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Discretionary Spending Under the Affordable Care Act (ACA)

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. 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 c11173008 Discretionary Spending Under the Affordable Care Act (ACA) . 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. c11173008 Congressional Research Service Discretionary Spending Under the Affordable Care Act (ACA) . 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 c11173008............ 46 Congressional Research Service Discretionary Spending Under the Affordable Care Act (ACA) . Contacts Author Contact Information........................................................................................................... 4847 Acknowledgments ......................................................................................................................... 4847 Key Policy Staff ............................................................................................................................. 4847 c11173008 Congressional Research Service Discretionary Spending Under the Affordable Care Act (ACA) . 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. Congressional Research Service 1 Discretionary Spending Under the Affordable Care Act (ACA) 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 c11173008 Congressional Research Service 1 Discretionary Spending Under the Affordable Care Act (ACA) . 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. c11173008 Congressional Research Service 2 Discretionary Spending Under the Affordable Care Act (ACA) . 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. Congressional Research Service 2 Discretionary Spending Under the Affordable Care Act (ACA) 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. c11173008 Congressional Research Service 3 Discretionary Spending Under the Affordable Care Act (ACA) . 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...) 7 Congressional Research Service 3 Discretionary Spending Under the Affordable Care Act (ACA) 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 (continued...) Congressional Research Service 4 Discretionary Spending Under the Affordable Care Act (ACA) 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 c11173008 Congressional Research Service 4 Discretionary Spending Under the Affordable Care Act (ACA) . 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. Congressional Research Service 5 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. c11173008 Congressional Research Service 5 Discretionary Spending Under the Affordable Care Act (ACA) . (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. c11173008 Congressional Research Service 6 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 Congressional Research Service 7 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 8 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. c11173008 Congressional Research Service 7 . 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 c11173008 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 c11173008 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 c11173008 CRS-10 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. c11173008 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. c11173008 CRS-21CRS-23 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 c11173008 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) c11173008 CRS-23 . 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 c11173008 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 c11173008 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 c11173008 CRS-26CRS-28 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 c11173008 CRS-27 . 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. c11173008 CRS-28 . 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. c11173008 CRS-29 . 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. c11173008 CRS-30 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. c11173008 CRS-31 . 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. c11173008 CRS-32 . 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). c11173008 CRS-33 . CRS-36 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 c11173008 CRS-34 . 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. c11173008 CRS-35 . CRS-38 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) c11173008 CRS-36CRS-39 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. c11173008 CRS-37 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. c11173008 CRS-38CRS-41 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 c11173008 CRS-39 . 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 c11173008 CRS-40 . 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 c11173008 CRS-41 . 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). c11173008 CRS-42CRS-45 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 c11173008 Congressional Research Service 43 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. 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.] c11173008 Congressional Research Service 44 Discretionary Spending Under the Affordable Care Act (ACA) . 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)) c11173008 Congressional Research Service 4645 Discretionary Spending Under the Affordable Care Act (ACA) . 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. c11173008 Congressional Research Service 4746 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