Appropriations and Fund Transfers in the
Patient Protection and Affordable Care Act
(ACA)
C. Stephen Redhead
Specialist in Health Policy
January 15, 2013
Congressional Research Service
7-5700
www.crs.gov
R41301
CRS Report for Congress
Pr
epared for Members and Committees of Congress
Appropriations and Fund Transfers in the Patient Protection and Affordable Care Act
Summary
Among its many provisions, the Patient Protection and Affordable Care Act (ACA) restructures
the private health insurance market, sets minimum standards for health coverage, and, beginning
in 2014, mandates that most U.S. residents obtain health insurance coverage or pay a penalty. The
law provides for the establishment by 2014 of state-based health insurance exchanges for the
purchase of private health insurance. Qualifying individuals and families will be able to receive
federal subsidies to reduce the cost of purchasing coverage through the exchanges. ACA also
expands eligibility for Medicaid; amends the Medicare program in ways that are intended to
reduce the growth in spending; and makes other changes to the tax code, Medicare, Medicaid, and
many other federal programs.
In addition, ACA appropriates billions of dollars to support new or existing grant programs and
other activities. These mandatory appropriations include funds for a temporary insurance program
for individuals who have been uninsured for several months and have a preexisting condition, as
well as funding for states to plan and establish exchanges. ACA also provides funding for various
Medicare and Medicaid demonstration programs, for the creation of a Center for Medicare and
Medicaid Innovation to test and implement innovative payment and service delivery models, and
for an independent board to provide Congress with proposals for reducing Medicare cost growth
and improving quality of care for Medicare beneficiaries.
ACA provides funding for health workforce and maternal and child health programs, and
establishes three multi-billion dollar funds. The first fund will provide a total of $11 billion over
five years for community health centers and the National Health Service Corps. (A separate
appropriation provides $1.5 billion for health center construction and renovation.) The second
fund will support comparative effectiveness research through FY2019 with a mix of
appropriations and transfers from the Medicare trust funds. The third fund, for which ACA
provides a permanent annual appropriation, is intended to support prevention, wellness, and other
public health-related programs authorized under the Public Health Service Act (PHSA).
Generally, the FY2013 mandatory appropriations in ACA would be fully sequestrable at the rate
applicable to nonexempt nondefense mandatory spending, under a sequestration order triggered
by the Budget Control Act.
Lawmakers opposed to ACA introduced numerous bills in the 112th Congress, several of which
saw legislative action. They included measures to repeal ACA and replace it with new law; repeal
or amend specific ACA provisions; eliminate certain mandatory appropriations and rescind all
unobligated funds; and block or otherwise delay ACA implementation. Similar legislation may be
introduced and debated during the 113th Congress.
In addition to the mandatory appropriations discussed in this report, ACA authorizes new funding
for numerous existing discretionary grant and other programs, primarily ones authorized under
the PHSA. The law also creates a number of new discretionary grant programs and activities and
provides for each an authorization of appropriations. Funding for all these discretionary programs
and activities is subject to action by congressional appropriators. A companion product, CRS
Report R41390, Discretionary Spending in the Patient Protection and Affordable Care Act (ACA),
summarizes all the provisions in ACA that include an authorization of appropriations.
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Appropriations and Fund Transfers in the Patient Protection and Affordable Care Act
Contents
Introduction ...................................................................................................................................... 1
Mandatory Appropriations and Fund Transfers in ACA .................................................................. 2
Discretionary Spending in ACA ...................................................................................................... 5
Potential Impact of Spending Cuts Under the Budget Control Act ................................................. 5
BCA Background ....................................................................................................................... 6
FY2013 Nondefense Direct Spending Reductions .................................................................... 7
Tables
Table 1. Summary of Mandatory Appropriations and Medicare Trust Fund Transfers in
the Affordable Care Act ................................................................................................................ 9
Table 2. ACA Appropriations and Fund Transfers by Fiscal Year ................................................. 19
Appendixes
Appendix A. Acronyms Used in the Report................................................................................... 24
Appendix B. ACA-Related Authorizing Legislation in the 112th Congress ................................... 25
Appendix C. ACA Provisions in Appropriations Bills (FY2011-FY2013) .................................... 28
Contacts
Author Contact Information........................................................................................................... 31
Acknowledgments ......................................................................................................................... 31
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Appropriations and Fund Transfers in the Patient Protection and Affordable Care Act
Introduction
The Patient Protection and Affordable Care Act (ACA)1 made significant changes to the way
health care is financed, organized, and delivered in the United States. Among its many provisions,
ACA restructures the private health insurance market, sets minimum standards for health
coverage, and, beginning in 2014, mandates that most U.S. residents obtain health insurance
coverage or pay a penalty. The law provides for the establishment by 2014 of state-based health
insurance exchanges for the purchase of private health insurance. Qualifying individuals and
families will be able to receive federal subsidies to reduce the cost of purchasing coverage
through the exchanges.
In addition to expanding private health insurance coverage, ACA, as enacted, requires state
Medicaid programs to expand coverage to all eligible nonelderly, non-pregnant individuals under
age 65 with incomes up to 133% of the federal poverty level (FPL). States that elect not to
expand their Medicaid programs risk losing their existing federal Medicaid matching funds.
Under ACA, the federal government will initially cover 100% of the expansion costs, phasing
down to 90% of the costs by 2020. On June 28, 2012, the U.S. Supreme Court, in National
Federation of Independent Business v. Sebelius, found that the Medicaid expansion violated the
Constitution by threatening states with the loss of their existing federal Medicaid matching
funds.2 The Court precluded the Secretary of Health and Human Services (HHS) from penalizing
states that choose not to participate in the Medicaid expansion (see text box below). ACA also
amends the Medicare program in an effort to reduce the rate of its projected growth; imposes an
excise tax on insurance plans found to have high premiums; and makes many other changes to the
tax code, Medicare, Medicaid, the State Children’s Health Insurance Program (CHIP), and other
federal programs.
ACA included numerous appropriations that provide billions of dollars to support new and
existing grant programs and other activities. Several other provisions require the HHS Secretary
to transfer amounts from the Medicare Part A and Part B trust funds for specified purposes. This
report summarizes all these mandatory spending provisions3 and, using publicly available
information, provides details on the status of obligation of the funds. It also includes a brief
discussion of ACA-related discretionary spending, which is provided in and controlled by annual
appropriations acts. Finally, the report provides some analysis of the impact that a sequestration
triggered by the Budget Control Act might have on ACA mandatory spending in FY2013. This
report is periodically revised and updated to reflect important legislative and other developments.
1 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 multiple health care and revenue provisions in ACA. Several other bills that were subsequently enacted
during the 111th and 112th Congresses made more targeted changes to specific ACA provisions (see Appendixes B and
C). All references to ACA in this report refer to the law as amended. Note that previous CRS reports on the Patient
Protection and Affordable Care Act used the acronym PPACA to refer to the law. CRS is now using the more common
acronym ACA.
2 NFIB v. Sebelius, No. 11-393, slip op. (June 28, 2012), available at http://www.supremecourt.gov/opinions/11pdf/11-
393c3a2.pdf.
3 Mandatory spending, also known as direct spending, refers to outlays from budget authority (i.e., the authority to
incur financial obligations that result in government expenditures) that is provided in laws other than annual
appropriations acts. Mandatory spending includes spending on entitlement programs.
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U.S. Supreme Court Decision on ACA (June 28, 2012)
In National Federation of Independent Business v. Sebelius (NFIB) the Court ruled on the constitutionality of both the
individual mandate, which requires most U.S. residents (beginning in 2014) to carry health insurance or pay a penalty,
and the Medicaid expansion. The Court upheld the individual mandate as a constitutional exercise of Congress’s
authority to levy taxes. The penalty is to be paid by taxpayers when they file their tax returns and enforced by the
Internal Revenue Service.
In a separate opinion, the Court found that compelling states to participate in the ACA Medicaid expansion—which
the Court determined to be essentially a new program—or risk losing their existing federal Medicaid matching funds
was coercive and unconstitutional under the Spending Clause of the Constitution and the Tenth Amendment. The
Court’s remedy for this constitutional violation was to prohibit HHS from penalizing states that choose not to
participate in the expansion by withholding any federal matching funds for their existing Medicaid program. However,
if a state accepts the new ACA expansion funds (initially a 100% federal match), it must abide by all the expansion
coverage rules.
Under NFIB v. Sebelius, all other provisions of ACA remain fully intact and operative. For more information, see CRS
Report R42698, NFIB v. Sebelius: Constitutionality of the Individual Mandate, by Erika K. Lunder and Jennifer Staman; and
CRS Report R42367, Medicaid and Federal Grant Conditions After NFIB v. Sebelius: Constitutional Issues and Analysis, by
Kenneth R. Thomas.
Mandatory Appropriations and Fund Transfers in
ACA
ACA appropriated billions of dollars for a number of short-term health care programs for targeted
groups, including (1) $5 billion for the Pre-Existing Condition Insurance Plan (PCIP), a
temporary insurance program to provide health insurance coverage for uninsured individuals with
a preexisting condition; (2) $5 billion for a temporary reinsurance program to reimburse
employers for a portion of the costs of providing health benefits to early retirees aged 55-64; and
(3) $6 billion for the Consumer Operated and Oriented Plan (CO-OP) program, to establish
temporary health insurance cooperatives. ACA also included money for states to plan and
establish health insurance exchanges.
The law created a Center for Medicare and Medicaid Innovation (CMMI) within the Centers for
Medicare and Medicaid Services (CMS), and appropriated $10 billion for the FY2011-FY2019
period—and $10 billion for each subsequent 10-year period—for CMMI to test and implement
innovative payment and service delivery models. It also established and funded an Independent
Payment Advisory Board (IPAB) to make recommendations to Congress for achieving specific
Medicare spending reductions if costs exceed a target growth rate. IPAB’s recommendations are
to take effect unless Congress overrides them, in which case Congress would be responsible for
achieving the same level of savings.
ACA also established four special funds and appropriated substantial amounts to each. First, the
Community Health Center Fund (CHCF) will provide a total of $11 billion in annual
appropriations over five years (FY2011-FY2015) for community health center operations and the
National Health Service Corps. A separate ACA appropriation provided $1.5 billion for health
center construction and renovation. While CHCF funding may have been intended to supplement
annual discretionary appropriations for health centers and the NHSC program, the funds have
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partially supplanted discretionary health center funding and have become the sole source of
funding for the NHSC program, which received no discretionary funds in FY2012.4 Second, the
Patient-Centered Outcomes Research Trust Fund (PCORTF) will support comparative
effectiveness research through FY2019 with a mix of annual appropriations—some of which are
offset by revenues from a fee imposed on private health plans—and transfers from the Medicare
Part A and Part B trust funds.
Third, the Prevention and Public Health Fund (PPHF), for which ACA provided a permanent
annual appropriation, is intended to support prevention, wellness, and other public health-related
programs and activities authorized under the Public Health Service Act (PHSA).5 PPHF funds
have been used to support several new discretionary grant programs authorized by ACA. The
funds are also supplementing, and in some cases supplanting, annual discretionary appropriations
for a number of established programs, including ones that were reauthorized by ACA (see
discussion below under “Discretionary Spending in ACA”). Fourth, ACA provided $1 billion to
the Health Insurance Reform Implementation Fund (HIRIF) to help cover the administrative costs
of implementing the law.
In addition, ACA appropriated $2.4 billion for maternal and child health programs. Overall, the
law included more than $100 billion in direct appropriations over the 10-year period FY2010-
FY2019, including $40 billion to provide two more years of funding for CHIP.
Table 1 summarizes all the ACA provisions that include an appropriation of funds, or a transfer of
amounts from the Medicare trust funds. The provisions are grouped under the following headings:
(1) Private Health Insurance; (2) Medicaid and the State Children’s Health Insurance Program
(CHIP); (3) Medicare; (4) Fraud and Abuse; (5) Health Centers and the National Health Service
Corps (NHSC); (6) Health Workforce; (7) Community-Based Prevention and Wellness; (8)
Maternal and Child Health; (9) Long-Term Care; (10) Comparative Effectiveness Research; (11)
Biomedical Research; and (12) ACA Implementation: Administrative Expenses.
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, either by
adding a new program or amending an existing one). The third column gives a brief description
of the program or activity, including details of the appropriation or fund transfer. The entry also
includes the name of the administering HHS agency and, if applicable, the Catalog of Federal
Domestic Assistance (CFDA) number for the grant program.6 The fourth column shows the
amount of obligations to date, based on information in the HHS Tracking Accountability in
Government Grants System (TAGGS), unless specified otherwise. The TAGGS database is a
central repository for grants awarded by all the HHS operating divisions (agencies) and several
4 For more information, see CRS Report R42433, Federal Health Centers, by Elayne J. Heisler.
5 Section 3205 of the Middle Class Tax Relief and Job Creation Act of 2012 (P.L. 112-96, 126 Stat. 156) reduced
ACA’s appropriations to the PPHF over the period FY2013-FY2021 by a total of $6.25 billion. Under ACA, the PPHF
would have received a total of $16.75 billion over that nine-year period; P.L. 112-96 reduced that amount to $10.50
billion. See Table 1 and Appendix B.
6 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.
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offices within the Office of the Secretary. It is updated daily with new data provided by these
entities.7
Readers are also encouraged to visit the website of the Center for Consumer Information and
Insurance Oversight (CCIIO, within CMS),8 which is responsible for implementing ACA’s private
health insurance provisions, as well as HealthCare.gov, which is tracking ACA implementation
state-by-state. Both sites include factsheets, press releases, and other information on the ACA
grant programs and activities summarized in this report.
In many instances, ACA provides annual appropriations of specified amounts for one or more
fiscal years. These funds must be obligated during the fiscal year in which the funds become
available for obligation. A few provisions are multiple-year appropriations, in which the amount
appropriated is available for obligation for a definite period of time in excess of one fiscal year
(e.g., for the period FY2011 through FY2014). Often the provision includes additional language
stating that the funds are to remain available “until expended” or “without fiscal year limitation.”
One ACA provision (i.e., Section 1311) appropriates an unspecified amount—such sums as may
be necessary, or SSAN—and authorizes the HHS Secretary to determine the amount necessary for
the grant program.9 Generally, the ACA appropriations or fund transfers are for one or more fiscal
years through FY2019. However, ACA includes four provisions (i.e., Sections 3021(a), 3403,
10323(b), and 4002) that continue to provide annual or multiple-year appropriations beyond
FY2019.
Table 2 provides additional details on each of the appropriations (and fund transfers) summarized
in Table 1. It shows the amount available for obligation in each fiscal year (or multi-year period)
over the 10-year period FY2010 through FY2019. Note that the provisions are organized and
grouped under the same headings used in Table 1. The final column in Table 2 (“Total”) shows
for each provision the cumulative amount of appropriations or fund transfers through FY2019. In
several cases, that amount has yet to be determined (see table entries for ACA Sections 1311,
3403, 6301(d) & (e), 9023(e), and 10323(a)). For three of the provisions that provide
appropriations beyond FY2019, the table shows the cumulative amount appropriated through
FY2019 (see table entries for ACA Sections 3021(a), 4002, and 10323(b)). Unless otherwise
stated, references to the Secretary in both tables refer to the HHS Secretary. A list of the acronyms
used in this report is provided in Appendix A.
Lawmakers opposed to specific provisions in ACA, or to the entire law, introduced numerous
bills in the 112th Congress to modify or repeal the law, including legislation to eliminate some of
the mandatory appropriations discussed in this report. Appendix B summarizes the ACA-related
authorizing legislation enacted during the 112th Congress, as well as the House-passed bills that
would have modified or repealed ACA. Appendix C summarizes the ACA-related provisions in
annual appropriations acts for FY2011-FY2013.
7 To access and search the TAGGS database, go to http://www.taggs.hhs.gov/.
8 http://cciio.cms.gov
9 Two other ACA provisions (i.e., Sections 5508(c), and 9023(e)) also appropriate SSAN to carry out a program, but in
each case there is an upper limit on the amount that may be appropriated. Another provision (i.e., Section 10323(a))
requires the HHS Secretary to transfer SSAN from the Medicare trust funds to carry out a pilot program.
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Discretionary Spending in ACA
In addition to its impact on mandatory spending, implementation of ACA is having an effect on
discretionary spending, which is provided in and controlled by annual appropriations acts. The
law reauthorized appropriations for numerous existing discretionary grant programs and activities
authorized under the PHSA. While the authorizations of appropriations for many of those
programs expired prior to their reauthorization in ACA, most of them continued to receive an
annual appropriation. ACA also created a number of new discretionary grant programs and
provided for each an authorization of appropriations.
Funding for all these discretionary programs will depend on future action taken by congressional
appropriators. However, with the renewed emphasis on reducing federal spending, it may prove
difficult to secure funding for new programs and activities. Even existing programs with an
established appropriations history may find it a challenge to maintain funding at current levels. A
companion product, CRS Report R41390, Discretionary Spending in the Patient Protection and
Affordable Care Act (ACA), provides more detailed analysis of all the provisions in ACA that
provide an authorization of appropriations for an existing or new program.
In addition to discretionary spending on grant programs authorized (or reauthorized) by ACA, the
Congressional Budget Office (CBO) estimates that both HHS and the Internal Revenue Service
(IRS) will incur substantial administrative costs to implement the policies established by ACA.
The IRS is responsible for implementing the eligibility determination, documentation, and
verification processes for ACA’s health exchange subsidies, while HHS must implement
numerous changes to Medicare, Medicaid, and CHIP, as well as some of the reforms to the
private health insurance market.
As already noted, ACA established a $1 billion implementation fund (i.e., HIRIF) to help cover
the administrative expenses associated with implementing the law. While HHS has used the
HIRIF to cover its own ACA administrative costs, the department has transferred a significant
portion of HIRIF funding to the IRS. HHS projected that all the HIRIF funds would be obligated
by the end of FY2012. Thereafter, ACA administrative costs will have to be funded through
annual discretionary appropriations (see Appendix C).
Potential Impact of Spending Cuts Under the
Budget Control Act
The Budget Control Act of 2011 (BCA) included procedures and a timetable for enactment of a
bill to reduce the federal deficit.10 In the event that Congress and the President failed to enact
such legislation, as was the case, the BCA required the President to order across-the-board
spending cuts—a process known as sequestration—for all nonexempt direct (i.e., mandatory) and
discretionary spending programs on January 2, 2013. That deadline was delayed for two months,
until March 1, 2013, by the American Taxpayer Relief Act of 2012 (ATRA).11 ATRA also reduced
the total amount of spending cuts for FY2013 by $24 billion, from $109.33 billion to $85.33
10 P.L. 112-25, 125 Stat. 240.
11 P.L. 112-240, 126 Stat. 2313.
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billion. This final section of the report provides an overview of the BCA’s mechanisms for
reducing spending. As discussed below, a FY2013 sequestration would impact many of the ACA
mandatory appropriations summarized in this report.
BCA Background
The BCA authorized the President to increase the nation’s debt limit by at least $2.1 trillion (and
up to $2.4 trillion under certain conditions) in three installments and established procedures
designed to reduce future federal spending by a comparable amount.12 To achieve the spending
reductions, the law placed enforceable limits, or caps, on discretionary spending for each of
FY2012 through FY2021. CBO estimated that adhering to these limits, which grow by
approximately 2% each year, would reduce federal spending by $917 billion through FY2021,
compared to the projected level of spending if annual appropriations were to grow at the rate of
inflation.13
In addition, the BCA created a Joint Select Committee on Deficit Reduction (Joint Committee)
and instructed it to develop deficit-reduction legislation for Congress to consider under expedited
floor procedures. If, by January 15, 2012, Congress and the President failed to enact a Joint
Committee bill reducing the deficit by an amount greater than $1.2 trillion over the period
FY2012-FY2021, then automatic annual spending reductions would be triggered beginning in
FY2013. On November 21, 2011, the Joint Committee announced that it was unable to agree on a
deficit-reduction bill. This meant that automatic spending reductions totaling $1.2 trillion were set
to take effect, pursuant to the procedures and timetable established in the BCA, unless new
legislation to modify or repeal the law was enacted.
Based on the formula in the BCA, the automatic spending reductions would cut $109.33 billion
for each fiscal year over the period FY2013-FY2021. [Note: ATRA’s $24 billion adjustment for
FY2013 is discussed below.] Each year’s cut would be equally divided between defense and
nondefense spending. The annual spending reduction in each of these two categories (i.e., $54.67
billion) would be further divided proportionately between discretionary spending and nonexempt
direct (i.e., mandatory) spending. In FY2013, both the discretionary and the direct spending
reductions in the two categories would be achieved through sequestration—a largely across-the-
board cancellation of budgetary resources in nonexempt accounts. In each of the remaining fiscal
years through FY2021, discretionary spending reductions would be achieved through a downward
adjustment of the BCA spending limits, while direct spending reductions would continue to be
executed through sequestration.
Under the sequestration rules, reductions in Medicare payments to health care providers and
health plans (which account for most of Medicare spending) are capped at 2%. Many other
federal direct spending programs, accounting for most of the government’s entitlement and other
direct spending (excluding Medicare), are exempt from sequestration altogether.14
12 For a more detailed examination of all the provisions in the BCA, see CRS Report R41965, The Budget Control Act
of 2011, by Bill Heniff Jr., Elizabeth Rybicki, and Shannon M. Mahan.
13 U.S. Congressional Budget Office, Analysis of Budget Control Act, August 1, 2011. Available at
http://www.cbo.gov/publication/41626.
14 The sequestration exemptions and rules are specified in sections 255 and 256, respectively, of the Balanced Budget
and Emergency Deficit Control Act (BBEDCA). For more information, see CRS Report R42050, Budget
“Sequestration” and Selected Program Exemptions and Special Rules, coordinated by Karen Spar.
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Discretionary spending reductions in FY2013 also would be achieved through a sequestration of
nonexempt discretionary appropriations. The sequestration rules exempt some discretionary
spending, notably for veterans’ health care and Pell grants.15 For each of the remaining fiscal
years (i.e., FY2014-FY2021), discretionary spending reductions would be achieved by lowering
the BCA discretionary spending caps. There would be no across-the-board cuts through
sequestration. Instead, the Appropriations Committees would decide how to apportion the cuts
within the reduced cap.
The BCA requires the OMB to calculate, and the President to order, a sequestration of nonexempt
discretionary appropriations for FY2013 and nonexempt direct spending for each of FY2013
through FY2021. As already noted, the sequestration for FY2013 was to be ordered on January 2,
2013. However, ATRA amended the BCA by delaying the sequestration order by two months. The
President is now instructed to order a FY2013 sequestration on March 1, 2013. The BCA requires
the sequestrations for subsequent fiscal years (i.e., FY2014-FY2021) to occur at the time of the
President’s annual budget submission in early February.
FY2013 Nondefense Direct Spending Reductions
On September 14, 2012, OMB released a report on the potential impact of a sequestration
triggered by the failure of the Joint Committee to propose, and Congress and the President to
enact, legislation to reduce the deficit by an amount greater than $1.2 trillion.16 The OMB report
provided a breakdown of exempt and nonexempt budget accounts, and included estimates of the
FY2013 funding reductions in nonexempt accounts. OMB calculated that sequestration would
result in a 7.6% reduction in nonexempt nondefense direct (i.e., mandatory) spending.
OMB emphasized that the estimates and budget account classifications in the report are
preliminary. The agency noted that “[i]f the sequestration were to occur, the actual results would
differ based on changes in law and ongoing legal, budgetary, and technical analysis.”17
In addition to delaying the FY2013 sequestration order, ATRA reduced the FY2013 sequestration
by $24 billion, from $109.33 billion to $85.33 billion. Because the sequestration is divided
equally between defense and nondefense spending, each of these two spending categories would
be subject to $12 billion less in spending cuts (i.e., $42.67 billion, instead of $54.67 billion).
Importantly, OMB’s preliminary estimates of the potential impact of a FY2013 sequestration
predate ATRA’s enactment and, therefore, do not take into account the $24 billion reduction.
Applying that adjustment to OMB’s calculations significantly reduces the estimated percentage
reduction in nonexempt nondefense direct (i.e., mandatory) spending under a FY2013
sequestration order.
The mandatory appropriations in ACA would, in general, be fully sequestrable at the rate
applicable to nonexempt nondefense mandatory spending. However, for any given fiscal year in
which sequestration was ordered, only new budget authority for that year (including advance
appropriations that first become available for obligation in that year) would be reduced.
15 Ibid. Note that all veterans programs, mandatory and discretionary, are exempt from sequestration.
16 U.S. Office of Management and Budget, OMB Report Pursuant to the Sequestration Transparency Act of 2012 (P.L.
112-155), http://www.whitehouse.gov/sites/default/files/omb/assets/legislative_reports/stareport.pdf.
17 Ibid., p. 1.
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Unobligated balances (nondefense only) carried over from previous fiscal years are exempt from
a sequestration order.18 Thus, an FY2013 sequestration order to reduce direct spending would not
apply to unobligated ACA funds that had been appropriated in a prior fiscal year (i.e., FY2010-
FY2012) and were still available for obligation.
The exemption for unobligated balances carried over from prior fiscal years would apply to a
number of ACA appropriations. As already mentioned, the appropriation provision often specifies
that the funds are to remain available “until expended” or “without fiscal year limitation.” One
example is the PCIP program to provide health insurance coverage for eligible individuals who
have been uninsured for six months and have a preexisting condition. The program terminates on
January 1, 2014. ACA appropriated $5 billion in FY2010, to remain available without fiscal year
limitation, to pay claims against the PCIP that are in excess of the premiums collected from
enrollees. Any unobligated PCIP funds in FY2013 would be exempt from sequestration.
According to OMB’s preliminary analysis, the FY2013 appropriations for both PPHF and
PCORTF would also be fully sequestrable at the rate applicable to nonexempt nondefense
mandatory spending. However, the reduction in CHCF funding would be capped at 2%. For more
discussion and analysis of the effect of BCA-triggered spending reductions on ACA mandatory
(and discretionary) spending in FY2013, see CRS Report R42051, Budget Control Act: Potential
Impact of Sequestration on Health Reform Spending, by C. Stephen Redhead.
18 An exemption for nondefense unobligated balances is provided in BBEDCA Section 255(e). It reads as follows:
“Unobligated balances of budget authority carried over from prior fiscal years, except balances in the defense category,
shall be exempt from reduction under any order issued under this part.” 2 U.S.C. §905(e).
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Table 1. Summary of Mandatory Appropriations and Medicare Trust Fund Transfers in the Affordable Care Act
ACA
Statutory
Obligations as of January 4, 2013, Based on TAGGS
Section
Authority
Program
Unless Specified Otherwise
Title I – Private Health Insurance
1002 New
PHSA
Consumer Assistance Program (CAP). Appropriates $30 million, to remain available
$46 million
Sec. 2793
without fiscal year limitation, for CAP grants to states to enable them (or the exchanges
operating in such states) to establish, expand, or provide support for offices of health
[Total includes original funding plus recent (summer 2012)
insurance consumer assistance, and health insurance ombudsman programs. [CMS/CCIIO;
awards of additional funds. See http://cciio.cms.gov/
CFDA 93.519]
programs/consumer/capgrants/index.html.]
1003 New
PHSA
Review of health insurance premium rates. Appropriates $250 million for grants to
$159 million
Sec. 2794
states over the five-year period FY2010-FY2014 to support programs that review annual
increases in health insurance premiums. No state may receive less than $1 million or more
[To date, two rounds of rate review grants have been
than $5 million in a grant year. Funds remaining unobligated at the end of FY2014 are to
awarded. See http://cciio.cms.gov/programs/marketreforms/
remain available for grants to states for planning and implementing ACA’s individual and
rates/index.html.]
group market reforms. [CMS/CCIIO; CFDA 93.511]
1101 New
authority
Pre-Existing Condition Insurance Plan (PCIP). Requires the Secretary to establish a
According to the most recent quarterly update, net PCIP
temporary program—PCIP—to provide health insurance coverage for eligible individuals
outlays through September 2012 totaled $1.861 billion.
who have been uninsured for six months and have a pre-existing condition. The PCIP is
federally administered in 23 states and DC; the remaining states administer their own PCIP
[PCIP has more than 90,000 enrollees to date. See
programs. Appropriates $5 billion, to remain available without fiscal year limitation, to pay
http://cciio.cms.gov/programs/pcip/index.html.]
claims against (and administrative costs of) the PCIP that are in excess of premiums
collected from enrollees. [CMS/CCIIO; CFDA 93.529]
1102 New
authority
Early Retiree Reinsurance Program (ERRP). Requires the Secretary to establish a
According to the most recent program update, ERRP
temporary ERRP, ending on January 1, 2014, to provide reimbursement to participating
outlays through February 2012 totaled $4.73 billion.
employer-based plans for a portion of the cost of providing health benefits to early retirees
age 55-64 and their families. Appropriates $5 billion, to remain available without fiscal year
[ERRP has provided payments to more than 2,800
limitation, to carry out the ERRP. [CMS/CCIIO]
employers and other sponsors of retiree plans. See
http://cciio.cms.gov/programs/errp/index.html.]
1311 New
authority
Health insurance exchange grants. Appropriates annually an amount (as determined by $2.049 billion
the Secretary) necessary to award exchange planning and establishment grants to states. No
grants may be awarded after January 1, 2015, by which time exchanges must be self-
[See http://cciio.cms.gov/programs/exchanges/index.html.]
sustaining. [CMS/CCIIO; CFDA 93.525]
1322 New
authority
Consumer Operated and Oriented Plan (CO-OP). Requires the Secretary to
According to a December 21, 2012 press release, the CO-
establish the CO-OP program to provide low-interest loans until July 1, 2013, for the
OP program has awarded a total of $1.981 billion to 24
creation of nonprofit member-run health insurance issuers that offer qualified health plans
nonprofits offering coverage in 24 states.
in the individual and small group markets. Appropriates $6 billion to carry out the CO-OP
program. Note: P.L. 112-10 and P.L. 112-74 together rescinded a total of $2.6 billion of the
[See http://cciio.cms.gov/programs/coop/index.html.]
original appropriation, and P.L. 112-240 rescinded all but 10% of the remaining unobligated
funds; see Appendix C. [CMS/CCIIO; CFDA 93.545]
CRS-9
ACA
Statutory
Obligations as of January 4, 2013, Based on TAGGS
Section
Authority
Program
Unless Specified Otherwise
1323 New
authority
Funding for territories. Appropriates $1 billion, available for the period FY2014-FY2019,
No obligations.
for U.S. territories that elect to establish a health insurance exchange. Funds must be used
to provide premium and cost-sharing assistance to territory residents who obtain health
insurance coverage through the exchange.
Title II – Medicaid and State Children’s Health Insurance Program (CHIP)
2701
New SSA Sec.
Medicaid adult health quality measures. Requires the Secretary to develop and, not
Initial core set of measures published in January 2012. No
1139B
later than January 1, 2012, publish an initial core set of quality measures for Medicaid-
public information located on funding obligations.
eligible adults. Appropriates $60 million for each of FY2010-FY2014, to remain available
until expended. Total amount = $300 million. [CMS; CFDA 93.609]
2707 New
authority
Medicaid emergency psychiatric demonstration program. Appropriates $75 million CMS announced the 11 participating states (plus DC) in
for FY2011, to remain available for obligation through December 2015, for a three-year
March 2012. No public information located on funding
demonstration in which eligible states are required to reimburse certain institutions for
obligations.
mental disease (IMDs) for services provided to Medicaid beneficiaries aged 21 through 64
who are in need of medical assistance to stabilize an emergency psychiatric condition.
[See http://innovations.cms.gov/initiatives/medicaid-
[CMS/CMMI; CFDA 93.537]
emergency-psychiatric-demo/.]
2801 Amends
SSA
Medicaid and CHIP Payment and Access Commission (MACPAC). Clarifies and
ACA funding was obligated in FY2011 and FY2012.
Sec. 1900
expands MACPAC’s duties; for example, to include a review and assessment of payment
policies under Medicaid and CHIP and how factors affecting expenditures and payment
[See http://www.macpac.gov/.]
methodologies enable beneficiaries to obtain services, affect provider supply, and affect
providers that serve a disproportionate share of low-income and other vulnerable
populations. Appropriates $9 million and transfers from CHIP funding an additional $2
million for FY2010. Total amount = $11 million, to remain available until expended.
4108 New
authority
Medicaid Incentives for the Prevention of Chronic Diseases (MIPCD). Requires
$30 million
the Secretary to award five-year grants to states, subject to annual renewal of funding, to
provide incentives for Medicaid beneficiaries to participate in evidence-based healthy
[MIPCD grants have been awarded to 10 states. See
lifestyle programs to prevent or help manage chronic disease. Appropriates $100 million for http://www.innovations.cms.gov/initiatives/MIPCD/
the five-year period beginning January 1, 2011, to remain available until expended.
index.html.]
[CMS/CMMI; CFDA 93.536]
4306 Amends
SSA
CHIP childhood obesity demonstration program. Appropriates $25 million for the
$12 million
Sec. 1139A(e)
period FY2010 through FY2014 for a program authorized by the Children’s Health
Insurance Program Reauthorization Act (CHIPRA; P.L. 111-3), which requires the Secretary [Funding has been awarded to four grantees. See
to conduct a demonstration project to develop a model for reducing childhood obesity.
http://www.cdc.gov/obesity/childhood/
[CDC; CFDA 93.535]
researchproject.html.]
CRS-10
ACA
Statutory
Obligations as of January 4, 2013, Based on TAGGS
Section
Authority
Program
Unless Specified Otherwise
10203(d) Amends
SSA CHIP annual appropriations, and outreach and enrollment grants. Appropriates
In 2009, and again in 2011, CMS awarded $40 million in
Secs. 2104 &
funding for the CHIP program for FY2014 ($19.147 billion) and FY2015 ($21.061 billion);
two-year grants to states and community organizations. In
2113
the program previously had been funded through FY2013. Also, extends the time period for 2010, CMS awarded $10 million in grants to tribal
CHIP outreach and enrollment grants through FY2015 and increases the existing
organizations.
appropriation for such grants from $100 million to $140 million. [CMS; CFDA 93.767]
[See https://www.cms.gov/apps/media/press/release.asp?
Counter=4063.]
Medicare
3014 Amends
SSA
Medicare quality and efficiency measures. Expands the duties of the consensus-based
No public information located on funding obligations.
Sec. 1890(b).
entity under contract with CMS pursuant to SSA Sec. 1890 (currently the National Quality
New SSA Sec.
Forum). Requires the entity to convene multi-stakeholder groups to provide input on the
1890A
national priorities for health care quality improvement (developed under ACA). In addition,
the multi-stakeholder groups are required to provide input on the selection of quality
measures for use in various specified Medicare payment systems for hospitals and other
providers, as well as in other health care programs, and for use in reporting performance
information to the public. Establishes a multi-step pre-rulemaking process and timeline for
the adoption, dissemination, and review of measures by the Secretary. Requires the
Secretary to transfer from the Medicare Part A and Part B trust funds $20 million for each
of FY2010 through FY2014, to remain available until expended.a Total amount = $100
million. [CMS]
3021(a)
New SSA Sec.
Center for Medicare and Medicaid Innovation (CMMI). Requires the Secretary, no
According to CMS’s FY2013 budget justification, FY2011
1115A
later than January 1, 2011, to establish the CMMI within CMS. The purpose of CMMI is to
obligations = $95 million; FY2012 obligations (est.) =
test and evaluate innovative payment and service delivery models to reduce program
$1.693 billion; FY2013 obligations (est.) = $1.362 billion.
expenditures under Medicare, Medicaid, and CHIP while preserving or enhancing the quality
of care furnished under these programs. In selecting the models, the Secretary is also
[For information on CMMI’s programs, which include
required to give preference to those that improve the coordination, quality, and efficiency
several of the initiatives summarized in this table, see
of health care services. Appropriates (1) $5 million for FY2010 for the selection, testing,
http://www.innovations.cms.gov/.]
and evaluation of new payment and service delivery models; and (2) $10 billion for the
period FY2011 through FY2019, plus $10 billion for each subsequent 10-year period, to
continue such activities and for the expansion and nationwide implementation of successful
models. Amounts are to remain available until expended.b [CMS]
3024
New SSA Sec.
Medicare independence at home demonstration program. Requires the Secretary
No public information located on funding obligations.
1866E
to conduct a three-year Medicare demonstration program, beginning no later than January
1, 2012, to test a payment incentive and service delivery model that uses physician- and
[For a fact sheet on the independence at home
nurse practitioner-directed primary care teams to provide home-based services to
demonstration, administered by CMMI, see
chronically ill patients. The Secretary must submit a plan, no later than January 1, 2016, for
http://www.innovations.cms.gov/initiatives/Independence-
expanding the program if it is determined that such expansion would improve the quality of
at-Home/index.html.]
care and reduce spending. Requires the Secretary to transfer from the Medicare Part A and
Part B trust funds $5 million for each of FY2010 through FY2015 for administering and
carrying out the demonstration, to remain available until expended.a Total amount = $30
million. [CMS]
CRS-11
ACA
Statutory
Obligations as of January 4, 2013, Based on TAGGS
Section
Authority
Program
Unless Specified Otherwise
3026 New
authority
Community-based care transitions program. Requires the Secretary to establish a
No public information located on funding obligations.
five-year program, beginning January 1, 2011, to provide funding to eligible hospitals and
community-based organizations that provide evidence-based transition services to Medicare [This program is being administered by CMMI, as part of its
beneficiaries with multiple chronic conditions who are at high risk for hospital readmission.
Partnership for Patients initiative. See
Requires the Secretary to transfer from the Medicare Part A and Part B trust funds $500
http://www.innovations.cms.gov/initiatives/Partnership-for-
million for the period FY2011 through FY2015, to remain available until expended.a [CMS]
Patients/index.html.]
3027(b)
Amends DRA
Medicare gainsharing demonstration program. CMS is supporting two projects that
No public information located on funding obligations.
Sec. 5007
allow hospitals to provide gainsharing payments to physicians that represent a share of the
savings incurred as a result of collaborative efforts to improve overall quality and efficiency.
ACA appropriates $1.6 million for FY2010, to remain available through FY2014 or until
expended, for carrying out the demonstration. [CMS]
3113 New
authority
Diagnostic laboratory test demonstration program. Requires the Secretary to
Payments under the demonstration began in January 2012.
conduct a two-year demonstration program beginning July 1, 2011, with a subsequent
report to Congress, to test the impact of direct payments for certain complex laboratory
[See http://www.cms.gov/Medicare/Demonstration-
tests on Medicare costs and quality of care. Payments are to be made from the Part B trust
Projects/DemoProjectsEvalRpts/Downloads/
fund and may not exceed $100 million. Transfers $5 million from the Medicare Part B trust
TCCDLT_FactSheet.pdf.]
fund, to remain available until expended, for carrying out the demonstration program and
preparing the subsequent report. [CMS]
3306 Amends Outreach and assistance for Medicare low-income programs. Transfers a total of
HHS announced grant awards totaling $45 million in
MIPPA Sec.
$45 million from the Medicare Part A and Part B trust funds for the period FY2010 through September 2010.
119
FY2012 to extend funding for the following beneficiary outreach and education activities for
Medicare low-income programs: (1) State Health Insurance Counseling and Assistance
Programs (SHIPs), $15 million; (2) Area Agencies on Aging (AAAs), $15 million; (3) Aging
and Disability Resource Centers (ADRCs), $10 million; and (4) the National Center for
Benefits Outreach and Enrollment (NCBOE), $5 million. Funds are to remain available until
expended.c Note: P.L. 112-240 appropriates $25 million for FY2013 for these programs: (1)
SHIPs, $7.5 million; (2) AAAs, $7.5 million; (3) ADRCs, $5 million; and (4) NCBOE, $5
million. [AoA, CMS; CFDA 93.518]
3403
New SSA Sec.
Independent Payment Advisory Board (IPAB). Creates an independent, 15-member
IPAB members have yet to be appointed.
1899A
advisory board tasked with presenting Congress with comprehensive proposals to reduce
excess cost growth and improve quality of care for Medicare beneficiaries. Appropriates
$15 million for FY2012 to support the board’s activities. For each subsequent fiscal year,
appropriates the amount from the previous fiscal year adjusted for inflation. Sixty percent
of the appropriation is to be derived by transfer from the Medicare Part A trust fund, and
40% is to be derived by transfer from the Medicare Part B trust fund. Note: P.L. 112-74
rescinds $10 million of IPAB’s $15 million appropriation for FY2012; see Appendix C.
CRS-12
ACA
Statutory
Obligations as of January 4, 2013, Based on TAGGS
Section
Authority
Program
Unless Specified Otherwise
4202(b) New
authority
Medicare prevention and wellness evaluation. Transfers $50 million from the
No public information located on funding obligations.
Medicare Part A and Part B trust funds, to remain available until expended, to fund an
evaluation of community-based prevention and wellness programs and, based on the
findings, develop a plan to promote healthy lifestyles and chronic disease self-management
among Medicare beneficiaries.a [CMS]
4204(e) New
authority
Medicare vaccine coverage. Appropriates $1 million for FY2010 for a GAO report on
Report released in December 2011 (GAO-12-61).
the impact of Medicare Part D vaccine coverage on access to those vaccines among
beneficiaries.
10323(a)
New SSA Sec.
Environmental health hazards. Extends Medicare eligibility to individuals with specified
No public information located on funding obligations.
1881A
health conditions linked to environmental exposures, who have resided for specified times
in an area subject to a Superfund public health emergency declaration. Requires the
Secretary to establish a pilot program, with appropriate reimbursement methodologies, to
provide comprehensive, coordinated, and cost-effective care to such individuals. Transfers
such sums as may be necessary from the Medicare Part A and Part B trust funds to carry
out the pilot program.a [CMS]
10323(b)
New SSA Sec.
Environmental health hazards. Appropriates $23 million for the period FY2010
$5 million
2009
through FY2014, and $20 million for each five-year period thereafter, for grants to state
and local government agencies, health care facilities, and other entities to (1) provide
[Funding provided for an asbestos health screening
screening for specified lung diseases and other environmental health conditions to
program in Libby, Montana.]
individuals who have resided for specified times in an area subject to a Superfund public
health emergency declaration; and (2) disseminate public information about the availability
of screening, the detection and treatment of environmental health conditions, and the
availability of Medicare benefits to certain individuals diagnosed with such conditions,
pursuant to new SSA Sec. 1881A (as added by ACA Sec. 10323(a)). [CMS; CFDA 93.534]
Fraud and Abuse
6402(i) &
Amends SSA
Health Care Fraud and Abuse Control (HCFAC) Account. Applies a permanent
No public information located on funding obligations.
HCERA
Sec. 1817(k)
inflation adjustment to the annual appropriation (provided under SSA Sec. 1817(k)) for the
Sec.
HCFAC account. Appropriates from the Medicare Part A trust fund the following
1303(a)
supplemental amounts for the HCFAC account: $10 million for each of FY2011 through
FY2020; plus an additional $95 million for FY2011, $55 million for FY2012, $30 million for
each of FY2013 and FY2014, and $20 million for each of FY2015 and FY2016. Funds are to
remain available until expended. Total amount = $350 million. [CMS]
Health Centers and the National Health Service Corps
4101(a) New
authority
School-based health centers (SBHCs). Appropriates $50 million for each of FY2010
$142 million
through FY2013, to remain available until expended, for a grant program to fund the
construction and renovation of school-based health centers. Total amount = $200 million.
[In December 2012, HRSA announced a third round of
[HRSA; CFDA 93.501]
awards to SBHCs totaling $80 million. See
http://bphc.hrsa.gov/about/schoolbased/index.html.]
CRS-13
ACA
Statutory
Obligations as of January 4, 2013, Based on TAGGS
Section
Authority
Program
Unless Specified Otherwise
10503(b)(1) New
authority Community Health Center Fund (CHCF). Transfers from the CHCF the following
In FY2011 and FY2012, HRSA awarded a total of
amounts for health center operations, to remain available until expended: FY2011 = $1
approximately $1.1 billion in ACA grants to support health
billion; FY2012 = $1.2 billion; FY2013 = $1.5 billion; FY2014 = $2.2 billion; and FY2015 =
center operations and related activities.
$3.6 billion. Total amount = $9.5 billion. [HRSA; CFDA 93.527]
[See http://bphc.hrsa.gov/about/healthcenterfactsheet.pdf.]
10503(b)(2) New
authority National Health Service Corps (NHSC). Transfers from the CHCF the following
According to the President’s FY2013 budget, obligations
amounts for NHSC operations, scholarships, and loan repayments, to remain available until
are as follows: FY2011 = $289 million; FY2012 (est.) =
expended: FY2011 = $290 million; FY2012 = $295 million; FY2013 = $300 million; FY2014
$296 million; FY2013 (est.) = $300 million.
= $305 million; and FY2015 = $310 million. Total amount = $1.5 billion. [HRSA; CFDA
93.547]
10503(c) New
authority
Health center construction and renovation. Appropriates $1.5 billion, to be available
$1.509 billion
for the period FY2011 through FY2015, and to remain available until expended, for health
center construction and renovation. [HRSA; CFDA 93.526]
Health Workforce
5507(a)
New SSA Sec.
Health workforce demonstration programs. Requires the Secretary to establish two
$195 million: Health Profession Opportunity Grant
2008
demonstration projects. The first is to award health profession opportunity grants to states, (HPOG)
Indian tribes, institutions of higher education, and local workforce investment boards to
help low-income individuals obtain education and training in health care jobs that pay well
$13 million: Personal and Home Care Aide State Training
and are in high demand. Funds may be used to provide financial aid and other supportive
(PHCAST) program
services. The second project is to provide states with grants to develop core training
[See http://www.acf.hhs.gov/programs/ofa/programs/hpog
competencies and certification programs for personal and home care aides. Appropriates
and http://bhpr.hrsa.gov/nursing/grants/phcast.html.]
$85 million for each of FY2010 through FY2014, of which $5 million in each of FY2010
through FY2012 is to be used for the second project. Total amount = $425 million. [ACF,
HRSA; CFDA 93.093, 93.512]
5507(b) Amends
SSA
Family-to-family health information centers. Renews funding for the family-to-family
$5 million (FY2012)
Sec. 501(c)
information centers, which assist families of children with disabilities or special health care
needs and the professionals who serve them, by appropriating $5 million for each of
[See http://mchb.hrsa.gov/programs/familytofamily/
FY2010 through FY2012, to remain available until expended. Total amount = $15 million.
index.html.]
Note: P.L. 112-240 appropriates $5 million for FY2013. [HRSA; CFDA 93.504]
5508(c) New
PHSA Teaching health centers. Appropriates such sums as may be necessary, not to exceed
$30 million
Sec. 340H
$230 million, for the period FY2011 through FY2015 to make payments for direct and
indirect graduate medical education (GME) costs to qualified teaching health centers
[See http://bhpr.hrsa.gov/grants/teachinghealthcenters/.]
(THCs). [HRSA; CFDA 93.530]
5509 New
authority
Medicare graduate nurse education demonstration program. Appropriates $50
CMMI, which is administering this program, has selected
million for each of FY2012 through FY2015, to remain available until expended, for a
the five participating hospitals and begun making
Medicare demonstration program under which up to five eligible hospitals will receive
reimbursement payments.
reimbursement for providing advanced practice nurses with clinical training in primary care,
preventive care, transitional care, and chronic care management. Total amount = $200
[See http://innovations.cms.gov/initiatives/GNE/index.html.]
million. [CMS/CMMI]
CRS-14
ACA
Statutory
Obligations as of January 4, 2013, Based on TAGGS
Section
Authority
Program
Unless Specified Otherwise
10502 New
authority
Health care facility construction. Appropriates $100 million for FY2010, to remain
$100 million
available for obligation until Sept. 30, 2011, for debt service on, or construction or
renovation of, a hospital affiliated with a state’s sole public medical and dental school.
[Funding awarded to Ohio State University.]
[HRSA; CFDA 93.502]
Community-Based Prevention and Wellness
4002 New
authority
Prevention and Public Health Fund (PPHF). Establishes a PPHF and originally
PPHF funds are annual appropriations that must be
provided a permanent annual appropriation to the fund, as follows: FY2010 = $500 million;
obligated during the fiscal year in which they are made
FY2011 = $750 million; FY2012 = $1 billion; FY2013 = $1.25 billion; FY2014 = $1.5 billion;
available. For a complete list of all PPHF obligations for
FY2015 and each year thereafter = $2 billion. Requires the Secretary to transfer amounts
FY2010 and FY2011, see the GAO report, Prevention and
from the fund to HHS accounts to increase funding, over the FY2008 level, for PHSA-
Public Health Fund: Activities Funded in Fiscal Years 2010 and
authorized prevention, wellness, and public health activities, including prevention research
2011 (GAO-12-788), at http://www.gao.gov/assets/650/
and health screenings. Authorizes House and Senate appropriators to transfer monies from
648310.pdf.
the PPHF to eligible activities. Note: P.L. 112-96 subsequently reduced the annual
appropriations to the PPHF over the period FY2013-FY2021, as follows: FY2013 through
For a summary of the activities and programs, by agency,
FY2017 = $1 billion; FY2018 and FY2019 = $1.25 billion; FY2020 and FY2021 = $1.5 billion;
that were supported with FY2012 PPHF funds, see
FY2022 and each year thereafter = $2 billion. [OS, CDC, HRSA, SAMHSA, ACL; CFDA
http://www.hhs.gov/open/recordsandreports/prevention/
93.507, 93.521, 93.522, 93.523, 93.524, 93.531, 93.533, 93.538, 93.539, 93.540, 93.542.]
index.html. [This website was mandated by P.L. 112-74; see
Appendix C.]
Note: The listed CFDA programs do not capture all the
uses of PPHF funding. PPHF funds have also been
integrated into existing programs that do not mention
PPHF.
Maternal and Child Health
2951
New SSA Sec.
Maternal, infant, and early childhood home visiting program. Appropriates the
$639 million
511
following amounts for grants to states, U.S. territories, and Indian tribes to develop and
implement early childhood home visiting programs that adhere to evidence-based models of [See http://mchb.hrsa.gov/programs/homevisiting/.]
service delivery: FY2010 = $100 million; FY2011 = $250 million, FY2012 = $350 million;
FY2013 = $400 million; FY2014 = $400 million. Total amount = $1.5 billion. Programs must
establish benchmarks to measure improvements for the participating families in maternal
and newborn health; prevention of child abuse or neglect or child injuries; school readiness
and achievement; reductions in crime or domestic violence; family economic self-sufficiency;
and coordination and referrals for other community resources and supports. [HRSA, ACF;
CFDA 93.505, 93.508]
2953
New SSA Sec.
Personal Responsibility Education Program (PREP). Establishes a state formula
$215 million
513
grant program to support evidence-based PREPs designed to educate adolescents about
abstinence, contraception, and adulthood. Also, requires the Secretary to award grants to
[See http://www.acf.hhs.gov/programs/fysb/programs/
implement innovative youth pregnancy prevention strategies and to target services at high-
adolescent-pregnancy-prevention/programs/prep-
risk populations. Appropriates $75 million for each of FY2010 through FY2014, of which
competitive.]
$10 million each year is to be reserved for the youth pregnancy prevention grants. Funds
are to remain available until expended. Total amount = $375 million. [ACF; CFDA 93.092]
CRS-15
ACA
Statutory
Obligations as of January 4, 2013, Based on TAGGS
Section
Authority
Program
Unless Specified Otherwise
2954 Amends
SSA
Abstinence education grants. Renews funding for the state formula grant program to
$83 million (FY2010-FY2012)
Sec. 510
support abstinence education programs by appropriating $50 million for each of FY2010
through FY2014. Total amount = $250 million. Funds are awarded to states based on the
[See http://www.acf.hhs.gov/programs/fysb/resource/aegp-
proportion of low-income children in each state compared to the national total, and may
fact-sheet.]
only be used for teaching abstinence. [ACF, CDC; CFDA 93.235]
10211-
New authority
Pregnancy assistance grants. Appropriates $25 million for each of FY2010 through
$72 million
10214
FY2019 (total amount = $250 million) to establish a Pregnancy Assistance Fund for the
purpose of awarding grants to states to assist pregnant and parenting teens and women.
[See http://www.hhs.gov/ash/oah/oah-initiatives/paf/
State grantees have the flexibility to make funds available to institutions of higher education, home.html.]
high schools and community service centers, and to the state attorneys general to improve
services for pregnant women who are victims of domestic violence, sexual assault, or
stalking. [OS; CFDA 93.500]
Long-Term Care
2403 Amends
DRA
Medicaid Money Follows the Person (MFP) demonstration program. Extends
$293 million (FY2012 only)
Sec. 6071(h)
funding for the MFP demonstration through FY2016. The program authorizes the Secretary
to award competitive grants to states to reduce their reliance on institutional care for
[See http://www.medicaid.gov/Medicaid-CHIP-Program-
people needing long-term care, and expand options for elderly people and individuals with
Information/By-Topics/Long-Term-Services-and-Support/
disabilities to receive home and community-based long-term care services. Appropriates
Balancing/Money-Follows-the-Person.html.]
$450 million for each of FY2012 through FY2016, to remain available through FY2016.
Total amount = $2.25 billion. [CMS; CFDA 93.791]
2405 New
authority
State Aging and Disability Resource Centers (ADRCs). Appropriates $10 million
$15 million
for each of FY2010 through FY2014 (total amount = $50 million) for ADRCs, authorized
under OAA Sec. 202. ADRCs serve as a single, coordinated resource for consumer
[See http://www.aoa.gov/AoA_programs/HCLTC/ADRC/
information on the range of long-term care options in community and institutional settings.
index.aspx.]
Some ADRCs also serve as the entry point to publicly administered long-term care
programs (e.g., Medicaid, OAA services, state assistance programs). AoA and CMS have
invested more than $100 million in the ADRC program since 2003. ADRCs currently
operate in over 350 community sites across 54 states and territories. See also the entry for
ACA Sec. 3306, above. [AoA; CFDA 93.517]
6201 New
authority
Background checks of long-term care providers. Requires the Secretary to establish
$48 million
a nationwide program for background checks on direct patient access employees of long-
term care facilities or providers, and to provide federal matching funds to states to conduct
these activities. Requires the Treasury Secretary to transfer to HHS an amount, not to
exceed $160 million, that is specified by the HHS Secretary as necessary to carry out the
program for the period FY2010 through FY2012. Funds are to remain available until
expended. [CMS; CFDA 93.506]
CRS-16
ACA
Statutory
Obligations as of January 4, 2013, Based on TAGGS
Section
Authority
Program
Unless Specified Otherwise
8002(d) Amends
DRA
National Clearinghouse for Long-Term Care Information. Appropriates $3 million
No public information located on funding obligations.
Sec. 6021(d)
for each of FY2011 through FY2015 for the National Clearinghouse for Long-Term Care
However, these are annual appropriations that must be
Information, and requires the Clearinghouse to include information on the Community
obligated during the fiscal year in which they are made
Living Assistance Services and Supports (CLASS) program, established under ACA Sec.
available.
8002(a). Total amount = $15 million. [AoA]
[See http://www.longtermcare.gov/LTC/Main_Site/
index.aspx.]
Comparative Effectiveness Research
6301(d)-(e)
New IRC Secs. Patient-Centered Outcomes Research Trust Fund (PCORTF). Establishes a
In June 2012, PCORI announced pilot project grant awards
9511, 4375, &
PCORTF to fund the new Patient-Centered Outcomes Research Institute (PCORI) and its
totaling $30 million over two years. In December 2012,
4376. New
comparative effectiveness research activities. Appropriates to the PCORTF $10 million for
PCORI announced its first comparative effectiveness
SSA Sec. 1183
FY2010, $50 million for FY2011, and $150 million for each of FY2012 through FY2019, for
research grant awards totaling $41 million over three
a total of $1.26 billion over that 10-year period. For each of FY2013 through FY2019, the
years.
PCORTF is to receive additional appropriations equal to the net revenues from a new
health insurance policy/plan fee,d as well as Medicare trust fund transfers.e Each fiscal year,
[See http://www.pcori.org/.]
20% of the funds in the PCORTF are to be transferred to the Secretary, to remain available
until expended. Of those transferred funds, 80% are to be provided to AHRQ. [OS,
AHRQ]
Biomedical Research
9023
New IRC Sec.
Therapeutic research and development tax credits and grants. Creates a two-year According to the IRS: total grant awards = $970 million;
48D
tax credit program, subject to an overall cap of $1 billion, for small companies (250 or
total tax credits = $17 million.
fewer employees) that invest in new therapies to prevent, diagnose, and treat cancer and
other diseases. Companies may apply for one or more tax credits, each covering up to 50%
[See http://www.irs.gov/Businesses/Small-Businesses-&-Self-
of the cost of qualifying research investments made in 2009 and 2010. However, the total
Employed/Qualifying-Therapeutic-Discovery-Project-
amount of tax credits any one company receives for the two years may not exceed $5
Credits-and-Grants.]
million. Companies may elect to receive one or more grants in lieu of tax credits, subject to
the same restrictions (i.e., grants may cover up to 50% of the cost of qualifying investments
made in 2009 and 2010; the total amount of grants any one company receives for the two
years may not exceed $5 million). Appropriates such sums as may be necessary to carry
out the grant program. [IRS]
ACA Implementation: Administrative Expenses
HCERA
New authority
Health Insurance Reform Implementation Fund (HIRIF). Appropriates $1 billion to
The HIRIF funds were projected to have all been obligated
Sec. 1005
the HIRIF for federal administrative expenses to carry out ACA. [OS; CFDA 93.528]
by the end of FY2012.
Source: Prepared by the Congressional Research Service based on the text of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148), as amended.
a. Transfers from the two trust funds are in such proportion as the Secretary determines appropriate.
b. Of the amounts appropriated for the period FY2011-FY2019, and for each subsequent 10-year period, at least $25 million must be made available each fiscal year for
the selection, testing, and evaluation of new payment and service delivery models.
CRS-17
c. Transfers from the two trust funds are in the same proportion as the Secretary determines under SSA Sec. 1853(f).
d. The health insurance fee is to equal $2 multiplied by the average number of covered lives in a policy/plan year ($1 in the case of a policy/plan year ending during
FY2013), updated annually by the rate of medical inflation beginning in FY2015.
e. The trust fund transfers are to equal $2 ($1 in FY2013) multiplied by the average number of individuals entitled to benefits under Part A or enrolled under Part B in a
given fiscal year, updated annually by the rate of medical inflation beginning in FY2015.
CRS-18
Table 2. ACA Appropriations and Fund Transfers by Fiscal Year
FY2010-FY2019
Appropriation (or Fund Transfer) in $ millions
ACA
Section
Program
FY2010
FY2011
FY2012
FY2013 FY2014 FY2015 FY2016 FY2017 FY2018
FY2019
Totala
Private Health Insurance
1002 Health
insurance
consumer
information
30b (Note: This section also authorizes to be appropriated SSAN for FY2011 and each fiscal year thereafter.)
30
1003
Review of health insurance
premium rates
250 — — — — — — — — —
250
1101
Temporary high-risk health
insurance pools
5,000b — — — — — — — — —
5,000
1102
Early retiree reinsurance
program
5,000b — — — — — — — — —
5,000
1311 Health
insurance
exchange Appropriates amounts necessary for grants each fiscal year, as
— — — —
TBDc
planning and establishment
determined by the Secretary; no grant awards after Jan. 1, 2015
1322
Consumer operated and
6,000d — — — — — — — — —
6,000
oriented plans (CO-OPs)
1323 Health
insurance
exchange —
—
—
—
$1 billion total for CY2014 through CY2109e 1,000
subsides (U.S. territories)
Medicaid and Children’s Health Insurance Program (CHIP)
2701
Medicaid adult health quality
measures
60 60 60 60 60 — — — — —
300f
2707 Medicaid
emergency
psychiatric demonstration
— 75g — — — — — — — — 75
2801
Medicaid and CHIP Payment
and Access Commission
11h (Note: This section also authorizes to be appropriated SSAN for FY2011 and each fiscal year thereafter.)
11
4108
Medicaid prevention and
—
$100 million total for CY2011 through CY2015f
— — — —
100
wellness incentives
4306
CHIP childhood obesity
$25 million total for FY2010
through
FY2014
— — — — — 25
demonstration
10203(d)
CHIP annual appropriationi — — — —
19,147
21,061 — — — —
40,208
10203(d)
CHIP outreach and
Increases total funding from $100 million to $140 million and extends
— — — — 40
enrollment grants
funding period through FY2015
CRS-19
Appropriation (or Fund Transfer) in $ millions
ACA
Section
Program
FY2010
FY2011
FY2012
FY2013 FY2014 FY2015 FY2016 FY2017 FY2018
FY2019
Totala
Medicare
3014
Medicare quality and
efficiency measures
20j 20 20 20 20 — — — — —
100
3021(a)
Center for Medicare and
Medicaid Innovation
5
plus $10 billion total for FY2011 through FY2019, and $10 billion for each subsequent 10-year period
10,005f
3024
Medicare independence at
home demonstration
5j 5 5 5 5 5 — — — — 30
3026 Community-based
care
transition services
—
$500 million total for FY2011 through FY2015j
— — — —
500
3027(b) Medicare
gainsharing
demonstration
2 — — — — — — — — — 2f
3113
Diagnostic laboratory test
5k — — — — — — — — — 5
demonstration
3306
Outreach and assistance for
$45 million total for FY2010
25l — — — — — — 70
low-income beneficiaries
through FY2012l
3403 Independent
Payment
— — 5m For FY2013 and each subsequent fiscal year, appropriates previous year’s amount
TBDc
Advisory Board
adjusted for inflation; funds derived from the Medicare trust funds.
4202(b)
Prevention and wellness
50j — — — — — — — — — 50
evaluation
4204(e)
GAO study of Medicare
1 — — — — — — — — — 1
vaccine coverage
10323(a) Environmental
health
pilot
SSANj
TBDc
program
10323(b) Environmental
health
$23 million total for FY2010 through FY2014
$20 million total for FY2015 though FY2019, and for
43f
screening and education
each 5-year period thereafter
Fraud and Abuse
6402(i) &
Health Care Fraud and
HCERA
Abuse Control (HCFAC)
— 105 65 40 40 30 30 10 10 10
350n
1303(a)
Account
Health Centers and the National Health Service Corps (NHSC)
4101(a)
School-based health center
establishment grants
50 50 50 50 — — — — — —
200f
CRS-20
Appropriation (or Fund Transfer) in $ millions
ACA
Section
Program
FY2010
FY2011
FY2012
FY2013 FY2014 FY2015 FY2016 FY2017 FY2018
FY2019
Totala
10503(b)(1) Community Health Centers
Fund, patient services
—
1,000
1,200
1,500
2,200
3,600 — — — —
9,500f
10503(b)(2) Community Health Centers
Fund, NHSC
— 290 295 300 305 310 — — — —
1,500f
10503(c)
Community health center
construction and renovation
—
$1.5 billion total for FY2011 through FY2015
—
—
—
—
1,500f
Health Workforce
5507(a) Health
workforce
demonstration grants
85 85 85 85 85 — — — — —
425
5507(b) Family-to-family
health
information centers
5 5 5
5o — — — — — —
20f
5508(c) Teaching
health
centers,
SSAN for FY2011 through FY2015, not to exceed $230
GME payments
—
million
— — — —
≤230
5509 Medicare
graduate
nurse
education demonstration
— — 50 50 50 50 — — — —
200f
10502 Health
care
facility
construction
100 — — — — — — — — —
100p
Community-Based Prevention and Wellness
4002
Prevention and Public Health
Fund
500 750 1,000 1,000 1,000 1,000 1,000 1,000 1,250 1,250
9,750q
Maternal and Child Health
2951
Maternal, infant, and early
100 250 350 400 400 — — — — —
1,500
childhood home visitation
2953 Personal
responsibility
75 75 75 75 75 — — — — —
375f
education program grants
2954
Abstinence education state
grants
50 50 50 50 50 — — — — —
250
10214 Pregnancy
assistance
grants 25 25 25 25 25 25 25 25 25 25
250
Long-Term Care
2403
Medicaid money follows the
— 450 450 450 450 450 450 — — —
2,700
person demonstration
CRS-21
Appropriation (or Fund Transfer) in $ millions
ACA
Section
Program
FY2010
FY2011
FY2012
FY2013 FY2014 FY2015 FY2016 FY2017 FY2018
FY2019
Totala
2405
State Aging and Disability
Resource Centers
10 10 10 10 10 — — — — — 50
6201
Background checks of long-
Up to $160 million total for
term care providers
FY2010 through FY2012
— — — — — — —
≤160r
8002(d)
National Clearinghouse for
Long-Term Care Information
— 3 3 3 3 3 — — — — 15
Comparative Effectiveness Research
6301(d) Patient-Centered
Outcomes
Research Trust Fund,
— — —
For each of FY2013-FY2019, transfers amounts from the Medicare trust funds
TBDs
Medicare transfers
as determined by a formula
6301(e) Patient-Centered
Outcomes
Research Trust Fund,
10 50 150
For each of FY2013-FY2019, appropriates $150 million plus an amount equal
TBDt
appropriations
to the net revenue from a fee levied on insurance policies and health plans
Biomedical Research
9023(e)
Grants for investment in
new therapeutics
SSAN — — — — — — — — —
≤1u
PPACA Implementation
HCERA
Health Insurance Reform
1,000 — — — — — — — — —
1,000
1005
Implementation Fund
Source: Prepared by the Congressional Research Service based on the text of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148), as amended.
Notes: Funds are provided from the Treasury unless otherwise noted. A dash means that ACA does not appropriate or transfer funds for the fiscal year(s) noted.
a. Total represents the cumulative amount of appropriations or fund transfers over the 10-year period FY2010-FY2019. Note that in several instances the 10-year total is
yet to be determined (TBD); see table entries for ACA Secs. 1311, 3403, 6301(d) & (e), 9023(e), and 10323(a). In addition, four provisions provide annual or multiple-
year appropriations beyond FY2019. The total shown in the table for three of these provisions represents the cumulative amount appropriated through FY2019; see
table entries for ACA Secs. 3021(a), 4002 (discussed in table note “q” below), and 10323(b). Finally, the total for ACA Sec. 6402(i) includes an amount appropriated in
FY2020 (see table note “n” below).
b. Funds are to remain available without fiscal year limitation.
c. To be determined.
d. ACA Sec. 1322 appropriated $6 billion for the CO-OP program. Subsequently, Division B, Title VIII, Sec. 1857 of P.L. 112-10 canceled $2.2 billion of that
appropriation; Division F, Title V, Sec. 524 of P.L. 112-74 rescinded an additional $400 million; and Sec. 644 of P.L. 112-240 rescinded all but 10% of the remaining
unobligated funds. See Appendix C.
e. Of this total amount, $925 million is for Puerto Rico, and the remaining $75 million is for the other U.S. territories in amounts as specified by the Secretary.
CRS-22
f.
Funds are to remain available until expended.
g. Funds are to remain available for obligation through Dec. 31, 2015.
h. Of this total amount, $9 million is appropriated, and the remaining $2 million is a transfer from CHIP funding for FY2010. Funds are to remain available until expended.
i.
Prior to enactment of ACA, the CHIP program was funded through FY2013.
j.
The Secretary is required to transfer amounts from the Medicare Part A and Part B trust funds each fiscal year in such proportion as the Secretary determines
appropriate. Funds are to remain available until expended.
k. The Secretary is required to transfer the $5 million from the Medicare Part B trust fund, to remain available until expended.
l.
The Secretary is required to transfer amounts from the Medicare Part A and Part B trust funds in the same proportion as the Secretary determines under SSA Sec.
1853(f). Funds are to remain available until expended. Note: Sec. 610 of P.L. 112-240 appropriated $25 million for FY2013 for the four outreach and assistance
programs funded under ACA Sec. 3306. See Table 1 and Appendix C.
m. Division F, Title V, Sec. 525 of P.L. 112-74 rescinded $10 million of IPAB’s appropriation for FY2012. See Appendix C.
n. Funds are to be appropriated from the Medicare Part A trust fund. Note: the total amount appropriated (i.e., $350 million) includes a final appropriation of $10 million
for FY2020.
o. Sec. 624 of P.L. 112-240 appropriated $5 million for FY2013 for this program.
p. Funds are to remain available for obligation until Sept. 30, 2011.
q. ACA Sec. 4002 originally provided a permanent annual appropriation to the Prevention and Public Health Fund, as follows: FY2010 = $500 million; FY2011 = $750
million; FY2012 = $1 billion; FY2013 = $1.25 billion; FY2014 = $1.5 billion; FY2015 and each year thereafter = $2 billion. Subsequently, P.L. 112-96 reduced the annual
appropriations to the PPHF over the period FY2013-FY2021, as follows: FY2013 through FY2017 = $1 billion; FY2018 and FY2019 = $1.25 billion; FY2020 and FY2021
= $1.5 billion; FY2022 and each year thereafter = $2 billion. Thus, appropriations to the fund now total $9.750 billion over the period FY2010-FY2019.
r. The HHS Secretary is required to notify the Treasury Secretary of the amount necessary to carry out activities under this section for the period of FY2010 through
FY2012, but not to exceed $160 million. The Treasury Secretary must then transfer the amount specified from the Treasury to the HHS Secretary. Funds are to
remain available until expended.
s. To be determined. ACA Sec. 6301(d) provided the following formula for the transfer of funds from the Medicare Part A and Part B trust funds to the Patient-Centered
Outcomes Research Trust Fund: (1) for FY2013, an amount from each respective Medicare trust fund equal to $1 multiplied by the average number of individuals
entitled to Part A benefits, or enrolled in Part B during that period; and (2) for each of FY2014-FY2019, an amount from each respective Medicare trust fund equal to
$2 multiplied by the average number of individuals entitled to Part A benefits, or enrolled in Part B during that fiscal year. Beginning in FY2015, amounts are subject to
adjustment for increases in health care spending.
t.
To be determined. In addition to the amounts transferred to the Patient-Centered Outcomes Research Trust Fund under ACA Sec. 6301(d), described in the
preceding table note, ACA Sec. 6301(e) appropriated to the Fund a specified amount for each of FY2010-FY2019, plus an additional amount for each of FY2013
through FY2019 equal to the net revenues received from a fee imposed on health insurance policies and self-insured plans. The fee equals $2 multiplied by the average
number of covered lives in a policy/plan year ($1 in the case of policy/plan years ending during FY2013). Beginning in FY2015, amounts are subject to adjustment for
increases in health care spending.
u. To be determined. ACA Sec. 9023(e) created a two-year tax credit program, subject to an overall cap of $1 billion, for small companies that invest in new therapies to
prevent, diagnose and treat cancer and other diseases. The total amount of tax credits any one company can receive for the two years may not exceed $5 million.
Companies may elect to receive one or more grants—for which SSAN are appropriated—in lieu of tax credits. Grant applications must be received before Jan. 1,
2013.
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Appropriations and Fund Transfers in the Patient Protection and Affordable Care Act
Appendix A. Acronyms Used in the Report
The following laws and federal agencies are referred to in this report by their acronym:
AoA
Administration on Aging
ACF
Administration for Children and Families
AHRQ
Agency for Healthcare Research and Quality
BBEDCA
Balanced Budget and Emergency Deficit Control Act of 1985 (P.L. 99-177)
CCIIO
Center for Consumer Information and Insurance Oversight
CDC
Centers for Disease Control and Prevention
CHIP
Children’s Health Insurance Program
CMS
Centers for Medicare & Medicaid Services
DRA
Deficit Reduction Act of 2005 (P.L. 109-171)
HCERA
Health Care and Education Reconciliation Act of 2010 (P.L. 111-152)
HRSA
Health Resources and Services Administration
OS
HHS Office of the Secretary
IRC
Internal Revenue Code
IRS
Internal Revenue Service
MIPPA
Medicare Improvements for Patients and Providers Act of 2008 (P.L. 110-275)
OAA
Older Americans Act
PHSA
Public Health Service Act
PPACA
Patient Protection and Affordable Care Act (P.L. 111-148)
SSA Social
Security
Act
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Appendix B. ACA-Related Authorizing Legislation
in the 112th Congress
Lawmakers opposed to specific provisions in ACA, or to the entire law, introduced numerous
bills in the 112th Congress to modify or repeal the law. Most of the legislative activity on these
bills took place in the House. The ACA-related legislation included bills that would have (1)
repealed the law in its entirety and, in some instances, replaced it with new law; (2) repealed or
amended specific provisions in the law; (3) eliminated certain mandatory appropriations in ACA
(discussed in this report) and rescinded all unobligated funds;19 (4) replaced the mandatory
appropriations for one or more ACA programs with authorizations of appropriations, and
rescinded all unobligated funds; and (5) blocked or otherwise delayed ACA implementation. A
few provisions, with sufficiently broad and bipartisan support were approved in both the House
and the Senate and signed into law.
This appendix summarizes the ACA-related provisions in authorization legislation enacted during
the 112th Congress. It also provides a brief overview of each of the ACA-related bills that were
passed by the House, but which were not approved by the Senate. Appendix C summarizes the
ACA-related provisions in annual appropriations acts for the period FY2011-FY2013.
Enacted Legislation
P.L. 112-9 (April 14, 2011; H.R. 4), Comprehensive 1099 Taxpayer Protection and
Repayment of Exchange Subsidy Overpayments Act of 2011. P.L. 112-9 repealed the ACA
requirement that businesses file an information report (IRS Form 1099) whenever they pay a
vendor more than $600 for goods in a single year. To pay for the 1099 repeal, P.L. 112-9 raised
the limits on the amount of excess premium tax credits that individuals would have to repay.
[Note: Under ACA, the amount received in premium credits is based on income as reported on
tax returns. These amounts are reconciled the following year, which could result in an
overpayment of credits if income increases. ACA placed limits on the amount of any premium
credit overpayment that had to be repaid to the government.]
P.L. 112-56 (November 21, 2011; H.R. 674), 3% Withholding Repeal and Job Creation Act.
Among its many provisions, P.L. 112-56 amended the calculation of Modified Adjusted Gross
Income (MAGI) to include Social Security benefits. MAGI will be used to determine eligibility
for health insurance exchange subsidies and Medicaid, beginning in 2014.
P.L. 112-96 (February 22, 2012; H.R. 3060), Middle Class Tax Relief and Job Creation Act
of 2012. Among its many provisions, P.L. 112-96: (1) reduced ACA’s annual appropriations to the
PPHF over the period FY2013-FY2021 by a total of $6.25 billion to help offset the costs of the
law’s extension of the payroll tax cut; (2) extended by one year the disproportionate share
hospital (DSH) allotment reduction imposed by ACA; and (3) corrected the formula to phase
down ACA’s Medicaid disaster-recovery FMAP adjustment as originally intended. [Note: The
purpose of the adjustment was to help Louisiana avoid a significant reduction in its federal
Medicaid match (i.e., Federal Medical Assistance Percentage, or FMAP) in the aftermath of
19 Of the total amount of funding available for obligation, the unobligated balance represents the funds that an agency
has not yet awarded or otherwise made a legal commitment to provide as payment for goods or services.
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Hurricane Katrina. As written in ACA, the formula for the disaster-recovery FMAP adjustment
unintentionally caused the FMAP adjustment to increase, rather than phase down, each year the
state qualifies for the adjustment.]
P.L. 112-141 (July 6, 2012; H.R. 4348), Moving Ahead for Progress in the 21st Century Act,
or “MAP-21”. Among its many provisions, P.L. 112-141 included a further adjustment to ACA’s
Medicaid disaster-recovery provision (see entry for P.L. 112-96, above).
P.L. 112-240 (January 2, 2013; H.R. 8), American Taxpayer Relief Act of 2012. Among its
many provisions, P.L. 112-240: (1) provided $25 million for FY2013 for the four outreach and
assistance programs that were funded by ACA Sec. 3306 through FY2012; (2) provided $5
million for FY2013 for the family-to-family information centers, which ACA Sec. 5507(b) funded
through FY2012; and (3) repealed the Community Living Assistance Services and Supports
(CLASS) program.
House-passed Bills
H.R. 2, Repealing the Job-Killing Health Care Law Act. Passed the House by a vote of 245-
189 on January 19, 2011; offered as an amendment during Senate floor debate on an unrelated bill
(S. 223) and rejected on a procedural motion by a vote of 47-51. H.R. 2 would have repealed
ACA in its entirety and restored the provisions of law amended or repealed by ACA as if it had
not been enacted.
H.R. 5, Protecting Access to Healthcare Act. Passed the House by a vote of 223-181 on March
22, 2012. Title II of H.R. 5 would have repealed the authority and appropriations for the
Independent Payment Advisory Board (IPAB).
H.R. 358, Protect Life Act. Passed the House by a vote of 251-172 on October 13, 2011. H.R.
358 would have prohibited using any funds authorized or appropriated by ACA to pay for an
abortion or to pay for any part of the costs of a health plan that covers abortions, except if the
pregnancy is the result of rape or incest, or the life of the pregnant female is at risk unless an
abortion is performed. It would have required insurers that offer plans through the exchanges that
cover abortion services to offer identical plans that do not cover abortion services. It also would
have prohibited federal, state or local government programs that receive ACA funding from
discriminating against health care entities that refuse to provide abortion services or abortion
training.
H.R. 436, Health Care Cost Reduction Act of 2012. Passed the House by a vote of 270-146 on
June 7, 2012. H.R. 436 would have (1) repealed ACA’s 2.3% excise tax on medical devices; (2)
repealed the law’s restrictions on using tax-preferred accounts to pay for over-the-counter drugs;
(3) allowed individuals to recoup up to $500 of unused funds remaining in their flexible spending
account (FSA) after the end of the plan year; and (4) eliminated all limits on repayment of any
premium credit overpayment, making individuals liable for the full amount.
H.R. 1173, Fiscal Responsibility and Retirement Security Act of 2012. Passed the House by a
vote of 267-159 on February 1, 2012. H.R. 1173 would have repealed the Community Living
Assistance Services and Supports (CLASS) program.
H.R. 1213, A bill to repeal ACA funding for health insurance exchanges. Passed the House by
a vote of 238-183 on May 3, 2011. H.R. 1213 would have repealed the authority and
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appropriations for state exchange planning and establishment grants and rescinded all unobligated
funds.
H.R. 1214, A bill to repeal ACA funding for school-based health center (SBHC)
construction. Passed the House by a vote of 235-191 on May 4, 2011. H.R. 1214 would have
repealed the authority and appropriations for SBHC construction grants and rescinded all
unobligated funds.
H.R. 1216, A bill to convert funding for graduate medical education (GME) in qualified
teaching health centers (THCs) to an authorization of appropriations. Passed the House by a
vote of 234-185 on May 25, 2011. H.R. 1216 would have replaced the appropriation for GME
payments to THCs with an authorization of appropriations for each of FY2012 through FY2015,
and rescinded all unobligated funds. It would have prohibited the GME funds from being used to
provide abortions, except in cases of rape or incest or when the woman’s life is in danger.
H.R. 1217, A bill to repeal the Prevention and Public Health Fund (PPHF). Passed the House
by a vote of 236-183 on April 13, 2011. H.R. 1217 would have repealed the authority and
appropriations for the PPHF and rescinded all unobligated funds.
H.R. 4628, Interest Rate Reduction Act. Passed the House by a vote of 215-195 on April 27,
2012. H.R. 4628 would have postponed by one year a scheduled increase in Stafford education
loan rates and, to offset the costs of that adjustment, repealed the authority and appropriations for
the PPHF and rescinded all unobligated funds. [Note: The one-year Stafford loan rate extension
was incorporated as Division F, Title III of MAP-21, the surface transportation reauthorization
bill (see entry for P.L. 112-141, above). The provision in H.R. 4628 to repeal PPHF and rescind
all unobligated funds was not included in MAP-21.]
H.R. 5652, Sequester Replacement Reconciliation Act of 2012. Passed the House by a vote of
218-199 on May 10, 2012. H.R. 5652, which was introduced pursuant to the reconciliation
instructions in the House FY2013 budget resolution (H.Con.Res. 112), would have replaced the
FY2013 sequestration of discretionary spending (as required under the Budget Control Act of
2011) with a $19 billion reduction in the FY2013 discretionary cap, and would have implemented
a series of mandatory program savings recommended by six House committees. Among its many
provisions, H.R. 5652 would have (1) eliminated all limits on repayment of any premium credit
overpayment, making individuals liable for the full amount; (2) repealed the authority and
appropriations for the exchange planning and establishment grants and rescinded all unobligated
funds; (3) repealed the authority and appropriations for the PPHF and rescinded all unobligated
funds; (4) rescinded all remaining unobligated funds for the Consumer Operated and Oriented
Plan (CO-OP) program; (5) extended by one year the DSH allotment reduction imposed by ACA;
and (6) repealed ACA’s Medicaid maintenance of effort requirements.
H.R. 6079, Repeal of Obamacare Act. Passed the House by a vote of 244-185 on July 11, 2012.
H.R. 6079 would have repealed all of ACA, except the authority for IPAB (see entry for H.R. 5,
above), and restored the provisions of law amended or repealed by ACA as if it had not been
enacted.
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Appendix C. ACA Provisions in Appropriations
Bills (FY2011-FY2013)
Numerous ACA-related provisions have been included in appropriations legislation introduced
and enacted since passage of the health reform law. These provisions, often referred to as
appropriations riders, generally are of two types: (1) appropriations restrictions that prohibit the
use of discretionary funds provided in the bill to implement specific ACA provisions or the entire
law; and (2) legislative language that amends or repeals specific ACA provisions.20 This appendix
summarizes the ACA provisions that were included in the enacted appropriations legislation for
FY2011 and FY2012. It also provides for each of those years a brief overview of the ACA-related
provisions that were added to both the Labor-HHS-Education and the Financial Services and
General Government appropriations acts introduced and, in most cases, reported by the House
and Senate Appropriations Committees. Only a few of those provisions were incorporated in the
final omnibus appropriations bills for FY2011 and FY2012 that were signed into law.
The appendix also provides some discussion of the ACA provisions in FY2013 appropriations
legislation. Congress has yet to complete action on any FY2013 appropriations bills. Currently,
the federal government is operating under a six-month continuing resolution (P.L. 112-175); see
discussion below under “FY2013 Appropriations”.
FY2011 Appropriations
On April 15, 2011, the Department of Defense and Full-Year Continuing Appropriations Act,
2011 (P.L. 112-10, H.R. 1473), was signed into law, marking the completion of the FY2011
appropriations process more than six months after the beginning of the fiscal year. Prior to the
enactment of P.L. 112-10, the President signed seven FY2011 interim continuing resolutions to
fund the federal government. P.L. 112-10 included the FY2011 Department of Defense regular
appropriations act and extended funding for the remaining 11 regular appropriations acts through
the end of FY2011, generally at the annualized rate provided in FY2010, but with spending
adjustments for numerous specified programs and activities.
Division B, Title VIII of P.L. 112-10 (Labor-HHS-Education) included the following ACA-related
provisions: (1) canceled $2.2 billion of the original $6 billion appropriation for the CO-OP
program; (2) repealed the free choice voucher program that would have required certain
employers to provide vouchers to qualified employees for purchasing coverage through a health
insurance exchange; (3) prohibited transfers from the Public Health and Social Services
Emergency Fund to pay for the new U.S. Public Health Sciences Track; (4) removed the
maintenance of effort requirement for use of the CHCF funds; and (5) mandated a GAO study of
the costs and processes of ACA implementation, and a Medicare actuarial analysis of the impact
of ACA’s private insurance reforms on employer-sponsored health insurance premiums. [Note:
20 House rules prohibit legislative language that establishes new law, or that amends or repeals current law, in regular
appropriations bills and supplemental appropriations measures. However, they do not prohibit such provisions in
continuing resolutions. These rules may be waived in a special rule adopted by the Rules Committee prior to floor
consideration of the appropriations bill or conference report. A comparable rule in the Senate prohibits legislative
language in both Senate Appropriations Committee amendments and non-committee amendments. For more
information, see CRS Report R42388, The Congressional Appropriations Process: An Introduction, by Jessica
Tollestrup.
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The House passed but the Senate rejected an enrollment correction to H.R. 1473 (H.Con.Res. 35)
that would have prohibited using any of the funds provided in P.L. 112-10 or in any previous act
to implement ACA.]
Several months prior to the enactment of P.L. 112-10, on August 2, 2010, the Senate
Appropriations Committee reported its version of the FY2011 Labor-HHS-Education
appropriations bill (S. 3686). The measure instructed the HHS Secretary to allocate the PPHF
funds for FY2011 (i.e., $750 million) to the programs specified, and in the amounts specified, in a
table included in the accompanying committee report (S.Rept. 111-243). The House
Appropriations Subcommittee on Labor-HHS-Education also approved a draft FY2011 bill, but
the full committee took no further action on it. On February 19, 2011, the House by a vote of 235-
189 passed its version of a full-year continuing resolution for FY2011 (H.R. 1). The bill included
nine separate but overlapping provisions that would have prohibited using any of the
discretionary funds provided in the bill to implement specific ACA provisions or the entire law.
The Senate subsequently rejected H.R. 1 by a vote of 44-56 on March 9, 2011.
FY2012 Appropriations
The Consolidated Appropriations Act, 2012 (P.L. 112-74, H.R. 2055), which included nine
FY2012 appropriations acts, was signed into law on December 23, 2011. Division F of P.L. 112-
74 (Labor-HHS-Education) included the following ACA-related provisions: (1) rescinded $400
million of the remaining $3.8 billion for the CO-OP program; see P.L. 112-10, above; (2)
rescinded $10 million of IPAB’s $15 million appropriation for FY2012; (3) instructed the HHS
Secretary to establish a website with detailed information on the allocation and use of FY2012
PPHF funds; and (4) prohibited the use of PPHF funds for lobbying, publicity, or propaganda
purposes.
Prior to the enactment of P.L. 112-74, the House and Senate Appropriations Committees took the
following actions on the FY2012 Labor-HHS-Education and the FY2012 Financial Services and
General Government appropriations acts:
• The chairman of the House Appropriations Subcommittee on Labor-HHS-
Education introduced a chairman’s bill (H.R. 3070) on September 29, 2011, but
the subcommittee did not mark up or report the measure to the full committee.
The bill received no full committee action. H.R. 3070, as introduced, included
the following ACA-related provisions: (1) rescinded the entire FY2012
appropriations for CHCF, PPHF, IPAB, the pregnancy assistance grants, the
home visitation program, state ADRCs, and the health workforce demonstration
grants; (2) rescinded all the remaining CO-OP funds (i.e., $3.8 billion); (3)
rescinded $1.862 billion of the $10 billion appropriation for CMMI for the period
FY2011-FY2019; and (4) prohibited using any of the discretionary funds
provided in the bill to implement and administer ACA until 90 days after all ACA
legal challenges are complete.
• The House Appropriations Committee reported the Financial Services and
General Government Appropriations Act, 2012 (H.R. 2434, H.Rept. 112-136) on
July 7, 2011. The measure included the following two ACA-related provisions:
(1) prohibited the IRS from using any of the discretionary funds provided in the
bill to implement the ACA individual mandate; and (2) prohibited the transfer of
any ACA funds to the IRS.
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• The Senate Appropriations Committee reported the Departments of Labor, Health
and Human Services, and Education, and Related Agencies Appropriations Act,
2012 (S. 1599) on September 22, 2011. Similar to the previous year’s bill, S.
1599, as reported, instructed the HHS Secretary to allocate the PPHF funds for
FY2012 (i.e., $1 billion) to the programs specified, and in the amounts specified,
in a table included in the accompanying committee report (S.Rept. 112-84). In
addition, S.Rept. 112-84 included language directing the HHS Secretary to
submit a detailed report on all the recipients of PPHF funding.
• The Senate Appropriations Committee reported the Financial Services and
General Government Appropriations Act, 2012 (S. 1573) on September 15, 2011.
The measure did not include any ACA provisions. However, the accompanying
committee report (S.Rept. 112-79) directed the IRS to submit a detailed table
itemizing each fund transfer from HHS to the IRS for the purpose of ACA
implementation.
FY2013 Appropriations
The President’s FY2013 budget requested more than $1 billion in new discretionary funding for
CMS and the IRS to pay for ongoing ACA administrative costs. It remains unclear, however,
whether congressional appropriators will provide those funds. Prior to FY2013, federal
administrative costs associated with ACA implementation were supported with mandatory funds
from the $1 billion Health Insurance Reform Implementation Fund (HIRIF); see the HIRIF
entries in Table 1 and Table 2. The HIRIF funds were projected to have all been obligated by the
end of FY2012.
Congress has yet to complete action on any of the FY2013 appropriations bills. Instead, it has
passed, and the President has signed, a continuing resolution to provide temporary funding for the
first six months of FY2013. The Continuing Appropriations Resolution, 2013 (P.L. 112-175,
H.J.Res. 117) funds government operations for most discretionary programs at an estimated
annualized rate of $1.047 trillion, which equals the FY2013 discretionary spending cap set by the
BCA. It increases funding for most federal agencies and programs by 0.612% over the FY2012
levels.21 P.L. 112-175 does not incorporate any of the new ACA funding that was requested in the
President’s FY2013 budget.
In the 112th Congress, the House and Senate Appropriations Committees took the following
actions on the FY2013 Labor-HHS-Education and the FY2013 Financial Services and General
Government appropriations acts:
• The House Appropriations Subcommittee on Labor-HHS-Education approved a
draft bill for FY2013 on July 18, 2012, but no further action was taken. The
measure did not include any of the new CMS funds requested in the President’s
FY2013 budget for ACA implementation, and it prohibited using any of the
discretionary funding provided in the bill to support CMS’s Center for Consumer
Information and Insurance Oversight (CCIIO). The draft bill also included the
following ACA-related provisions: (1) rescinded the entire FY2013
21 For more information, see CRS Report R42782, FY2013 Continuing Resolution: Analysis of Components and
Congressional Action, by Jessica Tollestrup.
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Appropriations and Fund Transfers in the Patient Protection and Affordable Care Act
appropriations for PPHF and IPAB, and rescinded the base appropriation of $150
million for PCORTF; (2) rescinded $3 billion of the remaining $3.4 billion for
the CO-OP funds (see P.L. 112-74, above); (3) rescinded $1.590 billion of the
$10 billion appropriation for CMMI for the period FY2011-FY2019; (4)
rescinded $300 million of the $1.5 billion CHCF appropriation in FY2013 for
community health centers; (5) prohibited using any of the discretionary funds
provided in the bill to implement and administer ACA; (6) instructed the HHS
Secretary to establish a website with detailed information on the allocation and
use of FY2013 PPHF funds; and (7) prohibited the use of PPHF funds for
lobbying, publicity, or propaganda purposes.
• The House Appropriations Committee reported the Financial Services and
General Government Appropriations Act, 2013 (H.R. 6020, H.Rept. 112-550) on
June 26, 2012. The measure did not include any of the new IRS funds requested
in the President’s FY2013 budget for ACA implementation. H.R. 6020 prohibited
the IRS from using any of the discretionary funds provided in the bill to carry out
the transfer of ACA funds to the agency.
• The Senate Appropriations Committee reported the Departments of Labor, Health
and Human Services, and Education, and Related Agencies Appropriations Act,
2013 (S. 3295) on June 14, 2012. Again, similar to the bills for the previous two
fiscal years, S. 3295, as reported, instructed the HHS Secretary to allocate the
PPHF funds for FY2013 (i.e., $1 billion, reflecting the rescission in P.L. 112-96)
to the programs specified, and in the amounts specified, in a table included in the
accompanying committee report (S.Rept. 112-176). In addition, the bill directed
the HHS Secretary to establish a website with detailed information on the
allocation and use of PPHF funds.
• The Senate Appropriations Committee reported the Financial Services and
General Government Appropriations Act, 2013 (S. 3301) on June 14, 2012. The
measure did not include any ACA provisions. However, the accompanying
committee report (S.Rept. 112-177) directed the IRS to submit a detailed table
itemizing each HIRIF fund transfer to the IRS for the purpose of ACA
implementation.
Author Contact Information
C. Stephen Redhead
Specialist in Health Policy
credhead@crs.loc.gov, 7-2261
Acknowledgments
The following analysts have contributed to this report: Kirsten Colello, Patricia Davis, Gary Guenther,
Elayne Heisler, Lisa Herz, Janet Kinzer, Sarah Lister, Alison Mitchell, Bernice Reyes, Amanda Sarata,
Pamela Smith, Carmen Solomon-Fears, Emilie Stoltzfus, and Susan Thaul.
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