CRS Insights
Congress Faces Calls to Address Expiring ACA Appropriations
C. Stephen Redhead, Specialist in Health Policy (credhead@crs.loc.gov, 7-2261)
Elayne J. Heisler, Specialist in Health Services (eheisler@crs.loc.gov, 7-4453)
November 25, 2014 (IN10185)
The Affordable Care Act (ACA), enacted in March 2010, appropriated billions of dollars of mandatory
funds to support grant programs and other activities authorized by the law. For example, it
appropriated a total of $16 billion to support three temporary health care programs for targeted groups
prior to the exchanges becoming operational, and provided an open-ended amount for state grants
through 2014 to plan and establish exchanges. The ACA also appropriated five years of funding for
home visitation and other maternal and child health (MCH) programs. And it included $11 billion over
five years for the Federal Health Centers program and the National Health Service Corps (NHSC).
The Primary Care "Cliff"
Advocates for the nation's primary care system are urging Congress to extend ACA funding for health
centers and the NHSC. Those funds expire this year (i.e., FY2015), setting up what the advocates are
calling a "primary care cliff" that will result in a significant drop in funding for primary care programs
that deliver services, place primary care providers in underserved areas, and train future providers.
The Health Centers and NHSC programs are cornerstones of the government's efforts to expand access
to primary care. The Health Centers program helps support more than 1,300 community-based health
centers operating over 9,200 delivery sites across the country. Health centers provide care to medically
underserved populations regardless of their ability to pay. The NHSC program awards scholarships and
loan repayment to certain health professionals who agree to practice in shortage areas, often at health
centers.
The ACA established the Community Health Center Fund (CHCF) to help support the Health Centers
and NHSC programs, and gave it a total of $11 billion in annual appropriations over the five-year
period FY2011-FY2015. CHCF funding was intended to supplement the discretionary funds that the two
funds to support grant programs and other activities. Specifically, it provided support for three programs focused on expanding access to primary care services for populations that are typically underserved. These three programs are the Health Centers program, the National Health Service Corps (NHSC), and payments to support medical residents training at teaching health centers—outpatient health facilities that primarily provide care to underserved populations.
The ACA funds were initially for five years, but funding for these three programs was subsequently extended for two years (i.e., for FY2016 and FY2017) in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA; P.L. 114-10). The President's FY2018 budget proposes extending funding for these programs for two more years.
Community Health Center Fund
The ACA established the Community Health Center Fund (CHCF) to help support the Health Centers and NHSC programs, and gave it a total of $11 billion in annual appropriations over the five-year period FY2011-FY2015. MACRA subsequently provided $7.2 billion for health centers and $580 million for the NHSC for an additional two years. CHCF funding was initially intended to supplement the annual discretionary funds that the two programs receive through the regular appropriations process. However,
the CHCF has partially replaced
CHCF funds have replaced a significant portion of the Health Center program's annual discretionary appropriations, which
have beenCongress has reduced since
FY2010 (see Table 1). In
FY2014FY2016, CHCF funding represented about
6071% of the Health Center
program's funding. In the case of the NHSC program, Congress eliminated its annual discretionary
appropriation entirely. Since FY2012
, the program has relied solely on CHCF funding (see Table 1
).
).
Table 1. Health Centers and NHSC Funding
(Millions of Dollars, by Fiscal Year)
Health Centers
Discretionary
CHCF
% CHCF
NHSC
Discretionary
CHCF
% CHCF
2010
2,141
NA
0%
141
NA
0%
2011
1,481
1,000
40.3%
25
290
92.1%
2012
1,472
1,200
48.3%
0
295
100%
2013
1,391
1,465
51.3%
0
285
100%
2014
1,400
2,145
60.5%
0
283
100%
2015
TBD
3,600
TBD
TBD
287
TBD
Source:
(Millions of Dollars, by Fiscal Year)
2010
|
2011
|
2012
|
2013
|
2014
|
2015
|
2016
|
2017
|
2018 (Request)
|
Health Centers
|
|
Discretionary
|
2,141
|
1,481
|
1,472
|
1,391
|
1,400
|
1,392
|
1,492
|
1,492
|
1,489
|
|
CHCF
|
NA
|
1,000
|
1,200
|
1,465
|
2,145
|
3,510
|
3,600
|
3,516
|
3,600a
|
|
% CHCF
|
0%
|
40.3%
|
48.3%
|
51.3%
|
60.5%
|
71.6%
|
70.7%
|
70.2%
|
70.7%
|
NHSC
|
|
Discretionary
|
141
|
25
|
0
|
0
|
0
|
0
|
0
|
0
|
0
|
|
CHCF
|
NA
|
290
|
295
|
285
|
283
|
287
|
310
|
289
|
310a
|
|
% CHCF
|
0%
|
92.1%
|
100%
|
100%
|
100%
|
100%
|
100%
|
100%
|
100%
|
Source: Prepared by CRS based on
HHS budget documents.
Notes: FY2013 reflects sequestrations of discretionary and CHCF funds; FY2014, FY2015, and FY2017 reflect sequestration of the CHCF.
a.
Proposed mandatory funding.
The teaching health center (THC) program was created by the ACA, which appropriated $230 million for five years. MACRA subsequently provided $60 million for each of FY2016 and FY2017. This program has never received discretionary funding. The THC program has trained 600 primary care residents primarily in underserved communities. More than three-quarters of the program's recent graduates are practicing primary care and nearly a third are doing so in a medically underserved areas.
The Primary Care "Cliff"
In FY2015, when the original ACA funding was set to expire, advocates for the nation's primary care system referred to this as a "primary care cliff" that would have resulted in a significant drop in funding for primary care programs that deliver services, place primary care providers in underserved areas, and train future providers.
The Health Centers and NHSC programs are cornerstones of the federal government's efforts to expand access to primary care. The Health Centers program helps support more than 1,400 community-based health centers operating over 10,500 delivery sites across the country. Health centers provide care to medically underserved populations regardless of their ability to pay. They provide care for more than 24 million people annually, or an average of one in 13 Americans. The NHSC program awards scholarships and loan repayment to certain health professionals—nearly 8,500 in recent years—who agree to practice in shortage areas, often at health centers.
No Funding for FY2018
Advocates of these programs see the loss of mandatory funds at the end of FY2017 as compounded by the reduction—in the case of the NHSC, the elimination—of annual discretionary funding for these programs. If the MACRA funding is not extended beyond the current fiscal year, congressional appropriations would face a need for more than $4 billion in new discretionary funds in FY2018 in order to maintain the current level of support for these programs. That could prove a tall order under the discretionary spending limits currently in place.
The President's FY2018 budget proposes new mandatory funding—$3.6 billion for health centers and $310 million for the NHSC—for each of FY2018 and FY2019 (see Table 1).
HHS budget documents.
Notes: FY2013, FY2014, and FY2015 (NHSC only) amounts reflect sequestration. NA
= not applicable. TBD = to be determined.
A bipartisan group of lawmakers has addressed the upcoming funding "cliff" in a letter to congressional
leaders. Advocates for the Health Center and NHSC programs have also sent a letter to the
congressional leadership signed by numerous national stakeholder groups. In addition to these two
programs, both letters mention the ACA's Teaching Health Center (THC) program, for which the ACA
appropriated $230 million. THCs are community-based outpatient facilities that train medical or dental
residents in primary care. The ACA's THC funds, which also expire in FY2015, help cover the costs of
training residents.
Though not addressed by advocates, another ACA provision is set to expire at the end of calendar year
2014 that may affect primary care access for Medicaid beneficiaries. The law provided higher Medicaid
reimbursement rates to certain primary care providers who serve Medicaid patients; these payments
will revert to their pre-ACA levels on January 1, 2015. ACA also included higher primary care payments
for Medicare providers, though these payment rates are in place through January 1, 2016.
Congress Has Extended and Rescinded ACA Appropriations
Congress has already acted on three separate occasions—in P.L. 112-240, P.L. 113-67, and P.L. 11393—to extend ACA funding for a number of MCH and health workforce programs. Other time-limited
ACA funding has been allowed to expire (e.g., school-based health center grants).
For the advocates of health centers and the NHSC, the loss of ACA mandatory funds at the end of
FY2015 is compounded by the fact that Congress has reduced—and, in the case of the NHSC,
eliminated—annual discretionary funding for these longstanding programs. If lawmakers choose not to
extend mandatory funding for the two programs, congressional appropriations may try to make up the
difference with discretionary funds. But that may prove challenging under the discretionary spending
limits currently in place.
Lawmakers opposed to specific ACA appropriations have succeeded in getting some of the funding
rescinded. Language added to appropriations acts for each of the past four years (i.e., FY2011-FY2014)
has rescinded funding for the ACA's Consumer Operated and Oriented Plan (CO-OP) program and the
Independent Payment Advisory Board (IPAB). In addition, the Middle Class Tax Relief Act of 2012 (P.L.
112-96) reduced funding for the Prevention and Public Health Fund (PPHF), which was established by
the ACA to support prevention, wellness, and other public health programs and activities. The ACA
provided the PPHF with a permanent annual appropriation that increased from $0.5 billion in FY2010 to
$2 billion in FY2015 and each year thereafter. P.L. 112-96 reduced the annual appropriations to the
PPHF over the period FY2013-FY2021 by a total of $6.25 billion.
To date, the other longer-term and permanent appropriations in the ACA have not been modified by
Congress. Those appropriations include (1) 10 years of funding—through a mix of annual
appropriations, fees on health plans, and transfers from the Medicare trust funds—for the PatientCentered Outcomes Research Trust Fund to support patient-centered comparative clinical effectiveness
research; and (2) a permanent appropriation, available for 10-year periods, for the Center for Medicare
& Medicaid Innovation to test and implement innovative health care payment and service delivery
models.