
and FY2014 for new SSA Sec. 2041.
Certified EHR technology grant program. Authorizes grants to LTC facilities
for specified activities that would assist such entities in offsetting costs related to
purchasing, leasing, developing, and implementing certified electronic health record
technology. See above authorization of appropriations for new SSA Sec. 2041.
Funding (FY2010-FY2015)
No appropriations identified.
No appropriations identified.
No appropriations identified.
No appropriations identified.
No appropriations identified.
No appropriations identified.
ACA
Section
Statutory
Authority
(Agency)
6703(a)
New SSA Sec.
2041(c)
6703(a)
New SSA Sec.
2042(a)
6703(a)
New SSA Sec.
2042(b)
6703(a)
New SSA Sec.
2042(c)
6703(a)
New SSA Sec.
2043(a)
6703(a)
New SSA Sec.
2043(b)
6703(b)
New freestanding
authority
CRS-40
Summary of Provision
Standards for transactions involving clinical data by LTC facilities. Requires
the Secretary to adopt electronic standards for the exchange of clinical data by LTC
facilities and, within 10 years, to have in place procedures to accept the optional
electronic submission of clinical data by LTC facilities pursuant to such standards. See
above authorization of appropriations for new SSA Sec. 2041.
Funding (FY2010-FY2016)
No appropriations identified.
No appropriations identified.
No appropriations identified.
No appropriations identified.
No appropriations identified.
No appropriations identified.
No appropriations identified.
.
ACA
Section
Statutory
Authority
(Agency)
Summary of Provision
6703(a)
New SSA Sec.
2042(a)
Adult protective service functions. Requires the Secretary to undertake various
activities with respect to adult protective services, including providing funding,
collecting and disseminating data on elder abuse, disseminating information on best
practices and training, conducting research, and providing technical assistance to
states and other entities. Authorizes the appropriation of $3 million for FY2011, and
$4 million for each of FY2012 through FY2014.
6703(a)
New SSA Sec.
2042(b)
6703(a)
New SSA Sec.
2042(c)
6703(a)
New SSA Sec.
2043(a)
6703(a)
New SSA Sec.
2043(b)
6703(b)
New freestanding
authority
6703(b)
New freestanding
authority
Grants to enhance provision of adult protective services. Requires the
Secretary to award formula grants to states to enhance adult protective services
programs provided by states and local governments. Authorizes the appropriation of
$100 million for each of FY2011 through FY2014.
Adult protective services demonstration grants. Requires the Secretary to
fund state demonstration programs for adult protective services that test methods to
prevent and detect elder abuse. Authorizes the appropriation of $25 million for each
of FY2011 through FY2014.
Long-term care ombudsman program grants. Requires the Secretary to award
grants to improve the capacity of state LTC ombudsman programs to address abuse
and neglect complaints, conduct pilot programs, and provide support for such
programs. Authorizes the appropriation of $5 million for FY2011, $7.5 million for
FY2012, and $10 million for each of FY2013 and FY2014.
Ombudsman training programs. Requires the Secretary to establish programs to
provide and improve ombudsman training with respect to elder abuse, neglect, and
exploitation for national organizations and state LTC ombudsman programs.
Authorizes the appropriation of $10 million for each of FY2011 through FY2014.
National Training Institute for Surveyors. Requires that the Secretary enter
into a contract with an entity to establish and operate a National Training Institute for
Federal and State Surveyors to train surveyors who investigate allegations of abuse in
programs and LTC facilities that receive payments under Medicare or Medicaid.
Authorizes the appropriation of $12 million for the period of FY2011 through
FY2014.
Funding (FY2010-FY2015)
No appropriations identified.
No appropriations identified.
No appropriations identified.
No appropriations identified.
No appropriations identified.
No appropriations identified.
No appropriations identified.
Statutory
Authority
(Agency)
ACA
Section
6703(b)
New freestanding
authority
6703(c)
New freestanding
authority
Summary of Provision
Grants to state survey agencies. Requires the Secretary to award grants to state
survey agencies that perform surveys of Medicare or Medicaid participating nursing
facilities to design and implement complaint investigation systems. Authorizes the
appropriation of $5 million for each of FY2011 through FY2014.
Grants to state survey agencies. Requires the Secretary to award grants to state
survey agencies that perform surveys of Medicare or Medicaid participating nursing
facilities to design and implement complaint investigation systems. Authorizes the
appropriation of $5 million for each of FY2011 through FY2014.
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Funding (FY2010-FY2016)
FY2015 = $4 million
FY2016 request = $25 million
No appropriations identified prior to FY2015. For more
information, see CRS Report R43707, The Elder Justice
Act: Background and Issues for Congress, by Kirsten J.
Colello.
No appropriations identified.
No appropriations identified.
No appropriations identified.
No appropriations identified.
No appropriations identified.
No appropriations identified.
.
Statutory
Authority
(Agency)
ACA
Section
6703(c)
New freestanding
authority
Summary of Provision
National nurse aide registry study and report. Requires the Secretary, in
consultation with appropriate government agencies and private sector organizations,
to conduct a study on establishing a national nurse aide registry and report on its
findings. Authorizes the appropriation of SSAN (no years specified) to carry out these
activities, with funding not to exceed $500,000.
Funding (FY2010-FY2015FY2016)
No appropriations identified.
No appropriations identified.
Source: Table prepared by the Congressional Research ServiceCRS based on the text of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended).
Table 11. ACA Discretionary Spending: Biomedical Research
Statutory
Authority
(Agency)
ACA
Section
10409
Amends PHSA
Secs. 402(b) and
499(c); new
PHSA Sec. 402Ca
(NIH)
Summary of Provision
Cures Acceleration Network (CAN). Establishes a CAN program within the
Office of the NIH Directora to award grants, contracts, or cooperative agreements to
support the development of treatments for diseases or conditions that are rare, and
for which market incentives are inadequate. Eligible grantees include public or private
entities, which may include private or public research institutions, institutions of
higher education, medical centers, biotechnology companies, pharmaceutical
companies, disease advocacy organizations, patient advocacy organizations, and
academic research institutions. Authorizes the appropriation of $500 million for
FY2010, and SSAN for subsequent fiscal years. Other funds appropriated under the
PHSA may not be allocated to CAN.
Funding (FY2010-FY2015FY2016)
FY2012 = $10 million
FY2013 = $9 million
FY2014 = $10 million
FY2015 = $10 million
FY2016 request = $3026 million
Sources: Table prepared by the Congressional Research ServiceCRS based on the text of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended).
Funding amounts are taken
from NIH’s budget documents, including the FY2014 operating plan, available at http://officeofbudget.od.nih.gov/br.html.
a.
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P.L. 112-74 created the National Center for Advancing Translational Sciences (NCATS) within NIH and transferred the CAN program from the Office of the NIH
Director to NCATS. It also redesignated PHSA Sec. 402C as Sec. 480.
.
Table 12. ACA Discretionary Spending: Biologics
Statutory
Authority
(Agency)
ACA
Section
7002
Amends PHSA
Sec. 351 (FDA)
Summary of Provision
Funding (FY2010-FY2016)
FDA approval of biosimilar biologics. Creates an abbreviated regulatory pathway
for approving biological products that are demonstrated to be biosimilar to, or
interchangeable with, an FDA-licensed biological product. Provides for the collection
of user fees, subject to congressional authorization, to cover regulatory costs
beginning in FY2013. Authorizes the appropriation of SSAN for each of FY2010
through FY2012. For more information on FDA regulation of biosimilar biological
products, see http://www.fda.gov/Drugs/DevelopmentApprovalProcess/
HowDrugsareDevelopedandApproved/ApprovalApplications/
TherapeuticBiologicApplications/Biosimilars/default.htm.
Funding (FY2010-FY2015)
No appropriations identified (FY2010-FY2012).
FY2013 = $1 million (user fees)
FY2014 = $1 million (user fees)
FY2015 request = $1 million (user fees)
Source: Table prepared by the Congressional Research Service.
Appropriators have provided for the following user fees
to be assessed:
FY2013 = $20 million
FY2014 = $21 million
FY2015 = $21 million
FY2016 request = $22 million
Source: Table prepared by CRS based on the text of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended).
Funding amounts are taken from
FDA’s budget documents, including the FY2014 operating plan, available at http://www.fda.gov/AboutFDA/ReportsManualsForms/
Reports/BudgetReports/default.htm.
Table 13. ACA Discretionary Spending: 340B Drug Pricing
Statutory
Authority
(Agency)
ACA
Section
7102
Amends PHSA
Sec. 340B(d)
(HRSA)
Summary of Provision
Improvements to 340B program integrity. Requires the Secretary to develop
systems to improve compliance and program integrity to (1) increase transparency
and strengthen monitoring, oversight, and investigation of the prices that
manufacturers charge covered entities; and (2) ensure covered entities do not divert
drugs or obtain multiple discounts. Further requires the Secretary to establish a new
administrative dispute resolution process to mediate and resolve covered entity
overpayment claims and manufacturer claims against covered entities for drug
diversion or multiple discounts. Authorizes the appropriation of SSAN for FY2010
and each succeeding fiscal year.
Funding (FY2010-FY2015FY2016)
FY2010 = $2 million
FY2011 = $4 million
FY2012 = $4 million
FY2013 = $4 million
FY2014 = $10 million
FY2015 = $10 million
FY2016 request = $1725 million (includes $78 million from a
proposed new user fee program)
Sources: Table prepared by the Congressional Research ServiceCRS based on the text of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended).
Funding amounts are taken
from HRSA’s budget documents, including the FY2014 operating plan, available at http://www.hrsa.gov/about/budget/index.html.
CRS-42
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.
Table 14. ACA Discretionary Spending: Medical Malpractice
Statutory
Authority
(Agent)
ACA
Section
10607
New PHSA Sec.
399V-4 (HRSA)
Summary of Provision
Liability reform demonstration program. Authorizes five-year demonstration
grants to states for the implementation and evaluation of alternatives to current tort
litigation for resolving disputes over injuries allegedly caused by health care providers
or organizations. Planning grants of up to $500,000 may be awarded to states for the
development of demonstration project applications. To receive a grant, a state must
develop an alternative system that allows for the resolution of disputes caused by
health care providers or organizations, and reduces medical errors by encouraging
the collection and analysis of patient safety data related to the resolved disputes.
Authorizes the appropriation of $50 million for the period FY2011 through FY2015.
Funding (FY2010-FY2015FY2016)
No appropriations identified.
Source: Table prepared by the Congressional Research ServiceCRS based on the text of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended).
Table 15. ACA Discretionary Spending: Pain Care Management
Statutory
Authority
(Agency)
ACA
Section
4305(a)
New freestanding
authority
Summary of Provision
Conference on pain. Requires the Secretary, within one year of appropriating
funds, to contract with the IOM to convene a Conference on Pain for the purpose of
assessing the public health impact of pain, reviewing pain research, care, and
education, and identifying barriers to improved pain care. A report summarizing the
Conference’s findings must be submitted to Congress by June 30, 2011. Authorizes
the appropriation of SSAN for each of FY2010 and FY2011. [Note: IOM released its
report on June 29, 2011. See http://painconsortium.nih.gov/.]
Funding (FY2010-FY2015FY2016)
No appropriations identified.
Source: Table prepared by the Congressional Research ServiceCRS based on the text of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended).
CRS-43
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.
Table 16. ACA Discretionary Spending: Medicaid
Statutory
Authority
(Agency)
ACA
Section
Summary of Provision
Funding (FY2010-FY2015FY2016)
2705
New freestanding
authority (CMS)
Global payment system demonstration program. Requires the Secretary, in
coordination with the Center for Medicare and Medicaid Innovation, to fund up to
five Medicaid demonstrations during the period FY2010 through FY2012 under which
a participating state will adjust payments made to a large safety net hospital system or
network from a fee-for-service model to a global capitated payment model.
Authorizes the appropriation of SSAN (no years specified).
No appropriations identified.
2706
New freestanding
authority (CMS)
Pediatric accountable care organization demonstration program. Requires
the Secretary to conduct a five-year Medicaid demonstration (Jan. 1, 2012, through
Dec. 31, 2016) under which a participating state is allowed to recognize pediatric
providers as an accountable care organization (ACO) for the purpose of receiving
incentive payments. Eligible pediatric providers must meet certain performance
guidelines established by the Secretary to be recognized as an ACO, and must achieve
a specified minimum level of Medicaid savings to receive an incentive payment.
Authorizes the appropriation of SSAN (no years specified).
No appropriations identified.
Source: Table prepared by the Congressional Research ServiceCRS based on the text of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended).
Table 17. ACA Discretionary Spending: Medicare
Statutory
Authority
(Agency)
ACA
Section
3129
Amends and
reauthorizes SSA
Sec. 1820 (HRSA)
Summary of Provision
Rural hospital flexibility grant program. Extends authorization of appropriations
for the rural hospital flexibility (Flex) grants that support a range of performance and
quality improvement activities at small rural hospitals. Permits the funding to be used
to help rural hospitals participate in delivery system reform programs authorized
under ACA. Authorizes the appropriation of SSAN for each of FY2011 and FY2012,
to remain available until expended. [CFDA 93.241]
Funding (FY2010-FY2015FY2016)
FY2010 = $41 million
FY2011 = $41 million
FY2012 = $41 million
FY2013 = $38 million
FY2014 = $41 million
FY2015 = $42 million
FY2016 request = $26 million
Sources: Table prepared by the Congressional Research ServiceCRS based on the text of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended).
Funding amounts are taken
from HRSA’s budget documents, including the FY2014 operating plan, available at http://www.hrsa.gov/about/budget/index.html.
CRS-44
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.
Table 18. ACA Discretionary Spending: Private Health Insurance
Statutory
Authority
(Agency)
ACA
Section
1334
New freestanding
authority (OPM)
Summary of Provision
Multi-state health plans. Requires OPM to contract with health insurers to offer
at least two multi-state health plans (at least one nonprofit) through exchanges in
each state. Authorizes OPM to prohibit multi-state plans that do not meet standards
for medical loss ratios, profit margins, and premiums. Requires multi-state plans to
cover essential health benefits and meet all the requirements of a qualified health plan.
Authorizes the appropriation of SSAN (no years specified). [Note: On March 11,
2013,
OPM published a final rule to implement the multi-state plan program (78
Federal Federal
Register 15560).]
Funding (FY2010-FY2015FY2016)
No appropriations identified.
Source: Table prepared by the Congressional Research ServiceCRS based on the text of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended).
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Discretionary Spending Under the Affordable Care Act (ACA)
Appendix. Expired and Expiring Authorizations of
Appropriations
Table A.
Appendix A. Discretionary Spending and the
Budget Control Act of 2011
Since FY2010, Congress has taken a number of steps to curb federal discretionary spending.
During negotiations to complete the FY2011 appropriations process and avert a government
shutdown in early 2011, lawmakers agreed to cuts in discretionary spending for a broad range of
agencies and programs. Congress and the President then enacted the Budget Control Act (BCA)
of 2011,24 which established enforceable discretionary spending limits, or caps, for each of
FY2012 through FY2021. Operating under the caps, Congress reduced funding for many
discretionary programs during the FY2012-FY2015 annual appropriations cycle process.
The BCA also triggered annual spending reductions beginning in FY2013 for both defense and
nondefense spending. All the spending on programs and activities summarized in this report falls
within the nondefense category. The BCA spending reductions involve a combination of
automatic across-the-board spending cuts to nonexempt programs through a process known as
sequestration, as well as lowering the BCA-imposed discretionary spending caps. More details on
the BCA annual spending reductions are provided in the text box below.
Trends in Nondefense Discretionary Spending
Nondefense discretionary (NDD) spending includes such activities as transportation, education
grants, housing assistance, public health programs, biomedical research, veterans’ health care,
most homeland security activities, the federal justice system, foreign aid, and environmental
protection.
According to CBO, federal NDD spending has represented a fairly stable share of the economy
since 1962, averaging about 3.8% of gross domestic product (GDP). NDD spending was at its
highest between 1975 and 1981, when it averaged almost 5% of GDP. It increased again between
2009 and 2011 as a result of stimulus spending under the American Recovery and Reinvestment
Act (ARRA). During this period NDD outlays represented 4.5% of GDP.25
NDD spending as a share of GDP is now declining and fell to 3.4% in 2014, CBO estimates.
Under the current deficit-reduction policies, CBO projects that NDD spending in 2016 will fall to
its lowest level as a share of GDP since 1962 and will continue to decline thereafter.26
24
P.L. 112-25, 125 Stat. 240.
U.S. Congressional Budget Office, The Budget and Economic Outlook: 2015 to 2025, January 2015, p. 79,
https://www.cbo.gov/sites/default/files/cbofiles/attachments/49892-Outlook2015.pdf.
26
Ibid., pp.83-84.
25
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Annual Spending Reductions Under the Budget Control Act
The BCA amended the Balanced Budget and Emergency Deficit Control Act of 1985 (BBEDCA) by establishing two
budget enforcement mechanisms to reduce federal spending over the 10-year period FY2012 through FY2021. First, it
established enforceable limits, or caps, on discretionary spending for each of those years. The discretionary spending
caps grow by about 2% each year. 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-the-board 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 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.
Congress has since revised the discretionary spending caps set by the BCA. First, the American Taxpayer Relief Act
of 2012 (ATRA; P.L. 112-240) adjusted the FY2013 and FY2014 caps. Second, the Bipartisan Budget Act of 2013
(BBA; P.L. 113-67, Division A) established new caps for FY2014 and FY2015 and eliminated the BCA-triggered cap
reductions for those two years.
The FY2013 sequestration order reduced spending on nonexempt nondefense mandatory programs by 5.1% and
reduced nondefense discretionary (NDD) spending by about 5.0% [Note: These amounts reflect adjustments made by
ATRA, which reduced the overall dollar amount that needed to be cut from FY2013 defense and nondefense
spending.] For technical reasons, OMB concluded that cuts in mandatory (i.e., CHCF) funding for community health
centers and migrant health centers are capped at 2%.
The FY2014 sequestration order reduced spending on nonexempt nondefense mandatory programs by 7.2%. OMB
also lowered the FY2014 NDD spending cap (adjusted by ATRA) by $37 billion, pursuant to the BCA. The BBA then
established a new NDD spending cap for FY2014 (i.e., $491.8 billion), which is more than $22 billion above the BCAlowered FY2014 spending cap that it replaced, and almost $24 billion above the FY2013 post-sequestration NDD
funding level.
The FY2015 sequestration order reduces spending on nonexempt nondefense mandatory programs by 7.3%. The
FY2015 NDD spending cap (i.e., $492.4 billion) is virtually unchanged from the FY2014 NDD spending cap, both set
by the BBA.
The FY2016 sequestration order reduces spending on nonexempt nondefense mandatory programs by 6.8%. The
BCA-lowered FY2016 NDD spending cap, which is projected by OMB to be $493.5 billion, is about $1 billion above
the NDD spending cap for the previous year. [Note: The discretionary spending cap reductions required by the BCA
resume in FY2016.]
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Appendix B. Expired and Expiring Authorizations
of Appropriations
Table B-1. Programs with Expired Authorizations of Appropriations
Listed by Topic Area, Program Name, and ACA Section Number
Health Centers and Clinics (Table 2)
School-Based Health Centers (Sec. 4101(b))
Nurse-Managed Health Clinics (Sec. 5208)
Health Care Workforce (Table 3)
Primary Care Training & Enhancement (Sec. 5301)
Community Health Worker Program (Sec. 5313)
Pediatric Specialist Loan Repayment Program (Sec. 5203)
CDC Training Fellowships (Sec. 5314)
Rural physician Training Grants (Sec. 10501(l))
USPHS Commissioned Corps Ready Reserve (Sec. 5210)
Nurse Faculty Loan Program (Sec. 5311(a))
Scholarships for Disadvantaged Students (Sec. 5402)
Nurse Faculty Loan Repayment Program (Sec. 5311(b)
Faculty Loan Repayment Program (Sec. 5402)
Family Nurse Practitioner Demonstration (Sec. 5316)
Health Careers Opportunity Program (Sec. 5402)
Geriatric Nursing Education and Training (Sec. 5305(c))
Area Health Education Centers (Sec. 5403(a))
Direct Care Worker Training (Sec. 5302)
Mental/Behavioral Health Education and Training (Sec. 5306)
Geriatric Workforce Development (Sec. 5305(a))
National Center for Health Care Workforce Analysis
(Sec. 5103)
Education and Training In Pain Care (Sec. 4305(c))
Prevention and Wellness (Table 4)
Offices of Women’s Health (Sec. 3509/3511)
Community Transformation Grants (Sec. 4201)
School-Based Dental Sealant Program (Sec. 4102(b))
Community Wellness Pilot Program (Sec. 4202(a))
Immunization Demonstration Grants (Sec. 4204(b))
Epidemiology & Laboratory Capacity Grants (Sec. 4304)
Rural Access to Emergency Devices (Sec. 10412)
Young Women’s Breast Health Awareness (Sec. 10413)
Oral Health Infrastructure (Sec. 4102(c))
National Diabetes Prevention Program (Sec. 10501(g))
Oral Health Surveillance (Sec. 4102(d))
Maternal and Child Health (Table 5)
Individuals with Postpartum Depression (Sec. 2952(b))
Health Care Quality (Table 6)
Quality and Efficiency Measures Development (Sec. 3013)
Health Care Delivery System Research (Sec. 3501)
Collection and Analysis of Quality Data (Sec. 3015)
Primary Care Extension Program (Sec. 5405)
Public Reporting of Quality Measures (Sec. 3015)
Co-Locating Primary and Specialty Care (Sec. 5604)
Health Disparities (Table 8)
Data Collection and Analysis (Sec. 4302(a))
Emergency Care and Trauma Services (Table 9)
Children’s Emergency Medical Services (Sec. 5603)
Emergency Medicine Research (Sec. 3504(b))
Regional Systems for Emergency Use (Sec. 3504(a))
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Elder Justice (Table 10)
Elder Justice Coordinating Council (Sec. 6703(a))
LTC Ombudsman Program & Training (Sec. 6703(a))
Forensic Centers and Expertise (Sec. 6703(a))
National Training Institute of Surveyors (Sec. 6703(b))
LTC Facility Staffing & Information Technology (Sec. 6703(a))
Grants to State Survey Agencies (Sec. 6703(b))
Adult Protective Services (Sec. 6703(a))
Medicare (Table 17)
Rural Hospital Flexibility Grant Program (Sec. 3129)
Source: Table prepared by the Congressional Research ServiceCRS based on the text of the Patient Protection and
Affordable Care Act (ACA; P.L.
111-148, as amended).
Notes: Programs listed in roman type have received annual discretionary appropriations. Programs for which
CRS could not identify any specific discretionary appropriations are listed in italic type. In some cases a program
may receive funding from another budget account; see Tables 2-18 for additional details on program funding.
Table AB-2. Programs Whose Authorizations of Appropriations Expire at the End of
FY2015
Listed by Topic Area, Program Name, and ACA Section Number
Health Care Workforce (Table 3)
General and Pediatric Dentistry Training (Sec. 5303)
Public Health & Allied Health Scholarships (Sec. 5206(b))
Public Health & Preventive Medicine (Sec. 10501(m)(2))
Cultural Competency, Prevention, Public Health, Disparities,
and Individuals with Disability Training (Secs. 5307(a)&(b))
Public Health Workforce Loan Repayment Program (Sec.
5204)
Prevention and Wellness (Table 4)
Congenital Heart Disease Program (Sec. 10411)
Small Business Wellness Program (Sec. 10408)
Health Care Quality (Table 6)
Patient Navigator Program (Sec. 3510)
Community-Based Collaborative Care Network (Sec. 10333)
Emergency Care and Trauma Services (Table 9)
Trauma Care Centers (Sec. 3505(a))
Trauma Service Availability Grants (Sec. 3505(b))
Medical Malpractice (Table 14)
Liability Reform Demonstration Program (Sec. 10607)
Source: Table prepared by the Congressional Research ServiceCRS based on the text of the Patient Protection and
Affordable Care Act (ACA; P.L.
111-148, as amended).
Notes: Programs listed in roman type have received annual discretionary appropriations. Programs for which
CRS could not identify any specific discretionary appropriations are listed in italic type. In some cases, a program
may receive funding from another budget account; see Tables 2-18 for additional details on program funding.
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Discretionary Spending Under the Affordable Care Act (ACA)
.
Author Contact Information
C. Stephen Redhead, Coordinator
Specialist in Health Policy
credhead@crs.loc.gov, 7-2261
Sarah A. Lister
Specialist in Public Health and Epidemiology
slister@crs.loc.gov, 7-7320
Kirsten J. Colello
Specialist in Health and Aging Policy
kcolello@crs.loc.gov, 7-7839
Amanda K. Sarata
Specialist in Health Policy
asarata@crs.loc.gov, 7-7641
Elayne J. Heisler
Specialist in Health Services
eheisler@crs.loc.gov, 7-4453
Acknowledgments
Kirsten J. Colello, Elayne J. Heisler, Sarah A. Lister, and Amanda K. Sarata helped prepare the tables in the
initial version of this report. They continue to provide and review revised funding information for each
report update.
Key Policy Staff
Area of Expertise
Health Centers and Clinics (Table 2)
Health Care Workforce (Table 3)
Long-Term Care (Table 3)
Prevention and Wellness (Table 4)
Maternal and Child Health (Table 5)
Health Care Quality (Table 6)
Nursing Homes (Table 7)
Health Disparities (Table 8)
Emergency Care (Table 9)
Elder Justice (Table 10)
Biomedical Research (Table 11)
Biologics (Table 12)
340B Drug Pricing (Table 13)
Medical Malpractice (Table 14)
Pain Care Management (Table 15)
Medicaid (Table 16)
Medicare (Table 17)
Private Health Insurance (Table 18)
c11173008
Congressional Research Service
Name
Elayne J. Heisler
C. Stephen Redhead
Elayne J. Heisler
Bernice Reyes-Akinbileje
Kirsten J. Colello
Sarah A. Lister
Emilie Stoltzfus
Amanda K. Sarata
Cliff Binder
C. Stephen Redhead
Elayne J. Heisler
Kirsten J. Colello
Judith A. Johnson
Judith A. Johnson
Cliff Binder
Vivian S. Chu
Kirsten J. Colello
Cliff Binder
Sibyl Tilson
Bernadette Fernandez
Annie Mach
Phone
7-4453
7-2261
7-4453
7-2260
7-7839
7-7320
7-2324
7-7641
7-7965
7-2261
7-4453
7-7839
7-7077
7-7077
7-7965
7-4576
7-7839
7-7965
7-7368
7-0322
7-7825
Email
eheisler@crs.loc.gov
credhead@crs.loc.gov
eheisler@crs.loc.gov
breyes@crs.loc.gov
kcolello@crs.loc.gov
slister@crs.loc.gov
estoltzfus@crs.loc.gov
asarata@crs.loc.gov
cbinder@crs.loc.gov
credhead@crs.loc.gov
eheisler@crs.loc.gov
kcolello@crs.loc.gov
jajohnson@crs.loc.gov
jajohnson@crs.loc.gov
cbinder@crs.loc.gov
vchu@crs.loc.gov
kcolello@crs.loc.gov
cbinder@crs.loc.gov
stilson@crs.loc.gov
bfernandez@crs.loc.gov
amach@crs.loc.gov
4847