Contents

• Introduction
• Administration Actions
• Congressional Actions
• The Emergency Supplemental Appropriations Request for Zika Response Efforts
• Health and Human Services
• Centers for Disease Control and Prevention (CDC)
• Public Health and Social Services Emergency Fund (PHSSEF)
• National Institutes of Health (NIH)
• Food and Drug Administration (FDA)
• Medicaid Funding for Territories
• Retroactive Reimbursement
• Transfer Authority
• Expanded Definition of "Security Countermeasure"
• International Assistance Programs
• Department of State
• USAID
• Use of Ebola Balances for Other Infectious Diseases
• Transfer Authority
• Notwithstanding Authority
• Direct Hiring Authority/Personal Services Contractors
• HHS, State/USAID, and DOD Unobligated Ebola Response Funds
Supplemental Request
• Reprogrammings
• Uses of Reprogrammed Funds
• Congressional Actions
• House Bill
• Senate Bill
• Conference Agreement
• For More Information

Summary

The second session of the 114^th Congress is considering whether and how to provide funds to control the spread of the Zika virus throughout the Americas. Zika infection, which is primarily spread by Aedes mosquitoes and sexual contact, has been linked to severe birth defects and other health concerns. Local transmission of the Zika virus has occurred in American Samoa, Puerto Rico, andPuerto Rico, American Samoa, the U.S. Virgin Islands, and is expected on the U.S. mainland this summer, in areas where Aedes mosquitoes are presentFlorida.

On February 22, 2016, the Obama Administration submitted a request forrequested more than $1.89 billion in supplemental funding to respond tofor the Zika epidemic, all of which is requested as emergency discretionary appropriations and therefore effectively exempt from spending limits per the Budget Control Act of 2011 (BCA, P.L. 112-25). The emergency request includesresponse, all of which it asked to be designated as an emergency requirement, which would effectively exempt the funds from discretionary spending limits. The request included $1.509 billion for the Department of Health and Human Services (HHS), $335 million for the U.S. Agency for International Development (USAID), and $41 million for the Department of State. The request also seeks authority to transfer some of those supplemental emergency appropriations across other federal agencies such as the Department of Defense, the Environmental Protection Agency, and the U.S. Department of Agriculture,sought authority to transfer the requested funds to other federal agencies to allow greater flexibility as circumstances change. It also wouldsought to provide HHS, the Department of State, and USAID with broad authority for direct hiring, not be limited to positions related to Zika response efforts, and would authorize personal services contracting by HHS, State and USAID, for the Zika virus, but not limited to Zika virusauthority for direct hiring and personal services contracting, not limited to positions related to Zika response efforts.

On April 6, 2016, the White House Office of Management and Budget (OMB) and the Secretary of HHS announced that they had identified $589 million—$510 million of it from "existing Ebola resources" within HHS within the Department of Health and Human Services and Department of State/USAID"—that can quickly—that could be redirected and spent on immediate efforts to control and respond to the spread of the Zika virusZika in the Americas.

On April 8, 2016, the Administration notified Congress of athe transfer of $295 million out of(included in the $510 million) from FY2015 unobligated USAID Ebola Economic Support Funds (ESF) to be used for the Zika response efforts and other purposes. Of that amount, USAID is providingwould provide $158 million to CDC including the Centers for Disease Control and Prevention (CDC)—$78 million for Zika response and $80 million for Ebola response. The remaining $137 million also from FY2015 ESF is funding various USAID activities for itswould fund various USAID Zika response efforts.

As of mid-May 2016, congressional action onactivities. In May, both the House and the Senate passed supplemental appropriations measures for Zika response. On May 18, the House passed a stand-alone bill (H.R. 5243) to provide $622.1 million, which would be available until September 30, 2016. It did not designate these funds as an emergency requirement, but instead rescinded an equal amount of budget authority. On May 19, as the Senate was considering a bill to provide regular FY2017 appropriations for Military Construction-Veterans Affairs and Transportation-Housing and Urban Development, it amended that bill so that it also would provide $1.1 billion for Zika response, to be available, depending on the account, either until September 30, 2017, or until expended (S.Amdt. 3900 to H.R. 2577). The Senate bill did not contain any rescissions and instead designated the Zika-related appropriations as emergency requirements.

A conference agreement to provide $1.1 billion in Zika response funding (H.Rept. 114-640, to accompany H.R. 2577) was filed on June 22 and agreed to by the House on June 23. Amounts to HHS and Department of State/USAID are generally similar to those in the Senate proposal. However, other aspects of the agreement have been the subject of some controversy. These appear to include a provision associated with health care funding that would be provided through the Social Services Block Grant (SSBG), and a provision that would rescind a total of $750 million, most of it from unspent funds provided by the Patient Protection and Affordable Care Act (ACA, P.L. 111-148, as amended) intended to establish health exchanges in the territories. The Senate has voted twice (in June and July) not to invoke cloture on the measure.

On August 11, 2016, the Administration reprogrammed $81 million within HHS to continue funding for Zika vaccine efforts.

Congress could continue to consider the issue of funding for Zika response during the remainder of the 114^th Congress in the context of H.R. 2577, or through the consideration of appropriations associated with other legislative vehicles.

This report tracks administrative and congressional action on FY2016 supplemental funding to address the Zika virus. It will be updated as changes occur. This report incorporates all information from CRS Report R44549, Supplemental Appropriations for Zika Response: The FY2016 Conference Agreement in Brief, with no substantive changes. That CRS report is no longer available. Updates of this CRS report will be forthcoming as details become available.

Introduction

In its second session, the 114^th Congress is considering whether and how to provide funds to control the spread of the Zika virus throughout the Americas. Zika infection, primarily spread by Aedes mosquitoes and sexual contact, has been linked to severe birth defects and other health concerns. Local transmission of the Zika virus has occurred in American Samoa, Puerto Rico, and the U.S. Virgin Islands, and transmission is expected on the U.S. mainland this summer, in areas where Aedes mosquitoes are present.¹

Federal efforts to address the outbreak include research on the infection and its effects, mosquito control measures, and efforts to develop a vaccine, and public service messaging about preventing infection. The public health focus, both domestically and elsewhere in the Americas, is to protect pregnant women from infection and prevent, thereby, to prevent potentially severe birth defects. Administration officials and some in Congress are concerned about the resources needed to prevent widespreadthe spread of Zika infections as the Northern Hemisphere summer approachesnumber of imported cases in the United States grows.

This report presentsdiscusses the Administration's actions on Zika response funding, including its request for FY2016 request for supplemental appropriations for the Zika response, supplemental appropriations measures that have received congressional action, and information about unobligated Ebola supplemental funds as of January 1, 2016 (the most recent publicly available). Updates will be forthcoming as details become available.

Administration Actions

On February 22, 2016, the Obama Administration submitted a request for more than $1.89 billion in supplemental funding to respond to the Zika epidemic, all of which is requested as emergency FY2016 discretionary appropriations, and therefore effectively exempt from spending limits in the Budget Control Act of 2011 (BCA, P.L. 112-25).² The Administration's request includes $1.509 billion for the Department of Health and Human Services (HHS)and reprogramming of existing funds to pay for response activities. It also discusses the FY2016 supplemental appropriations measures for Zika response that have been considered by Congress, including the conference report to H.R. 2577. A detailed summary of the Administration's supplemental request is provided in Appendix A. Information about unobligated Ebola supplemental funds is presented in Appendix B. Appendix C provides a glossary of acronyms used in tables in this report.

This report incorporates all information from CRS Report R44549, Supplemental Appropriations for Zika Response: The FY2016 Conference Agreement in Brief, with no substantive changes. That CRS report is no longer available. Updates of this CRS report will be forthcoming as details become available.

A major theme in congressional debates thus far has been over whether unobligated (generally, uncommitted for expenditure) FY2015 funds that had been provided to respond to the Ebola virus outbreak should be used to fund part of the Zika response, either temporarily or permanently.⁵ On April 6, 2016, the White House Office of Management and Budget (OMB) and the Secretary of HHS announced that they had identified $589 million—$510 million of it from "existing Ebola resources within the Department of Health and Human Services and Department of State/USAID"—that could quickly be reprogrammedredirected and spent on immediate efforts to control and respond to the spread of the Zika virus in the Americas.⁶

As part of the reprogramming, on April 8, 2016, USAID notified Congress of its intent to redirect $295 million of the $510 million from FY2015 unobligated Ebola Economic Support Funds (ESF) to be used for Zika response and other purposes. Of that amount, USAID transferred $158 million to CDCthe Centers for Disease Control and Prevention (CDC), including $78 million for international Zika response efforts and $80 million for Ebola response. The remaining $137 million, also from FY2015 ESF, iswas to be redirected to fund various USAID activities for Zika response efforts.

Congressional Actions

On May 16, 2016, the ChairmanZika response activities.

On August 11, 2016, the HHS Secretary notified Congress of her intent to redirect an additional $81 million in unobligated HHS funds for Zika vaccine development activities.⁷ Of this amount, $34 million was drawn from accounts at the National Institutes of Health (NIH), and $47 million in total was drawn from unspecified accounts at three other HHS agencies: the Administration for Children and Families (ACF), the Centers for Medicare and Medicaid Services (CMS), and the Substance Abuse and Mental Health Services Administration (SAMHSA).

According to HHS, out of the $589 million identified for reprogramming on April 6, $374 million was repurposed for domestic Zika control activities.⁹ HHS reports that almost all of this funding ($354 million) was distributed to three HHS agencies as follows:

• $222 million to CDC for various activities including field staff, state response teams, Zika virus testing, tracking of pregnant women who were infected with Zika, and grants for mosquito control and other Zika prevention activities.
• $47 million to NIH for Zika vaccine development, including clinical trials on the leading Zika vaccine candidate.¹⁰
• $85 million to the Biomedical Advanced Research and Development Authority (BARDA) for private sector development of Zika vaccines, treatments, and technologies to protect the blood supply, and other countermeasures.

From the second reprogramming in August, $34 million (i.e., the amount drawn from other NIH accounts) is to be used by NIH to continue clinical trials on its lead Zika vaccine candidate. The additional $47 million is to be used by BARDA for continued private sector Zika vaccine development.

Between May and July 2016, supplemental funding for Zika response has received floor consideration in both the House and the Senate. Most recently, the House and Senate have considered the conference report to H.R. 2577, which would provide a total of $1.1 billion in Zika response funding, but Senate action on the conference report has not been completed.

Senate Bill Senate action has occurred in the context of the FY2017 Military Construction-Veterans Affairs and Transportation-Housing and Urban Development appropriations bills. The texts of these bills were combined for the purposes of initial consideration in the Senate, and offered as a substitute amendment to an unrelated measure (S.Amdt. 3896 to H.R. 2577). On May 12, 2016, Senator McConnell (on behalf of Senator Blunt) proposed an amendment to that substitute (S.Amdt. 3900 to S.Amdt. 3896) that would provide $1.1 billion for Zika response and preparedness, which would be available until September 30, 2017 (with the exception of Global Health Funds, which would be available until expended). On May 19, 2016, the Senate adopted S.Amdt. 3900,⁸ followed by the pair of appropriations measures (i.e., H.R. 2577) to which it was amended.

See Table 1 below for a comparison of the Administration's supplemental request, S.Amdt. 3900, and House bill H.R. 5243. For a comparison of non-monetary provisions of these measures, see Table 2.

The; and Conference Report (H.Rept. 114-640). a. Medical countermeasures are vaccines, drugs, antidotes, therapies, diagnostic tools, and blood safety technologies needed for the response to public health emergencies. For more information about Zika countermeasures see BARDA, "BARDA's Medical Countermeasure Response to Zika," http://www.phe.gov/about/barda/zika/Pages/default.aspx. Appendix A. Summary of the Emergency Supplemental Appropriations Request for Zika Response Efforts

The following describes the Administration's February 2016 Zika emergency supplemental request components by agency.

It was reported on April 18 that the Administration submitted a revised Zika supplemental request to Congress, which would maintain departmental request totals, while redirecting some of the HHS funds requested for contingency use to vaccine research and development at the National Institutes of Health (NIH).⁹20 Detailed information about this is not publicly available, and the following narrative does not reflect this revision.

Health and Human Services

The Administration's emergency supplemental appropriations request to respond to the Zika outbreak seeks for HHS a total of $1.509 billion. Each HHS agency request includes the statement that funds would be "to prevent, prepare for, and respond to Zika virus, other vector-borne diseases, or other infectious diseases and related health outcomes, domestically and internationally.... " Most of the requested funds would support research, surveillance, vaccine and test development, and various domestic preparedness activities. A portion would support international response activities. The request proposes that all supplemental appropriations to HHS be designated as emergency spending, and remain available until expended.

Centers for Disease Control and Prevention (CDC)

A total of $828 million of the February 2016 request is for the CDC-Wide Activities and Program Support account. Proposed request language would, among other things, authorize the CDC Director to transfer funds between CDC accounts, and authorize funds to be used for real property acquisition and improvements to non-federal facilities. Funds would be used as follows:

• Grants and technical assistance to Puerto Rico and U.S. Territories—$225 million to, among other purposes, monitor pregnant women and establish a registry of women infected while pregnant; expand mosquito control activities; and enhance laboratory testing capacity.
• Domestic Response—$453 million to provide grants to southern and other U.S. states with Aedes mosquitoes for surveillance, improved test methods and testing capacity, public education and outreach, mosquito control measures in areas at risk, and additional federal and state response activities.
• International Response Activities—$150 million to expand the public health workforce, and enhance infectious disease surveillance and emergency response activities, in Zika-affected countries; and to support the laboratory network of the Pan American Health Organization (PAHO), the regional arm of the World Health Organization (WHO) for the Americas.

Public Health and Social Services Emergency Fund (PHSSEF)

The PHSSEF is a fund used by appropriators to provide the HHS Secretary with ongoing or one-time emergency funding, such as for the response to disease epidemics. The emergency supplemental request seeks $295 million for the PHSSEF for the following:

• several maternal and child health and home visitation programs for low-income pregnant women at risk of Zika infection, and families that have children born with birth defects related to Zika infection;
• several health care workforce assistance programs for Puerto Rico and other territories; and
• compensation for persons harmed by the use of tests or vaccines used under emergency authority.¹⁰

21The requested PHSSEF funds could, in consultation with OMB, be transferred to other agencies within HHS or across the federal government. The request stated that this transfer authority is to provide flexibility in response to changing needs. No congressional notification requirement is included.

National Institutes of Health (NIH)

The emergency supplemental request seeks $130 million for the NIH National Institute of Allergy and Infectious Diseases (NIAID) to expand research efforts to characterize the progression and effects of Zika infection and other vector-borne diseases, and to develop vaccines against them.¹¹22 Proposed request language would authorize the NIH Director to transfer funds between NIH accounts. No congressional notification requirement is included.

Food and Drug Administration (FDA)

The emergency supplemental request seeks $10 million for FDA's role in reviewing the safety and effectiveness of medical countermeasures (such as test methods, vaccines, and treatments), and post-market monitoring of such countermeasures if and when they become available.

Medicaid Funding for Territories¹²23

The emergency supplemental request would temporarily increase the federal matching rate for Medicaid in the territories. The territories operate Medicaid programs under different rules from those that apply to the 50 states and the District of Columbia. Federal Medicaid funding to the states and the District of Columbia is open-ended, but the territories receive capped annual allotments (i.e., the maximum amount of federal funds available in a year). In addition, the Patient Protection and Affordable Care Act (ACA, P.L. 111-148, as amended) provides the territories with additional federal Medicaid funding to use by September 30, 2019. The territories have a federal medical assistance percentage (FMAP) rate (i.e., federal matching rate) for Medicaid of 55%.¹³

The supplemental request includes a provision that would increase the FMAP rate for the territories to 65% for one year beginning with the first day of the fiscal quarter following enactment. This increased FMAP rate would be available for all Medicaid expenditures, not limited to those provided to treat Zika infection. The federal funding for the increased FMAP rate would not count against the territories' annual federal spending caps or additional ACA funding. The Administration estimates this FMAP rate increase would cause federal Medicaid expenditures to grow by $246 million.¹⁴25

There is some question about how this provision would affect Puerto Rico if it were to exhaust its additional ACA funding prior to FY2019.¹⁵26 Depending on the timing of enactment, Puerto Rico might not have access to its full annual Medicaid allotments or additional ACA funding for a portion of the time the provision would be in effect.¹⁶

Retroactive Reimbursement

The request proposes language that would allow funds provided in the act to be used to reimburse HHS accounts for Zika response expenses incurred prior to enactment.

Transfer Authority

The request proposes language that would allow funds appropriated to HHS in the act to be transferred to other federal accounts, including the Department of Defense, the Environmental Protection Agency, and the Department of Agriculture, "to prevent, prepare for, and respond to Zika virus, other vector-borne diseases, or other infectious diseases and related health outcomes, domestically and internationally.... ," following consultation with OMB. No congressional notification requirement is included.

Expanded Definition of "Security Countermeasure"

The request proposes language that would allow the government to support the advanced development and procurement of medical countermeasures against Zika virus through Project BioShield. Currently, Project BioShield supports only countermeasures against specific chemical, biological, radiological, and nuclear terrorist threats.¹⁷28 The proposed expansion is not limited to countermeasures against the Zika virus or vector-borne diseases, but rather is stated broadly as a "countermeasure to diagnose, mitigate, prevent, or treat harm from any infectious disease that may pose a threat to the public health."

International Assistance Programs

The Administration's February 2016 emergency supplemental appropriations request to respond to the Zika outbreak seeks for the Department of State and USAID a total of $376.1 million. This includes funds for control of the disease, prevention, surveillance, evacuating U.S. employees and American citizens, vaccine development, and diagnostic research, among other things. Specifically within the International Assistance section of the request is a request for transfer authority (without a requirement for congressional notification) with certain limitations, reimbursement authority, and hiring of personal services contractors, as well as authorization to use unobligated Ebola balances to combat Zika and other infectious diseases. Also worth noting is that, unlike HHS, funds for international assistance programs have varying periods of availability, as specified below.

Department of State

A total of $41.1 million is requested for the Department of State operations, multilateral assistance within International Organizations and Programs (IO&P), and international security assistance (nuclear research and techniques) as follows:

• Diplomatic and Consular Programs account (D&CP)—$14.6 million to remain available until September 30, 2017. Of this amount
• $8.4 million is to support the Office of Medical Services for medical support and possible evacuation under the Chief of Mission authority of at-risk U.S. employees in Zika-affected countries; and
• $6.2 million is to support regional coordination efforts and public diplomacy outreach, among other activities.
• Emergencies in the Diplomatic and Consular Service—$4 million to remain available until expended to support response efforts, including potential evacuation of U.S. citizens.
• Repatriation Loans Program—$1 million to remain available until expended to finance repatriation loans to U.S. citizens who may seek to leave Zika-affected areas or who have been exposed to or have contracted Zika.
• Nonproliferation, Anti-Terrorism, Demining and Related Programs (NADR)—$8 million to remain available until September 30, 2017, for additional voluntary U.S. contributions to the International Atomic Energy Agency (IAEA), an autonomous intergovernmental organization related to the United Nations that promotes the safe, secure, and peaceful use of nuclear technologies. Funds would support Zika research to develop and deploy nuclear techniques to help accelerate diagnosis, provide related specialized training, and to implement sterile insect projects to suppress mosquito populations.¹⁸
29
• International Organizations and Programs (IO&P)—$13.5 million to remain available until September 30, 2017, to support Zika response actions taken by UNICEF, the Food and Agriculture Organization, the WHO, and PAHO.

USAID

For the U.S. Agency for International Development, the Administration is requesting $335 million to cover USAID's health programs and implementation expenses:

• USAID Operating Expenses (OE)—$10 million to remain available until September 30, 2017, to support Zika response efforts.
• Global Health Programs (GHP)—$325 million to remain available until expended to prevent, treat, or respond to the Zika virus and related health concerns, other vector-borne diseases, or other infectious diseases. Multi-year funding commitments are requested to provide incentives for the development of global technologies such as vaccines, diagnostics equipment, and vector control innovations. Anticipated allocations include
• $100 million to implement vector management and control activities in Zika-affected countries;
• $100 million to stimulate private sector research and development of vaccines, diagnostics, and vector control innovations through public-private partnerships;
• $50 million for maternal and child health support in affected and at-risk countries, including training of health care workers; ensuring access to family planning information, services, and methods; providing support for children with microcephaly; and helping pregnant women and their partners have access to personal protection, including condoms and repellant to protect against mosquitoes;
• $25 million for public health communication and behavior change campaigns for affected communities and countries to take actions to protect themselves from Zika and other vector-borne diseases; and
• $50 million to issue Global Health Security Grand Challenges that would call for groundbreaking innovations in diagnostics, vector control, personal protection, community engagement and surveillance, and other tools to address Zika and other infectious diseases, as well as to develop public-private partnerships to accelerate development of innovative tools and practices.

Use of Ebola Balances for Other Infectious Diseases

Within the Department of State and Other International Programs General Provisions (in addition to the General Provisions for the entire request), the supplemental request would authorize the use of unobligated Ebola Funds (Title IX, Div. J, P.L. 113-235), stating: "[Unobligated Ebola funds] shall also be available to respond to the Zika virus and related health outcomes, other vector-borne diseases, or other infectious diseases."

As of January 1, 2016, the Department of State/USAID's unobligated Ebola funds totaled nearly $1.3 billion. Of that total, about $600 million is available until September 30, 2016 (just a few months away), and about $694 million is available until expended.¹⁹30 (See the subsequent section, "HHS, State/USAID, and DOD Unobligated Ebola Response Funds.")

Transfer Authority

The Department of State and Other International Programs General Provisions in the supplemental request would allow transfer of State Department-related funds in the request only among State Department-related accounts within the request and transfer of USAID-related funds in the request only among USAID-related accounts. No congressional notification requirement is included.

Notwithstanding Authority

The supplemental's request for notwithstanding authority could allow funds from this or prior acts supporting the U.S. Zika virus response to be expended despite any previously enacted restrictions and conditions on U.S. foreign aid. For example, if enacted, this authority could allow foreign aid to be provided to states that are otherwise restricted by law: those designated as sponsors of terrorism, those with debt arrearage, human rights violators, or states that practice coercive family planning. The Department of State has indicated in the Global Health Program (GHP) section, however, that funds will provide support for "ensuring access to voluntary family planning information, services, and methods."

Direct Hiring Authority/Personal Services Contractors

The General Provisions Title in the request, and also the General Provisions Title for the Department of State and Other International Programs, allows for expedited hiring authority to directly hire staff during critical public health threats, such as Zika, and to enter into contracts with individuals who are experts in Zika-related fields. This measure does not limit direct hiring or personal services contractors only for Zika-related purposes. This authority for direct hiring and personal services contractors could be used in a broader set of public health circumstances than the Zika virus.

Appendix B. HHS, State/USAID, and DOD Unobligated Ebola Response Funds

In December 2014, the Consolidated and Further Continuing Appropriations Act, 2015 (P.L. 113-235), provided $5.4 billion in emergency supplemental appropriations to HHS, the Departments of State and Defense, and USAID to address the Ebola outbreak that began in West Africa in January 2014.²⁰31 Because these funds were designated as emergency appropriations, they are effectively exempt from spending limits in the Budget Control Act of 2011 (BCA, P.L. 112-25).²¹

On April 6, 2016, the Obama Administration announced its plan to reprogram $510 million of unobligated FY2015 Ebola funding to respond to the Zika virus.²²33 HHS Ebola funds may be reprogrammable without additional congressional action (subject to existing restrictions on reprogramming, including notification). This is because the relevant appropriations measures stated the funds are available for Ebola and other infectious diseases. Some have debated whether congressional action is necessary to provide the Department of State and USAID with the authority to reprogram the unobligated Ebola funds, as much of the funding was appropriated with specific language to be used to "prevent, prepare for, or respond to the Ebola disease outbreak." 

Table 3B-1 provides, by account, the original appropriated Ebola funds, remaining (unobligated) amounts, the period of funding availability, and purpose of the funds, based on quarterly reports to Congress as required by the law. As of January 1, 2016, unobligated Ebola funds totaled $2.77 billion: $1.46 billion for HHS, $1.29 billion for State/USAID, and $17.3 million for Defense. A portion of the total, $652.9 million—most of which is USAID funding—expires September 30, 2016. Nearly all of the remaining unobligated funds expire September 30, 2019, or are available until expended. Table 3B-1 does not incorporate the Administration's announced plans to reprogram $510 million of unobligated Ebola funds.

Author Contact Information

Acknowledgments

The authors acknowledge the assistance of Grant D. Clinkingbeard, Research Associate; [author name scrubbed], Specialist in Science and Technology Policy; [author name scrubbed], Specialist in American National Government; Don Jansen, Specialist in Defense Health Care Policy; Kate Manuel, Legislative Attorney; [author name scrubbed], Specialist in Health Care Financing[author name scrubbed], Specialist in Health Services; Don Jansen, Specialist in Defense Health Care Policy; [author name scrubbed], Specialist in Social Policy; [author name scrubbed], Specialist in Health Care Financing; Kate Manuel, Legislative Attorney; [author name scrubbed], Specialist in Health Care Financing; [author name scrubbed], Senior Research Librarian; [author name scrubbed], Legislative Attorney; Barbara Schwemle, Analyst in American National Government; and [author name scrubbed], Specialist in Social Policy, in the preparation of this report.

Footnotes