Appropriations and Fund Transfers in the
Patient Protection and Affordable Care Act
(ACA)
C. Stephen Redhead
Specialist in Health Policy
May 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 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 also appropriates amounts for four special 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). The
fourth fund is helping cover the initial costs of ACA implementation. Finally, ACA provides
funding for health workforce and for maternal and child health programs.
Generally, the FY2013 mandatory appropriations in ACA are fully sequestrable at the rate
applicable to nonexempt nondefense mandatory spending under the March 1, 2013, 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. Some of these bills have
been reintroduced in 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
Automatic Annual Spending Reductions Under the Budget Control Act ........................................ 6
BCA’s Spending Reduction Procedures .................................................................................... 6
Direct Spending ................................................................................................................... 6
Discretionary Spending ....................................................................................................... 7
FY2013 Sequestration ............................................................................................................... 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 in Which Funds Are
Available for Obligation ............................................................................................................. 20
Appendixes
Appendix A. Acronyms Used in the Report................................................................................... 26
Appendix B. ACA-Related Authorizing Legislation in the 112th Congress ................................... 27
Appendix C. ACA Provisions in Appropriations Bills (FY2011-FY2013) .................................... 30
Contacts
Author Contact Information........................................................................................................... 33
Acknowledgments ......................................................................................................................... 33
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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 of the March 1, 2013,
sequestration 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
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.4 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
offices within the Office of the Secretary. It is updated daily with new data provided by these
entities.5
4 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.
5 To access and search the TAGGS database, go to http://www.taggs.hhs.gov/.
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Readers are also encouraged to visit the website of the Center for Consumer Information and
Insurance Oversight (CCIIO, within CMS),6 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.7 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.
As summarized in the tables, 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 (CMI) 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 CMI to test and implement
innovative payment and service delivery models. It also established and funded an Independent
6 http://cciio.cms.gov.
7 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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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 one:
• 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 partially supplanted discretionary health center funding and have
become the sole source of funding for the NHSC program, which received no
discretionary funds in FY2012.8
• 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.
• 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).9 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”).
• The Health Insurance Reform Implementation Fund (HIRIF), for which
ACA appropriated $1 billion, was to help cover the initial 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.
Lawmakers opposed to specific provisions in ACA, or to the entire law, have introduced
numerous bills 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
8 For more information, see CRS Report R42433, Federal Health Centers, by Elayne J. Heisler.
9 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.
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would modify or repeal ACA. Appendix C summarizes the ACA-related provisions in annual
appropriations acts for FY2011-FY2013.
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 actions taken by congressional
appropriators. With Congress now operating under enforceable discretionary spending limits, or
caps, imposed by the BCA, it may prove difficult to secure funding for new programs and
activities. Even maintaining current funding levels for existing programs with broad support and
an established appropriations history can be a challenge when there is pressure to reduce federal
discretionary spending. 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 provided $1 billion to the HIRIF to help cover the initial administrative
costs of implementation. Anticipating that all the HIRIF funds would be obligated by the end of
FY2012, the President’s FY2013 budget requested more than $1 billion in new discretionary
funding for CMS and the IRS to pay for ongoing ACA implementation costs. However, Congress
did not provide any of these new funds.
In FY2013, CMS reportedly will spend about $1.5 billion on ACA implementation, primarily to
establish federally facilitated exchanges in states that choose not to run their own exchanges and
to engage in consumer education and outreach. In the absence of any new FY2013 discretionary
funding for ACA implementation, HHS plans to transfer funds from the PPHF and other HHS
accounts. For more information on ACA administrative funding, see CRS Report R42051, Budget
Control Act: Potential Impact of Sequestration on Health Reform Spending.
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Automatic Annual Spending Reductions Under the
Budget Control Act
On March 1, 2013, President Obama ordered the sequestration (i.e., cancellation) of $85.33
billion in FY2013 budgetary resources from nonexempt budget accounts across the federal
government. The FY2013 sequestration order was issued pursuant to the Balanced Budget and
Emergency Deficit Control Act (BBEDCA), as amended by the Budget Control Act of 2011
(BCA).10 Under the BCA, the FY2013 sequestration was to be ordered on January 2, 2013. A
provision in the American Taxpayer Relief Act of 2012 (ATRA)11 delayed the order by two
months.
The FY2013 sequestration is the first of a series of automatic spending reductions under the BCA,
as amended by ATRA, that are required each year through FY2021. These annual spending
reductions were triggered by the failure of the Joint Select Committee on Deficit Reduction to
propose, and Congress and the President to enact, legislation to reduce the deficit by an amount
greater than $1.2 trillion over the period FY2012-FY2021.
BCA’s Spending Reduction Procedures
Based on the formula in the BCA, the automatic spending reductions triggered by the failure of
the Joint Committee must cut $109.33 billion in each fiscal year over the period FY2013-
FY2021. That amount is equally divided between defense and nondefense spending, each of
which is subject to a $54.67 billion annual cut. Importantly, ATRA reduced the cuts for FY2013
by $24 billion, which means that both defense and nondefense spending are subject to $12 billion
less in cuts in FY2013 (i.e., $42.67 billion, instead of $54.67 billion).12 The annual spending
reduction in each spending category—defense and nondefense—is further divided
proportionately between discretionary spending and nonexempt direct (i.e., mandatory) spending.
Direct Spending
Under the BCA, direct spending reductions are to be executed each year by an automatic across-
the-board cancellation of budgetary resources—a process known as sequestration—for
nonexempt accounts. The sequestration process is subject to exemptions and to certain rules,
which are specified in Sections 255 and 256, respectively, of the BBEDCA.13 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
10 P.L. 112-25, 125 Stat. 240. 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.
11 P.L. 112-240, 126 Stat. 2313.
12 For more information, see CRS Report R42949, The American Taxpayer Relief Act of 2012: Modifications to the
Budget Enforcement Procedures in the Budget Control Act, by Bill Heniff Jr.
13 For an overview of the BBEDCA exemptions and special rules, see CRS Report R42050, Budget “Sequestration”
and Selected Program Exemptions and Special Rules, coordinated by Karen Spar.
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spending programs, accounting for most of the government’s entitlement and other direct
spending (excluding Medicare), are exempt from sequestration altogether.14
Discretionary Spending
Discretionary spending reductions in FY2013 also are to 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), however, discretionary spending reductions will be achieved by
lowering the enforceable discretionary spending limits (i.e., caps) established under the BCA, as
amended by ATRA, by the total dollar amount of the reduction.16 Thus, policymakers will get to
decide how to apportion the cuts within the lowered spending caps rather than having the cuts
applied across-the-board to all nonexempt accounts through sequestration.
FY2013 Sequestration
On September 14, 2012, pursuant to the Sequestration Transparency Act of 2012 (STA),17 OMB
released a report on the potential impact of a BCA-triggered FY2013 sequestration on direct and
discretionary spending.18 The report provided a breakdown of exempt and nonexempt budget
accounts, and included estimates of the FY2013 funding reductions in nonexempt accounts. The
STA directed OMB to estimate the effects of sequestration based on FY2012 funding levels. The
estimates, which OMB emphasized were preliminary and subject to revision, predated ATRA’s
enactment and thus did not take into account the law’s $24 billion reduction in required spending
cuts for FY2013.
On March 1, 2013, the President ordered a sequestration of FY2013 budgetary resources in
accordance with OMB’s final calculations of the dollar amounts of the reduction to each
nonexempt budget account. Those calculations, which take into account ATRA’s $24 billion
adjustment, were provided in a report submitted to Congress.19
OMB calculated that sequestration will reduce nonexempt nondefense discretionary spending by
5.0% and reduce spending on nonexempt nondefense mandatory programs by 5.1%.
The mandatory appropriations in ACA are, in general, fully sequestrable at the rate applicable to
nonexempt nondefense mandatory spending. However, for any given fiscal year in which
sequestration is ordered, only new budget authority for that year (including advance
appropriations that first become available for obligation in that year) is reduced. Unobligated
14 Ibid.
15 Ibid. Note: All veterans programs, mandatory and discretionary, are exempt from sequestration.
16 The BCA established annual discretionary spending caps for each of FY2012 through FY2021. For more
information, see CRS Report R42051, Budget Control Act: Potential Impact of Sequestration on Health Reform
Spending, by C. Stephen Redhead.
17 P.L. 112-155, 126 Stat. 1210.
18 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.
19 U.S. Office of Management and Budget, OMB Report to the Congress on the Joint Committee Sequestration for
Fiscal Year 2013, http://www.whitehouse.gov/sites/default/files/omb/assets/legislative_reports/
fy13ombjcsequestrationreport.pdf.
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balances (nondefense only) carried over from previous fiscal years are exempt from a
sequestration order.20 Thus, the FY2013 sequestration order to reduce direct spending does not
apply to unobligated ACA funds that were appropriated in a prior fiscal year (i.e., FY2010-
FY2012) and are still available for obligation.
The exemption for unobligated balances carried over from prior fiscal years applies 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 are exempt from sequestration. Another example is CMI,
which received a $10 billion multiple-year appropriation in FY2011 to remain available for
obligation through FY2019.
The FY2013 appropriations for both PPHF and PCORTF are also fully sequestrable at the rate
applicable to nonexempt nondefense mandatory spending. However, the reduction in CHCF
funding is capped at 2%. For more discussion and analysis of the effect of BCA-triggered
spending reductions on ACA mandatory (and discretionary) spending, see CRS Report R42051,
Budget Control Act: Potential Impact of Sequestration on Health Reform Spending.
20 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 May 10, 2013, Based on TAGGS
Section
Authority
Program
Unless Specified Otherwise
Title I – Private Health Insurance
1002
New PHSA Sec.
Consumer Assistance Program (CAP). Appropriates $30 million, to
$47 million
2793
remain available without fiscal year limitation, for CAP grants to states to
enable them (or the exchanges operating in such states) to establish, expand, [Total includes original funding plus awards made using
or provide support for offices of health insurance consumer assistance, and
additional funds. See http://cciio.cms.gov/programs/consumer/
health insurance ombudsman programs. [CMS/CCIIO; CFDA 93.519]
capgrants/index.html.]
1003
New PHSA Sec.
Review of health insurance premium rates. Appropriates $250 million
$153 million
2794
for grants to states over the five-year period FY2010-FY2014 to support
programs that review annual increases in health insurance premiums. No
[To date, two rounds of rate review grants have been
state may receive less than $1 million or more than $5 million in a grant
awarded. CMS recently announced the availability of approx.
year. Funds remaining unobligated at the end of FY2014 are to remain
$87 million for a third round of awards. See
available for grants to states for planning and implementing ACA’s individual
http://cciio.cms.gov/programs/marketreforms/rates/
and group market reforms. [CMS/CCIIO; CFDA 93.511]
index.html.]
1101 New
authority
Pre-Existing Condition Insurance Plan (PCIP). Requires the Secretary
According to the most recent quarterly update, net PCIP
to establish a temporary program—PCIP—to provide health insurance
outlays through December 2012 totaled $2.406 billion.
coverage for eligible individuals who have been uninsured for six months and
have a pre-existing condition. The PCIP is federally administered in 23 states
[PCIP has more than 110,000 enrollees to date. Note: The
and DC; the remaining states administer their own PCIP programs.
federally-run PCIP and the state-based PCIPs stopped
Appropriates $5 billion, to remain available without fiscal year limitation, to
accepting new enrollees on February 16, 2003, and March 2,
pay claims against (and administrative costs of) the PCIP that are in excess of 2013, respectively, because of the limited amount of funding.
premiums collected from enrollees. [CMS/CCIIO; CFDA 93.529]
See http://cciio.cms.gov/programs/pcip/index.html; and
https://www.pcip.gov.]
1102 New
authority
Early Retiree Reinsurance Program (ERRP). Requires the Secretary to According to the most recent program update, ERRP outlays
establish a temporary ERRP, ending on January 1, 2014, to provide
through February 2012 totaled $4.73 billion.
reimbursement to participating employer-based plans for a portion of the
cost of providing health benefits to early retirees age 55-64 and their
[ERRP has provided payments to more than 2,800 employers
families. Appropriates $5 billion, to remain available without fiscal year
and other sponsors of retiree plans. See http://cciio.cms.gov/
limitation, to carry out the ERRP. [CMS/CCIIO]
programs/errp/index.html.]
1311 New
authority
Health insurance exchange grants. Appropriates annually an amount (as $3.869 billion
determined by the Secretary) necessary to award exchange planning and
establishment grants to states. No grants may be awarded after January 1,
[See http://cciio.cms.gov/programs/exchanges/index.html; and
2015, by which time exchanges must be self-sustaining. [CMS/CCIIO; CFDA
CRS Report R43066.]
93.525]
CRS-9
ACA
Statutory
Obligations as of May 10, 2013, Based on TAGGS
Section
Authority
Program
Unless Specified Otherwise
1322 New
authority
Consumer Operated and Oriented Plan (CO-OP). Requires the
According to a December 21, 2012 press release, the CO-OP
Secretary to establish the CO-OP program to provide low-interest loans
program has awarded a total of $1.981 billion to 24
until July 1, 2013, for the creation of nonprofit member-run health insurance
nonprofits offering coverage in 24 states.
issuers that offer qualified health plans in the individual and small group
markets. Appropriates $6 billion to carry out the CO-OP program. Note:
[See http://cciio.cms.gov/programs/coop/index.html.]
P.L. 112-10 and P.L. 112-74 together rescinded a total of $2.6 billion of the
original appropriation, and P.L. 112-240 transferred 10% of the remaining
unobligated funds to a new CO-OP contingency fund (to provide assistance
and oversight to CO-OP loan recipients) and rescinded the other 90% of
those funds. CMS no longer has the authority to make new loan awards. See
Appendix C. [CMS/CCIIO; CFDA 93.545]
1323 New
authority
Funding for territories. Appropriates $1 billion, available for the period
No obligations.
FY2014-FY2019, 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
$26 million
1139B
develop and, not later than January 1, 2012, publish an initial core set of
quality measures for Medicaid-eligible adults. Appropriates $60 million for
Initial core set of measures published in January 2012.
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.
Eleven states plus DC are participating in the demonstration,
Appropriates $75 million for FY2011, to remain available for obligation
which began in July 2012. No public information located on
through December 2015, for a three-year demonstration in which eligible
funding obligations.
states are required to reimburse certain institutions for mental disease
(IMDs) for services provided to Medicaid beneficiaries aged 21 through 64
[See http://innovations.cms.gov/initiatives/medicaid-
who are in need of medical assistance to stabilize an emergency psychiatric
emergency-psychiatric-demo/.]
condition. [CMS/CMI; CFDA 93.537]
2801 Amends
SSA
Medicaid and CHIP Payment and Access Commission (MACPAC).
ACA funding was obligated in FY2011 and FY2012.
Sec. 1900
Clarifies and expands MACPAC’s duties; for example, to include a review
and assessment of payment policies under Medicaid and CHIP and how
[See http://www.macpac.gov/.]
factors affecting expenditures and payment 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.
CRS-10
ACA
Statutory
Obligations as of May 10, 2013, Based on TAGGS
Section
Authority
Program
Unless Specified Otherwise
4108 New
authority
Medicaid Incentives for the Prevention of Chronic Diseases
$30 million
(MIPCD). Requires the Secretary to award five-year grants to states,
subject to annual renewal of funding, to provide incentives for Medicaid
[MIPCD grants have been awarded to 10 states. See
beneficiaries to participate in evidence-based healthy lifestyle programs to
http://www.innovations.cms.gov/initiatives/MIPCD/
prevent or help manage chronic disease. Appropriates $100 million for the
index.html.]
five-year period beginning January 1, 2011, to remain available until
expended. [CMS/CMI; CFDA 93.536]
4306 Amends
SSA
CHIP childhood obesity demonstration program. Appropriates $25
$12 million
Sec. 1139A(e)
million for the period FY2010 through FY2014 for a program authorized by
the Children’s Health Insurance Program Reauthorization Act (CHIPRA; P.L.
[Funding has been awarded to three research facilities to
111-3), which requires the Secretary to conduct a demonstration project to
identify effective childhood obesity prevention strategies, and
develop a model for reducing childhood obesity. [CDC; CFDA 93.535]
to a fourth facility to evaluate the strategies and share
successes. See http://www.cdc.gov/obesity/childhood/
researchproject.html.]
10203(d) Amends
SSA CHIP annual appropriations, and outreach and enrollment grants.
In September 2009, and again in August 2011, CMS awarded
Secs. 2104 &
Appropriates funding for the CHIP program for FY2014 ($19.147 billion) and $40 million in two-year outreach and enrollment grants to
2113
FY2015 ($21.061 billion); the program previously had been funded through
states, local governments, and community organizations. In
FY2013. Also, extends the time period for the Connecting Kids to Coverage
April 2010, CMS awarded $10 million in grants to tribal
Outreach and Enrollment grants through FY2015 and increases the existing
organizations. In January 2013, CMS announced the availability
appropriation for such grants from $100 million to $140 million. [CMS;
of another $40 million for a new round of awards.
CFDA 93.767]
[See http://www.grantsolutions.gov/preaward/
previewPublicAnnouncement.do?id=16205/
Medicare
3014 Amends
SSA
Medicare quality and efficiency measures. Expands the duties of the
No public information located on funding obligations.
Sec. 1890(b).
consensus-based entity under contract with CMS pursuant to SSA Sec. 1890
New SSA Sec.
(currently the National Quality Forum). Requires the entity to convene
1890A
multi-stakeholder groups to provide input on the 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]
CRS-11
ACA
Statutory
Obligations as of May 10, 2013, Based on TAGGS
Section
Authority
Program
Unless Specified Otherwise
3021(a)
New SSA Sec.
Center for Medicare and Medicaid Innovation (CMI). Requires the
According to the President’s FY2014 budget: FY2011
1115A
Secretary, no later than January 1, 2011, to establish the CMI within CMS.
obligations = $95 million; FY2012 obligations = $784 million;
The purpose of CMI is to test and evaluate innovative payment and service
FY2013 obligations (est.) = $1.313 billion; FY2014 (est.) =
delivery models to reduce program expenditures under Medicare, Medicaid,
$1.412 billion.
and CHIP while preserving or enhancing the quality of care furnished under
these programs. In selecting the models, the Secretary is also required to
[For information on CMI’s programs, which include several of
give preference to those that improve the coordination, quality, and
the initiatives summarized in this table, see
efficiency of health care services. Appropriates (1) $5 million for FY2010 for
http://www.innovations.cms.gov/.]
the selection, testing, 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
No public information located on funding obligations.
1866E
the Secretary to conduct a three-year Medicare demonstration program,
beginning no later than January 1, 2012, to test a payment incentive and
[Fifteen independent practices and three consortia are
service delivery model that uses physician- and nurse practitioner-directed
participating in the independence at home demonstration,
primary care teams to provide home-based services to chronically ill
administered by CMI, see http://www.innovations.cms.gov/
patients. The Secretary must submit a plan, no later than January 1, 2016, for initiatives/Independence-at-Home/index.html.]
expanding the program if it is determined that such expansion would
improve the quality of 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]
3026 New
authority
Community-based Care Transitions Program (CCTP). Requires the
No public information located on funding obligations.
Secretary to establish a five-year program, beginning January 1, 2011, to
provide funding to eligible hospitals and community-based organizations to
[There are currently 102 organizations participating in the
test models for improving care transitions from the hospital to other
CCTP, which is administered by CMI as part of its Partnership
settings for high-risk Medicare beneficiaries. Requires the Secretary to
for Patients initiative. See http://www.innovations.cms.gov/
transfer from the Medicare Part A and Part B trust funds $500 million for
initiatives/CCTP/.]
the period FY2011 through FY2015, to remain available until expended.a
Note: P.L. 113-6 rescinded $200 million of CCTP’s appropriation. See
Appendix C. [CMS]
3027(b) Amends
DRA Medicare hospital gainsharing demonstration program. CMS is
No public information located on funding obligations.
Sec. 5007
supporting two projects that allow hospitals to provide gainsharing payments
to physicians that represent a share of the savings incurred as a result of
[There are two hospitals participating in the gainsharing
collaborative efforts to improve overall quality and efficiency. ACA
demonstration, which is administered by CMI. See
appropriates $1.6 million for FY2010, to remain available through FY2014 or
http://innovation.cms.gov/initiatives/Medicare-Hospital-
until expended, for carrying out the demonstration. [CMS]
Gainsharing/.]
CRS-12
ACA
Statutory
Obligations as of May 10, 2013, Based on TAGGS
Section
Authority
Program
Unless Specified Otherwise
3113 New
authority
Diagnostic laboratory test demonstration program. Requires the
Payments under the demonstration began in January 2012.
Secretary to conduct a two-year demonstration program beginning July 1,
2011, with a subsequent report to Congress, to test the impact of direct
[See http://www.cms.gov/Medicare/Demonstration-Projects/
payments for certain complex laboratory tests on Medicare costs and quality DemoProjectsEvalRpts/Downloads/TCCDLT_FactSheet.pdf.]
of care. Payments are to be made from the Part B trust fund and may not
exceed $100 million. Transfers $5 million from the Medicare Part B trust
fund, to remain available until expended, for carrying out the demonstration
program and preparing the subsequent report. [CMS]
3306 Amends
MIPPA
Outreach and assistance for Medicare low-income programs.
HHS announced grant awards totaling $45 million in
Sec. 119
Transfers a total of $45 million from the Medicare Part A and Part B trust
September 2010.
funds for the period FY2010 through 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
IPAB members have yet to be appointed.
1899A
independent, 15-member 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 and P.L. 113-6 each rescinded
$10 million of IPAB’s FY2012 and FY2013 appropriations, respectively. See
Appendix C.
4202(b) New
authority
Medicare prevention and wellness evaluation. Transfers $50 million
No public information located on funding obligations.
from the 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
Report released in December 2011 (GAO-12-61).
GAO report on the impact of Medicare Part D vaccine coverage on access
to those vaccines among beneficiaries.
CRS-13
ACA
Statutory
Obligations as of May 10, 2013, Based on TAGGS
Section
Authority
Program
Unless Specified Otherwise
10323(a)
New SSA Sec.
Environmental health hazards. Extends Medicare eligibility to individuals
No public information located on funding obligations.
1881A
with specified 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
$5 million
2009
FY2010 through FY2014, and $20 million for each five-year period
thereafter, for grants to state and local government agencies, health care
[Funding provided for an asbestos health screening program
facilities, and other entities to (1) provide screening for specified lung
in Libby, Montana.]
diseases and other environmental health conditions to 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 No public information located on ACA funding obligations.
HCERA
Sec. 1817(k)
permanent inflation adjustment to the annual appropriation (provided under
Sec.
SSA Sec. 1817(k)) for the HCFAC account. Appropriates from the Medicare
1303(a)
Part A trust fund the following 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
$142 million
each of FY2010 through FY2013, to remain available until expended, for a
grant program to fund the construction and renovation of school-based
[See http://bphc.hrsa.gov/about/schoolbased/index.html.]
health centers. Total amount = $200 million. [HRSA; CFDA 93.501]
10503(b)(1) New
authority Community Health Center Fund (CHCF). Transfers from the CHCF
In FY2011 and FY2012, HRSA awarded a total of
the following amounts for health center operations, to remain available until
approximately $1.2 billion in ACA grants to support health
expended: FY2011 = $1 billion; FY2012 = $1.2 billion; FY2013 = $1.5 billion;
center operations and related activities.
FY2014 = $2.2 billion; and FY2015 = $3.6 billion. Total amount = $9.5
billion. [HRSA; CFDA 93.527]
[See http://bphc.hrsa.gov/about/healthcenterfactsheet.pdf.]
CRS-14
ACA
Statutory
Obligations as of May 10, 2013, Based on TAGGS
Section
Authority
Program
Unless Specified Otherwise
10503(b)(2) New
authority National Health Service Corps (NHSC). Transfers from the CHCF the
According to the President’s FY2014 budget: FY2011
following amounts for NHSC operations, scholarships, and loan repayments,
obligations = $289 million; FY2012 obligations = $297 million;
to remain available until expended: FY2011 = $290 million; FY2012 = $295
FY2013 obligations (est.) = $300 million; FY2014 obligations
million; FY2013 = $300 million; FY2014 = $305 million; and FY2015 = $310
(est.) = $305 million.
million. Total amount = $1.5 billion. [HRSA; CFDA 93.547]
10503(c) New
authority Health center construction and renovation. Appropriates $1.5 billion,
$1.498 billion
to be available 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 $195 million: Health Profession Opportunity Grant (HPOG)
2008
establish two demonstration projects. The first is to award health profession
opportunity grants to states, Indian tribes, institutions of higher education,
$13 million: Personal and Home Care Aide State Training
and local workforce investment boards to help low-income individuals obtain (PHCAST) program
education and training in health care jobs that pay well and are in high
[See http://www.acf.hhs.gov/programs/ofa/programs/hpog and
demand. Funds may be used to provide financial aid and other supportive
http://bhpr.hrsa.gov/nursing/grants/phcast.html.]
services. The second project is to provide states with grants to develop core
training competencies and certification programs for personal and home
care aides. Appropriates $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
$5 million (FY2012)
Sec. 501(c)
family-to-family information centers, which assist families of children with
disabilities or special health care needs and the professionals who serve
[See http://mchb.hrsa.gov/programs/familytofamily/
them, by appropriating $5 million for each of FY2010 through FY2012, to
index.html.]
remain available until expended. Total amount = $15 million. Note: P.L. 112-
240 appropriated $5 million for FY2013. [HRSA; CFDA 93.504]
5508(c)
New PHSA Sec.
Teaching health centers. Appropriates such sums as may be necessary,
$30 million
340H
not to exceed $230 million, for the period FY2011 through FY2015 to make
payments for direct and indirect graduate medical education (GME) costs to
[See http://bhpr.hrsa.gov/grants/teachinghealthcenters/.]
qualified teaching health centers (THCs). [HRSA; CFDA 93.530]
5509 New
authority
Medicare graduate nurse education demonstration program.
CMI, which is administering this program, has selected the
Appropriates $50 million for each of FY2012 through FY2015, to remain
five participating hospitals and begun making reimbursement
available until expended, for a Medicare demonstration program under
payments.
which up to five eligible hospitals will receive reimbursement for providing
advanced practice nurses with clinical training in primary care, preventive
[See http://innovations.cms.gov/initiatives/GNE/index.html.]
care, transitional care, and chronic care management. Total amount = $200
million. [CMS/CMI]
CRS-15
ACA
Statutory
Obligations as of May 10, 2013, Based on TAGGS
Section
Authority
Program
Unless Specified Otherwise
10502 New
authority
Health care facility construction. Appropriates $100 million for FY2010, $100 million
to remain 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
[Funding awarded to Ohio State University.]
medical and dental school. [HRSA; CFDA 93.502]
Community-Based Prevention and Wellness
4002 New
authority
Prevention and Public Health Fund (PPHF). Establishes a PPHF and
PPHF funds are annual appropriations that must be obligated
originally provided a permanent annual appropriation to the fund, as follows:
during the fiscal year in which they are made available. For an
FY2010 = $500 million; FY2011 = $750 million; FY2012 = $1 billion; FY2013
analysis and complete list of all PPHF awards for FY2010 and
= $1.25 billion; FY2014 = $1.5 billion; FY2015 and each year thereafter = $2
FY2011, see the GAO report, Prevention and Public Health
billion. Requires the Secretary to transfer amounts from the fund to HHS
Fund: Activities Funded in Fiscal Years 2010 and 2011 (GAO-12-
accounts to increase funding, over the FY2008 level, for PHSA-authorized
788), at http://www.gao.gov/assets/650/648310.pdf.
prevention, wellness, and public health activities, including prevention
research and health screenings. Authorizes House and Senate appropriators
For a summary of the allocation of PPHF funds for FY2012
to transfer monies from the PPHF to eligible activities. Note: P.L. 112-96
and FY2013, by agency and program, see http://www.hhs.gov/
subsequently reduced the annual appropriations to the PPHF over the
open/recordsandreports/prevention/index.html. [This website
period FY2013-FY2021, as follows: FY2013 through FY2017 = $1 billion;
was mandated by P.L. 112-74 and continued by P.L. 113-6; see
FY2018 and FY2019 = $1.25 billion; FY2020 and FY2021 = $1.5 billion;
Appendix C.]
FY2022 and each year thereafter = $2 billion. [OS, CDC, HRSA, SAMHSA,
Note: The listed CFDA programs do not capture all the uses
ACL; CFDA 93.507, 93.521, 93.522, 93.523, 93.524, 93.531, 93.533, 93.538,
of PPHF funding. PPHF funds have also been integrated into
93.539, 93.540, 93.542.]
existing programs that do not mention PPHF.
Maternal and Child Health
2951
New SSA Sec.
Maternal, infant, and early childhood home visiting program.
$719 million
511
Appropriates the following amounts for grants to states, U.S. territories, and
Indian tribes to develop and implement early childhood home visiting
[See http://mchb.hrsa.gov/programs/homevisiting/.]
programs that adhere to evidence-based models of 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]
CRS-16
ACA
Statutory
Obligations as of May 10, 2013, Based on TAGGS
Section
Authority
Program
Unless Specified Otherwise
2953
New SSA Sec.
Personal Responsibility Education Program (PREP). Establishes a
$231 million
513
state formula grant program to support evidence-based PREPs designed to
educate adolescents about abstinence, contraception, and adulthood. Also,
[See http://www.acf.hhs.gov/programs/fysb/programs/
requires the Secretary to award grants to implement innovative youth
adolescent-pregnancy-prevention/programs/prep-
pregnancy prevention strategies and to target services at high-risk
competitive.]
populations. Appropriates $75 million for each of FY2010 through FY2014,
of which $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]
2954 Amends
SSA
Abstinence education grants. Renews funding for the state formula grant $121 million (FY2010-FY2013)
Sec. 510
program to support abstinence education programs by appropriating $50
million for each of FY2010 through FY2014. Total amount = $250 million.
[See http://www.acf.hhs.gov/programs/fysb/resource/aegp-
Funds are awarded to states based on the proportion of low-income
fact-sheet.]
children in each state compared to the national total, and may only be used
for teaching abstinence. [ACF, CDC; CFDA 93.235]
10211-
New authority
Pregnancy assistance grants. Appropriates $25 million for each of
$72 million
10214
FY2010 through FY2019 (total amount = $250 million) to establish a
Pregnancy Assistance Fund for the purpose of awarding grants to states to
[See http://www.hhs.gov/ash/oah/oah-initiatives/paf/
assist pregnant and parenting teens and women. State grantees have the
home.html.]
flexibility to make funds available to institutions of higher education, 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
$340 million (FY2012-FY2013)
Sec. 6071(h)
program. Extends funding for the MFP demonstration through FY2016.
The program authorizes the Secretary to award competitive grants to states
[See http://www.medicaid.gov/Medicaid-CHIP-Program-
to reduce their reliance on institutional care for people needing long-term
Information/By-Topics/Long-Term-Services-and-Support/
care, and expand options for elderly people and individuals with disabilities
Balancing/Money-Follows-the-Person.html.]
to receive home and community-based long-term care services.
Appropriates $450 million for each of FY2012 through FY2016, to remain
available through FY2016. Total amount = $2.25 billion. [CMS; CFDA
93.791]
CRS-17
ACA
Statutory
Obligations as of May 10, 2013, Based on TAGGS
Section
Authority
Program
Unless Specified Otherwise
2405 New
authority
State Aging and Disability Resource Centers (ADRCs). Appropriates
$15 million
$10 million for each of FY2010 through FY2014 (total amount = $50 million)
for ADRCs, authorized under OAA Sec. 202. ADRCs serve as a single,
[See http://www.aoa.gov/AoA_programs/HCLTC/ADRC/
coordinated resource for consumer information on the range of long-term
index.aspx.]
care options in community and institutional settings. 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
$52 million
Secretary to establish 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]
8002(d) Amends
DRA National Clearinghouse for Long-Term Care Information.
No public information located on funding obligations.
Sec. 6021(d)
Appropriates $3 million for each of FY2011 through FY2015 for the
However, these are annual appropriations that must be
National Clearinghouse for Long-Term Care Information, and requires the
obligated during the fiscal year in which they are made
Clearinghouse to include information on the Community Living Assistance
available.
Services and Supports (CLASS) program, established under ACA Sec.
8002(a). Note: P.L. 112-240 repealed the CLASS program; see Appendix B. [See http://www.longtermcare.gov/LTC/Main_Site/
Total amount = $15 million. [AoA]
index.aspx.]
Comparative Effectiveness Research
6301(d)-(e)
New IRC Secs.
Patient-Centered Outcomes Research Trust Fund (PCORTF).
In May 2013, PCORI announced grant awards totaling $89
9511, 4375, &
Establishes a PCORTF to fund the new Patient-Centered Outcomes
million, which brings the total amount awarded to fund
4376. New SSA
Research Institute (PCORI) and its comparative effectiveness research
PCORI’s research agenda to $129 million. PCORI has also
Sec. 1183
activities. Appropriates to the PCORTF $10 million for FY2010, $50 million
awarded $30 million for a series of pilot projects.
for FY2011, and $150 million for each of FY2012 through FY2019, for a total
of $1.26 billion over that 10-year period. For each of FY2013 through
[See http://www.pcori.org/.]
FY2019, the 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, 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]
CRS-18
ACA
Statutory
Obligations as of May 10, 2013, Based on TAGGS
Section
Authority
Program
Unless Specified Otherwise
Biomedical Research
9023
New IRC Sec.
Therapeutic research and development tax credits and grants.
According to the IRS: total grant awards = $970 million; total
48D
Creates a two-year tax credit program, subject to an overall cap of $1
tax credits = $17 million.
billion, for small companies (250 or fewer employees) that invest in new
therapies to prevent, diagnose, and treat cancer and other diseases.
[See http://www.irs.gov/Businesses/Small-Businesses-&-Self-
Companies may apply for one or more tax credits, each covering up to 50%
Employed/Qualifying-Therapeutic-Discovery-Project-Credits-
of the cost of qualifying research investments made in 2009 and 2010.
and-Grants.]
However, the total amount of tax credits any one company receives for the
two years may not exceed $5 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).
According to the President’s FY2014 Budget, there was an
Sec. 1005
Appropriates $1 billion to the HIRIF for federal administrative expenses to
unobligated balance of $241 million at the beginning of
carry out ACA. [OS; CFDA 93.528]
FY2013.
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.
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-19
Table 2. ACA Appropriations and Fund Transfers by Fiscal Year in Which Funds Are Available for Obligation
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-20
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 FY2015k
— — — —
500
3027(b) Medicare
gainsharing
demonstration
2 — — — — — — — — — 2f
3113
Diagnostic laboratory test
5l — — — — — — — — — 5
demonstration
3306
Outreach and assistance for
$45 million total for FY2010
25m — — — — — — 70
low-income beneficiaries
through FY2012m
3403 Independent
Payment
— — 15n 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
350o
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-21
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
5p — — — — — —
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 — — — — — — — — —
100q
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
9,750r
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-22
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
— — — — — — —
≤160s
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
TBDt
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
TBDu
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 — — — — — — — — —
≤1v
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 transferred 10% of the remaining
unobligated funds to a new CO-OP contingency fund (to provide assistance and oversight to CO-OP loan recipients) and rescinded the other 90% of those funds. CMS
no longer has the authority to make new loan awards. See Appendix C.
CRS-23
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.
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 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. Note: Division F, Title V, Sec. 1520 of P.L. 113-6 rescinded $200 million of CCTP’s appropriation. See
Appendix C.
l.
The Secretary is required to transfer the $5 million from the Medicare Part B trust fund, to remain available until expended.
m. 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.
n. Division F, Title V, Sec. 525 of P.L. 112-74 rescinded $10 million of IPAB’s appropriation for FY2012. Division F, Title V, Sec. 1521 rescinded $10 million of IPAB’s
appropriation for FY2013. See Appendix C.
o. 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.
p. Sec. 624 of P.L. 112-240 appropriated $5 million for FY2013 for this program.
q. Funds are to remain available for obligation until Sept. 30, 2011.
r. 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.
s. 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.
t.
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.
u. 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.
CRS-24
v. 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.
CRS-25
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;21 (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. 3630), 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
21 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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Appropriations and Fund Transfers in the Patient Protection and Affordable Care Act
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; (3) transferred 10% of the remaining unobligated CO-OP funds to a new CO-
OP contingency fund (to provide assistance and oversight to CO-OP loan recipients) and
rescinded the other 90% of those funds; and (4) 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.
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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
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 ACA in its entirety 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.22 This appendix
summarizes the ACA provisions that were included in the enacted appropriations legislation for
FY2011, FY2012, and FY2013. 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 legislation that was signed into law.
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:
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.]
22 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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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 CMI 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.
• 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
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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 Consolidated and Further Continuing Appropriations Act, 2013 (P.L. 113-6, 127 Stat.
198), which funds seven of the 12 regular appropriations—including Labor-HHS-Education—
through a full-year continuing resolution, was signed into law on March 26, 2013, almost six
months after the beginning of the fiscal year. This law funds most (with some anomalies) HHS
discretionary programs that receive funding through the Labor-HHS-Education appropriations act
at their FY2012 levels minus an across-the-board rescission of 0.2%. Division F, Title V of P.L.
113-6 (Labor-HHS-Education) included the following ACA-related provisions: (1) rescinded
$200 million of CCTP’s $500 million appropriation; and (2) rescinded $10 million of IPAB’s
FY2013 appropriation. In addition, the PPHF website and the prohibition on using PPHF funds
for lobbying, publicity, or propaganda purposes, which were included in P.L. 112-74, remain in
effect under P.L. 113-6. Finally, P.L. 113-6 did not provide any new funds for ACA
implementation.
Prior to the enactment of P.L. 113-6, 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
appropriations for PPHF and IPAB, and rescinded the FY2013 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 CMI 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
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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 earlier versions of 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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