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The Affordable Care Act (ACA), enacted in March 2010, appropriated billions of dollars of mandatory funds to support grant programs and other activities. Specifically, it provided support formandatory funds to support 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 Partial FY2020 funding has been provided in P.L. 116-94 through May 22, 2020. A longer funding extension has not been enacted, but a number of bills to provide longer extensions have been introduced, as discussed below. 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 themandatory ACA funds for these programs were initially provided for five years. Funding for each of these three programs had been subsequently extended through the end of FY2019.The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA;, P.L. 114-10) provided the funding extensions for FY2016 and FY2017. The Bipartisan Budget Act of 2018 (BBA 2018, P.L. 115-123) provided the funding extensions for FY2018 and FY2019. BBA 2018 also included a number of changes to each program's authorizations and increased funding for health centers and for teaching health centers.
Community Health Center Fund
The ACA established the Community Health Center Fund (CHCF) to help support the Health Centers and NHSC programs P.L. 114-10). The President's FY2018 budget proposes extending funding for these programs for two more years.
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 receivetypically received through the regular appropriations process. However, CHCF funds have replaced a significant portion of the Health Center program's annual discretionary appropriations, which Congress has reduced since FY2010 (see Table 1). In FY2016Since F2015, CHCF funding represented about 71has represented more than 70% 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).
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. |
(Millions of Dollars, by Fiscal Year) 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Health Centers
Discretionary 2,141 1,481 1,472 1,391a 1,397 1,392 1,392 1,387 1,507 1,506 1,506 CHCF NA 1,000 1,200 1,465a 2,145a 3,509a 3,600 3,511a 3,800 4,000 2,575b % CHCF 0% 40% 45% 51% 59% 72% 72% 72% 72% 73% 63%b NHSC Discretionary 141 25 0 0 0 0 0 0 105c 120c 120c CHCF NA 290 295 285a 283a 287a 310 289a 310 310 200b % CHCF 0% 92.1% 100% 100% 100% 100% 100% 100% 75% 72% 62%b Source: Prepared by CRS based on HHS budget documents and P.L. 116-94. a. Amounts were reduced by sequestration. FY2013 reflects sequestration of discretionary and CHCF funds; FY2014, FY2015, and FY2017 reflect sequestration of the CHCF. b. FY2020 CHCF amounts are partial-year funding for October 1, 2019 -May 22, 2020. As such, these amounts are not strictly comparable to those shown in other columns. c. NHSC discretionary amounts for FY2018-FY2020 were appropriated to expand the program to opioid treatment providers. FY2019 and FY2020 NHSC discretionary appropriations also included $15 million to place additional NHSC providers at Indian Health Service facilities.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 FY2017no annual discretionary appropriations were provided from FY2012 through FY2017, but subsequent discretionary appropriations provided funds for loan repayment for NHSC opioid treatment providers in FY2018-FY2020. Discretionary appropriations for FY2019 and FY2020 also included an additional $15 million for loan repayment to NHSC providers placed at Indian Health Service facilities. For FY2020, partial-year CHCF funding represents approximately 60% of each programs' funding.
Table 1. Health Centers and NHSC Funding
Teaching Health Centers
The teaching health center (THC) program was created in the ACA, which appropriated $230 million to be spent over a five-year period from FY2011 to FY2015. MACRA then provided $60 million for each of FY2016 and FY2017. BBA 2018 subsequently expanded funding for the program to permit additional programs to be developed and added additional reporting requirements. It provided $126.5 million annually for FY2018 and FY2019. This program has never received discretionary funding. The THC program has trained 600approximately 880 primary care residents primarily in underserved communities. More than three-quarters of theNearly two-thirds of recent program program's recent graduates are practicing primary care, and nearly a third60% are doing so in a medically underserved areas.
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 resultedThe expiration of these funds has been referred to as the primary care "cliff," because it would (in the absence of new funding) 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 federal government's efforts to expand access to primary care. The Health Centers program helps support more than 1, Legislation has been introduced in the 116th Congress that would extend the CHCF and the teaching health center program for five years (H.R. 1943, H.R. 1983, H.R. 2328, S. 106, S. 192, and S. 962). This differs from prior two-year extensions. A longer extension may provide these programs with funding stability. The bills under consideration include different amounts of funding for these programs. Separate legislation (H.R. 2815, S. 304, and S. 1191) has also been introduced to extend and increase funding for teaching health centers (but not the CHCF). In addition to these bills, a five-year funding extension for the health center program (with a funding increase) is included in a larger health care package under consideration related to prescription drug prices (H.R. 3). This bill does not include the extension of the NHSC or of teaching health centers. Five-year funding extensions of all three programs are also included in legislation that aims to address surprise medical billing. This bill would maintain program funding at FY2019 levels. 400400 community-based health centers operating over 10,50012,000 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 2428 million people annually, or an average of one in 13average of 1 in 12 Americans. The NHSC program awards scholarships and loan repayment to certain health professionals—nearly 8,500 in recent yearsmore than 10,000 in FY2017—who agree to practice in shortage areas, often at health centers. Funding for teaching health centers has also been included in discussions of this "cliff" because the program aims to increase the primary care workforce in underserved areas.
Various Options for FY2020 and Future Year Funding
, often at health centers.
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).