Discretionary Spending in the Patient
Protection and Affordable Care Act (ACA)
C. Stephen Redhead
Specialist in Health Policy
Sarah A. Lister
Specialist in Public Health and Epidemiology
Kirsten J. Colello
Specialist in Health and Aging Policy
Amanda K. Sarata
Specialist in Health Policy
Elayne J. Heisler
Analyst in Health Services
July 1, 2013
Congressional Research Service
7-5700
www.crs.gov
R41390
CRS Report for Congress
Pr
epared for Members and Committees of Congress

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Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)

Summary
The Patient Protection and Affordable Care Act (ACA) reauthorized funding for numerous
existing discretionary grant programs and other activities. ACA also created multiple new
discretionary grant programs and provided for each an authorization of appropriations. Funding
for all these discretionary programs is subject to action by congressional appropriators. This
report summarizes all the discretionary spending provisions in ACA. A companion product, CRS
Report R41301, Appropriations and Fund Transfers in the Patient Protection and Affordable
Care Act (ACA), summarizes all the mandatory appropriations in the law.
Among the provisions that are intended to strengthen the nation’s health care safety net and
improve access to care, ACA permanently reauthorized the federal health centers program and the
National Health Service Corps (NHSC). The NHSC provides scholarships and student loan
repayments to individuals who agree to a period of service as a primary care provider in a
federally designated Health Professional Shortage Area. In addition, ACA addressed concerns
about the current size, specialty mix, and geographic distribution of the health care workforce. It
reauthorized and expanded existing health workforce education and training programs under
Titles VII and VIII of the Public Health Service Act (PHSA). Title VII supports the education and
training of physicians, dentists, physician assistants, and public health workers through grants,
scholarships, and loan repayment. ACA created several new programs to increase training
experiences in primary care, in rural areas, and in community-based settings, and provided
training opportunities to increase the supply of pediatric subspecialists and geriatricians. It also
expanded the nursing workforce development programs authorized under PHSA Title VIII.
As part of a comprehensive framework for federal community-based public health activities,
including a national strategy and a national education and outreach campaign, ACA authorized
several new grant programs with a focus on preventable or modifiable risk factors for disease
(e.g., sedentary lifestyle, tobacco use). The new law also leveraged a number of mechanisms to
improve the quality of health care, including new requirements for quality measure development,
collection, analysis, and public reporting; programs to develop and disseminate innovative
strategies for improving the quality of health care delivery; and support for care coordination
programs such as medical homes, patient navigators, and the co-location of primary health care
and mental health services. Additionally, ACA authorized funding for programs to prevent elder
abuse, neglect, and exploitation; grants to expand trauma care services and improve regional
coordination of emergency services; and demonstration projects to implement alternatives to
current tort litigation for resolving medical malpractice claims, among other provisions.
The Congressional Budget Office estimated that ACA’s discretionary spending provisions, if fully
funded by appropriations acts, would result in appropriations of approximately $100 billion over
the 10-year period FY2012-FY2021. Much of that funding would be for discretionary programs
that existed prior to, and whose funding was reauthorized by, ACA. While most of those existing
discretionary programs continue to receive an annual discretionary appropriation, few of the new
grant programs authorized under ACA have received any discretionary funding. However, several
of the new programs have received mandatory funds from ACA’s Prevention and Public Health
Fund. This report is periodically revised and updated to reflect important legislative and other
developments.

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Contents
Introduction ...................................................................................................................................... 1
Discretionary Spending in ACA ...................................................................................................... 3
ACA Administrative Costs and Funding ................................................................................... 4
Mandatory Appropriations in ACA .................................................................................................. 6
Automatic Annual Spending Reductions Under the Budget Control Act ........................................ 7
BCA’s Spending Reduction Procedures .................................................................................... 7
Direct Spending ................................................................................................................... 7
Discretionary Spending ....................................................................................................... 8
FY2013 Sequestration ............................................................................................................... 8

Tables
Table 1. ACA Discretionary Spending: Health Centers and Clinics .............................................. 10
Table 2. ACA Discretionary Spending: Health Care Workforce .................................................... 11
Table 3. ACA Discretionary Spending: Prevention and Wellness ................................................. 22
Table 4. ACA Discretionary Spending: Maternal and Child Health .............................................. 25
Table 5. ACA Discretionary Spending: Health Care Quality ......................................................... 26
Table 6. ACA Discretionary Spending: Nursing Homes................................................................ 30
Table 7. ACA Discretionary Spending: Health Disparities Data Collection .................................. 31
Table 8. ACA Discretionary Spending: Emergency Care and Trauma Services ............................ 32
Table 9. ACA Discretionary Spending: Elder Justice .................................................................... 33
Table 10. ACA Discretionary Spending: Biomedical Research ..................................................... 35
Table 11. ACA Discretionary Spending: Biologics........................................................................ 35
Table 12. ACA Discretionary Spending: 340B Drug Pricing ........................................................ 36
Table 13. ACA Discretionary Spending: Medical Malpractice ...................................................... 36
Table 14. ACA Discretionary Spending: Pain Care Management ................................................. 37
Table 15. ACA Discretionary Spending: Medicaid ........................................................................ 37
Table 16. ACA Discretionary Spending: Medicare ........................................................................ 38
Table 17. ACA Discretionary Spending: Private Health Insurance ............................................... 38

Contacts
Author Contact Information........................................................................................................... 39
Acknowledgments ......................................................................................................................... 39
Key Policy Staff ............................................................................................................................. 39

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Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)

Introduction
The Patient Protection and Affordable Care Act (ACA)1 makes 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). 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.
Implementation of ACA is projected to have a significant impact on federal revenues and direct
(also referred to as mandatory) spending.3 The law includes direct spending to subsidize the
purchase of health insurance coverage through the exchanges, as well as increased outlays for the
expansion of the Medicaid program. ACA also includes numerous mandatory appropriations to
fund temporary programs to increase access to health care for targeted groups, provide funding to
states to plan and establish exchanges, and support many other research and demonstration
programs and activities (see discussion below under “Mandatory Appropriations in ACA”). The
costs of expanding public and private health insurance coverage and other mandatory spending
are offset by revenues from new taxes and industry fees, and by savings from payment and health
care delivery system reforms designed to slow the growth in spending on Medicare and other
federal health care programs.4

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 made
more targeted changes to specific ACA provisions. All references to ACA in this report refer to the law as amended.
2 NFIB v. Sebelius, No. 11-393, slip op. (June 28, 2012), available at http://www.supremecourt.gov/opinions/11pdf/11-
393c3a2.pdf.
3 Direct, or mandatory, spending generally refers to outlays from budget authority (i.e., the authority to incur financial
obligations that result in government expenditures, such as purchasing services or awarding grants) that is provided in
laws other than the annual appropriations acts. Mandatory spending includes spending on entitlement programs (e.g.,
Medicare, Social Security).
4 For more information on ACA’s provisions and its projected impact on federal revenues and direct spending, see CRS
(continued...)
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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, 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.
ACA implementation affects not only direct spending and revenues but also discretionary
spending, which is subject to the annual appropriations process.5 The law includes numerous
discretionary spending provisions that authorize the appropriation of funds to implement grant
programs and other activities. These provisions are of two kinds:
• Authorizations of appropriations for new discretionary grant and other programs
created by ACA.
• Authorizations of appropriations for existing programs, primarily ones
authorized under the Public Health Service Act (PHSA). In most instances, the
appropriation authorizations for these established programs expired prior to their
reauthorization by ACA. However, almost all of them continued to receive an
annual appropriation.6
Many of the ACA discretionary spending provisions authorize annual appropriations of specified
amounts for one or more fiscal years to carry out the program or activity. Other provisions
authorize the appropriation of specified amounts for FY2010 or FY2011 and unspecified
amounts—such sums as may be necessary, or SSAN—for later years. A few provisions authorize
multi-year appropriations, available for obligation for a period in excess of one fiscal year (e.g.,
for the period FY2011 through FY2014). Numerous other provisions simply authorize the
appropriation of SSAN, in a few cases without specifying any fiscal years.

(...continued)
Report R42051, Budget Control Act: Potential Impact of Sequestration on Health Reform Spending, by C. Stephen
Redhead.
5 Discretionary spending refers to outlays from budget authority that is provided in and controlled by annual
appropriations acts.
6 ACA also reauthorized the Indian Health Care Improvement Act (IHCIA), which includes many discretionary Indian
Health Service (IHS) programs and services, and it extended indefinitely the authorizations of appropriations for these
programs and services. For more information on ACA’s Indian health provisions, which are not included in this report,
see CRS Report R41630, The Indian Health Care Improvement Act Reauthorization and Extension as Enacted by the
ACA: Detailed Summary and Timeline, by Elayne J. Heisler.
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Funding for all discretionary programs in ACA depends on actions taken by congressional
appropriators, a process that may lead to greater or smaller amounts than the sums authorized by
the law. With Congress now operating under enforceable discretionary spending limits (i.e., caps)
set by the Budget Control Act (BCA),7 as amended, 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.
This report, which is periodically revised and updated to reflect important legislative and other
developments, summarizes all the discretionary spending provisions in ACA that authorize (or
reauthorize) appropriations for grant programs and other activities. It also includes a brief
discussion of two trust funds that were created and funded by ACA, and that are helping support
several discretionary programs summarized in the tables below. Finally, the report provides some
analysis of the impact of the March 1, 2013 sequestration on ACA-related discretionary spending
in FY2013.
Discretionary Spending in ACA
The law’s discretionary spending provisions are organized by general topic in a series of tables
with the following headings: Health Centers and Clinics (Table 1); Health Care Workforce (Table
2); Prevention and Wellness (Table 3); Maternal and Child Health (Table 4); Health Care Quality
(Table 5); Nursing Homes (Table 6); Health Data Collection (Table 7); Emergency Care (Table
8); Elder Justice (Table 9); Biomedical Research (Table 10); Biologics (Table 11); 340B Drug
Pricing (Table 12); Medical Malpractice (Table 13); Pain Care Management (Table 14);
Medicaid (Table 15); Medicare (Table 16); and Private Health Insurance (Table 17).
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 name of the administering agency or
office within HHS is also included, if known. The third column provides a brief description of the
program or activity, including the types of entities and/or individuals eligible for funding.8 The
fourth column gives details of the authorization of appropriations and shows the FY2011,
FY2012, and FY2013 funding levels for those programs and activities that received funding
during that period. The FY2013 levels reflect the March 1, 2013, sequestration (see discussion
under “Automatic Annual Spending Reductions Under the Budget Control Act”). The FY2014
funding request, if applicable, is also provided.9
Note that in several of the larger tables with multiple entries (i.e., Tables 1, 2, 3, 5 and 8), the
ACA provisions are grouped based on whether they reauthorize funding for existing programs or
authorize funding for new programs. Where available, the table entry includes the Catalog of

7 P.L. 112-25, 125 Stat. 240.
8 Not applicable if the funding is to support programs and activities carried out by the federal agency.
9 The funding amounts in the tables are taken from HHS agency budget documents, including the FY2013 sequestration
operating plans, available at http://www.hhs.gov/budget/.
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Federal Domestic Assistance (CFDA) number for the grant program.10 Unless otherwise stated,
all references in the tables to the Secretary refer to the HHS Secretary.
The Congressional Budget Office (CBO)
Acronyms Used in the Tables in
estimated that ACA’s discretionary spending
This Report
provisions, if fully funded by future
appropriations acts, would result in
Agency for Healthcare Research and Quality (AHRQ)
appropriations of almost $100 billion over the
Centers for Disease Control and Prevention (CDC)
period FY2012-FY2021.11 However, much of
Centers for Medicare and Medicaid Services (CMS)
that funding—about $85 billion—would be
for three programs that were in existence prior
Community Health Center Fund (CHCF)
to, and whose funding was reauthorized by,
Federal Food, Drug, and Cosmetic Act (FFDCA)
ACA; namely, the National Health Service
Food and Drug Administration (FDA)
Corps, the federal health centers program, and
Health Resources and Services Administration (HRSA)
the Indian Health Service (IHS).
Indian Health Service (IHS)
Most, though not all, of the existing grant
National Institutes of Health (NIH)
programs that were reauthorized under ACA
Office of Personnel Management (OPM)
received a discretionary appropriation for
FY2011, FY2012, and FY2013, as well as a
Office of the Secretary (OS)
FY2014 request for continued funding. In
Prevention and Public Health Fund (PPHF)
contrast, few of the new grant programs
Public Health Service Act (PHSA)
authorized under ACA have received annual
discretionary appropriations.12 However,
Substance Abuse and Mental Health Services
Administration (SAMHSA)
several of the new programs have received
mandatory funds from ACA’s Prevention and
Social Security Act (SSA)
Public Health Fund (see discussion below
under “Mandatory Appropriations in ACA”).
ACA Administrative Costs and Funding
In addition to the costs of fully funding ACA’s discretionary grant programs and other activities,
CBO projected that both HHS and the Internal Revenue Service (IRS) will incur substantial
administrative costs to implement the law’s private health insurance reforms and its changes to

10 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.
11 U.S. Congress, House Committee on Energy and Commerce, Subcommittee on Health, “CBO’s Analysis of the
Major Health Care Legislation Enacted in March 2010,” Statement of Douglas W. Elmendorf, Director, 112th Cong., 1st
sess., March 30, 2011. Available at http://www.cbo.gov/ftpdocs/121xx/doc12119/03-30-HealthCareLegislation.pdf.
See p. 16. CBO’s estimate of ACA discretionary spending includes (1) amounts specified in ACA, plus estimated
amounts for subsequent years (adjusted for anticipated inflation) where ACA specified an amount for the first year
(FY2010 or FY2011) and authorized SSAN for subsequent years; and (2) estimated amounts for subsequent years
(adjusted for anticipated inflation) where there is an appropriation for FY2010 under prior law and ACA authorized the
appropriation of SSAN for later years. The CBO estimate does not include new ACA programs for which the law
provided only an authorization for the appropriation of SSAN.
12 Examples include CDC’s congenital heart disease and breast health awareness programs (see Table 3) and the Cures
Acceleration Network (CAN) program at NIH (see Table 10).
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the federal health care programs. CBO estimated that the costs to the IRS of implementing the
eligibility determination, documentation, and verification processes for the health insurance
subsidies will probably total between $5 billion and $10 billion over 10 years. It further estimated
that the costs to HHS of implementing the changes in Medicare, Medicaid, and CHIP, as well as
some of the reforms to the private insurance market, will require similar amounts over 10 years.13
The Health Care and Education Reconciliation Act (HCERA) established, and appropriated $1
billion to, the Health Insurance Reform Implementation Fund (HIRIF) to help cover the initial
administrative costs of implementation. The HIRIF is one of many sources of mandatory funding
provided by ACA to support various new and existing HHS programs and activities (see
discussion below under “Mandatory Appropriations in ACA”). The Administration’s FY2013
budget projected that all the HIRIF funds would be obligated by the end of FY2012 and so
requested more than $1 billion in new discretionary funding for CMS and the IRS to pay for
ongoing administrative costs of ACA implementation. However, Congress did not provide any
new discretionary funds for FY2013 for ACA implementation.14
In FY2013, CMS reportedly will spend about $1.5 billion on ACA implementation, primarily to
establish federally facilitated insurance exchanges in states that elect not to run their own
exchanges and to engage in consumer education and outreach.15 HHS officials have stated that, in
the absence of any new FY2013 discretionary funding for ACA implementation, the department
will use funds from the following sources:16
• $235 million in unobligated HIRIF funds carried over from FY2012;
• $454 million from the Prevention and Public Health Fund (see discussion below
under “Mandatory Appropriations in ACA”);
• $450 million from the non-recurring expenses fund;17 and
• $116 million from the Secretary’s authority to transfer funds from other HHS
accounts.18


13 CBO, March 30, 2011, see footnote 11.
14 The Continuing Appropriations Resolution, 2013 (P.L. 112-175, 126 Stat. 1313), enacted on September 28, 2012,
provided temporary funding for the first six months of FY2013. It increased funding for most discretionary programs
by 0.612% over the FY2012 levels. Congress completed action on FY2013 appropriations when it passed the
Consolidated and Further Continuing Appropriations Act, 2013 (P.L. 113-6, 127 Stat. 198), which was signed into law
on March 26, 2013. P.L. 113-6 funded most HHS discretionary programs at their FY2012 levels minus an across-the-
board rescission of 0.2%, with some anomalies (i.e., provisions that specify alternative amounts for particular programs
or activities).
15 John Reichard, “HHS Using Several Sources to Fund Federal Health Insurance Exchange,” CQ Roll Call, April 10,
2013.
16 Ibid.
17 The non-recurring expenses fund, within the Department of the Treasury, was established by Division G, Section 223
of the Consolidated Appropriations Act, 2008 (P.L. 110-161, 121 Stat. 2188). The HHS Secretary may transfer to the
fund unobligated balances of expired annual discretionary funds up to five years after the fiscal year in which those
funds were available for obligation. The amounts transferred to the fund are available until expended for use by HHS
for various specified purposes. Congressional appropriators must be notified in advance of any planned use of funds.
18 Each year, the HHS Secretary is provided with authority to transfer funds between appropriation accounts. No more
than 1% of the funds in any given account may be transferred, and recipient accounts may not be increased by more
than 3%. Congressional appropriators must be notified in advance of any transfer.
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Mandatory Appropriations in ACA
Separate from the discretionary spending authorizations summarized in the tables in this report,
ACA included numerous mandatory appropriations that provide billions of dollars to fund new
and existing grant programs and activities within HHS.19
Of particular note, ACA established two multi-billion dollar funds that are providing amounts to
several of the discretionary grant programs authorized (or reauthorized) under ACA:
• The Community Health Center Fund (CHCF), to which ACA provided a total
of $11 billion in annual appropriations over a five-year period (i.e., FY2011-
FY2015), is helping support the federal health centers program and the National
Health Service Corps (NHSC).20 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
appropriations and have become the sole source of funding for the NHSC
program, which received no discretionary funds in FY2012 or FY2013 (see
Table 1 and Table 2). Note: A separate ACA appropriation provided $1.5 billion
for health center construction and renovation (see Table 1).21
• The Prevention and Public Health Fund (PPHF), for which ACA provided a
permanent annual appropriation, is intended to fund prevention, wellness, and
other public health-related programs and activities authorized under the PHSA.22
PPHF funds have been used to support several new discretionary grant programs
authorized by ACA.23 In addition, PPHF funds have supplemented, and in some
cases supplanted, annual discretionary appropriations for a number of established
programs, including ones that were reauthorized by ACA (see Table 2, Table 3,
and Table 5).

19 All the appropriations provided in ACA, as well as details of the obligation of these funds, are summarized in a
companion product, CRS Report R41301, Appropriations and Fund Transfers in the Patient Protection and Affordable
Care Act (ACA), by C. Stephen Redhead.
20 ACA Section 10503(a)-(b). The law appropriated the following amounts to the CHCF for health center operating
grants: FY2011 = $1 billion; FY2012 = $1.2 billion; FY2013 = $1.5 billion; FY2014 = $2.2 billion; and FY2015 = $3.6
billion. It also appropriated the following amounts to the CHCF for the National Health Service Corps: FY2011 = $290
million; FY2012 = $295 million; FY2013 = $300 million; FY2014 = $305 million; and FY2015 = $310 million.
21 ACA Section 10503(c). See also CRS Report R42433, Federal Health Centers, by Elayne J. Heisler.
22 ACA Section 4002. As originally enacted, ACA appropriated the following amounts to the PPHF: FY2010 = $500
million; FY2011 = $750 million; FY2012 = $1 billion; FY2013 = $1.25 billion; FY2014 = $1.5 billion; and FY2015
and each fiscal year thereafter = $2 billion. The Middle Class Tax Relief and Job Creation Act of 2012 (P.L. 112-96,
Sec. 3205) amended Section 4002 and reduced the amounts appropriated over the period FY2013-FY2021 by a total of
$6.25 billion. The reduced appropriations for each of those fiscal years are as follows: FY2013 = $1 billion; FY2014 =
$1 billion; FY2015 = $1 billion; FY2016 = $1 billion; FY2017 = $1 billion; FY2018 = $1.25 billion; FY2019 = $1.25
billion; FY2020 = $1.5 billion; and FY2021 = $1.5 billion.
23 Those programs include (1) Sec. 5208, Nurse-Managed Health Clinics, see Table 1; (2) Sec. 5306, Mental and
Behavioral Health Education and Training Grants, see Table 2; (3) Sec. 5102, State Health Care Workforce
Development Grants, see Table 2; (4) Sec. 4201, Community Transformation Grants, see Table 3; (5) Sec. 10408,
Small Business Workplace Wellness Grants, see Table 3; and (6) Sec. 10501(g), National Diabetes Prevention
Program, see Table 3.
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Automatic Annual Spending Reductions Under the
Budget Control Act
On March 1, 2013, President Obama ordered the sequestration, or 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).24 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)25 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).26 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 all
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.27 Under the
sequestration rules, reductions in Medicare payments to health care providers and health plans
(which account for most of Medicare spending) are capped at 2%. Many other federal direct
spending programs, accounting for most of the government’s entitlement and other direct
spending (excluding Medicare), are exempt from sequestration altogether.28

24 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.
25 P.L. 112-240, 126 Stat. 2313.
26 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.
27 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.
28 Ibid.
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Discretionary Spending
Discretionary spending reductions in FY2013 also were achieved through a sequestration of
nonexempt discretionary appropriations. The sequestration rules exempt some discretionary
spending, notably for veterans’ health care and Pell grants.29 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.30 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),31 OMB
released a report on the potential impact of a BCA-triggered FY2013 sequestration on direct and
discretionary spending.32 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.33
OMB calculated that sequestration will reduce nonexempt nondefense discretionary spending by
5.0% and reduce spending on nonexempt nondefense mandatory programs by 5.1%.34

29 Ibid. Note: All veterans programs, mandatory and discretionary, are exempt from sequestration.
30 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.
31 P.L. 112-155, 126 Stat. 1210.
32 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.
33 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.
34 The March 1, 2013 sequestration was ordered before enactment of full-year appropriations for FY2013. As instructed
by the BBEDCA, OMB calculated the percentage reduction for discretionary spending based on annualized funding
levels under the six-month FY2013 continuing resolution (P.L. 112-175), which generally funded discretionary
programs at their FY2012 levels plus 0.612%. OMB then applied that percentage to the funding levels provided in the
continuing resolution to determine the dollar amount reduction for each nonexempt account. Congress completed its
work on FY2013 appropriations with passage of the Consolidated and Further Continuing Appropriations Act, 2013
(P.L. 113-6), which was signed into law on March 26, 2013. It funds most HHS discretionary programs at their FY2012
levels minus an across-the-board rescission of 0.2%, with some anomalies. Thus, final discretionary funding levels in
P.L. 113-6 are slightly lower than the annualized funding levels provided in the six-month continuing resolution.
Pursuant to the BBEDCA, OMB did not recompute the percentage reduction for discretionary spending, but instead
appears to have applied the dollar amount reductions calculated based on the six-month continuing resolution to the
(continued...)
Congressional Research Service
8

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Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)

In general, ACA-related discretionary spending in FY2013 is fully sequestrable at the 5.0% rate
applicable to nonexempt nondefense discretionary spending. Importantly, OMB has concluded
that the sequestration rules under BBEDCA Section 256, which include a 2% limit on cuts in
spending on community health centers, migrant health centers, and the IHS, apply only to
mandatory spending reductions and not to cuts in discretionary spending.35 Thus, while FY2013
discretionary spending on all health centers is fully sequestrable, cuts in CHCF (mandatory)
funding for community health centers and migrant health centers are capped at 2%.36
As already noted, discretionary spending reductions for each of the remaining years (i.e.,
FY2014-FY2021) will be achieved through a downward adjustment of the revised statutory
spending caps. In contrast to the automatic spending reductions achieved through sequestration,
lowering the annual discretionary spending caps allows Congress and the President to determine
through the annual appropriations process which accounts are to be reduced, and by how much, in
order to meet those caps.37 Lowering the annual discretionary spending caps also may make it
more difficult to maintain funding levels for existing programs.
Note that the FY2013 funding amounts listed in the tables below reflect the March 1, 2013,
sequestration.38





(...continued)
marginally lower final FY2013 levels.
35 Based on its statutory interpretation of BBEDCA, OMB determined that the March 1, 2013 Joint Committee
sequestration order was not an order pursuant to BBEDCA Sec. 254, under which sequestrations may be ordered to
enforce the discretionary spending limits (BBEDCA Sec. 251) and the pay-as-you-go, or PAYGO, requirements
(BBEDCA Sec. 252). This is significant because the Sec. 256 sequestration rules apply only to a sequestration order
issued under Sec. 254. Thus, OMB concluded that the Sec. 256 rules “do not apply to a Joint Committee sequestration,
except to the extent those rules are otherwise made applicable by another provision of law.” While Sec. 251A(8) of
BBEDCA specifically applies the Sec. 256 rules to a Joint Committee sequestration of nonexempt direct (i.e.,
mandatory) spending, there is no such provision for discretionary spending in Sec. 251A(7).
36 A small amount of the CHCF funding for health centers is provided to other types of facilities that are supported
under the federal health center program, including those that serve the homeless and residents of public housing. This
funding is fully sequestrable at the rate applicable to nonexempt mandatory programs.
37 The revised discretionary spending limits for FY2014-FY2021 would be enforced through a separate sequestration
process pursuant to BBEDCA Sec. 251 (see footnote 32).
38 For more discussion and analysis of the impact of spending reductions triggered by the BCA, see CRS Report
R42051, Budget Control Act: Potential Impact of Sequestration on Health Reform Spending, by C. Stephen Redhead.
Congressional Research Service
9

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Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)

Table 1. ACA Discretionary Spending: Health Centers and Clinics
Statutory
ACA
Authority
Authorization of Appropriations
Section
(Agency)
Summary of Provision
Funding (FY2011-FY2014)
Health Centers: Existing Program
5601 Reauthorizes
Health centers. Permanently reauthorizes funding for the program
$2,989 million for FY2010, $3,862 million for FY2011, $4,991 million for
PHSA Sec. 330
that provides operating grants to health centers serving federally
FY2012, $6,449 million for FY2013, $7,333 million for FY2014, and
(HRSA)
designated medically underserved populations and furnishing
$8,333 million for FY2015; amounts in subsequent years based on
comprehensive primary care services, referrals, and other services
previous year’s funding, subject to adjustment.
needed to facilitate access to such care, regardless of ability to pay.
Eligible grantees include community, migrant, public housing, and
FY2011 funding = $2,581 million (incl. $1,000 million from the
homeless health centers that meet the statutory requirements of PHSA
CHCF); FY2012 funding = $2,767 million (incl. $1,200 million from
Sec. 330.
the CHCF); FY2013 funding = $2,944 million (incl. $1,465 million
from the CHCF); FY2014 request = $3,767 million (incl. $2,200

million from the CHCF).a [CFDA 93.224, 93.527]
Note: ACA Sec. 10503(c) appropriated $1.5 billion for the period
FY2011 through FY2015 for health center construction and renovation;
see CRS Report R41301.
Health Centers and Clinics: New Programs
4101(b)
New PHSA Sec.
School-based health centers (SBHCs). Requires the Secretary to
SSAN for each of FY2010 through FY2014.
399Z-1 (HRSA)
award grants to fund the management and operation of SBHCs that
provide comprehensive physical and behavioral health services to
Note: ACA Sec. 4101(a) appropriated a total of $200 million for SBHC
children and adolescents, subject to parental consent. SBHCs that meet
construction and renovation; see CRS Report R41301.
certain specified criteria and match 20% of the grant amount with non-
federal funds (unless waived). Preference may be given to SBHCs serving
children and adolescents who have limited access to or difficulty
accessing health care.
5208
New PHSA Sec.
Nurse-managed health clinics (NMHCs). Requires the Secretary to $50 million for FY2010, and SSAN for each of FY2011 through FY2014.
330A-1 (HRSA)
award grants to fund the operation of NMHCs—associated with
schools, colleges, federally qualified health centers (FQHCs), or
Note: This new program received $15 million in FY2010 funds from the
nonprofit health/social services agencies—that provide comprehensive
PPHF but has not received any funding since that time. [CFDA 93.515]
primary health care and wellness services to vulnerable or underserved
populations regardless of income or insurance status. At least one
advanced practice nurse must hold an executive management position in
the NMHC.
CRS-10

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Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)

Statutory
ACA
Authority
Authorization of Appropriations
Section
(Agency)
Summary of Provision
Funding (FY2011-FY2014)
10504 New
authority
Access to affordable care demonstration program. Within six
SSAN (no years specified).
(HRSA)
months of enactment, requires the Secretary to establish a three-year
demonstration project in up to 10 states—each state may receive up to
$2 million—to provide access to comprehensive health care services to
the uninsured. Eligible grantees must be state-based, nonprofit, public-
private partnerships that provide access to comprehensive health care
services to the uninsured at reduced fees.
Sources: Table 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).
Funding amounts are taken from HRSA’s budget documents, including the FY2013 sequestration operating plan, available at http://www.hrsa.gov/about/budget/index.html.
Note: For more information on health centers, see CRS Report R42433, Federal Health Centers, by Elayne J. Heisler.
a. Annual funding totals for health centers include the following amounts for the Federal Tort Claims Act (FTCA) program: FY2011 = $100 million; FY2012 = $95 million;
FY2013 = $89 million; FY2014 request = $95 million. Under the FTCA, health center employees and contractors are considered federal employees and are immune
from medical malpractice lawsuits while acting within the scope of their employment. The federal government assumes responsibility for such malpractice claims.

Table 2. ACA Discretionary Spending: Health Care Workforce
Statutory
ACA
Authority
Authorization of Appropriations
Section
(Agency)
Summary of Provision
Funding (FY2011-FY2014)
National Health Service Corps (NHSC)
5207 Reauthorizes
NHSC scholarships and loan repayments. Permanently
$320 million for FY2010, $414 million for FY2011, $535 million for
PHSA Title III,
reauthorizes funding for the NHSC program. In exchange for a
FY2012, $691 million for FY2013, $893 million for FY2014, and $1,155
Part D, Subpart III commitment to work in a federally designated Health Professional
billion for FY2015; amounts in subsequent years based on previous
(HRSA)
Shortage Area (HPSA), the program provides (1) scholarships to
year’s funding, subject to adjustment.
students training in a primary care discipline to cover tuition, fees, other
educational costs, and a stipend; and (2) student loan repayments of up
FY2011 funding = $315 million (incl. $290 million from the CHCF);
to $50,000 a year to primary care and mental health clinicians. To be
FY2012 funding = $295 million (all CHCF); FY2013 funding = $285
eligible for a scholarship, a student must be accepted or enrolled in a
million (all CHCF); FY2014 request = $305 million (all CHCF).
training program for medicine, dentistry, family nurse practitioner, nurse
[CFDA 93.162, 93.288, 93.547]
midwife, or physician assistant, and agree to two to four years of service
in an NHSC-approved site in a HPSA. Loan repayments are for primary
care, dental, and mental health clinicians who agree to at least two years
of service in an NHSC-approved site in a HPSA.
CRS-11

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Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)

Statutory
ACA
Authority
Authorization of Appropriations
Section
(Agency)
Summary of Provision
Funding (FY2011-FY2014)
Physicians: Existing Program
5301 Amends
and
Primary care training and enhancement program. (1) Authorizes For both grant programs, $125 million for FY2010, and SSAN for each
reauthorizes
five-year grants to public and nonprofit private hospitals, medical
of FY2011 through FY2014. Note: 15% of the amount appropriated must
PHSA Sec. 747
schools, academically affiliated physician assistant training programs, and
be used for physician assistant training programs.
(HRSA)
other public and nonprofit private entities to support training programs
in primary care. Funds are to be used to plan, develop and operate
A separate authorization of $750,000 for each of FY2010 through
accredited training programs, including residency and internship
FY2014 is provided for capacity building grants to integrate academic
programs, in family medicine, general internal medicine, and general
units.
pediatrics and to provide financial assistance (e.g., traineeships). (2)
FY2011 funding = $39 million; FY2012 funding = $39 million; FY2013
Authorizes five-year grants to medical schools for primary care capacity
funding = $37 million; FY2014 request = $51 million. [CFDA 93.510,
building. Funds are to be used to create academic units or programs that 93.514, 93.884]
improve clinical teaching in the primary care fields, and (in a separate
authorization) to integrate academic units to enhance interdisciplinary
Note: For FY2010, this program received $198 million in PPHF funds in
recruitment, training, and faculty development. Funding priority given to
addition to its annual discretionary appropriation of $39 million.
entities proposing innovative approaches to primary care training and
with a record of training primary care providers, among other things.
Physicians: New Programs
5203
New PHSA Sec.
Pediatric specialist loan repayment program. Requires the
$30 million for each of FY2010 through FY2014 for loan repayments to
775 (HRSA)
Secretary to implement a loan repayment program that pays up to
pediatric specialists and surgeons; $20 million for each of FY2010
$35,000 for each year of service (for a maximum of three years) to
through FY2013 for loan repayments to mental health providers.
practicing or in-training pediatric specialists and surgeons, as well as
child and adolescent mental health specialists, who agree to at least two
FY2014 request = $5 million.
years of service in a HPSA.
5508(a)
New PHSA Sec.
Teaching health centers development grants. Authorizes three-
$25 million for FY2010, $50 million for each of FY2011 and FY2012, and
749A (HRSA)
year grants of up to $500,000 to FQHCs, rural health clinics, Indian
SSAN for each fiscal year thereafter.
health centers, and entities receiving PHSA Title X (family planning)
funds that establish or expand a primary care residency training
program.
10501(l)
New PHSA Sec.
Rural physician training grants. Requires the Secretary to (1) award
$4 million for each of FY2010 through FY2013.
749B (HRSA)
grants medical schools for recruiting students most likely to practice in
underserved rural communities and for providing rural-focused training
and experience; and (2) within 60 days of enactment, by regulation,
define underserved rural communities. Priority is given to entities that
train students to practice in rural communities, that have established
partnerships with rural community health centers, or who submit a long-
term plan for tracking where graduates practice. [Note: HRSA published
an interim final rule on May 26, 2010 (75 Federal Register 29447).]
CRS-12

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Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)

Statutory
ACA
Authority
Authorization of Appropriations
Section
(Agency)
Summary of Provision
Funding (FY2011-FY2014)
Dentistry: Existing Program
5303
New PHSA Sec.
General, pediatric, and public health dentistry training.
$30 million for FY2010, and SSAN for each of FY2011 through FY2015;
748; authority
Authorizes grants or contracts to dental and dental hygiene schools, as
permits grantees to carry over funds for up to three fiscal years.
previously part of
well as approved residency or advanced education programs in general,
Sec. 747 (HRSA)
pediatric, or public health dentistry, for dental training activities including FY2011 funding = $17 million; FY2012 funding = $20 million; FY2013
faculty development, financial assistance, faculty loan repayment
funding = $19 million (est.); FY2014 request = $21 million. [CFDA
programs, technical assistance for pediatric dental programs, and pre-
93.059, 93.884]
and post-doctoral training programs in dental primary care. Gives
Note: HRSA also administers a state oral health workforce grant
priority to entities that train individuals from disadvantaged backgrounds, program (PHSA Sec. 340G): FY2011 funding = $16 million; FY2012
who have a record of placing graduates in facilities that provide care to
funding = $12 million; FY2013 funding = $11 million (est.); FY2014
the underserved, or whose programs focus on providing care to the
request = $12 million. [CFDA 93.236]
underserved through demonstrated partnerships with FQHCs, rural
health clinics, or through having programs focused on specific topics,

such as HIV/AIDs.
Dentistry: New Program
5304
New PHSA Sec.
Alternative dental health care provider demonstration
SSAN (no years specified).
340G-1 (HRSA)
program. Authorizes the Secretary to award 15 five-year grants of not
less than $4 million to train or employ alternative dental health care
Note: The Department of Defense and Full-Year Continuing
providers (e.g., community dental health coordinators, dental health
Appropriations Act, 2011(P.L. 112-10) and the Consolidated
aides) to increase access to dental health care services in rural and other Appropriations Act, 2012 (P.L. 112-74) prohibited HRSA funding for this
underserved communities. Eligible grantees include institutions of higher
demonstration program in FY2011 and FY2012, respectively. This
education; public-private entities; FQHCs; facilities operated by the IHS
prohibition was continued in FY2013 by the Full-Year Continuing
or by Indian tribes or organizations; state or county public health clinics;
Appropriations Act, 2013 (P.L. 113-6).
public hospitals or health systems; and accredited dental education
programs.
CRS-13

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Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)

Statutory
ACA
Authority
Authorization of Appropriations
Section
(Agency)
Summary of Provision
Funding (FY2011-FY2014)
Nursing: Existing Programs
5309(a) Amends
and Nurse education, practice, quality, and retention program.
SSAN for each of FY2010 through FY2014. See also ACA Sec. 5312
reauthorizes
Authorizes grants or contracts to expand enrollment in baccalaureate
below, which reauthorized appropriations for several Title VIII nursing
PHSA Sec. 831
nursing programs; provide training in new technologies; develop cultural
education programs including Sec. 831.
(HRSA)
competencies; expand nursing practice arrangements in non-institutional
settings; and support nurse retention programs that offer career
FY2011 funding = $40 million; FY2012 funding = $40 million; FY2013
advancement for nursing personnel, enhance collaboration among nurses funding = $37 million; FY2014 request = $40 million. [CFDA 93.359,
and other health professionals, and promote nurse involvement in
93.503]
clinical decision making. Eligible grantees include nursing schools, health
care facilities (including NMHCs), or partnerships of the two.
5311(a) Amends
and Nursing faculty loan program. Authorizes loans to nursing school
SSAN for each of FY2010 through FY2014.
reauthorizes
students pursuing advanced degrees to become qualified nursing faculty.
PHSA Sec. 846A
Sets the annual loan limit at $35,500 for FY2010 and FY2011; for
FY2011 funding = $25 million; FY2012 funding = $25 million; FY2013
(HRSA)
subsequent fiscal years, the loan limit is subject to a cost-of-attendance
funding = $23 million; FY2014 request = $25 million. [CFDA 93.264]
adjustment. Students who go on to serve as nursing school faculty may
have up to 85% of their loan repayment cancelled.
5312 Amends
PHSA
Authorization of appropriations. Reauthorizes funding for the
For PHSA Secs. 811, 821, 831, and new 831A (see ACA Sec. 5309(b)
Sec. 871;
following PHSA Title VIII nursing workforce programs:
below), $338 million for FY2010, and SSAN for each of FY2011 through
previously Sec.
FY2016.
841 (HRSA)
1. Advanced nursing education (PHSA Sec. 811) – grants to accredited
programs for advanced nurse education including combined registered
Sec. 811: FY2011 funding = $64 million; FY2012 funding = $63
nurse masters degree programs, authorized nurse practitioner
million; FY2013 funding = $60 million; FY2014 request = $83
programs, accredited nurse midwifery programs, and accredited nurse
million. [CFDA 93.124, 93.247, 93.358, 93.513]
anesthesia programs.
Sec. 821: FY2011 funding = $16 million; FY2012 funding = $16
2. Nursing workforce diversity (PHSA Sec. 821) – grants to nursing
million; FY2013 funding = $15 million; FY2014 request = $16
schools, academic health centers, state or local governments, and other
million. [CFDA 93.178]
appropriate public or private nonprofit entities for stipends and
scholarships so as to increase nursing education opportunities for
Sec. 831: see ACA Sec. 5309(a) above for funding amounts.
disadvantaged individuals.
3. Nurse education, practice, quality, and retention (PHSA Sec. 831) –
see ACA Sec. 5309(a) above.
Note: ACA did not reauthorize funding for the nursing education loan
repayment and scholarship programs authorized under PHSA Sec. 846.a
CRS-14

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Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)

Statutory
ACA
Authority
Authorization of Appropriations
Section
(Agency)
Summary of Provision
Funding (FY2011-FY2014)
Nursing: New Programs
5309(b)
New PHSA Sec.
Nurse retention program. New authority that largely duplicates the
SSAN for each of FY2010 through FY2012. See also ACA Sec. 5312
831A (HRSA)
nurse retention grant program authorized under PHSA Sec. 831; see
above.
ACA Sec. 5309(a) above.
5311(b)
New PHSA Sec.
Nursing faculty loan repayment program. Authorizes a loan
SSAN for each of FY2010 through FY2014.
847 (HRSA)
repayment program for qualified nursing students or graduates who
agree to serve as nursing faculty for four to six years. Sets the annual
loan limit for FY2010 and FY2011 at $10,000 for individuals with a
master’s or equivalent degree in nursing ($20,000 for those with a
doctorate or equivalent degree in nursing), and an aggregate loan limit of
$40,000 for individuals with a master’s or equivalent degree in nursing
($80,000 for those with a doctorate or equivalent degree in nursing).
Thereafter, the annual and aggregate loan limits are subject to a cost-of-
attendance adjustment.
5316 New
authority
Family nurse practitioner demonstration program. Requires the
SSAN for each of FY2011 through FY2014.
Secretary to award three-year demonstration grants to FQHCs and
NMHCs, not to exceed $600,000 a year, for programs to train nurse
practitioners as primary care providers (as defined in ACA Sec. 5208).
Preference given to bilingual individuals.
Geriatrics and Long-Term Care: Existing Program
5305(c) Amends
and Geriatric nursing education and training. Provides grants for
SSAN for each of FY2010 through FY2014.
reauthorizes
traineeships for individuals preparing for advanced degrees in geriatric
PHSA Sec. 865;
nursing or other nursing areas that specialize in elder care. Eligible
FY2011 funding = $5 million; FY2012 funding = $4 million; FY2013
previously Sec.
grantees include nursing schools, health care facilities, programs leading
funding = $4 million; FY2014 request = $4 million. [CFDA 93.265]
855 (HRSA)
to certification as a certified nurse assistant, and partnerships of such
schools, facilities, and programs.
Geriatrics and Long-Term Care (LTC): New Programs
5302
New PHSA Sec.
Direct care worker training. Requires the Secretary to establish a
$10 million for the period FY2011 through FY2013.
747A (HRSA)
grant program to provide new training opportunities, such as tuition and
fee assistance, for direct care workers employed in LTC settings.
Individuals who receive assistance are required to work in the field of
geriatrics, disability services, LTC services and supports, or chronic care
management for a minimum of two years. Eligible grantees include
institutions of higher education that have an established partnership with
an LTC entity, as specified.
CRS-15

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Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)

Statutory
ACA
Authority
Authorization of Appropriations
Section
(Agency)
Summary of Provision
Funding (FY2011-FY2014)
5305(a) Amends
PHSA
Geriatric workforce development; geriatric career incentive
(1) $10.8 million for the period FY2011 through FY2014. (2) $10 million
Sec. 753 by
awards. (1) Requires the Secretary to award no more than 24 grants or for the period FY2011 through FY2013.
adding new
contracts for $150,000 to entities that operate geriatric education
subsections (d)-
centers to support short-term intensive courses on geriatrics and LTC,
Note: The three existing geriatric education and training programs
(e) (HRSA)
and support training for family caregivers and direct care workers.
authorized under PHSA Sec. 753(a)-(c), which support activities that are
Eligible grantees include accredited schools of allied health, medicine,
broadly comparable to those authorized in the new ACA programs,
nursing, dentistry, osteopathic medicine, optometry, podiatric medicine,
have received the following amounts: FY2011 funding = $34 million;
veterinary medicine, public health, or chiropractic care; accredited
FY2012 funding = $31 million, FY2013 funding = $29 million; FY2014
graduate programs in clinical psychology, clinical social work, health
request = $31 million. [CFDA 93.156, 93.250, 93.969]
administration, marriage and family therapy, and counseling; and
physician assistant programs. (2) Requires the Secretary to award grants
or contracts to advance practice nurses, clinical social workers,
pharmacists, and psychologists pursuing an advanced degree in geriatrics
or a related field, in return for agreeing to teach or practice in the field
of geriatrics, LTC, or chronic care management for a minimum of five
years upon completion of the degree.
Pain Care: New Program
4305(c)
New PHSA Sec.
Education and training in pain care. Authorizes a grant program to
SSAN for each of FY2010 through FY2012, to remain available until
759 (HRSA)
train health professionals in pain care. Eligible grantees include health
expended.
professions schools, hospices, and other public and private entities.
Applicants must agree to include training and education on recognizing
the signs and symptoms of pain; applicable laws and policies on
controlled substances; interdisciplinary approaches to pain care delivery;
barriers to care in underserved populations; and recent developments in
pain care. [See also Table 14.]
Public Health: Existing Programs
10501(m)(2) Amends
PHSA
Public health and preventive medicine programs. Reauthorizes
$43 million for FY2011, and SSAN for each of FY2012 through FY2015.
Sec. 770 (HRSA)
funding for the public health workforce programs authorized under
PHSA Secs. 765-769. They include grants for public health training
FY2011 funding = $30 million (incl. $20 million from the PPHF);
centers; tuition, fees, and stipends for traineeships in public health and in FY2012 funding = $33 million (incl. $25 million from the PPHF);
health administration; and residency programs in preventive medicine
FY2013 funding = $8 million; FY2014 request = $8 million (incl. $5
and dental public health. Several programs mention preference for
million from the PPHF). [CFDA 93.117, 93.249, 93.516, 93.964]
underserved communities or underrepresented minorities. Eligible
grantees include accredited academic institutions, as well as state, local
and tribal public health departments.
CRS-16

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Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)

Statutory
ACA
Authority
Authorization of Appropriations
Section
(Agency)
Summary of Provision
Funding (FY2011-FY2014)
Public Health: New Programs
5204
New PHSA Sec.
Public health workforce loan repayment program. Requires the
$195 million for FY2010, and SSAN for each of FY2011 through FY2015.
776 (HRSA)
Secretary to establish a student loan repayment program that pays up to
$35,000 a year, or one-third of total debt, whichever is less, to increase
the supply of public health professionals. Eligible individuals must agree
to work for at last three years in a public health agency or related
training fellowship.
5206(b)
New PHSA Sec.
Public health and allied health scholarship program. Authorizes
$60 million for FY2010, and SSAN for each of FY2011 through FY2015.
777 (HRSA)
grants to accredited institutions for scholarships to help support the
training of mid-career professionals in public health and allied health.
Available grant funds are to be divided 50:50 between supporting public
health and allied health professionals.
5313
New PHSA Sec.
Community health worker (CHW) program. Requires CDC to
SSAN for each of FY2010 through FY2014.
399V (CDC)
award grants to promote healthy behaviors and outcomes for
populations in medically underserved communities through programs of
training and supervision of CHWs. Eligible grantees include states and
subdivisions, health departments, free clinics, hospitals, and FQHCs.
Priority is to be given to applicants that target areas with a high
proportion of uninsured or underinsured individuals, or with high rates
of chronic illness or infant mortality.
5314
New PHSA Sec.
CDC training fellowships. Authorizes the Secretary to expand
$39.5 million for each of FY2010 through FY2013 ($24.5 million for EIS,
778 (CDC)
existing CDC training fellowships in epidemiology, laboratory science,
and $5 million each for epidemiology, laboratory science, and
and informatics; the Epidemic Intelligence Service (EIS); and other
informatics).
training programs that meet similar objectives. Participants may be
placed in state and local health agencies, and states can receive federal
assistance for loan repayment programs for such participants. [CFDA
93.065]
5315
New PHSA Title
United States Public Health Sciences Track. Authorizes the
Requires the Secretary to transfer SSAN from the Public Health and
II, Part D – Secs.
establishment of a science track at academic sites selected by the
Social Services Emergency Fund for FY2010 and each fiscal year
271-274 (U.S.
Secretary to award degrees that emphasize team-based service, public
thereafter. Note: P.L. 112-10 prohibited any such transfer of funds.b
Surgeon General)
health, epidemiology, and emergency preparedness and response. Funds
may be used for program development and for tuition and stipends for
students who meet a service obligation, including in the United States
Public Health Service (USPHS) Commissioned Corps.
CRS-17

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Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)

Statutory
ACA
Authority
Authorization of Appropriations
Section
(Agency)
Summary of Provision
Funding (FY2011-FY2014)
5210 Amends
PHSA
USPHS Commissioned Corps. Establishes a Ready Reserve Corps
$17.5 million for each of FY2010 through FY2014 ($5 million for
Sec. 203 (U.S.
of officers who are subject to involuntary call to active duty (including
recruitment and training, $12.5 million for the Ready Reserve Corps).
Surgeon General)
for training) by the Surgeon General, in order to bolster the available
workforce for both routine and emergency public health missions.
Workforce Diversity, Health Disparities, Cultural Competency: Existing Programs
5307(a) Amends
and Cultural competency, prevention, public health, disparities, and SSAN for each of FY2010 through FY2015.
reauthorizes
individuals with disability training. Authorizes grants, contracts, or
PHSA Sec. 741
cooperative agreements under PHSA Title VII (Health Professions
(HRSA)
Education) for the development and evaluation of research,
demonstration projects, and model curricula that provide training in
cultural competency, prevention, public health proficiency, reducing
health disparities, and aptitude for working with individuals with
disabilities. The Secretary is required to coordinate this program with
the one authorized under PHSA Sec. 807.
5307(b) Amends
and Cultural competency, prevention, public health, disparities, and SSAN for each of FY2010 through FY2015.
reauthorizes
individuals with disability training. Authorizes grants, contracts, or
PHSA Sec. 807
cooperative agreements under PHSA Title VIII (Nursing Workforce
(HRSA)
Development) for the development and evaluation of research,
demonstration projects, and model curricula that provide training in
cultural competency, prevention, public health proficiency, reducing
health disparities, and aptitude for working with individuals with
disabilities. The Secretary is required to coordinate this program with
the one authorized under PHSA Sec. 741.
5401 Amends
and
Centers of excellence (COE). Requires the Secretary to fund COEs
$50 million for each of FY2010 through FY2015, and SSAN for each
reauthorizes
at health professions schools that recruit, enroll and graduate
subsequent fiscal year.
PHSA Sec. 736
underrepresented minorities or that recruit underrepresented
(HRSA)
minorities serving in faculty or administrative positions.
FY2011 funding = $24 million; FY2012 funding = $23 million; FY2013
funding = $21 million; FY2014 request = $23 million. [CFDA 93.157]
CRS-18

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Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)

Statutory
ACA
Authority
Authorization of Appropriations
Section
(Agency)
Summary of Provision
Funding (FY2011-FY2014)
5402 Amends
PHSA
Authorization of appropriations. Reauthorizes funding for the
For Sec. 737, $51 million for FY2010, and SSAN for each of FY2011
Sec. 740 (HRSA)
following PHSA Title VII workforce diversity programs:
through FY2014. For Sec. 738, $5 million for each of FY2010 through
FY2014. For Sec. 739, $60 million for FY2010, and SSAN for each of
1. Scholarships for disadvantaged students (PHSA Sec. 737) – grants
FY2011 through FY2014.
to health professions schools for awarding scholarships to students from
disadvantaged backgrounds with financial need.
Sec. 737: FY2011 funding = $49 million; FY2012 funding = $47
million; FY2013 funding = $44; FY2014 request = $47 million. [CFDA
2. Faculty loan repayment program (PHSA Sec. 738) – loan repayment
93.925]
program for health profession graduates from disadvantaged
backgrounds who serve as faculty at an eligible health professions college Sec. 738: FY2011 funding = $1 million; FY2012 funding = $1 million;
for at least two years.
FY2013 funding = $1 million; FY2014 request = $1 million. [CFDA
93.923]
3. Health careers opportunity program (PHSA Sec. 739) – grants to
health professions schools and other educational institutions to improve
Sec. 739: FY2011 funding = $22 million; FY2012 funding = $15
recruitment and academic preparation of students from disadvantaged
million; FY2013 funding = $14 million; FY2014 request = $0. [CFDA
backgrounds.
93.822]
5403(a) Amends
and Area Health Education Centers (AHECs). Requires the Secretary
$125 million for each of FY2010 through FY2014; funds may be carried
reauthorizes
to award grants (with a matching requirement) to medical and nursing
over for up to three fiscal years.
PHSA Sec. 751
schools of at least $250,000 to (1) plan, develop, and operate AHEC
(HRSA)
programs; and (2) to maintain and improve the effectiveness of existing
FY2011 funding = $33 million; FY2012 funding = $27 million; FY2013
AHEC programs. AHECs recruit, train, and prepare individuals from
funding = $28 million; FY2014 request = $0. [CFDA 93.107, 93.824]
minority populations or from disadvantaged or rural backgrounds to
work in medically underserved areas.
Workforce Diversity, Health Disparities, Cultural Competency: New Program
5403(b)
New PHSA Sec.
Continuing educational support for health professionals serving $5 million for each of FY2010 through FY2014, and SSAN for each
752 (HRSA)
in underserved communities. Requires the Secretary to award
subsequent fiscal year.
grants to enhance education through distance learning, continuing
education, collaborative conferences, and telehealth, with a focus on
primary care. Eligible grantees include health professions schools,
academic health centers, state or local governments, or other public or
nonprofit entities participating in training activities. [CFDA 93.189]
CRS-19

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Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)

Statutory
ACA
Authority
Authorization of Appropriations
Section
(Agency)
Summary of Provision
Funding (FY2011-FY2014)
Mental and Behavioral Health: New Program
5306 Redesignates
Mental and behavioral health education and training grants.
$35 million for the period of FY2010 through FY2013 ($8 million for
PHSA Sec. 756 as
Authorizes grants for the recruitment and education of students in
training in social work, $12 million for training in graduate psychology,
Sec. 757, and
social work, interdisciplinary psychology training, and internships or
$10 million for training in professional child and adolescent mental
adds a new Sec.
other field placement programs related to child and adolescent mental
health, and $5 million for training in paraprofessional child and
756 (HRSA)
health. Priority for social work grants given to schools of social work
adolescent mental health).
meeting certain criteria such as recruiting from and placing graduates
into areas with a high-need and high-demand population. Priority for
HRSA: FY2012 funding = $10 million (all PPHF); FY2013 funding =
psychology grants given to institutions that focus on the needs of
$0; FY2014 request = $0. Note: SAMHSA’s FY2014 budget requests
specified vulnerable groups. Priority for grants to train professional and
$35 million to expand the mental and behavioral health workforce,
paraprofessional child and adolescent mental health workers given to
through a partnership with HRSA. [CFDA 93.732]
applicants that can, among other things, assess workforce needs and that Note: HRSA’s graduate psychology education program, which predates
have programs designed to increase the number of child and adolescent
ACA, received $3 million in each of FY2011, FY2012, and FY2013. The
mental health workers serving high-priority populations.
FY2014 request is for the same amount.
Policy and Planning: Existing Program
5103 Amends
and
Health care workforce program assessment. Requires the
For the National Center, $7.5 million for each of FY2010 through
reauthorizes
Secretary to establish a National Center for Health Care Workforce
FY2014; for state and regional centers, $4.5 million for each of FY2010
PHSA Sec. 761
Analysis, award grants to support state and regional centers for health
through FY2014; and for longitudinal evaluations, SSAN for FY2010
(HRSA)
workforce analysis, and increase funding for longitudinal evaluations of
through FY2014.
specified individuals who have received education, training, or financial
assistance from programs under PHSA Title VII.
FY2011 funding = $3 million; FY2012 funding = $3 million; FY2013
funding = $3 million; FY2014 request = $5 million. Note: These
amounts also include funding for Sec. 792 (health professions data) and
Sec. 806 (nursing grant program data). [CFDA 93.300]
Policy and Planning: New Programs
5101 New
authority
National Health Care Workforce Commission. Establishes a 15-
SSAN (no years specified).
member commission focused on evaluating and meeting the need for
health care workers in the United States. The commission is required to
conduct studies, produce annual reports beginning in 2011, and make
recommendations on high-priority topics related to the health care
workforce.
CRS-20

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Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)

Statutory
ACA
Authority
Authorization of Appropriations
Section
(Agency)
Summary of Provision
Funding (FY2011-FY2014)
5102 New
authority
State health care workforce development grants. Establishes a
For planning grants, $8 million for FY2010, and SSAN for each
(HRSA)
matching grants program for state partnerships to plan and implement
subsequent fiscal year. For implementation grants, $150 million for
activities leading to coherent and comprehensive health care workforce
FY2010, and SSAN for each subsequent fiscal year.
development strategies at the state and local levels. Planning grants of up
to $150,000 are for up to one year and require a 15% match.
Note: This program received $6 million in FY2010 funds from the PPHF.
Implementation grants are for up to two years (with up to one
[CFDA 93.509]
additional year of funding) and require a 25% match.
Sources: Table 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).
Funding amounts are taken from HRSA’s budget documents, including the FY2013 sequestration operating plan, available at http://www.hrsa.gov/about/budget/index.html.
a. The nursing education loan repayment program repays 60% of a registered nurse’s educational loans in return for a two-year commitment to work in a health care
facility with a critical shortage of nurses. Participants may have an additional 25% of their loan repaid in exchange for one more year of service. The nurse scholarship
program offer scholarships to individuals attending nursing school in exchange for at least two years working in a health care facility with a critical shortage of nurses.
Together the two programs, which are authorized under PHSA Sec. 846 and collectively known as NURSE Corps, received $94 million in FY2010, $93 million in
FY2011, $83 million in FY2012, and $78 million in FY2013. The FY2014 request is for $83 million. The authorization of appropriations for Sec. 846 expired at the end
of FY2007 and was not reauthorized by ACA.
b. The Department of Defense and Full-Year Continuing Appropriations Act, 2011 (P.L. 112-10, Div. B, Sec. 1828) prohibited the transfer of funds from the Public Health
and Social Services Emergency Fund (PHSSEF) to support the U.S. Public Health Sciences Track. The PHSSEF is an HHS account administered by the Secretary.
Congress has historically used the PHSSEF to provide one-time funding for non-routine activities. Each fiscal year, Congress appropriates amounts to the PHSSEF for
specified purposes. ACA did not authorize or appropriate funds to the PHSSEF.
CRS-21

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Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)

Table 3. ACA Discretionary Spending: Prevention and Wellness
Statutory
ACA
Authority
Authorization of Appropriations
Section
(Agency)
Summary of Provision
Funding (FY2011-FY2014)
Community-Based Prevention: Existing Programs
3509/3511
New PHSA Secs.
Offices on Women’s Health. Establishes offices of women’s health in
For the new offices, SSAN for each of FY2010 through FY2014. For NIH
229 (OS), 310A
OS, CDC, AHRQ, HRSA, and FDA. Grants, agreements, or contracts
and SAMHSA offices, SSAN (no years specified).
(CDC), 925
may be awarded for activities of the OS office to establish an
(AHRQ); new
information center and coordinating committee. Activities at the other
OS Office on Women’s Health: FY2011 funding = $34 million;
SSA Sec. 713
offices include making recommendations regarding grant-making through
FY2012 funding = $34 million; FY2013 funding = $33 million; FY2014
(HRSA); and new
other agency accounts, not direct grant-making.
request = $27 million.
FFDCA Sec. 1011
NIH Office of Research on Women’s Health: FY2011 funding = $42
(FDA). Amends
Amends the existing authorities for NIH’s Office of Research on
million; FY2012 funding = $42 million; FY2013 funding = $40 million
PHSA Secs.
Women’s Health (ORWH) and SAMHSA’s Associate Administrator for
(est.); FY2014 request = $43 million.
486(a) (NIH) and
Women’s Services by specifying that the ORWH director and the
501(f) (SAMHSA). Associate Administrator are to report directly to the NIH Director and
the SAMHSA Administrator, respectively.
4003 Amends
PHSA
Clinical and community preventive services task forces.
SSAN for each fiscal year to carry out the activities of the USPSTF and
Sec. 915(a)
Reauthorizes and expands the authority for the U.S. Preventive Services
the TFCPS.
(AHRQ). New
Task Force (USPSTF) to review and recommend effective clinical
PHSA Sec. 399U
preventive services. Provides explicit statutory authority for the existing
AHRQ funding for USPSTF: FY2011 funding = $11 million (incl. $7
(CDC).
Task Force on Community Preventive Services (TFCPS) to review and
million from the PPHF); FY2012 funding = $11 million (incl. $7
recommend effective community-based interventions.
million from the PPHF); FY2013 funding = $10 million (incl. $6
million from the PPHF) (est.); FY2014 request = $11 million.
4102(b) Amends
PHSA
School-based dental sealant program. Amends the existing school-
Authority expired at end of FY2005; ACA does not authorize new
Sec. 317M(c)
based dental sealant grant program, which was discretionary, by
funding.
(CDC, HRSA)
requiring the Secretary to award grants to the 50 states and to Indian
tribes for school-based dental sealant programs.
Funding for all CDC’s existing oral health programs under Sec.
317M: FY2011 = $15 million; FY2012 = $15 million, FY2013 funding
= $14 million; FY2014 request = $16 million.
4204 Amends
PHSA
Immunization programs. Provides explicit authority for states to
SSAN for each of FY2010 through FY2014 for demonstration grants;
Sec. 317 and adds
purchase vaccines at prices negotiated by Secretary. Permanently
SSAN (no years specified) for other authorities.
a new subsection
reauthorizes state immunization grants. Requires new immunization
(m) (CDC)
demonstration grants.
Funding for the Sec. 317 vaccination program: FY2011 = $589
million (incl. $100 million from the PPHF); FY2012 = $620 million
(incl. $190 million from the PPHF); FY2013 = $528 million (incl.
$119 million from the PPHF and transfers); FY2014 request = $581
million (incl. $72 million from the PPHF). [CFDA 93.185, 93.268,
93.533, 93.539]
Note: The amounts above include funding for program implementation
and accountability.
CRS-22

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Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)

Statutory
ACA
Authority
Authorization of Appropriations
Section
(Agency)
Summary of Provision
Funding (FY2011-FY2014)
10334 Amends
PHSA
Offices of Minority Health. Elevates the existing OS Office of
SSAN for each of FY2011 through FY2016 for OS office.
Sec. 1707 (OS)
Minority Health and NIH National Center on Minority Health and
and PHSA Title IV Health Disparities (NCMHD); instructs the OS office to award grants
NIMHD: FY2011 funding = $276 million; FY2012 funding = $276
(NIH)
and undertake other activities to improve minority health status; and
million; FY2013 funding = $260 million; FY2014 request = $283
gives the new NIH National Institute on Minority Health and Health
million.
Disparities (NIMHD) responsibility for minority health disparities
OS Office of Minority Health: FY2011 funding = $56 million;
research and other health disparities research at NIH.
FY2012 funding = $56 million; FY2013 funding = $40 million; FY2014
request = $41 million.
10412 Reauthorizes
Rural access to emergency devices. Reauthorizes a program of
$25 million for each of FY2003 through FY2014.
PHSA Sec. 312
grants to community partnerships for the purchase and distribution of
(HRSA)
automatic external defibrillators (AEDs) in rural communities, and to
FY2011 funding = $0.2 million; FY2012 funding = $1 million; FY2013
support AED training for first responders.
funding = $2 million; FY2014 request = $0. [CFDA 93.259]
Community-Based Prevention: New Programs
4004 New
authority
Education and outreach regarding prevention. Requires the
SSAN for each fiscal year; no more than $500 million total.
Secretary to carry out various specified communications activities
regarding health promotion and disease prevention, for common and
Note: Education and outreach for health promotion are core public
serious chronic health problems. They include establishing, within one
health activities and a part of many HHS programs, authorized in broad
year of enactment, a national media campaign on health promotion and
language in the PHSA. Thus, it is not possible to identify total funding for
disease prevention.
Sec. 4004 implementation. However, HHS reported using $30 million in
FY2012 PPHF funds for tobacco prevention media activities and
prevention education and outreach. HHS did not allocate PPHF funds for
comparable activities in FY2013, or request such funds for FY2014. CRS
did not find comparable information for FY2011.
4102(a)
New PHSA Secs.
Oral health activities. Requires CDC, subject to appropriations, to
SSAN (no years specified).
399LL, 399LL-1,
fund a five-year national oral health education campaign, and award
and 399LL-2
grants to community-based providers of dental services for dental caries
(CDC)
disease management programs, among other things.
4102(c) Amends
PHSA
Oral health infrastructure. Requires the Secretary to enter into
SSAN for FY2010 through FY2014.
Sec. 317M by
cooperative agreements with states and tribal entities to establish oral
adding a new
health leadership and programs to improve oral health.
subsection (d)
(CDC)
CRS-23

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Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)

Statutory
ACA
Authority
Authorization of Appropriations
Section
(Agency)
Summary of Provision
Funding (FY2011-FY2014)
4102(d) New
authority
Oral health surveillance. Requires the Secretary to expand the
SSAN (no years specified) for PRAMS; SSAN for each of FY2010
(CDC, AHRQ)
following surveillance systems to include more information on oral
through FY2014 for NOHSS; no explicit authorization of appropriations
health: Pregnancy Risk Assessment Monitoring System (PRAMS);
for NHANES/MEPS expansion.
National Health and Nutrition Examination Survey (NHANES); National
Oral Health Surveillance System (NOHSS); and Medical Expenditure
Panel Survey (MEPS).
4201 New
authority
Community transformation grants. Requires CDC to fund
SSAN for each of FY2010 through FY2014.
(CDC)
competitive grants for the implementation, evaluation, and dissemination
of evidence-based community preventive health activities.
FY2011 funding = $145 million (all PPHF); FY2012 funding = $226
million (all PPHF); FY2013 funding = $146 million (all PPHF);
FY2014 request = $146 million (incl. $136 from the PPHF). [CFDA
93.531]
4202(a) New
authority
Community wellness pilot program. Requires CDC to award
SSAN for each of FY2010 through FY2014.
(CDC)
grants state and local health departments, and to Indian tribes, for five-
year pilot programs to provide community prevention interventions,
screenings, and clinical referrals for individuals between 55 and 64 years
of age.
4206 Amends
PHSA
Individualized wellness plan demonstration program. Requires
SSAN (no years specified).
Sec. 330 by
the Secretary to establish a pilot program in not more than 10
adding a new
community health centers to test the impact of providing at-risk
subsection (s)
individuals who use the centers with individualized wellness plans.
4304
New PHSA Sec.
Epidemiology and laboratory capacity grants. Codifies existing
$190 million for each of FY2010 through FY2013 (at least $95 million
2821 (CDC)
grant programs to strengthen national epidemiology, laboratory, and
for epidemiology, $60 million for information management, and $32
information management capacity for the response to infectious diseases million for laboratories).
and other conditions of public health importance.
Funding for Epidemiology and Laboratory Capacity (ELC): FY2011
= $40 million (all PPHF); FY2012 = $40 million (all PPHF); FY2013
funding = $40 million (PPHF and transfers); FY2014 request = $40
million (all PPHF).
10407 New
authority
Diabetes activities. Requires CDC to conduct several diabetes
SSAN (no years specified).
(CDC)
prevention activities including state assessments, vital statistics, physician
education, and funding of an Institute of Medicine (IOM) report.
10411
New PHSA Secs.
Congenital heart disease programs. Authorizes CDC to establish a
SSAN for each of FY2011 through FY2015 for both the surveillance
399V-2 (CDC)
National Congenital Heart Disease Surveillance System (NCHDSS), or
system and the expanded research program.
and 425 (NIH)
to award one grant to establish such a system. Authorizes NIH to
expand and coordinate research on congenital heart disease.
CDC: FY2012 funding = $2 million; FY2013 funding = $2 million;
FY2014 request = $2 million (all PPHF).
CRS-24

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Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)

Statutory
ACA
Authority
Authorization of Appropriations
Section
(Agency)
Summary of Provision
Funding (FY2011-FY2014)
10413
New PHSA Sec.
Young women’s breast health awareness. Among other things,
$9 million for each of FY2010 through FY2014.
399NN (OS,
requires CDC to conduct an education campaign and award grants for a
CDC)
media campaign regarding breast health in young women, and to conduct FY2011 funding = $5 million; FY2012 funding = $5 million; FY2013
prevention research; requires the Secretary to award grants to provide
funding = $5 million; FY2014 request amount not specified.
education and assistance to young women diagnosed with breast disease.
10501(g)
New PHSA Sec.
National diabetes prevention program. Among other things,
SSAN for each of FY2010 through FY2014.
399V-3 (CDC)
requires the Secretary to award grants for community-based diabetes
prevention program model sites.
FY2011 funding = $0 million; FY2012 funding = $10 million (all
PPHF); FY2013 funding = $0; FY2014 request = $0.
Workplace Wellness: New Program
10408 New
authority
Small business wellness program. Requires the Secretary to award
$200 million for the period of FY2011 through FY2015, to remain
(CDC)
grants to employers to provide their employees with access to
available until expended.
comprehensive workplace wellness programs. Eligible employers are
those with fewer than 100 employees, who work at least 25 hours per
FY2011 funding = $10 million (all PPHF); FY2012 funding = $10
week.
million (all PPHF); FY2013 funding = $0; FY2014 request = $0.
Sources: Table 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).
Funding amounts are taken from agency budget documents, including the FY2013 sequestration operating plans, available at http://www.hhs.gov/budget/, and
communications with the CDC Washington Office.

Table 4. ACA Discretionary Spending: Maternal and Child Health
Statutory
ACA
Authority
Authorization of Appropriations
Section
(Agency)
Summary of Provision
Funding (FY2011-FY2014)
2952(b)
New SSA Sec.
Services to individuals with a postpartum condition. Authorizes
$3 million for FY2010, and SSAN for each of FY2011 and FY2012.
512 (HRSA)
grants to establish, operate and coordinate effective and cost-efficient
systems for the delivery of essential services to individuals with, or at
risk of, postpartum depression and their families. Eligible grantees
include public or nonprofit private entities, state or local government
public-private partnerships, recipients of Healthy Start grants, public or
nonprofit private hospitals, community-based organizations, hospices,
ambulatory care facilities, community health centers, and primary care
centers.
Source: Table 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).
CRS-25

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Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)


Table 5. ACA Discretionary Spending: Health Care Quality
Statutory
ACA
Authority
Authorization of Appropriations
Section
(Agency)
Summary of Provision
Funding (FY2011-FY2014)
Quality Measure Development, Analysis, and Public Reporting: New Programs
3013(a)&(c)
New PHSA 931
Quality measure development. Requires the Secretary, in
$75 million for each of FY2010 through FY2014, to remain available until
(AHRQ)
consultation with AHRQ and CMS, to (1) identify gaps where no quality
expended. At least 50% of the amounts appropriated must be used
measures exist or where existing measures need improvement, updating
pursuant to SSA Sec. 1890A(e), as added by ACA Sec. 3013(b). See
or expansion consistent with the National Strategy for Quality
below.
Improvement; and (2) fund or enter into agreements with eligible
entities that have demonstrated expertise in measure development to
develop, improve, update or expand quality measures in areas identified
as gap areas.
3013(b)
Amends new SSA
Quality and efficiency measures development. Requires CMS, in
See ACA Sec. 3013(a)&(c) above.
Sec. 1890A, as
consultation with AHRQ, through contracts, to develop quality and
added by ACA
efficiency measures as determined appropriate for use under the SSA.
Sec. 3014(b), by
adding a new
subsection (e)
(CMS)
3015
New PHSA Sec.
Collection and analysis of data for quality and resource use
SSAN for each of FY2010 through FY2014.
399II
measures. Requires the Secretary to establish and implement an
overall strategic framework to carry out the public reporting of
performance information. Requires the Secretary to collect and
aggregate consistent data on quality and resource use measures, and
authorizes the Secretary to award grants or contracts for this purpose.
Authorizes the Secretary to award grants or contracts to multi-
stakeholder entities to support new, or improve existing, efforts to
collect and aggregate quality and resource use measures.
3015
New PHSA Sec.
Public reporting of performance information. Requires the
SSAN for each of FY2010 through FY2014.
399JJ
Secretary to make available to the public, through standardized websites,
performance information summarizing data on quality measures. The
information must include clinical conditions to the extent such data is
available and, where appropriate, be provider-specific and sufficiently
disaggregated and specific to meet the needs of patients with different
clinical conditions.
CRS-26

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Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)

Statutory
ACA
Authority
Authorization of Appropriations
Section
(Agency)
Summary of Provision
Funding (FY2011-FY2014)
Quality Improvement Research, Training, and Implementation: New Programs
3501
New PHSA Sec.
Health care delivery system research. Requires AHRQ to (1)
$20 million for FY2010 through FY2014.
933 (AHRQ)
identify, develop, evaluate, and disseminate innovative strategies for
quality improvement practices in the delivery of health care services that
represent best practice; (2) support research on health care delivery
improvement and facilitate adoption of best practices; and (3) make the
research findings available to the public; among other specified functions.
3501/3511
New PHSA Sec.
Quality improvement technical assistance and implementation. SSAN (no years specified).
934 (AHRQ)
Requires AHRQ to award grants (with a matching requirement) to
eligible entities for providing technical support to health care providers
in order to help them understand, adapt, and implement the models and
practices identified by the research conducted by the agency. Grantees
must have demonstrated expertise in providing information and
technical support and assistance to health care providers regarding
quality improvement.
3508/3511 New
authority Quality and patient safety training. Authorizes the Secretary to
SSAN (no years specified).
award demonstration grants (with a matching requirement) to eligible
health professions schools or consortia to develop and implement
academic curricula that integrate quality improvement and patient safety
into clinical education of health professionals.
Health Care Coordination: Existing Program
3510 Amends
and
Patient navigator program. Prohibits the Secretary from awarding a
$3.5 million for FY2010, and SSAN for each of FY2011 through FY2015.
reauthorizes
grant to an entity under this section unless the entity provides
PHSA Sec. 340A
assurances that patient navigators recruited, assigned, trained, or
FY2011 funding = $5 million. [CFDA 93.191]
(HRSA)
employed using these grant funds meet certain minimum core
proficiencies. Eligible grantees include public or nonprofit private health
centers (including FQHCs), IHS facilities, hospitals, cancer centers, rural
health clinics, academic health centers, and nonprofit entities that
partner or coordinate referrals with such a facility to provide patient
navigator services.
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Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)

Statutory
ACA
Authority
Authorization of Appropriations
Section
(Agency)
Summary of Provision
Funding (FY2011-FY2014)
Health Care Coordination: New Programs
3502/3511 New
authority Community health team grants to support medical homes.
SSAN (no years specified).
Requires the Secretary to award grants to or enter into contracts with
states, state-designated entities, and tribal organizations to support
community-based interdisciplinary, interprofessional health teams in
assisting primary care practices. Funding must be used to establish the
health teams and to provide capitated payments to the providers.
3503/3511
New PHSA Sec.
Medication therapy management (MTM) grants. Requires the
SSAN (no years specified).
935 (AHRQ)
Secretary, not later than May 1, 2010, to provide grants to support
MTM services provided by licensed pharmacists that are targeted at
patients who take four or more prescribed medications, take high-risk
medications, have two or more chronic diseases, or have undergone a
transition of care or other factors that are likely to create a high risk for
medication-related problems.
3506
New PHSA Sec.
Program to facilitate shared decision making. Requires the
SSAN for FY2010 and each subsequent fiscal year.
936 (AHRQ)
Secretary, through a contract, to develop and identify standards for
patient decision aids, to review patient decision aids, and develop a
certification process for determining whether patient decision aids meet
those standards. The contract is to be awarded to the entity that holds
the contract under SSA Sec. 1890 (currently the National Quality
Forum). Further requires the Secretary to (1) award grants or contracts
to develop, update, and produce patient decision aids, to test such
materials to ensure they are balanced and evidence-based, and to
educate providers on their use; and (2) to award grants for establishing
Shared Decision Making Resource Centers to develop and disseminate
best practices to speed adoption and effective use of patient decision
aids and shared decision making. Also requires the Secretary to award
grants to providers for the development and implementation of shared
decision-making techniques.
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Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)

Statutory
ACA
Authority
Authorization of Appropriations
Section
(Agency)
Summary of Provision
Funding (FY2011-FY2014)
5405
New PHSA Sec.
Primary care extension program. Requires the Secretary to
$120 million for each of FY2011 and FY2012, and SSAN for each of
399V-1 (AHRQ)
establish a Primary Care Extension Program to award state planning and
FY2013 and FY2014.
implementation grants for Primary Care Extension Program State Hubs,
consisting of the state health department and other specified entities.
State hubs must contract with and provide grant funds to county and
local entities to serve as Primary Care Extension Agencies that assist
primary care providers in implementing patient-centered medical homes
and develop and support primary care learning communities, among
other functions.
5604
New PHSA Sec.
Co-locating primary and specialty care in community-based
$50 million for FY2010, and SSAN for each of FY2011 through FY2014.
520K (SAMHSA)
mental health settings. Requires the Secretary to fund
demonstration projects for providing coordinated and integrated
Note: SAMHSA’s Primary & Behavioral Health Care Integration (PBHCI)
services to individuals with mental illness and co-occurring chronic
program, authorized under PHSA Sec. 520A, predates ACA and has
diseases through the co-location of primary and specialty care services in received the following amounts: FY2011 funding = $63 million (incl. $35
community-based mental and behavioral health settings.
million from the PPHF); FY2012 = $66 (incl. $35 million from the PPHF);
FY2013 funding = $29; FY2014 request = $28 million (all PPHF).
10333
New PHSA Sec.
Community-based collaborative care network program.
SSAN for each of FY2011 through FY2015.
340H
Authorizes the Secretary to award grants to support community-based
collaborative care networks (CCN). An eligible CCN is a consortium of
health care providers with a joint governance structure that provides
comprehensive coordinated and integrated health care services (as
defined by the Secretary) for low-income populations. CCNs must
include a safety net hospital and all FQHCs in the community, as
specified.
10410
New PHSA Sec.
Centers of excellence for depression. Requires SAMHSA to award
$100 million for each of FY2011 through FY2015, and $150 million for
520B (SAMHSA)
five-year grants (with a matching requirement) on a competitive basis to
each of FY2016 through FY2020.
eligible institutions of higher education or research institutions to
establish national centers of excellence for depression. One grantee is to
be designated as the coordinating center and required to establish and
maintain a national database. Centers of excellence may receive a grant
of up to $5 million; the coordinating center may receive a grant of up to
$10 million.
Sources: Table 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).
Funding amounts are taken from agency budget documents, including the FY2013 sequestration operating plans, available at http://www.hhs.gov/budget/.

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Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)

Table 6. ACA Discretionary Spending: Nursing Homes
Statutory
ACA
Authority
Authorization of Appropriations
Section
(Agency)
Summary of Provision
Funding (FY2011-FY2014)
6112 New
authority
National independent monitor demonstration program.
SSAN (no years specified); a monitored chain must contribute a portion
Requires the Secretary, within one year of enactment, to implement a
of costs of the demonstration, as determined by the Secretary.
two-year demonstration to develop, test, and implement an independent
monitoring program to oversee interstate and large intrastate chains of
skilled nursing facilities (SNFs) and nursing facilities (NFs).
6114 New
authority
Culture change and information technology demonstration
SSAN (no years specified).
programs. Requires the Secretary, within one year of enactment, to
award one or more competitive grants to support each of the following
two three-year demonstration projects for SNFs and NFs: (1) develop
best practices for culture change (i.e., patient-centric models of care);
and (2) develop best practices for the use of health information
technology.
Source: Table 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).
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Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)

Table 7. ACA Discretionary Spending: Health Disparities Data Collection
Statutory
ACA
Authority
Authorization of Appropriations
Section
(Agency)
Summary of Provision
Funding (FY2011-FY2014)
4302(a)
New PHSA Title
Health disparities data collection and analysis. Not later than two
SSAN for each of FY2010 through FY2014; however, data may not be
XXXI; new Sec.
years after enactment, requires federally conducted and supported
collected unless funds are directly appropriated for such purpose.
3101
health programs and surveys, to the extent practicable, to collect and
report data on race, ethnicity, sex, primary language, and disability
status, as well as other demographic data on health disparities as
deemed appropriate by the Secretary. Requires the Secretary to adopt
standards for the measurement and collection of such data. Requires the
Secretary to analyze the data collected on health disparities; provide for
the public reporting and dissemination of the data and analyses; and
safeguard the privacy of the information. [Note: On October 31, 2011,
HHS published final standards for collecting and reporting health
disparities data. See http://minorityhealth.hhs.gov/templates/
browse.aspx?lvl=2&lvlid=208.]
5605 New
authority
Key national indicators. Establishes a Commission on Key National
$10 million for FY2010, and $7.5 million for each of FY2011 through
Indicators composed of eight members appointed by Congress. [Note:
FY2018, with amounts appropriated to remain available until expended.
The Commission members were appointed in Dec. 2010. See
http://www.stateoftheusa.org/content/commission-on-key-national-
ind.php.] Requires the commission to contract with the National
Academy of Sciences to review available public and private sector
research on key national indicator set selection and determine how best
to establish a key national indicator system, among other things.
Mandates a Government Accountability Office (GAO) study of previous
efforts by public, private, or foreign entities to develop best practices for
a key national indicator system. [Note: GAO released its study in March
2011. See http://www.gao.gov/new.items/d11396.pdf.]
Source: Table 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).
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Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)

Table 8. ACA Discretionary Spending: Emergency Care and Trauma Services
Statutory
ACA
Authority
Authorization of Appropriations
Section
(Agency)
Summary of Provision
Funding (FY2011-FY2014)
Emergency Care and Trauma Services: Existing Programs
3505(a) Amends
and Trauma care centers. Requires the Secretary to establish separate
$100 million for FY2009, and SSAN for each of FY2010 through FY2015.
reauthorizes
grant programs for IHS and tribal trauma care centers to (1) help defray
PHSA Secs. 1241-
substantial uncompensated care costs, (2) further the core missions of
1245 (HRSA)
trauma care centers, and (3) provide emergency relief to ensure the
continued availability of trauma services.
5603 Amends
and
Children’s emergency medical services demonstration grants.
$25 million for FY2010, $26.3 million for FY2011, $27.6 million for
reauthorizes
Expands emergency services for children who need treatment for
FY2012, $28.9 million for FY2013, and $30.4 million for FY2014.
PHSA Sec. 1910
trauma or critical care by lengthening the period for demonstration
(HRSA)
grants to four years (with an optional fifth year).
FY2011 funding = $21 million; FY2012 funding = $21 million; FY2013
funding = $20 million; FY2014 request = $21 million. [CFDA 93.127]
Emergency Care and Trauma Services: New Programs
3504(a)
New PHSA Sec.
Regional systems for emergency care. Requires the Assistant
$24 million for each of FY2010 through FY2014.
1204 (OS)
Secretary for Preparedness and Response to award at least four multi-
year contracts or grants (with matching requirement) to states and
Note: This provision reauthorized funding for several existing trauma
Indian tribes for pilot projects to improve regional coordination of
care grant programs in PHSA Title XII Parts A and B (i.e., Secs. 1202,
emergency services. Priority given to entities that serve a medically
1203, and 1211-1222), as well as for the new program (i.e., Sec. 1204).
underserved population.
3504(b)
New PHSA Sec.
Emergency medicine research. Requires the Secretary to expand
SSAN for each of FY2010 through FY2014.
498D (NIH,
and accelerate basic, translational, and service delivery research on
AHRQ, HRSA,
emergency medical care systems and emergency medicine, including
CDC)
pediatric emergency medical care. Also requires the Secretary to
support research on the economic impact of coordinated emergency
care systems.
3505(b)
New PHSA Secs.
Trauma service availability grants. Requires the Secretary to award $100 million for each of FY2010 through FY2015.
1281-1282
grants to states for the purpose of supporting trauma-related physician
specialties and broadening access to and availability of trauma care
services. States must use at least 40% of the funds for grants to safety
net trauma centers.
Sources: Table 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).
Funding amounts are taken from HRSA’s budget documents, including the FY2013 sequestration operating plan, available at http://www.hrsa.gov/about/budget/index.html.
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Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)

Table 9. ACA Discretionary Spending: Elder Justice
Statutory
ACA
Authority
Authorization of Appropriations
Section
(Agency)
Summary of Provision
Funding (FY2011-FY2014)
6703(a)
New SSA Sec.
Elder Justice Coordinating Council. Establishes an Elder Justice
SSAN (no years specified). See also new SSA Sec. 2024 below.
2021 (OS)
Coordinating Council to include the Secretary as chair and the U.S.
Attorney General, as well as the head of each federal department or
agency, identified by the chair, as having administrative responsibility or
administering programs related to elder abuse, neglect, and exploitation.
6703(a)
New SSA Sec.
Advisory Board on Elder Abuse, Neglect, and Exploitation.
SSAN (no years specified). See also new SSA Sec. 2024 below.
2022
Establishes an advisory board to create a short- and long-term
multidisciplinary plan for development of the field of elder justice and to
make recommendations to the Elder Justice Coordinating Council.
6703(a)
New SSA Sec.
Authorization of appropriations. Authorizes funding for new SSA
$6.5 million for FY2011, and $7.0 million for each of FY2012 through
2024
Secs. 2021 (Coordinating Council), 2022 (Advisory Board), and 2023
FY2014.
(human subject protection guidelines for researchers).
6703(a)
New SSA Sec.
Forensic centers and expertise. Requires the Secretary to award
$4 million for FY2011, $6 million for FY2012, and $8 million for each of
2031
grants to eligible entities to establish and operate stationary and mobile
FY2013 and FY2014.
forensic centers and to develop forensic expertise pertaining to elder
abuse, neglect, and exploitation.
6703(a)
New SSA Sec.
Incentives for LTC staffing. Requires the Secretary to award grants
For new SSA Sec. 2041: $20 million for FY2011, $17.5 million for
2041(a)
to LTC facilities for them to offer continuing training and varying levels
FY2012, and $15 million for each of FY2013 and FY2014.
of certification to employees providing direct care to residents, and to
improve management practices so as to promote retention of direct
care workers.
6703(a)
New SSA Sec.
Certified EHR technology grant program. Authorizes grants to
See above authorization of appropriations for SSA Sec. 2041.
2041(b)
LTC facilities for specified activities that would assist such entities in
offsetting costs related to purchasing, leasing, developing, and
implementing certified electronic health record technology.
6703(a)
New SSA Sec.
Standards for transactions involving clinical data by LTC
See above authorization of appropriations for SSA Sec. 2041.
2041(c)
facilities. Requires the Secretary to adopt electronic standards for the
exchange of clinical data by LTC facilities and, within 10 years, to have in
place procedures to accept the optional electronic submission of clinical
data by LTC facilities pursuant to such standards.
6703(a)
New SSA Sec.
Adult protective service functions. Requires the Secretary to
$3 million for FY2011, and $4 million for each of FY2012 through
2042(a)
undertake various activities with respect to adult protective services,
FY2014.
including providing funding, collecting and disseminating data on elder
abuse, disseminating information on best practices and training,
conducting research, and providing technical assistance to states and
other entities.
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Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)

Statutory
ACA
Authority
Authorization of Appropriations
Section
(Agency)
Summary of Provision
Funding (FY2011-FY2014)
6703(a)
New SSA Sec.
Grants to enhance provision of adult protective services.
$100 million for each of FY2011 through FY2014.
2042(b)
Requires the Secretary to award formula grants to states to enhance
adult protective services programs provided by states and local
governments.
6703(a)
New SSA Sec.
Adult protective services demonstration grants. Requires the
$25 million for each of FY2011 through FY2014.
2042(c)
Secretary to fund state demonstration programs for adult protective
services that test methods to prevent and detect elder abuse.
6703(a)
New SSA Sec.
Long-term care ombudsman program grants. Requires the
$5 million for FY2011, $7.5 million for FY2012, and $10 million for each
2043(a)
Secretary to award grants to improve the capacity of state LTC
of FY2013 and FY2014.
ombudsman programs to address abuse and neglect complaints, conduct
pilot programs, and provide support for such programs.
6703(a)
New SSA Sec.
Ombudsman training programs. Requires the Secretary to establish $10 million for each of FY2011 through FY2014.
2043(b)
programs to provide and improve ombudsman training with respect to
elder abuse, neglect, and exploitation for national organizations and state
LTC ombudsman programs.
6703(b) New
authority
National Training Institute for Surveyors. Requires that the
$12 million for the period of FY2011 through FY2014.
Secretary enter into a contract with an entity to establish and operate a
National Training Institute for Federal and State Surveyors to provide
and improve training of surveyors investigating allegations of abuse in
programs and LTC facilities that receive payments under Medicare or
Medicaid.
6703(b) New
authority
Grants to state survey agencies. Requires the Secretary to award
$5 million for each of FY2011 through FY2014.
grants to state survey agencies that perform surveys of Medicare or
Medicaid participating nursing facilities to design and implement
complaint investigation systems.
6703(c) New
authority
National nurse aide registry study and report. Requires the
SSAN (no years specified) to carry out these activities, with funding not
Secretary, in consultation with appropriate government agencies and
to exceed $500,000.
private sector organizations, to conduct a study on establishing a
national nurse aide registry and report on its findings.
Source: Table 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).
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Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)

Table 10. ACA Discretionary Spending: Biomedical Research
Statutory
ACA
Authority
Authorization of Appropriations
Section
(Agency)
Summary of Provision
Funding (FY2011-FY2014)
10409 Amends
PHSA
Cures Acceleration Network (CAN). Establishes a CAN program
$500 million for FY2010, and SSAN for subsequent fiscal years. Other
Secs. 402(b) and
within the Office of the NIH Directora to award grants, contracts, or
funds appropriated under the PHSA may not be allocated to CAN.
499(c); new
cooperative agreements to support the development of treatments for
PHSA Sec. 402Ca
diseases or conditions that are rare, and for which market incentives are FY2012 funding = $10 million; FY2013 funding = $9 million; FY2014
(NIH)
inadequate. Eligible grantees include public or private entities, which may request = $50 million.
include private or public research institutions, institutions of higher
education, medical centers, biotechnology companies, pharmaceutical
companies, disease advocacy organizations, patient advocacy
organizations, and academic research institutions.
Sources: Table 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).
Funding amounts are taken from NIH’s budget documents, including the FY2013 sequestration operating plan, available at http://officeofbudget.od.nih.gov/br.html.
a. P.L. 112-74 created the National Center for Advancing Translational Sciences (NCATS) within NIH and transferred the CAN program from the Office of the NIH
Director to the new Center. It also redesignated PHSA Sec. 402C as Sec. 480.

Table 11. ACA Discretionary Spending: Biologics
Statutory
ACA
Authority
Authorization of Appropriations
Section
(Agency)
Summary of Provision
Funding (FY2011-FY2014)
7002 Amends
PHSA
FDA approval of follow-on biologics. Creates an abbreviated
SSAN for each of FY2010 through FY2012.
Sec. 351 (FDA)
regulatory pathway for approving biological products that are
demonstrated to be biosimilar to, or interchangeable with, an FDA-
licensed biological product. Provides for the collection of user fees,
subject to congressional authorization, to cover regulatory costs
beginning in FY2013. [Note: On February 9, 2012, FDA released three
guidance documents to assist industry in developing biosimilar products
and submitting them to the agency for approval. See http://www.fda.gov/
Drugs/DevelopmentApprovalProcess/
HowDrugsareDevelopedandApproved/ApprovalApplications/
TherapeuticBiologicApplications/Biosimilars/default.htm.]
Source: Table 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).
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Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)

Table 12. ACA Discretionary Spending: 340B Drug Pricing
Statutory
ACA
Authority
Authorization of Appropriations
Section
(Agency)
Summary of Provision
Funding (FY2011-FY2014)
7102 Amends
PHSA
Improvements to 340B program integrity. Requires the Secretary
SSAN for FY2010 and each succeeding fiscal year.
Sec. 340B(d)
to develop systems to improve compliance and program integrity to (1)
(HRSA)
increase transparency and strengthen monitoring, oversight, and
FY2011 funding = $4 million; FY2012 funding = $4 million; FY2013
investigation of the prices that manufacturers charge covered entities;
funding = $4 million; FY2014 request = $6 million (proposed new
and (2) ensure covered entities do not divert drugs or obtain multiple
user fee program).
discounts. Further requires the Secretary to establish a new
administrative dispute resolution process to mediate and resolve
covered entity overpayment claims and manufacturer claims against
covered entities for drug diversion or multiple discounts.
Sources: Table 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).
Funding amounts are taken from HRSA’s budget documents, including the FY2013 sequestration operating plan, available at http://www.hrsa.gov/about/budget/index.html.

Table 13. ACA Discretionary Spending: Medical Malpractice
Statutory
ACA
Authority
Authorization of Appropriations
Section
(Agent)
Summary of Provision
Funding (FY2011-FY2014)
10607
New PHSA Sec.
Liability reform demonstration program. Authorizes five-year
$50 million for the period FY2011 through FY2015.
399V-4 (HRSA)
demonstration grants to states for the implementation and evaluation of
alternatives to current tort litigation for resolving disputes over injuries
allegedly caused by health care providers or organizations. Planning
grants of up to $500,000 may be awarded to states for the development
of demonstration project applications. To receive a grant, a state must
develop an alternative system that allows for the resolution of disputes
caused by health care providers or organizations, and reduces medical
errors by encouraging the collection and analysis of patient safety data
related to the resolved disputes.
Source: Table 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).
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Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)

Table 14. ACA Discretionary Spending: Pain Care Management
Statutory
ACA
Authority
Authorization of Appropriations
Section
(Agency)
Summary of Provision
Funding (FY2011-FY2014)
4305(a) New
authority
Conference on pain. Requires the Secretary, within one year of
SSAN for each of FY2010 and FY2011.
appropriating funds, to contract with the IOM to convene a Conference
on Pain for the purpose of assessing the public health impact of pain,
reviewing pain research, care, and education, and identifying barriers to
improved pain care. A report summarizing the Conference’s findings
must be submitted to Congress by June 30, 2011. [Note: IOM released
its report on June 29, 2011. See http://painconsortium.nih.gov/.]
Source: Table 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).

Table 15. ACA Discretionary Spending: Medicaid
Statutory
ACA
Authority
Authorization of Appropriations
Section
(Agency)
Summary of Provision
Funding (FY2011-FY2014)
2705 New
authority
Global payment system demonstration program. Requires the
SSAN (no years specified).
(CMS)
Secretary, in coordination with the Center for Medicare and Medicaid
Innovation, to fund up to five Medicaid demonstrations during the
period FY2010 through FY2012 under which a participating state will
adjust payments made to a large safety net hospital system or network
from a fee-for-service model to a global capitated payment model.
2706 New
authority
Pediatric accountable care organization demonstration
SSAN (no years specified).
(CMS)
program. Requires the Secretary to conduct a five-year Medicaid
demonstration (Jan. 1, 2012 through Dec. 31, 2016) under which a
participating state is allowed to recognize pediatric providers as an
accountable care organization (ACO) for the purpose of receiving
incentive payments. Eligible pediatric providers must meet certain
performance guidelines established by the Secretary to be recognized as
an ACO, and must achieve a specified minimum level of Medicaid savings
to receive an incentive payment.
Source: Table 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).
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Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)

Table 16. ACA Discretionary Spending: Medicare
Statutory
ACA
Authority
Authorization of Appropriations
Section
(Agency)
Summary of Provision
Funding (FY2011-FY2014)
3129 Amends
and
Rural hospital flexibility grant program. Extends authorization of
SSAN for each of FY2011 and FY2012, to remain available until
reauthorizes SSA
appropriations for the rural hospital flexibility (Flex) grants that support
expended.
Sec. 1820 (HRSA) a range of performance and quality improvement activities at small rural
hospitals. Permits the funding to be used to help rural hospitals
FY2011 funding = $41 million; FY2012 funding = $41 million; FY2013
participate in delivery system reform programs authorized under ACA.
funding = $38 million; FY2014 request = $26 million. [CFDA 93.241]
Sources: Table 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).
Funding amounts are taken from HRSA’s budget documents, including the FY2013 sequestration operating plan, available at http://www.hrsa.gov/about/budget/index.html.

Table 17. ACA Discretionary Spending: Private Health Insurance
Statutory
ACA
Authority
Authorization of Appropriations
Section
(Agency)
Summary of Provision
Funding (FY2011-FY2014)
1334 New
authority
Multi-state health plans. Requires OPM to contract with health
SSAN (no years specified).
(OPM)
insurers to offer at least two multi-state health plans (at least one
nonprofit) through exchanges in each state. Authorizes OPM to prohibit

multi-state plans that do not meet standards for medical loss ratios,
profit margins, and premiums. Requires multi-state plans to cover
essential health benefits and meet all the requirements of a qualified
health plan. Note: On March 11, 2013, OPM published a final rule to
implement the multi-state plan program (78 Federal Register 15560).
Source: Table 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).


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Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)

Author Contact Information

C. Stephen Redhead
Amanda K. Sarata
Specialist in Health Policy
Specialist in Health Policy
credhead@crs.loc.gov, 7-2261
asarata@crs.loc.gov, 7-7641
Sarah A. Lister
Elayne J. Heisler
Specialist in Public Health and Epidemiology
Analyst in Health Services
slister@crs.loc.gov, 7-7320
eheisler@crs.loc.gov, 7-4453
Kirsten J. Colello

Specialist in Health and Aging Policy
kcolello@crs.loc.gov, 7-7839

Acknowledgments
Pamela W. Smith provided extensive editorial comments during the development of the initial version of
this report.
Key Policy Staff
Area of Expertise
Name
Phone
E-mail
Health Centers and Clinics
Elayne J. Heisler
7-4453
eheisler@crs.loc.gov
C. Stephen Redhead
7-2261
credhead@crs.loc.gov
Health Care Workforce
Elayne J. Heisler
7-4453
eheisler@crs.loc.gov
Bernice Reyes-Akinbileje
7-2260
breyes@crs.loc.gov
Long-Term Care
Kirsten J. Colello
7-7839
kcolello@crs.loc.gov
Prevention and Wellness
Sarah A. Lister
7-7320
slister@crs.loc.gov
Maternal and Child Health
Emilie Stoltzfus
7-2324
estoltzfus@crs.loc.gov
Amalia Corby-Edwards
7-0423
acorbyedwards@crs.loc.gov
Health Care Quality
Amanda K. Sarata
7-7641
asarata@crs.loc.gov
Nursing Homes
Cliff Binder
7-7965
cbinder@crs.loc.gov
Health Disparities
Amalia Corby-Edwards
7-0423
acorbyedwards@crs.loc.gov
Emergency Care
Elayne J. Heisler
7-4453
eheisler@crs.loc.gov
Elder Justice
Kirsten J. Colello
7-7839
kcolello@crs.loc.gov
Biomedical Research
Pamela W. Smith
7-7048
psmith@crs.loc.gov
Biologics
Judith A. Johnson
7-7077
jajohnson@crs.loc.gov
340B Drug Pricing
Cliff Binder
7-7965
cbinder@crs.loc.gov
Medical Malpractice
Vivian S. Chu
7-4576
vchu@crs.loc.gov
Pain Care Management
Kirsten J. Colello
7-7839
kcolello@crs.loc.gov
Medicaid Cliff
Binder
7-7965
cbinder@crs.loc.gov
Medicare Sibyl
Tilson
7-7368
stilson@crs.loc.gov
Private Health Insurance
Bernadette Fernandez
7-0322
bfernandez@crs.loc.gov


Congressional Research Service
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