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Public Health Service Agencies:
Overview and Funding
C. Stephen Redhead, Coordinator
Specialist in Health Policy
Erin Bagalman
Analyst in Health Policy
Elayne J. Heisler
Analyst in Health Services
Judith A. Johnson
Specialist in Biomedical Policy
Sarah A. Lister
Specialist in Public Health and Epidemiology
Amanda K. Sarata
Specialist in Health Policy
Susan Thaul
Specialist in Drug Safety and Effectiveness
October 8, 2014
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Summary
Within the Department of Health and Human Services (HHS), eight agencies are designated
components of the U.S. Public Health Service (PHS). The PHS agencies are funded primarily
with annual discretionary appropriations. They also receive significant amounts of funding from
other sources including mandatory funds from the Affordable Care Act (ACA), user fees, and
third-party reimbursements (collections).
• The Agency for Healthcare Research and Quality (AHRQ) funds research on
improving the quality and delivery of health care. AHRQ does not receive a
direct appropriation. It relies on redistributed (“set-aside”) funds from other PHS
agencies for most of its funding, with supplemental amounts from the ACA’s
Patient-Centered Outcomes Research Trust Fund (PCORTF). AHRQ’s total
funding rose from $403 million to $464 million between FY2010 and FY2014
despite a decrease in set-aside funding over that period. The drop in set-aside
funds was more than offset by increasing amounts of PCORTF funding.
• The Centers for Disease Control and Prevention (CDC) is the federal
government’s lead public health agency. CDC obtains its funding from multiple
sources besides discretionary appropriations. The agency’s funding fluctuated
between FY2010 and FY2014 but the overall level was sustained at about $10.8
billion. CDC experienced a drop in its discretionary appropriations during that
time, which was offset by funding from other sources, primarily the ACA’s
Prevention and Public Health Fund (PPHF). The Agency for Toxic Substances
and Disease Registry (ATSDR) investigates the public health impact of
exposure to hazardous substances. ATSDR is headed by the CDC director and
included in the discussion of CDC in this report.
• The Food and Drug Administration (FDA) regulates drugs, medical devices,
food, and tobacco products, among other consumer products. FDA saw its
funding increase significantly between FY2010 and FY2014 from $3.1 billion to
$4.4 billion. The agency is funded with annual discretionary appropriations and
industry user fees. While appropriations increased modestly over the FY2010-
FY2014 period, user fees more than doubled and now account for 42% of FDA’s
total funding.
• The Health Resources and Services Administration (HRSA) funds programs
and systems that provide health care services to the uninsured and medically
underserved. HRSA, like CDC, relies on funding from several different sources.
The agency’s funding increased from $8.1 billion in FY2010 to $8.9 billion in
FY2014 despite a significant drop in its discretionary appropriation during that
time. The growth in overall funding was driven largely by increasing amounts
from the ACA’s Community Health Center Fund (CHCF).
• The Indian Health Service (IHS) supports a health care delivery system for
Native Americans. IHS’s funding, which includes discretionary appropriations
and collections from third-party payers of health care, increased significantly
between FY2010 and FY2014 from $5.1 billion to $5.8 billion. Appropriations
and collections both increased during that period.
• The National Institute of Health (NIH) funds basic, clinical, and translational
biomedical and behavioral research. NIH gets more than 99% of its funding from
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discretionary appropriations. Its funding dropped from $31.2 billion in FY2010
to $30.2 billion in FY2014.
• The Substance Abuse and Mental Health Services Administration
(SAMHSA) funds mental health and substance abuse prevention and treatment
services. SAMHSA’s funding, about 95% of which comes from discretionary
appropriations, has remained at about $3.6 billion over the FY2010-FY2014
period.
Congress has yet to complete work on any of the regular appropriations bills for FY2015, which
began on October 1, 2014. On September 19, 2014, the President signed the Continuing
Appropriations Resolution, 2015 (P.L. 113-164; H.J.Res. 124), which provides continuing
appropriations through December 11, 2014. Generally, P.L. 113-164 funds discretionary
programs at the same rate (and under the same conditions) as in FY2014, minus an across-the-
board reduction of 0.0554%. This report will be updated with information on PHS agency funding
for FY2015 once legislative action on appropriations for the new fiscal year is completed.
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Contents
Introduction to the Public Health Service Agencies ........................................................................ 1
Sources of PHS Agency Funding ..................................................................................................... 2
Transfers .................................................................................................................................... 2
PHS Program Evaluation Set-Aside .......................................................................................... 3
Mandatory Funding, User Fees, and Collections ...................................................................... 4
Mandatory Appropriations .................................................................................................. 4
User Fees ............................................................................................................................. 5
Collections ........................................................................................................................... 5
Recent Trends in PHS Agency Funding .......................................................................................... 6
Impact of Budget Caps and Sequestration ................................................................................. 6
Mandatory Spending ........................................................................................................... 7
Discretionary Spending ....................................................................................................... 7
Report Roadmap .............................................................................................................................. 8
Agency for Healthcare Research and Quality (AHRQ) ................................................................... 9
Agency Overview ...................................................................................................................... 9
FY2010-FY2014 Funding ....................................................................................................... 10
FY2015 Budget Request .......................................................................................................... 11
Centers for Disease Control and Prevention (CDC) ...................................................................... 12
Agency Overview .................................................................................................................... 12
FY2010-FY2014 Funding ....................................................................................................... 13
FY2015 President’s Budget Request ....................................................................................... 13
Food and Drug Administration (FDA) ........................................................................................... 16
Agency Overview .................................................................................................................... 16
FY2010-FY2014 Funding ....................................................................................................... 17
FY2015 President’s Budget Request ....................................................................................... 18
Health Resources and Services Administration (HRSA) ............................................................... 20
Agency Overview .................................................................................................................... 20
FY2010-FY2014 Funding ....................................................................................................... 21
FY2015 President’s Budget Request ....................................................................................... 23
Indian Health Service (IHS) .......................................................................................................... 26
Agency Overview .................................................................................................................... 26
FY2010-FY2014 Funding ....................................................................................................... 27
FY2015 President’s Budget Request ....................................................................................... 29
National Institutes of Health (NIH) ............................................................................................... 30
Agency Overview .................................................................................................................... 30
FY2010-FY2014 Funding ....................................................................................................... 31
FY2015 President’s Budget Request ....................................................................................... 32
Substance Abuse and Mental Health Services Administration (SAMHSA) .................................. 34
Agency Overview .................................................................................................................... 34
FY2010-FY2014 Funding ....................................................................................................... 35
FY2015 President’s Budget Request ....................................................................................... 36
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Figures
Figure C-1. Funding for CDC Chronic Disease Prevention and Health Promotion,
FY2008-FY2015 ......................................................................................................................... 43
Tables
Table 1. Impact of BCA Annual Spending Reductions on PHS Agency Funding ........................... 7
Table 2. Agency for Healthcare Research and Quality (AHRQ) ................................................... 11
Table 3. Centers for Disease Control and Prevention (CDC) and Agency for Toxic
Substances and Disease Registry (ATSDR)................................................................................ 14
Table 4. Food and Drug Administration (FDA) ............................................................................. 19
Table 5. Health Resources and Services Administration (HRSA) ................................................. 24
Table 6. Indian Health Service (IHS) ............................................................................................. 29
Table 7. National Institutes of Health (NIH) ................................................................................. 33
Table 8. Substance Abuse and Mental Health Services Administration (SAMHSA) .................... 36
Table B-1. Community Health Center Fund, FY2011-FY2015 ..................................................... 39
Table C-1. PPHF Transfers to HHS Agencies ............................................................................... 41
Table D-1. Distribution of PCORTF Funding ................................................................................ 44
Table E-1. FDA User Fee Authorizations and Revenue................................................................. 45
Appendixes
Appendix A. American Recovery and Reinvestment Act (ARRA): FY2009 Supplemental
Appropriations ............................................................................................................................ 38
Appendix B. Community Health Center Fund .............................................................................. 39
Appendix C. Prevention and Public Health Fund (PPHF) ............................................................. 40
Appendix D. Patient-Centered Outcomes Research Trust Fund .................................................... 44
Appendix E. FDA User Fee Authorizations ................................................................................... 45
Contacts
Author Contact Information........................................................................................................... 46
Acknowledgments ......................................................................................................................... 46
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Introduction to the Public Health Service Agencies
The Department of Health and Human Services (HHS) has designated eight of its 11 operating
divisions (agencies) as components of the U.S. Public Health Service (PHS). The PHS agencies
are: (1) the Agency for Healthcare Research and Quality (AHRQ), (2) the Agency for Toxic
Substances and Disease Registry (ATSDR), (3) the Centers for Disease Control and Prevention
(CDC), (4) the Food and Drug Administration (FDA), (5) the Health Resources and Services
Administration (HRSA), (6) the Indian Health Service (IHS), (7) the National Institutes of Health
(NIH), and (8) the Substance Abuse and Mental Health Services Administration (SAMHSA).1
Collectively, the PHS agencies provide and support essential public health services. Individually,
the missions of the PHS agencies vary. With the exception of FDA, the agencies have limited
regulatory responsibilities. Two of them—NIH and AHRQ—are primarily research agencies. NIH
conducts and supports basic, clinical, and translational medical research. AHRQ conducts and
supports research on the quality and effectiveness of health care services and systems.
Three of the agencies—IHS, HRSA, and SAMHSA—provide health care services or help support
systems that deliver such services. IHS supports a health care delivery system for American
Indians and Alaska Natives. Health services are provided directly by the IHS, as well as through
tribally contracted and operated health programs, and through services purchased from private
providers. HRSA funds programs and systems to improve access to health care among low-
income populations, pregnant women and children, persons living with HIV/AIDS, rural and
frontier populations, and others who are medically underserved. SAMHSA funds community-
based mental health and substance abuse prevention and treatment services.
CDC is a public health agency that develops and supports community-based and population-wide
programs and systems to promote quality of life and prevent the leading causes of disease, injury,
disability, and death. ATSDR, which is headed by the CDC director and included in the discussion
of CDC in this report, is tasked with identifying potential public health effects from exposure to
hazardous substances. Finally, FDA is primarily a regulatory agency, whose mission is to ensure
the safety of foods, dietary supplements, and cosmetics, and the safety and effectiveness of drugs,
vaccines, medical devices, and other health products. In 2009, Congress gave FDA the authority
to regulate the manufacture, marketing, and distribution of tobacco products in order to protect
public health.
The programs and activities of five of the PHS agencies—AHRQ, CDC, HRSA, NIH, and
SAMHSA—are mostly authorized under the Public Health Service Act (PHSA).2 While some of
FDA’s regulatory activities are also authorized under the PHSA, the agency and its programs
1 HHS also includes three human services agencies that are not part of the Public Health Service: (1) the Administration
for Children and Families (ACF); (2) the Administration for Community Living (ACL), which was created in April
2012 by consolidating the Administration on Aging (AoA), the HHS Office on Disability, and ACF’s Administration
on Developmental Disability; and (3) the Centers for Medicare & Medicaid Services (CMS). Departmental leadership
is provided by the Office of the Secretary (OS), which is comprised of various subdivisions including the Assistant
Secretary for Preparedness and Response (ASPR), the Assistant Secretary for Health (ASH), the Office of the Surgeon
General, the Office for Civil Rights (OCR), the Office of the Inspector General (OIG), and the Office of the National
Coordinator for Health Information Technology (ONC). For more information on HHS and links to the PHS agency
websites, see http://www.hhs.gov/.
2 42 U.S.C. §§201 et seq.
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largely derive their statutory authority from the Federal Food, Drug, and Cosmetic Act
(FFDCA).3 HRSA’s maternal and child health programs are authorized by the Social Security Act
(SSA),4 and many of the IHS programs and services are authorized by the Indian Health Care
Improvement Act.5 ATSDR was created by the Comprehensive Environmental Response,
Compensation and Liability Act (CERCLA, the “Superfund” law).6
Sources of PHS Agency Funding
The primary source of funding for each PHS agency is the discretionary budget authority it
receives through the annual appropriations process.7 AHRQ, CDC, HRSA, NIH, and SAMHSA
are funded through the Departments of Labor, Health and Human Services, Education, and
Related Agencies (Labor-HHS-ED) appropriations act. Funding for ATSDR and IHS is provided
through the Department of the Interior, Environment, and Related Agencies
(Interior/Environment) appropriations act. FDA gets its funding through the Agriculture, Rural
Development, Food and Drug Administration, and Related Agencies (Agriculture) appropriations
act.8
The economic stimulus package enacted in February 2009—the American Reinvestment and
Recovery Act (ARRA)—provided a total of $15.1 billion in supplemental FY2009 discretionary
appropriations to five of the PHS agencies.9 Details of the allocation of those funds are provided
in Appendix A. Almost all of the ARRA appropriations were designated as two-year funds,
available for obligation through the end of FY2010.
Transfers
The annual Labor-HHS-ED appropriations act gives the HHS Secretary limited authority to
transfer funds from one budget account to another within the department. The Secretary may
3 21 U.S.C. §§301 et seq.
4 SSA Title V, 42 U.S.C. §§701 et seq.
5 25 U.S.C. §§1601 et seq.
6 42 U.S.C. §9604(i).
7 Budget authority is the authority provided in federal law to incur financial obligations that will result in expenditures,
or outlays, of federal funds. Such obligations include contracts for the purchase of supplies and services, liabilities for
salaries and wages, and grant awards. Appropriations are the most common form of budget authority. Discretionary
budget authority represents funding that is provided in and controlled by the annual appropriations acts.
8 For an overview of each of these three appropriations acts, see CRS Report CRS Report R43236, Labor, Health and
Human Services, and Education (L-HHS-ED): FY2014 Appropriations, coordinated by Karen E. Lynch; CRS Report
R43142, Interior, Environment, and Related Agencies: FY2013 and FY2014 Appropriations, by Carol Hardy Vincent;
and CRS Report R43110, Agriculture and Related Agencies: FY2014 and FY2013 (Post-Sequestration)
Appropriations, coordinated by Jim Monke.
9 P.L. 111-5, 123 Stat. 115. The PHS agency appropriations were included in Title VII (Interior/Environment) and Title
VIII (Labor-HHS-ED) of Division A of ARRA. In addition to these discretionary appropriations, ARRA included
several HHS mandatory spending provisions. For example, ARRA temporarily increased federal payments to states
under the Medicaid and the Temporary Assistance for Needy Families (TANF) programs. ARRA also incorporated the
Health Information Technology for Economic and Clinical Health (HITECH) Act, which established multibillion dollar
incentive programs under Medicare and Medicaid to encourage hospitals and physicians to adopt and use interoperable
electronic health record technology. For more information, see CRS Report R40537, American Recovery and
Reinvestment Act of 2009 (P.L. 111-5): Summary and Legislative History, by Clinton T. Brass et al.
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transfer up to 1% of the funds in any given account. However, a recipient account may not be
increased by more than 3%. Congressional appropriators must be notified in advance of any
transfer.10
The HHS Secretary used this transfer authority in FY2013 and again in FY2014 as part of a
broader effort to provide the Centers for Medicare & Medicaid Services (CMS) with additional
funding to implement the Affordable Care Act (ACA). In FY2013, for example, NIH was the
primary source of transfers both to CMS for ACA implementation and to CDC and SAMHSA to
help offset a loss of funding to those two agencies from the ACA’s Prevention and Public Health
Fund (PPHF). A significant portion of the FY2013 PPHF funds that were originally allocated to
CDC and SAMHSA were reallocated to CMS for ACA implementation (discussed in more detail
later in this report). In FY2014, NIH once again accounted for the lion’s share of transfers to
CMS to support ACA implementation.11
PHS Program Evaluation Set-Aside
In addition to the transfer authority provided in the annual Labor-HHS-ED appropriations act,
Section 241 of the PHSA authorizes the HHS Secretary, with the approval of congressional
appropriators, to use a portion of the funds appropriated for PHSA programs to evaluate their
implementation and effectiveness. Under this budget mechanism, which is known as the PHS
Program Evaluation Set-Aside (“set-aside”), the appropriations of a number of HHS agencies and
offices are subject to a budget “tap.” The tapped funds are redistributed within the department for
evaluation and other specified purposes. Although the PHSA limits the set-aside to no more than
1% of program appropriations, in recent years the annual Labor-HHS-ED appropriations act has
specified a higher amount. The FY2014 Labor-HHS-ED appropriations act capped the set-aside at
2.5%.12 For FY2015, the President’s budget proposed increasing the maximum amount of set-
aside funds to 3.0%.
Following passage of the annual Labor-HHS-ED appropriations act, the HHS Budget Office
calculates the amount of set-aside funds to be tapped from the various donor agencies and offices.
It then allocates those funds to recipient agencies and programs, including offices within the
Office of the Secretary, based on the amounts specified in the appropriations act.13
NIH, whose annual discretionary appropriation exceeds that of all the other PHS agencies
combined, is by far the largest donor of set-aside funds. NIH contributed $710 million (69%) of
the $1.026 billion in tapped funds in FY2013. However, the agency got back only $8 million,
10 The HHS Secretary’s FY2014 transfer authority is provided in Section 206 of the FY2014 Labor-HHS-ED
appropriations act (P.L. 113-76, Division H).
11 For more discussion of ACA implementation funding, see CRS Report R43066, Federal Funding for Health
Insurance Exchanges, by Annie L. Mach and C. Stephen Redhead.
12 P.L. 113-76, Division H, Section 205, 128 Stat. 382.
13 See Chapter I of HHS, Office of the Assistant Secretary for Planning and Evaluation, “Evaluation: Performance
Improvement 2009,” Washington, DC, 2010, pp. 6-8, http://aspe.hhs.gov/pic/perfimp/2009/report.pdf. Most of the
funds appropriated for CDC, HRSA, NIH, and SAMHSA are subject to the set-aside. The annual Labor-HHS-ED
appropriations act excludes some funding from the set-aside; still other funding is excluded by convention. For
example, funds appropriated for HHS block grants targeting prevention, substance abuse, and mental health as well as
funds for program management activities and for buildings and facilities are typically excluded from the set-aside.
Funds appropriated for programs not authorized by the PHSA, such as HRSA’s maternal and child health block grant,
are also excluded.
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making it a significant net donor of set-aside funds. Similarly, HRSA contributed more set-aside
funds than it received in FY2013. On the other hand both CDC and SAMHA were net recipients
of set-aside funding.14 AHRQ is also a recipient of this funding. Importantly, AHRQ has not
received an annual discretionary appropriation in recent years. The agency has been entirely
supported by set-aside funds and smaller amounts from other sources (see Table 2).
Mandatory Funding, User Fees, and Collections
Although the bulk of PHS agency funding is provided through annual discretionary
appropriations, agencies also receive mandatory funding, user fees, and third-party collections.15
As discussed briefly below, and in more detail in the relevant sections later in this report, these
additional sources of funding are a substantial component of the budget of several PHS agencies.
Mandatory Appropriations
The Patient Protection and Affordable Care Act (ACA)16 included numerous appropriations that
together are providing billions of dollars in mandatory spending to support new and existing grant
programs and other activities.17 Some of the ACA appropriations fund specific programs and
activities within the PHS agencies. These appropriations are itemized in the funding tables in this
report.
The ACA also established three multibillion dollar trust funds to help support PHS agency
programs and activities. First, the Community Health Center Fund (CHCF), for which the
ACA provided a total of $11.000 billion in annual appropriations over the five-year period
FY2011-FY2015, is supporting the federal health center program and the National Health Service
Corps (NHSC), both administered by HRSA.18 The contribution of CHCF funds to HRSA’s
budget is discussed in more detail in the HRSA section of this report. A table summarizing each
fiscal year’s CHCF appropriation and the allocation of funds appears in Appendix B.
Second, the Prevention and Public Health Fund (PPHF), for which the ACA provided a
permanent annual appropriation, is intended to support prevention, wellness, and other public
health programs and activities.19 To date, CDC has received the majority of PPHF funds, while
AHRQ, HRSA, and SAMHSA have received smaller amounts. The HHS Secretary transferred
almost half of the FY2013 PPHF funds to CMS to support ACA implementation. The
14 See HHS, “Use of Public Health Service Set-Aside Authority for Fiscal Year 2013, Report to Congress.” This report
includes a table that lists the amount of set-aside funds donated and received by each agency and office in FY2013.
15 Mandatory spending, also known as direct spending, refers to outlays from budget authority that is provided in laws
other than annual appropriations acts. Mandatory spending includes spending on entitlement programs.
16 ACA was signed into law on March 23, 2010 (P.L. 111-148, 124 Stat. 119). 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. A number of other subsequently enacted laws have made more targeted
changes to specific ACA provisions. All references to ACA in this report refer to the law as amended.
17 For a complete list and discussion of all the appropriations in the ACA, including details of the obligation of these
funds, see CRS Report R41301, Appropriations and Fund Transfers in the Affordable Care Act (ACA), by C. Stephen
Redhead.
18 ACA Section 10503(a)-(b).
19 ACA Section 4002.
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contribution of PPHF funds to CDC’s budget is discussed in more detail in the CDC section of
this report. A broader analysis of the allocation of PPHF funding is provided in Appendix C.
The Patient-Centered Outcomes Research Trust Fund (PCORTF) is supporting comparative
effectiveness research over a 10-year period (FY2010-FY2019) with a mix of appropriations—
some of which are offset by revenue from a fee imposed on health insurance policies and self-
insured health plans—and transfers from the Medicare Part A and Part B trust funds.20 A portion
of the PCORTF is allocated for AHRQ. More information on the PCORTF, including the
appropriation and transfer formulas, is provided in Appendix D.
In addition to the ACA funding, HRSA, CDC, and IHS each receive mandatory funds from other
sources. HRSA’s Family-to-Family Health Information Centers Program has been funded by a
series of mandatory appropriations since FY2007; CDC receives Medicaid funding to support the
Vaccines for Children program; and both IHS and NIH receive mandatory funds for diabetes
programs. These and other mandatory appropriations are itemized in the agency funding tables in
this report.
User Fees
Several PHS agencies assess user fees on third parties to help fund their programs and activities.
User fees collected by CDC, HRSA, and SAMHSA represent a very small portion of each
agency’s overall budget.21 In comparison, the industry user fees that FDA collects help finance a
broad range of the agency’s regulatory activities and account for a substantial and growing share
of the agency’s budget.
It has been more than 20 years since the Prescription Drug User Fee Act (PDUFA)22 established
the first user fee program at FDA. Since PDUFA’s enactment, Congress has created several other
FDA user fee programs. These programs provide FDA with additional resources that allow it to
hire more personnel and expedite the process of reviewing and approving new product
applications. User fees also support information technology infrastructure. FDA’s user fee
programs now support the agency’s regulation of prescription drugs, animal drugs, medical
devices, tobacco products, and foods, among other activities. The amount of user fees that FDA
collects under these programs has increased steadily since PDUFA was enacted, both in absolute
terms and as a share of FDA’s overall budget. In FY2014, user fees accounted for 42% of the
FDA overall budget. More discussion of user fees is provided in the FDA section of this report
and in Appendix E.
Collections
IHS supplements its annual discretionary appropriation with third-party collections from public
and private payers. Most of these funds come from Medicare and Medicaid, which reimburse IHS
for services provided to American Indians and Alaska Natives enrolled in these programs at
facilities operated by IHS and the tribes. IHS also collects reimbursements from private health
insurers. IHS collections (and reimbursements) are reflected in Table 6 of this report.
20 ACA Section 6301(d)-(e).
21 These user fees are listed in the agency-specific tables in this report.
22 P.L. 102-571, 106 Stat. 4491.
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Recent Trends in PHS Agency Funding
Congress has taken a number of recent steps through both the annual appropriations process and
the enactment of deficit-reduction legislation to reduce the growth in federal spending. These
actions, which are briefly discussed below, have helped reduce discretionary funding for several
PHS agencies over the past five years (i.e., FY2010-FY2014). Among the five PHS agencies that
are funded through the Labor-HHS-ED appropriations act, only SAMHSA received funding in
FY2014 that was essentially level with the amount it received in FY2010. CDC, HRSA, and NIH
each received a smaller discretionary appropriation in FY2014 than they had received in FY2010.
Similarly, AHRQ’s set-aside funding in FY2014 was less than the amount provided to the agency
in FY2010. With the exception of NIH, however, the decline in discretionary funding for the
other three agencies (i.e., AHRQ, CDC, and HRSA) has been offset by the receipt of mandatory
ACA funds.
FDA and IHS, neither of which receives discretionary funding through the Labor-HHS-ED
appropriation act, have both seen their appropriations increase over the five-year period FY2010-
FY2014. Both agencies have also witnessed a steady increase in funding from other sources; user
fees at FDA, and third-party collections at IHS. ATSDR’s funding, which is included in the
discussion of CDC, has been essentially flat since FY2010. All these funding trends are examined
in more detail in the upcoming sections of this report.
Impact of Budget Caps and Sequestration
In April 2011, lawmakers agreed to cuts in discretionary spending for a broad range of agencies
and programs as part of negotiations to complete the FY2011 appropriations process and avert a
government shutdown. Congress and the President then enacted the Budget Control Act of 2011
(BCA),23 which amended the Balance Budget and Emergency Deficit Control Act of 1985
(BBEDCA).24 The BCA established enforceable discretionary spending limits, or caps, for
defense and nondefense spending for each of FY2012 through FY2021 and triggered annual
spending reductions, equally divided between defense and nondefense spending, beginning in
FY2013. Within each spending category the cuts are divided proportionately between
discretionary spending and nonexempt mandatory spending. All the spending summarized in this
report falls within the nondefense category.
Under the BCA, the spending reductions are achieved through a combination of sequestration
(i.e., an across-the-board cancellation of budgetary resources) and lowering the BCA-imposed
discretionary spending caps. The Office of Management and Budget (OMB) is responsible for
calculating the percentages and amounts by which mandatory and discretionary spending are
required to be reduced each year, and for applying the BBEDCA’s sequestration exemptions and
special rules.
23 P.L. 112-25, 125 Stat. 240. A detailed analysis of the BCA, and the amendments made to it by the American
Taxpayer Relief Act of 2012 and the Bipartisan Budget Act of 2013, is beyond the scope of this report. For more
information, see CRS Report R41965, The Budget Control Act of 2011, by Bill Heniff Jr., Elizabeth Rybicki, and
Shannon M. Mahan, and 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.
24 P.L. 99-177, Title II, 99 Stat. 1038.
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Mandatory Spending
The BCA requires the mandatory spending reductions to be executed each year by a sequestration
of all nonexempt accounts. Generally, the ACA and other mandatory funding discussed in this
report is fully sequestrable at the applicable percentage rate for nonexempt nondefense mandatory
spending (see Table 1), with two key exceptions. First, the funds for the CDC-administered
Vaccines for Children program come from Medicaid, which is exempt from sequestration.
Second, for legal reasons beyond the scope of this report, OMB made the determination that the
cuts in ACA (i.e., CHCF) funding for community health centers and migrant health centers and
the cuts in mandatory diabetes funding for IHS are capped at 2% (see Table 1).
Discretionary Spending
Under the BCA, only FY2013 discretionary spending was subject to sequestration. In general,
PHS agency discretionary appropriations for that year were fully sequestrable at the applicable
percentage rate for nonexempt nondefense discretionary (NDD) spending (see Table 1). As a
result, each agency saw a dip in its discretionary funding for FY2013. OMB also determined that
FDA user fees for FY2013 were fully sequestrable at the NDD percentage rate. But it concluded
that IHS’s third-party collections in FY2013 were exempt from sequestration.
Table 1. Impact of BCA Annual Spending Reductions on PHS Agency Funding
FY2013-FY2015
Percent Reduction
Program
FY2013
FY2014
FY2015
Mandatory Spending
Nonexempt programs
5.1%a 7.2% 7.3%
Community health centers, migrant health centers, IHS
2.0%
2.0%
2.0%
Discretionary Spending
Nonexempt programs
5.0%a NAb NAb
Sources: OMB Report to the Congress on the Joint Committee Sequestration for Fiscal Year 2013, March 1,
2013; OMB Report to the Congress on the Joint Committee Reductions for Fiscal Year 2014, May 20, 2013;
OMB Report to the Congress on the Joint Committee Reductions for Fiscal Year 2015, March 10, 2014.
a. These percentages reflect adjustments made by the American Taxpayer Relief Act of 2012 (ATRA; P.L. 112-
240), which amended the BCA by reducing the overal dol ar amount that needed to be cut from FY2013
spending.
b. NA = not applicable. Beginning in FY2014, the annual spending reductions in discretionary spending are
achieved by lowering the discretionary spending caps rather than by sequestration. Thus, congressional
appropriators, working within the caps, get to determine how to apply the cuts across programs.
For each of the remaining years (i.e., FY2014 through FY2021), the annual reductions in
discretionary spending are achieved by lowering the discretionary spending caps by the total
dollar amount of the required reduction. This means that congressional appropriators get to decide
how to apportion the cuts within the lowered spending cap rather than having the cuts applied
across-the-board to all nonexempt accounts through the sequestration process.
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For FY2014, OMB lowered the NDD spending cap by $37 billion. However, the Bipartisan
Budget Act of 2013 (BBA)25 subsequently amended the BCA by establishing new NDD spending
caps for FY2014 and FY2015 and eliminating the BCA requirement that these caps be lowered.
Congressional appropriators now have more funding available for those two fiscal years. The new
FY2014 NDD cap is $22 billion above the BCA-lowered FY2014 cap that it replaced, and almost
$24 billion above the FY2013 post-sequestration NDD funding level. The new FY2015 spending
cap, which is virtually unchanged from the new FY2014 cap, is $9 billion above the BCA-
lowered FY2015 cap that it replaced.
Report Roadmap
The remainder of this report consists of seven sections, one for each PHS agency beginning with
AHRQ.26 Each section includes (1) an overview of the agency’s statutory authority and principal
activities; (2) a summary of agency funding over the period FY2010-FY2014; and (3) highlights
of the agency’s FY2015 budget request. This material is accompanied by a detailed funding table
showing the FY2010-FY2014 funding levels and the FY2015 budget request for the agency. The
amounts in the funding tables in this report are taken from the departmental and agency budget
documents submitted to the appropriations committees, as well as agency operating plans.27
Specific documents are listed in the source note under each table.
The funding tables are formatted in a similar, though not identical, manner. The formatting
generally matches the way in which each agency’s funding is presented in the congressional
budget documents. Each table shows the funding for all the agency’s budget accounts and,
typically, for selected programs and activities within those accounts. These amounts are summed
to give the agency’s total, or program level, funding. At the bottom of the table any user fees, set-
aside funds, ACA funds, and other nondiscretionary amounts are subtracted from the program
level to give the agency’s discretionary budget authority (i.e., annual discretionary
appropriations).
The tables for AHRQ, CDC, HRSA, and SAMHSA include non-add entries—italicized and in
parentheses—to indicate the contribution of funding from sources other than the agency’s
discretionary appropriations to specific accounts. Almost all of the CDC accounts are funded with
discretionary appropriations plus amounts from multiple other sources (see Table 3). As already
discussed, AHRQ is a special case because it does not receive any discretionary appropriations.
Instead, it relies entirely on set-aside funds supplemented by smaller amounts of ACA funding
(see Table 2).
A dash is used in the funding tables to indicate either that there was no mandatory funding
appropriated for that fiscal year or that there was no request and appropriation of discretionary
funds for that year. A zero indicates that congressional appropriators chose to disregard an
authorization or request for funding and provide no funds.
It is important to keep in mind that the PHS agency funding tables that appear in budget
documents and appropriations committee reports, as well as the tables in this report, show only
25 P.L. 113-67, Division A, 127 Stat. 1165.
26 ATSDR and its budget are included in the discussion of CDC.
27 All the budget documents and operating plans are available at http://www.hhs.gov/budget/.
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the amount of set-aside funds received. They do not reflect the amount of funding tapped from
agency accounts. As a result, the funding tables for the four donor agencies (i.e., CDC, HRSA,
NIH, and SAMHSA) give a somewhat distorted view of available budgetary resources. This
effect is particularly significant in the case of NIH. As mentioned earlier, NIH loses
approximately $700 million as a result of the tap and gets back only $8 million. While funding
tables for NIH show the receipt of $8 million in set-aside funds, which count towards the
agency’s overall program level funding, the amounts shown for each agency account have not
been reduced to reflect the tap. Thus, NIH appears to have about $700 million more than is in fact
the case.
Note that the funding tables show the post-sequestration amounts for the accounts that were
subject to sequestration both in FY2013 and in FY2014. The amounts shown for the FY2015
request do not reflect sequestration.
Congress has yet to complete work on any of the regular appropriations bills for FY2015, which began on October 1,
2014. On September 19, 2014, the President signed the Continuing Appropriations Resolution, 2015 (P.L. 113-164;
H.J.Res. 124), which provides continuing appropriations through December 11, 2014. General y, P.L. 113-164 funds
discretionary programs at the same rate (and under the same conditions) as in FY2014, minus an across-the-board
reduction of 0.0554%. This report will be updated with information on PHS agency funding for FY2015 once legislative
action on appropriations for the new fiscal year is completed.
Agency for Healthcare Research and Quality
(AHRQ)
Agency Overview
AHRQ is the federal agency charged with supporting research designed to improve the quality of
health care, increase the efficiency of its delivery, and broaden access to health services. Specific
research efforts are aimed at reducing the costs of care, promoting patient safety, measuring the
quality of health care, and improving health care services, organization, and financing. AHRQ
also is required to disseminate its research findings to health care providers, payers, and
consumers, among others. In addition, the agency collects data on health care expenditures and
utilization through the Medical Expenditure Panel Surveys (MEPS) and the Healthcare Cost and
Utilization Project (HCUP).
AHRQ has evolved from a succession of agencies concerned with fostering health services
research and health care technology assessment. The Omnibus Budget Reconciliation Act of 1989
(P.L. 101-239) added a new PHSA Title IX and established the Agency for Health Care Policy
and Research (AHCPR), a successor agency to the former National Center for Health Services
Research and Health Care Technology Assessment (NCHSR). AHCPR was reauthorized in 1992
(P.L. 102-410). On December 6, 1999, President Clinton signed the Healthcare Research and
Quality Act of 1999 (P.L. 106-129), which renamed AHCPR as the Agency for Healthcare
Research and Quality (AHRQ) and reauthorized appropriations for its programs and activities
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through FY2005.28 Congress has yet to revisit the agency and further reauthorize its funding.
Despite the expired authorizations of appropriations, AHRQ continues to get annual funding.
Since FY2003, AHRQ has not received any annual discretionary appropriations. Instead, the
agency has relied almost entirely on the PHS evaluation set-aside to fund its activities and
programs. Over the past few years AHRQ has received additional funds from the PPHF and the
PCORTF (see Table 2).
The AHRQ budget is organized according to three program areas: (1) Healthcare Costs, Quality
and Outcomes (HCQO) Research; (2) MEPS; and (3) program support. HCQO research focuses
on six priority areas, summarized in the text box below.
Healthcare Costs, Quality and Outcomes (HCQO) Research Areas
Health Information Technology (HIT). Research evaluating HIT and its impact on the quality and efficiency of
health care.
Patient Safety. Research on reducing and preventing medical errors, with a focus on health care-associated
infections (HAIs).
Patient-Centered Health. Research comparing the effectiveness of different treatment options (previously
referred to as comparative effectiveness research).
Health Services Research, Data, and Dissemination. Research on quality of health care that spans multiple
priority areas including, for example, the annual National Healthcare Quality and National Healthcare Disparities
Reports.
Value. Research and projects supporting value in health care, focusing on reducing cost and improving quality.
Prevention/Care Management. Research on improving the delivery of primary care and preventive services.
FY2010-FY2014 Funding
As shown in Table 2, AHRQ’s total program level increased by $61 million (15%) between
FY2010 and FY2014, from $403 million to $464 million. This overall growth was the result of
increasing ACA fund transfers during this time, which offset a $33 million (8.3%) decrease in set-
aside funding for the agency. Between FY2010 and FY2014, total transfers from the PPHF and
the PCORTF increased from $6 million to $100 million. During FY2011 and FY2012, transfers
from the PPHF increased, but returned in FY2013 and FY2014 to close to the FY2010 level,
while PCORTF transfers increased steadily according to the statutory formulas (see Appendix
D). The total program level for the agency for FY2014 includes $364 million in set-aside funding
and a total of $100 million in ACA fund transfers (i.e., $7 million from the PPHF and $93 million
from the PCORTF).
Notable shifts in program area funding levels between FY2010 and FY2014 include the changing
level for Patient-Centered Health Research, which increased by $72 million during this period, as
a result of the fund transfers from PCORTF. Funds transferred from the PPHF have supported an
increase in funding for prevention and care management activities over this period, and have been
used in part to fund the activities of the U.S. Preventive Services Task Force (USPSTF). Finally,
funding for Patient Safety Research decreased between FY2010 and FY2014 by $19 million.
28 See the AHRQ website at http://www.ahrq.gov.
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FY2015 Budget Request
For FY2015, the President requested a total program level of $440 million for AHRQ, which
represents a decrease of $24 million (5.2%) from the FY2014 program level of $464 million (see
Table 2). The FY2015 request includes $334 million in set-aside funds and a transfer of $106
million from the PCORTF. It continues the trend of decreasing set-aside funding being offset by
increasing ACA fund transfers. AHRQ’s FY2015 request does not include any PPHF funds. The
agency has received PPHF funding in each of the preceding years since the establishment of the
fund in FY2010. Under the FY2015 request, most of the HCQO research program areas would
see a decrease in their funding. The exceptions are Patient-Centered Health Research, which
would receive an increase of $13 million as a result of the increased PCORTF transfer, and
Patient Safety Research, which would receive a modest increase of $1 million over the FY2014
level.
Table 2. Agency for Healthcare Research and Quality (AHRQ)
(Millions of Dollars, by Fiscal Year)
2015
Program or Activity
2010
2011
2012
2013
2014
req.
Health Costs, Quality and Outcomes
(HCQO)
Research
276
266
272
300 331 306
Health Information Technology
Research
28
28
26
26 30 23
Patient Safety Research
91
66
66
67
72
73
Patient-Centered Health Research
21
29
41
68
93
106
PCORTF Transfer (non-add)
—
(8)
(24)
(58)
(93)
(106)
Health Services Research, Data, and
Disseminationa 112
112
108
111
111
93
Value
4
4
4
4
3
—
Prevention/Care Management
21
28
28
26
23
11
PPHF Transfer (non-add)
(6)
(12)
(12)
(6) (7) —
Medical Expenditure Panel Surveys
(MEPS)
59
59
59
61 64 64
Program Support
68
68
74
68 69 70
Total, Program Level
403
392
405
429
464
440
Less Funds From Other Sources
PHS Evaluation Set-Aside
397
372
369
365
364
334
PCORTF Transfers
—
8
24
58 93 106
PPHF Transfers
6
12
12
6
7
—
Total, Discretionary Budget Authority
0
0
0
0
0
0
Sources: Funding amounts for FY2010 and FY2011 are taken from AHRQ’s FY2012 and FY2013 congressional
budget justification documents. Funding amounts for FY2012 and FY2013 are taken from AHRQ’s Sequestration
Operating Plan for FY2013. Funding amounts for FY2014 and FY2015 are taken from the FY2015 HHS Budget in
Brief. All these documents are available at http://www.hhs.gov/budget/.
Notes: Individual amounts may not add to subtotals or totals due to rounding.
a. Formerly “Crosscutting Activities;” also formerly “Research Innovations.”
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Centers for Disease Control and Prevention (CDC)
Agency Overview
According to CDC, its mission is “to protect America from health, safety and security threats,
both foreign and in the [United States].”29 CDC is organized into a number of centers, institutes,
and offices, some focused on specific public health challenges (e.g., injury prevention), others
focused on general public health capabilities (e.g., surveillance and laboratory services).30 The
Agency for Toxic Substances and Disease Registry (ATSDR) is headed by the CDC Director and
is discussed in this section.
Many CDC activities are not specifically authorized but are based in broad, permanent authorities
in the PHSA.31 Four CDC operating divisions are explicitly authorized. The National Institute for
Occupational Safety and Health (NIOSH) was permanently authorized by the Occupational
Safety and Health Act of 1970.32 The National Center on Birth Defects and Developmental
Disabilities (NCBDDD) was established in PHSA Section 317C by the Children’s Health Act of
2000.33 The National Center for Health Statistics (NCHS) was established in PHSA Section 306
by the Health Services Research, Health Statistics, and Medical Libraries Act of 1974.34 ATSDR
was established by the Comprehensive Environmental Response, Compensation and Liability Act
of 1980 (CERCLA, the “Superfund” law).35 Authorizations of appropriations for NCBDDD,
NCHS, and ATSDR have expired, but the programs continue to receive annual appropriations.
CDC provides financial and technical assistance to state, local, municipal, tribal, and foreign
governments, and to academic and non-profit entities. Nearly 85% of the agency’s funding is
spent on grants and contracts.36 CDC has few regulatory responsibilities.
Table 3 presents funding levels for CDC programs for FY2010 through the FY2015 request. In
addition to annual discretionary appropriations, program level amounts for recent years include
funds from the following four mandatory appropriations: (1) the Vaccines for Children (VFC)
program;37 (2) NIOSH activities to support the Energy Employees Occupational Illness
Compensation Program Act (EEOICPA);38 (3) the World Trade Center (WTC) Health Program;39
and (4) appropriations provided under ACA, principally through the PPHF.40 CDC also receives
29 See the CDC website at http://www.cdc.gov/about/organization/mission.htm.
30 Information about CDC’s organization is available at http://www.cdc.gov/about/organization/cio.htm.
31 For example, PHSA Section 301 authorizes the Secretary of HHS to conduct research and investigations as necessary
to control disease, and Section 317 authorizes the Secretary to award grants to states for preventive health programs.
32 29 U.S.C. §671.
33 42 U.S.C. §247b-4.
34 42 U.S.C. §242k.
35 42 U.S.C. §9604(i).
36 See CDC, Procurements and Grants, http://www.cdc.gov/about/business/funding.htm.
37 See CDC, Vaccines for Children Program, http://www.cdc.gov/vaccines/programs/vfc/index.html.
38 See CDC, EEOICPA, “Frequently Asked Questions,” http://www.cdc.gov/niosh/ocas/faqsact.html.
39 See CDC, World Trade Center Health Program, http://www.cdc.gov/niosh/topics/wtc/.
40 CRS Report R41301, Appropriations and Fund Transfers in the Affordable Care Act (ACA), by C. Stephen Redhead.
See more information about the PPHF in Appendix C of this report.
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annual set-aside funds and authorized user fees, and may also receive funding through
supplemental appropriations and other transfers.
FY2010-FY2014 Funding
While CDC’s discretionary budget authority decreased from FY2010 to FY2014, reaching its
lowest point in FY2013, the CDC/ATSDR program level generally held steady or increased
during that period, with the exception of FY2013. Program levels have generally been sustained,
despite the decreases in discretionary budget authority, by transfers from the PPHF. The decrease
in program level for FY2013 was due both to sequestration of discretionary and nonexempt
mandatory funding, which reduced CDC’s program level by $293 million compared with
FY2012,41 and to a reduction in PPHF funding that year. As noted earlier in the report, almost half
of the FY2013 PPHF funds were transferred to CMS for ACA implementation. As a result, CDC’s
allocation of PPHF funding was $346 million less than for FY2012. (See Appendix C for more
discussion of the allocation of PPHF funds.) To partially offset the decrease in FY2013 PPHF
funding, the HHS Secretary transferred $79 million to CDC from other HHS accounts, principally
at NIH.42
FY2015 President’s Budget Request
For FY2015, the Administration requests $5.400 billion in CDC budget authority and $397
million in set-aside funds, and proposes also to transfer $810 million from the PPHF. These three
amounts provide CDC with its general operating budget, given that the remaining mandatory
accounts each support narrow, specific activities. CDC notes that the FY2015 request would
provide the second lowest general operating level since FY2010 (with FY2013 being the
lowest).43
The FY2015 request would reduce funding for certain CDC “safety net” programs that deliver
healthcare services, in light of the expansion of access to insurance coverage for these services
under ACA. These programs include the National Breast and Cervical Cancer Early Detection
Program, the Colorectal Cancer Screening Program, and the Section 317 Immunization
Program.44 In FY2014 appropriations, congressional appropriators asked the HHS Secretary to
include with the FY2016 budget an analysis of how the ACA’s requirements for private insurance
coverage of preventive services, such as cancer screenings and immunizations, will impact
eligibility for discretionary HHS programs such as these.45 As with several previous years, the
Administration proposes to eliminate the Preventive Health and Health Services block grant for
FY2015, stating that PPHF funds serve the same purpose.46
41 CDC Office of the Chief Operating Officer, June 13, 2013.
42 CDC Office of the Chief Operating Officer, June 13, 2013. See also John Reichard, “HHS to Use $454 Million From
Prevention Fund for Health Insurance Enrollment,” CQ HealthBeat, April 15, 2013.
43 CDC, “CDC Overview,” Budget Fact Sheet, p. 2, http://www.cdc.gov/fmo/topic/Budget%20Information/FY-2015-
fact-sheets.html.
44 See “Program Decreases and Eliminations” in FY2015 CDC congressional budget justification, p. 12,
http://www.cdc.gov/fmo. However, CDC estimates an increase in mandatory funding for the Vaccine for Children
Program (VFC), citing, among other things, increases in the cost of covered vaccines. See p. 9 in the justification.
45 P.L. 113-76, Consolidated Appropriations Act, 2014, Division H, Title II, Section 226, January 17, 2014.
46 FY2015 CDC congressional budget justification, p. 11.
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The Administration requests new or increased FY2015 funding for several activities. These
include, among others: $10 million for gun violence prevention research and $12 million to
expand the National Violent Death Reporting System (NVDRS) to all 50 states; a $45 million
increase to enhance global health security activities; a $30 million increase to combat antibiotic
resistance; a $16 million increase to combat prescription drug overdoses; and a $10 million
increase to improve foodborne illness detection.47
CDC’s FY2015 budget implements the “Working Capital Fund,” a revolving fund to be used by
agency programs to “pay for” agency-wide services—such as human resources and
procurement—that received direct appropriations in the past.48 In order to implement the new
fund, the Administration proposes to apply certain business services funds previously assigned to
the Cross-cutting Activities and Program Support account across the various programmatic
accounts instead. This has the effect of increasing the amounts in those accounts.
Table 3. Centers for Disease Control and Prevention (CDC) and
Agency for Toxic Substances and Disease Registry (ATSDR)
(Millions of Dollars, by Fiscal Year)
2015
Program or Activity
2010
2011
2012
2013a
2014
req.
Immunization and Respiratory Diseases
721
748
779
718
785
748
PHS Evaluation Set-Aside (non-add)
(13) (13) (13) (13) (13) (13)
PPHF Transfer (non-add)
—
(100)
(190)
(91)
(160)
(127)
PHSSEF Transfer (non-add)
—
(156)
—
(12)
—
—
Vaccines for Childrenb
3,761 3,953 4,006 3,607 3,562 4,077
HIV/AIDS, Viral Hepatitis, STI and TB
1,119
1,116
1,110
1,095
1,121
1,128
PHS Evaluation Set-Aside (non-add)
—
—
—
(4)
—
(3)
PPHF Transfer (non-add)
(30)
—
(10)
—
—
—
Emerging & Zoonotic Infectious Diseases
281
304
304
341
390
445
PPHF Transfer (non-add)
(20)
(52) (52) (44) (52) (52)
Chronic Disease Prevention and Health
924 1,075 1,167 1,003 1,188 1,078
Promotion
PPHF Transfer (non-add)
(59)
(301) (411) (233) (446) (470)
Birth Defects, Developmental Disabilities,
144 136 137 134 132 132
Disability and Health
PPHF Transfer (non-add)
—
—
—
—
—
(71)
Environmental
Health
181 170 140 142 180 169
PPHF Transfer (non-add)
—
(35) (35) (21) (13) (37)
Injury Prevention and Control
149
144
138
139
151
194
PHS Evaluation Set-Aside (non-add)
—
—
—
—
—
(6)
47 Ibid, pp. 8 ff.
48 Ibid, p. 16.
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2015
Program or Activity
2010
2011
2012
2013a
2014
req.
Public Health Scientific Services
441
468
462
493
483
526
PHS Evaluation Set-Aside (non-add)
(248) (248) (248) (248) (86) (95)
PPHF Transfer (non-add)
(32)
(72) (70) (52) — (53)
Occupational Safety and Healthc
430 442 536 605 651 618
PHS Evaluation Set-Aside (non-add)
(92)
(92)
(111)
(111)
(112)
(281)
EEOICPA
(non-add)
(55) (55) (55) (51) (50) (55)
World Trade Ctr. Health Program (non-add)d
— (71) (188) (231) (268) (282)
Global
Health
354 340 348 363 417 464
Public Health Preparedness and Response
1,522
1,415
1,329
1,279
1,371
1,317
PPHF
Transfer
(non-add)
—
(10) — — — —
PHSSEF Transfer (non-add)
—
(69)
(30)
—
—
—
Crosscutting Activities and Program Supporte 730e 605 659 251 299 124
PPHF Transfer (non-add)
(50)
(41) (41) (23) (160) —
Prevention Block Grant (non-add)
(100)
(80)
(80)
(75)
(160)f —
ATSDR
100 77 76 72 75 95
Medical Monitoring (ACA Sec. 10323(b)) (non-
(23)g — — — —
(20)g
add)
Childhood Obesity (ACA Sec. 4306)
25h — — — — —
User
Fees
2 2 2 2 2 2
Total, CDC/ATSDR Program Level
10,884
10,995
11,193
10,243
10,806
11,117
Less Funds From Other Sources
Vaccines
for
Children
3,761 3,953 4,006 3,607 3,562 4,077
EEOICPA
55 55 55 51 50 55
PHSSEF
Transfers
— 225 30 12 — —
PHS
Evaluation
Set-Aside
352 352 371 375 211 397
ACA Mandatory Funds: PPHF Transfers
192
611
809
463
831
810
ACA Mandatory Funds: Other
48
—
—
—
—
20
World Trade Ctr. Health Program
—
71
188
231
268
282
User
Fees
2 2 2 2 2 2
Total, CDC/ATSDR Discretionary BA
6,474
5,726
5,732
5,503
5,882
5,474
Less ATSDR Discretionary BA
77
77
76
72
75
75
Total, CDC Discretionary BA
6,397
5,649
5,656
5,430
5,807
5,400
Sources: CDC and ATSDR congressional budget justifications for FY2012 through FY2015, http://www.cdc.gov/
fmo.
Notes: BA and program level amounts for FY2013, FY2014, and the FY2015 President’s budget reflect a
proposed realignment of funds from certain business services in the Cross-cutting Activities and Program
Support account into most other accounts, in order to implement the Working Capital Fund, discussed in the
text of this report. As a result, amounts for these years are not necessarily comparable to amounts for previous
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years. Individual amounts may not add to subtotals or totals due to rounding. PHSSEF is the Public Health and
Social Services Emergency Fund, a fund used by appropriators to provide the Secretary with ongoing or one-time
emergency funding, such as for the response to influenza epidemics. STI is sexually transmitted infection.
a. Amounts for FY2013 include a transfer of $79 million from other HHS agencies, pursuant to the Secretary’s
transfer authority (see discussion under “Transfers”).
b. The Vaccines for Children (VFC) program provides free pediatric vaccines to doctors who serve eligible
(generally low-income) children. VFC is funded entirely as an entitlement through federal Medicaid
appropriations and is exempt from sequestration. Amounts for FY2014 and FY2015 are estimates.
c. Program levels for Occupational Safety and Health include Energy Employees and World Trade Center
mandatory program funds.
d. Beginning July 1, 2011 (i.e., for the final quarter of FY2011), the World Trade Center Health Program,
previously funded through discretionary appropriations to NIOSH, was replaced by a mandatory program.
e. Amounts for FY2010 include amounts previously designated as Public Health Leadership and Support,
Business Services Support, Buildings and Facilities, and Preventive Health and Health Services Block Grant.
f.
FY2014 funding for the Preventive Health and Health Services Block Grant (“Prevention Block Grant”) was
provided from the PPHF pursuant to P.L. 113-76, the FY2014 Consolidated Appropriations Act. Amounts
for prior fiscal years were provided through annual discretionary appropriations.
g. ACA appropriated $23 million for the period FY2010-2014, and $20 million for each five‐year period
thereafter, in no‐year funding for the early detection of certain medical conditions related to environmental
health hazards in Libby, Montana.
h. ACA appropriated $25 million for a childhood obesity demonstration project, http://www.cdc.gov/obesity/
childhood/researchproject.html.
Food and Drug Administration (FDA)
Agency Overview
FDA regulates the safety of human foods, dietary supplements, cosmetics, and animal foods; and
the safety and effectiveness of human drugs, biological products (e.g., vaccines), medical devices,
radiation-emitting products, and animal drugs. In 2009, Congress gave FDA the authority to
regulate the manufacture, marketing, and distribution of tobacco products in order to protect
public health.
Seven centers within FDA represent the broad program areas for which the agency has
responsibility: the Center for Biologics Evaluation and Research (CBER), the Center for Devices
and Radiological Health (CDRH), the Center for Drug Evaluation and Research (CDER), the
Center for Food Safety and Applied Nutrition (CFSAN), the Center for Veterinary Medicine
(CVM), the National Center for Toxicological Research (NCTR), and the Center for Tobacco
Products (CTP). Several other offices have agency-wide responsibilities.
The Federal Food, Drug, and Cosmetic Act (FFDCA) is the principal source of FDA’s statutory
authority.49 FDA is also responsible for administering certain provisions in other laws, most
notably the PHSA.50 Although the FDA’s authorizing committees in Congress are the committees
49 21 U.S.C. §§301 et seq.
50 PHSA Section 351 (21 U.S.C. §262) authorizes the regulation of biological products and states that FFDCA
requirements apply to biological products licensed under the PHSA. A listing of other laws containing provisions for
which FDA is responsible is at http://www.fda.gov/RegulatoryInformation/Legislation/default.htm.
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with jurisdiction over public health issues—the Senate Committee on Health, Education, Labor,
and Pensions, and the House Committee on Energy and Commerce—FDA’s assignment within
the appropriations committees reflects its origin as part of the Department of Agriculture. The
Senate and House appropriations subcommittees on Agriculture, Rural Development, FDA, and
Related Agencies have jurisdiction over FDA’s budget, even though the agency has been part of
various federal health agencies (HHS and its predecessors) since 1940.
FDA’s budget has two funding streams: annual appropriations (i.e., discretionary budget
authority, or BA) and industry user fees.51 In FDA’s annual appropriation, Congress sets both the
total amount of appropriated funds and the amount of user fees that the agency is authorized to
collect and obligate for that fiscal year. Appropriated funds are largely for the Salaries and
Expenses account, with a much smaller amount for the Buildings and Facilities account. The
several different user fees, which accounted for 42% of FDA’s total FY2014 program level,
contribute only to the Salaries and Expenses account.
The largest and oldest FDA user fee that is linked to a specific program was first authorized by
the Prescription Drug User Fee Act (PDUFA, P.L. 102-571) in 1992. Appendix E presents the
authorizing legislation for current FDA user fees, sorted by the dollar amount they contribute to
the agency’s budget. After PDUFA, Congress added user fee authorities regarding medical
devices, animal drugs, animal generic drugs, tobacco products, priority review, food reinspection,
food recall, voluntary qualified food importer, generic drugs, biosimilars, and, most recently,
outsourcing facilities (related to drug compounding) and some wholesale distributors and third-
party logistics providers (related to pharmaceutical supply chain security).52 Each of the medical
product fee authorities requires reauthorization every five years. Several indefinite authorities
apply to fees for mammography inspection, color additive certification, export certification, and
priority review vouchers.53
FY2010-FY2014 Funding
From FY2010 to FY2014, Congress increased FDA’s annual appropriations by $192 million
(8.1%), from $2.369 billion to $2.561 billion (see Table 4). However, because of a 144% increase
in user fee revenue, the total program level for FDA increased by $1.269 billion (40.7%) over that
period, from $3.118 billion to $4.387 billion. In addition to increasing collections from continuing
user fee programs, FDA had also implemented several newly authorized user fees. Between
FY2010 and FY2014, the proportion of the agency’s budget that came from user fees increased
from 30% to 42%.
51 For additional information on the history of the FDA budget, see CRS Report RL34334, The Food and Drug
Administration: Budget and Statutory History, FY1980-FY2007, coordinated by Judith A. Johnson.
52 CRS Report R42366, Prescription Drug User Fee Act (PDUFA): 2012 Reauthorization as PDUFA V, by Susan
Thaul; CRS Report R42508, The FDA Medical Device User Fee Program, by Judith A. Johnson; CRS Report R40443,
The FDA Food Safety Modernization Act (P.L. 111-353), coordinated by Renée Johnson; CRS Report R42680, The
Food and Drug Administration Safety and Innovation Act (FDASIA, P.L. 112-144), coordinated by Susan Thaul; and
CRS Report R43290, The Proposed Drug Quality and Security Act (H.R. 3204), by Susan Thaul.
53 User fees provide varying proportions of funding for several FDA programs (see Table 4). For example, the
agency’s tobacco regulatory activities are entirely supported through user fees paid by tobacco product manufacturers
and importers and the toxicology program receives no user fee funds. In FY2014, PDUFA revenues account for 63.8%
of the human drugs program budget; fees provide 37.5% of the biologics budget, 25.0% of the devices and radiological
health budget, 18.4% of the animal drugs and feeds budget, and 1.9% of the foods budget. Appendix E of this report
presents additional detail.
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FDA’s statutory responsibilities have increased since FY2010, and new user fees do not cover all
the new activities. The Food and Drug Administration Amendments Act of 2007 (FDAAA, P.L.
110-85), the Food Safety Modernization Act (FSMA, P.L. 111-353), the Food and Drug
Administration Safety and Innovation Act (FDASIA, P.L. 112-144), and the Drug Quality and
Security Act (DQSA, P.L. 113-54) added requirements concerning food, drug, biologics, and
device regulation.54
As noted earlier in the report, OMB determined that FDA user fees were fully sequestrable in
FY2013 at the NDD percentage rate, along with the agency’s discretionary appropriations. The
FDA Commissioner estimated that FDA would lose about $83 million in user fees in FY2013 as a
result of sequestration.55 Congressional appropriators subsequently released those sequestered
funds and made them available to the FDA in the FY2014 Agriculture appropriations act.56
FY2015 President’s Budget Request
The President requested a FY2015 FDA total program level of $4.745 billion, including $2.584
billion (54.5%) in discretionary appropriations and $2.161 billion (45.5%) in user fees. As is
customary, the request included $260 million in new user fees that Congress would have to
authorize.57 Without those proposed fees, which the appropriators cannot include in the FY2015
bill unless Congress and the President enact them into law, the total program level request is
$4.485 billion, 2.2% above the FY2014 level (see Table 4). That total includes $2.584 billion
(57.6%) in appropriations and $1.901 billion (42.4%) in authorized user fees; 0.9% and 4.1%
above the FY2014 levels, respectively.
54 See, for example, statement of Margaret A. Hamburg, Commissioner of Food and Drugs, FDA, before the House
Committee on Appropriations, Subcommittee on Agriculture, Rural Development, Food and Drug Administration, and
Related Agencies, “President’s Fiscal Year 2014 Budget Request for the FDA,” April 26, 2013; and Stephen
Grossman, “Funding Cutbacks at FDA: A Sequester Primer,” FDA Matters, March 7, 2013. For details of the
additional responsibilities, see CRS Report RL34465, FDA Amendments Act of 2007 (P.L. 110-85), by Susan Thaul;
CRS Report R40443, The FDA Food Safety Modernization Act (P.L. 111-353), coordinated by Renée Johnson; CRS
Report R42680, The Food and Drug Administration Safety and Innovation Act (FDASIA, P.L. 112-144), coordinated by
Susan Thaul; and CRS Report R43290, The Proposed Drug Quality and Security Act (H.R. 3204), by Susan Thaul.
55 Remarks by Margaret A. Hamburg, Commissioner of Food and Drugs, 2013 FDLI Annual Conference, Washington,
DC, April 23, 2013.
56 Section 747 in Division A (Agriculture) of the Consolidated Appropriations Act, 2014 (P.L. 113-76) states that
“[F]ees deposited under the heading ‘Department of Health and Human Services—Food and Drug Administration—
Salaries and Expenses’ in fiscal year 2013 and sequestered pursuant to [the BBEDCA] shall be available until
expended for the same purpose for which those funds were originally appropriated.”
57 Revenue from the five proposed new users fees is allocated across the following FDA program areas (foods, $210.5
million; human drugs, $0.5 million; animal drugs and feeds, $17.8 million; devices and radiological health, $3.8
million; headquarters and Office of the Commissioner, $15.6 million; GSA rent, $7.2 million; and other rent and rent-
related activities, $4.1 million).
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Table 4. Food and Drug Administration (FDA)
(Millions of Dollars, by Fiscal Year)
2015
Program area
2010
2011
2012
2013
2014
req.
Foods 783
836
883
813
900
914
BA 783
836
866
797
883
903
User Fees
—
—
17
17
17
10
Human drugs
884
950
979
1,187
1,289
1,335
BA 462
478
478
439
466
480
User Fees
421
472
501
748
823
856
Biologics 291
302
329
308
338
343
BA 206
212
212
195
211
210
User Fees
86
90
117
113
127
133
Animal drugs and feeds
154
159
166
155
173
172
BA 134
139
138
126
142
145
User Fees
20
20
28
29
32
27
Devices and radiological health
370
379
376
384
428
437
BA 314
322
323
296
321
318
User Fees
57
56
53
88
107
119
Tobacco products
64
136
455
459
501
532
BA
—
—
—
—
—
—
User Fees
64
136
455
459
501
532
Toxicological research
59
61
60
55
62
59
BA 59
61
60
55
62
59
User Fees
—
—
—
—
—
—
Headquarters/Commissioner’s Office
178
187
223
251
275
279
BA 141
150
154
160
172
175
User Fees
37
37
69
91
103
104
GSA rent
178
178
205
199
220
229
BA 145
151
161
150
162
169
User Fees
32
27
45
49
58
60
Other rent and rent-related activitiesa 124
129
132
157
178
164
BA 103
100
106
118
133
116
User Fees
21
30
26
40
46
48
Export and color certification funds
10
11
11
12
12
14
BA —
—
—
—
—
—
User Fees
10
11
11
12
12
14
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2015
Program area
2010
2011
2012
2013
2014
req.
Buildings & Facilities
22
13
9
5
9
9
BA 22b 13 9 5 9 9
User Fees
—
—
—
—
—
—
Food and drug safety
— — — 46c 0 0
BA —
—
—
46
0
0
User Fees
—
—
—
0
0
0
Total, Program Level
3,118
3,339
3,832
4,031
4,387
4,485
Less Funds From Other Sources
User Fees
748
879
1,326
1,645
1,826
1,901
Total, Discretionary Budget Authority
2,369
2,460
2,506
2,386
2,561
2,584
Sources: Funding amounts for FY2010 and FY2011 are taken from FDA’s FY2012 and FY2013 congressional
budget justification documents. Funding amounts for FY2012 and FY2013 are taken from FDA’s FY2013
Sequestration Operating Plan; the FY2013 figures reflect sequestration. FY2014 amounts are from FDA’s FY2014
Operating Plan, issued after enactment of the Consolidated Appropriations Act, 2014. FY2015 request amounts
are taken from the FY2015 congressional budget justification.
Notes: Consistent with the Administration and congressional committee formats, each program area includes
funding designated for the responsible FDA center (e.g., the Center for Drug Evaluation and Research or the
Center for Food Safety and Applied Nutrition) and the portion of effort budgeted for the agency-wide Office of
Regulatory Affairs to commit to that area. It also apportions user fee revenue across the program areas as
indicated in the Administration’s request (e.g., 90% of the animal drug user fee revenue is designated for the
animal drugs and feeds program, with the rest going to headquarters and Office of the Commissioner, GSA rent,
and other rent and rent-related activities categories).
a. Other rent and rent-related activities include White Oak consolidation.
b. The FY2010 Buildings & Facilities appropriation included about $7 million for the National Center for
Natural Products Research, as directed by the Committee on Appropriations.
c. The FY2013 Sequestration Operating Plan notes food safety and drug safety items that had not been
included in the program-level appropriations.
Health Resources and Services Administration
(HRSA)
Agency Overview
HRSA is the federal agency charged with improving access to health care for those who are
uninsured, isolated, or medically vulnerable. The agency currently awards funding to more than
3,000 grantees, including community-based organizations; colleges and universities; hospitals;
state, local, and tribal governments; and private entities to support health services projects, such
as training health care workers or providing specific health services.58 HRSA also administers the
health centers program, which provides grants to non-profit entities that provide primary care
58 See HRSA’s website at http://www.hrsa.gov.
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services to people who experience financial, geographic, cultural, or other barriers to health
care.59
HRSA is organized into five bureaus (see text box below) and ten offices. Some offices focus on
specific populations or health care issues (e.g., Office of Women’s Health, Office of Rural Health
Policy), while others provide agency-wide support or technical assistance to HRSA’s regional
offices (e.g., Office of Planning, Analysis and Evaluation; Office of Regional Operations).60
HRSA Bureaus
The Bureau of Primary Health Care administers the Health Centers program, authorized under Title III of the
PHSA. Community and other health centers provide access to primary care for individuals who are low-income,
uninsured, or living where health care is scarce.
The Bureau of Health Workforce administers scholarship, loan and loan repayment programs that help
underserved communities recruit and retain health professionals. These programs include the National Health Service
Corps, NURSE Corps, and the Faculty Loan Repayment Program. The bureau also administers a number of programs
for health professions training and development of diversity and cultural competence in the health workforce. These
programs include the Oral Health Training Program, the Nursing Workforce Diversity Program, the Children’s
Hospitals Graduate Medical Education Program, the Teaching Health Center Graduate Medical Education program
funded under ACA, and the Scholarships for Disadvantaged Students Program. The Bureau of Health Professions also
administers the National Practitioner and Healthcare Integrity Protection Data Banks and the National Center for
Health Workforce Analysis. Titles III, VII, and VIII of the PHSA authorize programs in this bureau.
The Maternal and Child Health Bureau administers the Maternal and Child Health Block Grant61 and other
programs that support the infrastructure for maternal and child health services, including the Maternal, Infant, and
Early Childhood Home Visiting Program that was authorized and funded by ACA. These programs are authorized in
Title V of the Social Security Act (SSA). This bureau also administers Healthy Start, newborn hearing screening,
autism, and other programs authorized under Titles III, XI, XII, and XIX of the PHSA.
The HIV/AIDS Bureau administers the Ryan White HIV/AIDS program, which is the largest discretionary grant
program within HRSA and is focused on HIV/AIDS care. The Ryan White HIV/AIDS program administers grant
programs that provide early intervention, minority, and family services. It also administers the AIDS Drug Assistance
Program (ADAP). Title XXVI of the PHSA authorizes the Ryan White HIV/AIDS programs.
The Healthcare Systems Bureau provides national leadership and direction in targeted areas, such as organ and
bone marrow transplantation, poison control centers, and others. It also administers the 340B drug pricing program.
Titles III and XII of the PHSA authorize programs in this bureau.
As noted in the text box, the majority of HRSA’s programs are authorized by the PHSA or, in
some cases, by the SSA. Additionally, Section 427(e) of the Federal Mine Safety and Health
Amendments Act (P.L. 95-164) authorizes the Black Lung Program, which supports clinics that
provide services to retired coal miners and others.
FY2010-FY2014 Funding
As shown in Table 5, HRSA’s discretionary budget authority decreased by 21.8% from $7.492
billion in FY2010 to $5.861 billion in FY2013. It then increased by 3.4% to $6.061 billion in
FY2014. Overall, HRSA’s discretionary budget authority in FY2014 was $1.431 billion (19.1%)
below the FY2010 level. However, the agency’s total program level over the five-year period
59 For more information, see CRS Report R42433, Federal Health Centers, by Elayne J. Heisler.
60 See HRSA’s website at http://www.hrsa.gov.
61 For more information, see CRS Report R42428, The Maternal and Child Health Services Block Grant: Background
and Funding, by Carmen Solomon-Fears.
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FY2010-FY2014 increased by $848 million (10.5%) from 8.067 billion to $8.915 billion due to
the inclusion of significant amounts of ACA mandatory funding, primarily from the CHCF, as
well as smaller amounts of set-aside funds and user fees.
Funding for the health centers program, administered by the Bureau of Primary Health Care,
increased by $1.404 billion (65.6%) from $2.141 billion in FY2010 to $3.545 billion in FY2014.
That increase was entirely due to CHCF mandatory funds, which increased from $1 billion to
$2.145 billion over that period and provided a growing share of the total funding for the program.
Other ACA funding for this bureau included $1.5 billion in FY2011 for health center
construction, and four years of funding totaling $197 million for the School-Based Health Centers
program.62
Total funding for health workforce programs decreased by $204 million (16.3%) from $1.249
billion in FY2010 to $1.045 billion in FY2014. Of particular note is the fact that the National
Health Service Corps (NHSC) has received no discretionary funding since FY2012 and has been
entirely funded by the CHCF. See Appendix B for more discussion of the CHCF.
Total funding for maternal and child health programs at HRSA increased $236 million (24%)
from $984 million in FY2010 to $1.220 billion in FY2014. This increase was largely due to the
ACA appropriation of mandatory funds for the Maternal, Infant, and Early Childhood Home
Visiting program. Discretionary funding for the Maternal and Child Health Block Grant
decreased from $661 million in FY2010 to $634 million in FY2014.63 The ACA also appropriated
$5 million for each of FY2010 through FY2012 for the Family-to-Family Health Information
Centers program. Funding for the program was further extended first by the American Taxpayer
Relief Act of 2012,64 then by the Bipartisan Budget Act of 2013.65
While funding for the Ryan White HIV/AIDS programs has fluctuated over the past five years,
the FY2014 level ($2.319 billion) is almost the same as the FY2010 level ($2.315 billion).66 For
each of FY2010 through FY2014, HRSA received a total of $25 million in set-aside funds, which
have been used to help support Ryan White HIV/AIDS programs.
The Healthcare Systems Bureau received a one-time ACA appropriation of $100 million in
FY2010 for hospital construction grants. FY2010 also was the final year of funding for the State
Health Access Grant Program, which received $74 million that year. While funding for several of
the programs administered by the Healthcare Systems Bureau (e.g., National Cord Blood
Inventory, C.W. Bill Young Cell Transplantation Program) has remained relatively flat since
FY2010, the 340B drug pricing program has seen its funding increase five-fold over the period
FY2010-FY2014 from $2 million to $10 million. By comparison, funding for Poison Control
Centers decreased $10 million (34.5%) from $29 million in FY2010 to $19 million in FY2014.
62 The ACA appropriated $50 million for each of FY2010 through FY2013 for school-based health centers; however,
the FY2013 amount was reduced by sequestration.
63 Funding for the Maternal Child Health Block Grant was $605 million in FY2013 after sequestration.
64 P.L. 112-240, 126 Stat. 2313.
65 P.L. 113-67, Division B, 127 Stat. 1195.
66 See CRS Report RL33279, The Ryan White HIV/AIDS Program, by Judith A. Johnson for more information on this
program.
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Rural health funding decreased from $185 million in FY2010 to $142 million in FY2014, largely
due to the elimination of funding for the Delta Health Initiative and the Denali Project. Also of
note is the elimination of HRSA’s congressionally directed projects, or earmarks, in the FY2011
appropriations cycle. Congressional earmarks, which in the years prior to their elimination had
become a significant component of HRSA’s budget, totaled $337 million in FY2010.
FY2015 President’s Budget Request
The President’s Budget for FY2015 requested $10.753 billion in program level funding for
HRSA, which is $1.838 billion (20.6%) above the FY2014 level. That amount is almost evenly
split between discretionary budget authority and other, mostly mandatory, funding. Specifically,
the FY2015 request includes $5.300 billion in discretionary budget authority and $5.453 billion
from other funding sources: $3.910 billion in CHCF funding, $1.430 billion in proposed new
mandatory funding, $87 million in set-aside funds, and $26 million in user fees (see Table 5).
The FY2015 budget request generally would fund HRSA programs at the FY2014 funding level,
with some exceptions. It would reduce funding for Training for Diversity Programs, eliminate
funding for the Children’s Hospital Graduate Medical Education (GME), and reduce or eliminate
funding for certain rural health programs. Specifically, it proposed to eliminate funding for Rural
Emergency Devices and to reduce funding for Rural Hospital Flexibility Grants. The budget also
would consolidate funding for Part C (Early Intervention Programs) and Part D (Children, Youth,
and Families) of the Ryan White Program.67
The FY2015 budget request included three proposals for new mandatory funds to support HRSA-
administered programs. First, it proposed a total of $3.950 billion over the six-year period
FY2015-FY2020, including $400 million for FY2015, to continue funding for the NHSC. As
already noted, the NHSC has been supported entirely by CHCF funds since FY2012. Those funds
end in FY2015. The FY2015 budget provided a total of $810 million for the NHSC. That amount
includes the final installment of $310 million from the CHCF, $400 million in proposed new
mandatory funding, and $100 in discretionary appropriations. The health centers program also
receives its final installment of CHCF funding ($3.6 billion) in FY2015. However, unlike the
NHSC proposal, there are no new mandatory funds in the FY2015 budget for the health centers
program. That program has seen its annual discretionary appropriation decline and be partially
supplanted (replaced) by CHCF funding in the past few years.
Second, the FY2015 budget request proposed a total of $15 billion in new mandatory funds to
extend and expand the Maternal, Infant, and Early Childhood Home Visiting program through
FY2024, including $500 million for FY2015. ACA funding for this program ended in FY2014.
However, the Protecting Access to Medicare Act of 2014 (P.L. 113-93), which was enacted
shortly after the FY2015 budget request was released, appropriated $400 million for the home
visiting program for FY2015.
Finally, the President’s FY2015 budget proposed transferring a total of $5.230 billion from the
Medicare Part A trust fund over the 10-year period FY2015-FY2024, including $530 million in
FY2015, for the new Targeted Support for GME Program. This program would incorporate the
existing Children’s Hospital GME program, for which no FY2015 discretionary funds are
67 For more information on the Ryan White Program, see CRS Report RL33279, The Ryan White HIV/AIDS Program,
by Judith A. Johnson.
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requested, and the Teaching Health Center GME program, which was created by the ACA. The
budget proposes setting aside $100 million of the new mandatory funds in FY2015 for the
Children’s Hospital GME Program.
Table 5. Health Resources and Services Administration (HRSA)
(Millions of Dollars, by Fiscal Year)
2015
Bureau or Activity
2010
2011
2012
2013
2014
req.
Primary
Care
2,253 4,149 2,817 2,992 3,640 4,600
Health
Centers
2,141 2,481 2,672 2,856 3,545 4,511
CHCF
Transfer
(non-add)
— (1,000) (1,200) (1,465) (2,145) (3,600)
Health Center Tort Claims
44
100
95
89
95 89
School Based Health Centers (ACA Sec. 4101(a))
50
50
50
47
—
—
Health Center Construction (ACA Sec. 10503(c))
— 1,500
—
—
— —
Hansen’s Disease Programsa
18 18 — — — —
Health Workforceb
1,249 1,357 1,086 1,001 1,045 1,798
National Health Service Corps (NHSC)
141
315
295
285
283
410
CHCF Transfer (non-add)
—
(290)
(295)
(285)
(283)
(310)
NHSC (New mandatory proposal)
—
—
—
—
—
400c
Faculty Loan Repayment Program
1
1
1
1
1
1
Training for Diversityd
96 95 85 80 81 67
Primary Care Training and Enhancement
237
39
39
37
37
37
PPHF Transfer (non-add)
(198)
—
—
—
—
—
Rural Physician Training Grants
— — — — — 4
Interdisciplinary, Community-Based Linkagese
72 72 73 62 72 51
PPHF Transfer (non-add)
—
—
(12)
(2)
—
—
Public Health Workforce Development
30f 30 33 8 18 18
PPHF Transfer (non-add)
(21)f (20) (25) —
—
—
Nursing Workforce Developmentg
290 242 231 218 224 224
PPHF
Transfer
(non-add)
(47) — — — — —
Children’s Hospital GME Payments
317
268
265
251
265
—
GME Targeted Support (New mandatory
—
—
— — —
530h
proposal)
Teaching Health Center GME Payments (ACA
— 230 —
—
—
—
Sec.5508(c))
Other Health Workforce Programsi
41 41 35 34 37 37
National Practitioner Data Bank (User Fees)
24
24
28
27
27
19
Maternal and Child Health
984
1,128
1,208
1,193
1,220
1,346
Maternal and Child Health Block Grant
661
656
639
605
634
634
Healthy
Start
105 104 104 98 101 101
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2015
Bureau or Activity
2010
2011
2012
2013
2014
req.
Maternal, Infant Home Visiting (ACA Sec. 2951)
100
250
350
380
371
—
Home Visiting (New mandatory proposal)
—
—
—
—
—
500j
Family-to-Family Health Centers (ACA Sec. 5507)k 5 5 5 5 3 —
Other Maternal and Child Health Programsl
113 113 112 105 110 110
Ryan White HIV/AIDS
2,315
2,337
2,392
2,249
2,319
2,323
Health Care Systems
267
87
101
95
103
111
Health Care Systems Programsm
93 87 82 78 86 93
Hansen’s
Disease
Programs
— — 18 17 17 17
Health Center Infrastructure (ACA Sec. 10502)
100
—
—
—
—
—
State
Health
Access
Grants
74 — — — — —
Rural
Health
185 138 138 131 142 125
Other
Activities
813 467 460 436 446 451
Congressional Earmarks
337
—
—
—
—
—
Family
Planning
317 299 294 278 286 286
Program
Management
147 162 160 151 153 157
Healthy Weight Collaborative (PPHF Transfer)
5
—
—
—
—
—
Vaccine Injury Compensation Program Operations
7
6
6
6
6
8
Total, Program Level
8,067
9,662
8,202
8,097
8,915 10,753
Less Funds From Other Sources
PHS
Evaluation
Set-Aside
25 25 25 25 25 87
User
Fees
24 24 28 27 27 26
ACA Mandatory Funds: PPHF Transfers
271
20
37
2
—
—
ACA Mandatory Funds: CHCF Transfers
—
1,290
1,495
1,750
2,428
3,910
ACA Mandatory Funds: Other
255
2,035
405
432
374
—
New Mandatory Proposals for FY2015
—
—
—
—
—
1,430
Total, Discretionary Budget Authority
7,492
6,269
6,212
5,861
6,061
5,300
Sources: The funding amounts for FY2010, FY2011, and FY2012 are taken from HRSA’s FY2012 and FY2013
congressional budget justification documents. Funding amounts for FY2013, FY2014, and FY2015 are taken from
HRSA’s FY2015 congressional budget justification. These documents are available at http://www.hhs.gov/budget/.
Note: Individual amounts may not add to subtotals or totals due to rounding.
a. Beginning in FY2012, funding for the Hansen’s Disease Programs appears under the Health Care Systems
budget account.
b. Health Workforce does not include the Home Health Aide Demonstration, which was authorized and
funded by ACA Sec. 5507(a). The demonstration received an annual appropriation of $5 million for each of
FY2010 through FY2012. [Note: The Bureau of Health Workforce was created in May 2014 by combining
the Bureau of Health Professions, which administered most of HRSA’s primary care training programs, and
the Bureau of Clinician Recruitment and Service, which administered the NHSC, NURSE Corps, and the
Faculty Loan Repayment Program.]
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c. The President’s FY2015 budget proposed a total of $3.950 billion in new mandatory funds over the period
FY2015-FY2020 to support the NHSC, including $400 million in FY2015.
d. Training for Diversity includes the fol owing programs: Centers for Excel ence, Scholarships for
Disadvantaged Students, and the Health Careers Opportunity Program.
e. Interdisciplinary, Community-Based Linkages includes the fol owing programs: Area Health Education
Centers (AHEC), Geriatric Programs, and Mental and Behavioral Health Education and Training.
f.
Total includes $6 million for State Health Workforce Development grants.
g. Nursing Workforce Development includes the fol owing programs: NURSE Corps (formerly the Nursing
Education Loan Repayment and Scholarship Program); Advanced Nursing Education; Nursing Workforce
Diversity; Nurse Education, Practice, Quality and Retention; Nurse Faculty Loan Program; and
Comprehensive Geriatric Education.
h. The President’s FY2015 budget proposed transferring a total of $5.230 billion from the Medicare Part A
trust fund over the 10-year period FY2015-FY2024, including $530 million in FY2015, for the new Targeted
Support for Graduate Medical Education Program. This program would incorporate the existing Children’s
Hospital GME program and the Teaching Health Center GME program (created by the ACA).
i.
Other Health Workforce Programs include Health Care Workforce Assessment, Oral Health Training, and
the Patient Navigator Program (funded through FY2011).
j.
As shown in the table, the ACA funded the Maternal, Infant, and Early Childhood Home Visiting Program
through FY2014. The President’s FY2015 budget proposed a total of $15 billion in new mandatory funds to
extend and expand the home visiting program through FY2024, including $500 million for FY2015. The
Protecting Access to Medicare Act of 2014 (P.L. 113-93), which was enacted after the FY2015 budget was
released, appropriated $400 million for the home visiting program for FY2015.
k. The ACA appropriated $5 million for each of FY2010 through FY2012 for Family-to-Family Health
Information Centers. Subsequently, the American Taxpayer Relief Act of 2012 (P.L. 112-240) appropriated
$5 million for FY2013, and the Pathway for SGR Reform Act of 2013 (P.L. 113-67, Division B) appropriated
$2.5 million for the first half of FY2014. The Protecting Access to Medicare Act of 2014 (P.L. 113-93), which
was enacted after the FY2015 budget was released, appropriated $2.5 million for the second half of FY2014
and $2.5 million for the first half of FY2015.
l.
Other Maternal and Child Health Programs include Autism and Other Developmental Disorders, Traumatic
Brain Injury, Sickle Cell Services Demonstration, Universal Newborn Hearing Screening, Emergency Medical
Services for Children, and Heritable Disorders.
m. Health Care Systems Programs include Organ Transplantation, National Cord Blood Inventory, C.W. Bil
Young Cel Transplantation Program, Poison Control Centers, and the 340B Drug Pricing Program.
Indian Health Service (IHS)
Agency Overview
IHS provides health care for approximately 2.2 million eligible American Indians/Alaska Natives
through a system of programs and facilities located on or near Indian reservations, and through
contractors in certain urban areas.68 IHS provides services to members of 566 federally
recognized tribes either directly or through facilities and programs operated by Indian Tribes or
Tribal Organizations through self-determination contracts and self-governance compacts
authorized in the Indian Self-Determination and Education Assistance Act (ISDEAA).69
68 For more information about the Indian Health Service (IHS), see CRS Report R43330, The Indian Health Service
(IHS): An Overview, by Elayne J. Heisler.
69 P.L. 93-638; 25 U.S.C. §§450 et seq.
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The Snyder Act of 192170 provides general statutory authority for IHS.71 In addition, specific IHS
programs are authorized by two acts: the Indian Sanitation Facilities Act of 195972 and the Indian
Health Care Improvement Act (IHCIA).73 The Indian Sanitation Facilities Act authorizes the IHS
to construct sanitation facilities for Indian communities and homes, and IHCIA authorizes
programs such as urban health, health professions recruitment, and substance abuse and mental
health treatment, and permits IHS to receive reimbursements from Medicare, Medicaid, the State
Children’s Health Insurance Program (CHIP), the Department of Veterans Affairs (VA), and third-
party insurers.
As discussed earlier, IHS receives its appropriations through the Interior/Environment
appropriations act, not the Labor-HHS-ED appropriations act. Also, IHS funding is not subject to
the PHS Program Evaluation Set-Aside.
FY2010-FY2014 Funding
Program level funding for the IHS increased by $318 million (6.2%) from $5.100 billion in
FY2010 to $5.418 billion in FY2012. Funding declined in FY2013 by $111 million (2.1%) to
$5.307 billion because of the sequestration of discretionary budget authority, but then increased
by $454 million (8.6%) in FY2014 to $5.761 billion. Overall, IHS program level funding
increased by $661 million (13%) between FY2010 and FY2014 (see Table 6).
The majority of these increases were used to fund additional clinical services, including providing
additional funding for purchased/referred care. The purchased/referred care program—formerly
the contract health service (CHS) program—purchases essential health services from local and
community health care providers when IHS cannot provide medical care and specific services
through its own system. In general, funding has not allowed the program to meet all requests, so
IHS prioritizes payments based on relative medical need and denies other requests. Decreasing
the number of denied requests has been a priority.74
The increase in IHS appropriations is also providing additional funding for contract support costs
(CSCs). CSC funding goes to tribes to help pay for administering IHS-funded programs under
70 P.L. 67-85, as amended; 25 U.S.C. §13.
71 The Snyder Act established this authority as part of the Bureau of Indian Affairs within the Department of the
Interior. The Transfer Act of 1954 (P.L. 83-568) transferred this authority to the U.S. Surgeon General within the
Department of Health, Education, and Welfare (now the Department of Health and Human Services).
72 P.L. 86-121; 42 U.S.C. §2004a.
73 P.L. 94-437, as amended; 25 U.S.C. §§1601 et seq., and 42 U.S.C. §§1395qq and 1396j (and amending other
sections). This act was permanently reauthorized as part of the ACA. 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.
74 See U.S. Dept. of Health and Human Services, Indian Health Service, Fiscal Year 2014 Indian Health Service
Justification of Estimates, p. CJ-142, http://www.ihs.gov/BudgetFormulation/documents/
FY2014BudgetJustification.pdf. The Senate Committee on Indian Affairs has also held hearings on this program and
noted that IHS should work to reduce the number of denials. See U.S. Congress, Senate Committee on Indian Affairs,
Access to Contract Health Services in Indian Country, 110th Cong., 2nd sess., June 26, 2008, S.Hrg.110-519
(Washington: GPO, 2008). GAO has also released reports on the CHS program. See, for example, GAO-13-272, Indian
Health Service: Capping Payments for Nonhospital Services Could Save Millions of Dollars for Contract Health
Services, 13-272, April 11, 2013, http://www.gao.gov/products/GAO-13-272.
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self-determination contracts or self-governance compacts authorized by ISDEAA.75 CSC funding
pays for the costs that tribes incur for such items as financial management, accounting, training,
and program start-up. Shortfalls in funding for the CSC program have resulted in reduced
services or decreased administrative efficiency for tribes with contracts and compacts.76 A 2012
Supreme Court decision in Salazar v. Ramah Navajo77 found that a lack of sufficient
appropriations does not release the federal government from its obligation to provide adequate
contract support costs.78 IHS works with Indian Tribes and Tribal Organizations to allocate the
CSC increase, to determine appropriate CSC levels in future years, and to balance CSC priorities
with any offsets in funding for direct health care services for IHS beneficiaries.
The IHS’s FY2013 appropriation initially was above the FY2012 level. But the FY2013
sequestration reduced that appropriation to an amount that was $175 million (4.1%) below the
FY2012 appropriation (see Table 6). This decrease was not expected because the BBEDCA
sequestration rules include a 2% limit on cuts to IHS.79 However, as noted earlier in this report,
OMB determined that the 2% limit applied only to IHS’s mandatory (i.e., diabetes) funding; the
agency’s discretionary appropriation was fully sequestrable, resulting in a 5% reduction (see
Table 1).80 Although IHS collected more in reimbursements in FY2013 than it did in FY2012—
an additional $67 million—the increase in those funds, which are exempt from sequestration, was
not sufficient to offset the amount reduced by the sequestration (see Table 6).
The FY2014 IHS budget increased funding for IHS above both the FY2013 and FY2012
operating levels. Specifically, it continued funding increases in clinical services—mainly
allocated to increase funding for purchased/referred care—and CSCs. IHS also expects that the
trend of increasing third-party collections will continue. As a result of the ACA’s implementation,
the IHS is expecting increased reimbursements from Medicare, Medicaid, CHIP, and other third-
party insurers for services provided at IHS-funded facilities. Specifically, IHS is expecting that
collections will increase by approximately $151 million because additional IHS beneficiaries will
be eligible for Medicaid81 and because some will enroll in private insurance offered through the
exchanges established by the ACA.82 IHS also is projecting increased collections from the VA. It
estimates that it will receive $36 million from the VA in FY2014.
75 25 U.S.C. §§450 et seq.
76 See GAO, Indian Self-Determination Act: Shortfalls in Indian Contract Support Costs Need to Be Addressed,
GAO/RCED-99-150, June 1999, http://www.gao.gov/archive/1999/rc99150.pdf.
77 Salazar v. Ramah Navajo, No. 11-551, slip op. (June 18, 2012), available at http://www.supremecourt.gov/opinions/
11pdf/11-551.pdf.
78 CRS Report WSLG119, Supreme Court Holds the Government Liable for Contract Support Costs in Indian Self-
Determination Contracts Even When Congress Fails to Appropriate Adequate Funds, by Jane M. Smith.
79 Rob Carpiccioso, “A Miscalculation on the Sequester Has Already Harmed Indian Health,” Indian Country, March
11, 2013, http://indiancountrytodaymedianetwork.com/2013/03/11/miscalculation-sequester-has-already-harmed-
indian-health-148110.
80 See CRS Report R42050, Budget “Sequestration” and Selected Program Exemptions and Special Rules, coordinated
by Karen Spar.
81 This would only occur in states where the Medicaid program is expanded. See CRS Report R41210, Medicaid and
the State Children’s Health Insurance Program (CHIP) Provisions in ACA: Summary and Timeline, by Evelyne P.
Baumrucker et al.
82 IHS beneficiaries are exempt from the ACA requirement to have insurance coverage; however, ACA included
provisions that would make it easier for IHS beneficiaries who choose to participate in a health insurance plan through
the exchanges. Specifically, IHS beneficiaries have a special enrollment period for health insurance plans offered
through the exchanges and, if their incomes are not more than 300% of the federal poverty level, are exempt from cost-
(continued...)
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FY2015 President’s Budget Request
The FY2015 President’s Budget would increase the IHS’s program level funding by $228 million
(4.0%) from $5.761 billion to $5.989 billion (see Table 6). This is primarily due to the agency’s
request for more appropriations. But is also reflects continued growth in third-party collections.
The agency’s discretionary budget authority would increase by $199 million (4.6%) to $4.634
billion from the FY2014 level of $4.435 billion. The additional funds would be mainly used to
increase funding for clinical services, including purchased/referred care. Additional funds also
would be allocated for preventive health services, CSCs, and for staffing and operations at newly
constructed IHS facilities.
Under the President’s Opportunity, Growth, and Security Initiative,83 IHS would receive an
additional $200 million for construction projects. These amounts are not included in Table 6.
Table 6. Indian Health Service (IHS)
(Millions of Dollars, by Fiscal Year)
2015
Program or Activity
2010
2011
2012
2013
2014
req.
Clinical and Preventive Services
4,139
4,171
4,335
4,277
4,566
4,746
Clinical Services
3,845a 3,877b 4,038c 3,987d 4,271e 4,440f
Purchased/Referred Care (non-add)g
(779) (780) (844) (801) (879) (929)
Preventive
Health
144 144 147 143 148 156
Special Diabetes Program for Indiansh
150 150 150 147 147 150
Other
Health
Services
560 559 636 603 735 772
Urban
Health
Projects
43 43 43 41 41 41
Indian
Health
Professions
41 41 41 38 33 38
Tribal
Management/Self-Governance
9 9 9 8 6 8
Direct
Operations
69 69 72 68 68 68
Contract
Support
Costs
398 398 471 448 587 617
Health
Facilities
401 411 448 427 460 470
Maintenance and Improvement
60i 60i 61j 59j 62k 62k
Sanitation
Facilities
Construction
96 96 80 75 79 79
Health Care Facilities Construction
29
39
85
77
85
85
Facilities/Environmental Health Support
193 193 199 194 211 221
(...continued)
sharing when enrolled in a plan offered through an exchange. In addition, IHS beneficiaries, like the general
population, are eligible for income-determined subsidies to purchase insurance. See CRS Report R41152, Indian
Health Care: Impact of the Affordable Care Act (ACA), by Elayne J. Heisler.
83 This $56 billion discretionary spending initiative, split evenly between defense and nondefense spending, was
proposed in the President’s FY2015 Budget. It would provide additional funding in, and investments for, a broad range
of programs designed to spur economic growth and strengthen national security. The cost would be offset by a mix of
spending and tax reforms. For more information, see http://www.whitehouse.gov/omb/budget.
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2015
Program or Activity
2010
2011
2012
2013
2014
req.
Medical
Equipment
23 23 23 21 23 23
Total, Program Level
5,100
5,140
5,418
5,307
5,761
5,989
Less Funds from Other Sources
Col ections
891 915 954 1,021 1,172 1,197
Rental of Staff Quarters
6
6
8
8
8
8
Special Diabetes Program for Indiansh
150 150 150 147 147 150
Total, Discretionary Budget Authority
4,052
4,069
4,306
4,131
4,435
4,634
Sources: Funding amounts for FY2010, FY2011, and FY2012 are taken from IHS’s FY2012, FY2013, and FY2014
congressional budget justification documents, respectively. Funding amounts for FY2013, FY2014, and FY2015
are taken from the FY2015 HHS Budget in Brief. These documents are available at http://www.hhs.gov/budget/.
Notes: Individual amounts may not add to subtotals or totals due to rounding.
a. Includes $891 million in collections from Medicare, Medicaid, CHIP, private insurance, and other programs.
b. Includes $915 million in collections from Medicare, Medicaid, CHIP, private insurance, and other programs.
c. Includes $954 million in collections from Medicare, Medicaid, CHIP, private insurance, and other programs.
d. Includes an estimated $1,021 million in collections from Medicare, Medicaid, CHIP, private insurance, and
other programs.
e. Includes an estimated $1,172 million in collections from Medicare, Medicaid, CHIP, the Department of
Veterans Affairs, private insurance, and other programs.
f.
Includes an estimated $1,197 million in collections from Medicare, Medicaid, CHIP, the Department of
Veterans Affairs, private insurance, and other programs.
g. This was previously referred to as “Contract Health Services.”
h. PHSA Sec. 330C provides an annual appropriation of $150 million through FY2015 for this program. These
mandatory funds are subject to a 2% sequestration.
i.
Includes $6 million that IHS received from rental of staff quarters.
j.
Includes $8 million that IHS received from rental of staff quarters.
k. Includes $8 million that IHS estimates the agency will receive from rental of staff quarters.
National Institutes of Health (NIH)
Agency Overview
NIH is the primary agency of the federal government charged with performing and supporting
biomedical and behavioral research. Its activities cover a wide range of basic, clinical, and
translational research, as well as research training and health information collection and
dissemination. The agency is organized into 27 research institutes and centers, headed by the NIH
Director. The Office of the Director (OD) sets overall policy for NIH and coordinates the
programs and activities of all NIH components, particularly in areas of research that involve
multiple institutes. The institutes and centers (collectively called ICs) focus on particular diseases,
areas of human health and development, or aspects of research support. Each IC plans and
manages its own research programs in coordination with the Office of the Director.
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The bulk of NIH’s budget, about 83%, goes out to the extramural research community through
grants, contracts, and other awards. The funding supports research performed by more than
300,000 non-federal scientists and technical personnel who work at more than 2,500 universities,
hospitals, medical schools, and other research institutions around the country and abroad.84 A
smaller proportion of the budget, about 11%, supports the intramural research programs of the
NIH institutes and centers, funding research performed by NIH scientists and non-employee
trainees in the NIH laboratories and Clinical Center. The remaining 6% funds various research
management, support, and facilities’ needs.
NIH derives its statutory authority from the PHSA. Title III, Section 301 of the PHSA grants the
Secretary of HHS broad permanent authority to conduct and sponsor research. In addition, Title
IV, “National Research Institutes,” authorizes in greater detail various activities, functions, and
responsibilities of the NIH Director and the institutes and centers. All of the ICs are covered by
specific provisions in the PHSA, but they vary considerably in the amount of detail included in
the statutory language. There are few time-and-dollar authorization levels specified for individual
activities. Congress mandated a significant reorganization of IC responsibilities in the FY2012
Consolidated Appropriations Act (P.L. 112-74, Division F) by creating a new National Center for
Advancing Translational Sciences (NCATS) and eliminating the National Center for Research
Resources (NCRR). Activities relating to translational sciences from NCRR and many other ICs
were consolidated in NCATS, and NCRR’s other programs were moved to several other ICs and
the OD.
As shown in Table 7, the annual Labor-HHS-ED appropriations act provides separate
appropriations to 24 of the ICs, the OD, and the Buildings and Facilities account. NIH receives
additional funds from the Interior/Environment appropriations act and from a mandatory
appropriation for type 1 diabetes research.
FY2010-FY2014 Funding
In program level funding, the FY2010 total of $31.243 billion for NIH was higher than funding in
each of the four following years (see Table 7). Program level funding declined by $317 million
(1.0%) from FY2010 to FY2011 and further decreased by $66 million (0.2%) to $30.860 billion
in FY2012. As a result of the FY2013 sequestration of discretionary funding and other
adjustments, NIH’s program level funding for that fiscal year was $1.709 billion (5.5%) below
FY2012.85 The Consolidated Appropriations Act, 2014, (P.L. 113-76) provided NIH with a
program level total of $30.150, a $1 billion increase over the FY2013 post-sequestration level but
still almost $1 billion below the FY2010 program level.
The ICs have shared about equally in the increases and decreases each year. A few programs that
were moved in the NCATS/NCRR reorganization have received additional emphasis, and an HHS
initiative on Alzheimer’s disease research has brought additional funding to the National Institute
84 U.S. Department of Health and Human Services, FY2015 Budget in Brief, March 4, 2014, p. 39, http://www.hhs.gov/
budget/fy2015/fy-2015-budget-in-brief.pdf.
85 The FY2010 and FY2011 appropriations included about $300 million each that did not remain with NIH. Funds for
the U.S. contribution to the Global Fund to Fight AIDS, Tuberculosis, and Malaria were appropriated to NIH (in the
account for NIAID, the National Institute of Allergy and Infectious Diseases) but were then transferred to non-HHS
agencies that manage overseas assistance programs. Since FY2012 Congress has appropriated Global Fund money
directly to the relevant agencies.
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on Aging (NIA). In FY2013, the initial enacted appropriation gave NIH a slight increase over
FY2012 by adding funding for the OD. The FY2013 sequestration, however, reduced each NIH
account by about 5%, and an HHS transfer under the Secretary’s authority resulted in a further
reduction of $173 million (about 0.55% from each IC and a larger amount from OD).
The main funding mechanism for supporting extramural research is research project grants
(RPGs), which are competitive, peer-reviewed, and largely investigator-initiated. In FY2013, NIH
supported a total of 34,840 RPGs, including 8,234 in the “new and competing awards” category.
In FY2014, NIH expects to support 34,213 RPGs, including 8,997 competing awards.86
FY2015 President’s Budget Request87
The FY2015 President’s Budget requested a program level total of $30.362 billion for NIH, $211
million (0.7%) more than the comparable FY2014 amount of $30.151 billion (see Table 7). In
FY2015 NIH estimates that it will be able to support 34,197 RPGs, including 9,326 new and
competing awards. Most of the institutes and ICs would receive essentially level funding in the
request compared to FY2014 with very few exceptions such as a $50 million (9%) increase for
the Common Fund and a $25 million (4%) increase for NCATS. The Common Fund supports
research in emerging areas of scientific opportunity, public health challenges, or knowledge gaps
that might benefit from collaboration between two or more institutes or centers.
Under the President’s Opportunity, Growth, and Security Initiative,88 NIH would receive an
additional $970 million, increasing the NIH budget to a total program level of $31.3 billion in
FY2015 (these amounts are not reflected in Table 7). The additional funds would provide support
for 650 new grants in FY2015 as well as added resources for certain specific topic areas, such as
the multi-agency Brain Research through Application of Innovative Neurotechnologies (BRAIN)
initiative, sharing and analysis of complex data sets, and Alzheimer’s disease research and
vaccine development.89
86 U.S. Department of Health and Human Services, FY2015 Budget in Brief, March 4, 2014, p. 43, http://www.hhs.gov/
budget/fy2015/fy-2015-budget-in-brief.pdf.
87 For additional details, see the NIH section of CRS Report R43086, Federal Research and Development Funding:
FY2014, coordinated by John F. Sargent Jr.
88 This $56 billion discretionary spending initiative, split evenly between defense and nondefense spending, was
proposed in the President’s FY2015 Budget. It would provide additional funding in, and investments for, a broad range
of programs designed to spur economic growth and strengthen national security. The cost would be offset by a mix of
spending and tax reforms. For more information, see http://www.whitehouse.gov/omb/budget.
89 For further background on NIH, see CRS Report R41705, The National Institutes of Health (NIH): Background and
Congressional Issues, by Judith A. Johnson, and for current funding information, see the NIH section of CRS Report
R43086, Federal Research and Development Funding: FY2014, coordinated by John F. Sargent Jr.
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Table 7. National Institutes of Health (NIH)
(Millions of Dollars, by Fiscal Year)
2015
Institutes and Centers (ICs)
2010a
2011b
2012c
2013
2014
req.
Cancer
(NCI)
5,098 5,059 5,067 4,783 4,923 4,931
Heart/Lung/Blood
(NHLBI)
3,094 3,070 3,076 2,900 2,983 2,988
Dental/Craniofacial
Research
(NIDCR)
413 410 410 387 397 397
Diabetes/Digestive/Kidney (NIDDK)d
1,959 1,942 1,945 1,835 1,881 1,893
Neurological
Disorders/Stroke
(NINDS)
1,634 1,622 1,625 1,532 1,586 1,608
Allergy/Infectious Diseases (NIAID)e
4,815 4,776 4,486 4,230 4,393 4,423
General
Medical
Sciences
(NIGMS)
2,048 2,034 2,428 2,291 2,362 2,369
Child
Health/Human
Development
(NICHD)
1,327 1,318 1,320 1,245 1,281 1,283
Eye
(NEI)
706 701 702 656 674 675
Environmental
Health
Sciences
(NIEHS)
695 684 685 646 665 665
NIEHS, Interior/Environmentf
79 79 79 75 77 77
Aging
(NIA)
1,108 1,100 1,121 1,039 1,169 1,171
Arthritis/Musculoskeletal/Skin
(NIAMS)
538 534 535 505 519 520
Deafness/Communication
Disorders
(NIDCD)
418 415 416 392 403 404
Mental
Health
(NIMH)
1,494 1,477 1,479 1,394 1,417 1,440
Drug
Abuse
(NIDA)
1,067 1,051 1,052 992 1,016 1,023
Alcohol
Abuse/Alcoholism
(NIAAA)
462 458 459 433 445 446
Nursing
Research
(NINR)
145 144 145 136 140 140
Human
Genome
Research
(NHGRI)
524 511 513 483 497 498
Biomedical
Imaging/Bioengineering
(NIBIB)
316 314 338 319 326 329
Minority
Health/Health
Disparities
(NIMHD)
211 210 276 260 268 268
Complementary/Alternative
Med
(NCCAM)
129 128 128 121 124 125
[former] Ctr for Research Resources (NCRR)
1,267
1,258
—
—
—
—
Advancing
Translational
Sciences
(NCATS)
— — 575 542 632 657
Fogarty
International
Center
(FIC)
70 69 70 66 67 68
National Library of Medicine (NLM)g
349 345 346 360 375 381
Office of Director (OD)
1,177
1,167
1,459
1,411
1,400
1,452
Buildings & Facilities (B&F)
100
50
125
118
129
129
Total, Program Level
31,243
30,926
30,860
29,151
30,151 30,362
Less Funds From Other Sources
PHS
Evaluation
Set-Aside
(NLM)
8 8 8 8 8 8
Type 1 Diabetes Research (NIDDK)d
150 150 150 142 139 150
Total, Discretionary Budget Authority
31,084
30,767
30,702
29,001
30,003
30,203
Sources: Funding amounts for FY2010 are taken from the NIH FY2012 congressional budget justification.
Amounts for FY2011 are from the FY2013 justification. Amounts for FY2012 are from the FY2014 justification,
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available (along with older years) at http://officeofbudget.od.nih.gov/. Funding amounts for FY2013, FY2014 and
FY2015 are from the FY2015 HHS Budget in Brief, http://www.hhs.gov/budget/fy2015/fy-2015-budget-in-brief.pdf.
Notes: FY2010 through FY2013 IC and NLM amounts are not comparable to FY2014 as they do not reflect
transfers from ICs to NLM. FY2010 and FY2011 are not adjusted for comparability for the NCATS/NCRR
reorganization. Totals may differ from the sum of the components due to rounding.
a. FY2010 reflects real transfer of $1 million from HHS Office of the Secretary to NIMH, $4.6 million transfer
to HRSA Ryan White program (Secretary’s authority), and transfers among ICs for the Genes, Environment,
and Health Initiative (NIH Director’s authority).
b. FY2011 reflects real transfer of almost $1 million from HHS Office of the Secretary to NIMH for the
Interagency Autism Coordinating Committee.
c. FY2012 reflects Secretary’s transfer of $8.727 million to HRSA for Ryan White AIDS and Secretary’s net
transfer of $18.273 million for Alzheimer’s disease research to NIA from other ICs.
d. NIDDK program level includes mandatory funds for type 1 diabetes research appropriated in PHSA Sec.
330B (provided by P.L. 110-275, P.L. 111-309, and P.L. 112-240). Funds have been appropriated through
FY2014 and are proposed for reauthorization in FY2015. The FY2013 and FY2014 amounts are post-
sequestration levels.
e. FY2010 and FY2011 amounts include funds appropriated to NIAID for transfer to the Global Fund to Fight
AIDS, Tuberculosis, and Malaria ($300 million in FY2010 and $297.3 million in FY2011); see report footnote
85. FY2010 amount includes BioShield transfer of $304 million; for more information, see CRS Report
R43607, The Project BioShield Act: Issues for the 113th Congress, by Frank Gottron.
f.
This is a separate account in the Interior/Environment appropriations act for NIEHS research activities
related to Superfund.
g. NLM program level includes $8 million in set-aside funds each year.
Substance Abuse and Mental Health Services
Administration (SAMHSA)
Agency Overview
SAMHSA is the lead federal agency for increasing access to behavioral health services.90 It
supports community-based mental health and substance abuse treatment and prevention services
through formula grants to the states and U.S. territories and through numerous competitive grant
programs that fund states, territories, tribal organizations, local communities, and private entities.
Under SAMHSA’ s charitable choice provisions, religious organizations are eligible to receive
funding in order to provide substance abuse services without altering their religious character.
The agency also collects information on the incidence and prevalence of mental illness and
substance abuse at the national and state levels.
SAMHSA and most of its programs and activities are authorized under Title V of the PHSA.
However, the agency’s two largest programs, the Substance Abuse Prevention and Treatment
(SAPT) block grant and the Community Mental Health Services (CMHS) block grant, which
together accounted for 63.5% of SAMHSA’s program-level funding in FY2014, are separately
authorized under PHSA Title XIX, Part B.
90 Unless otherwise noted, information in this section is summarized from CRS Report R41477, Substance Abuse and
Mental Health Services Administration (SAMHSA): Agency Overview and Reauthorization Issues, by C. Stephen
Redhead.
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Under PHSA Title V, SAMHSA is organized into three centers: the Center for Mental Health
Services (CMHS), the Center for Substance Abuse Treatment (CSAT), and the Center for
Substance Abuse Prevention (CSAP). Each center has general statutory authority, called
Programs of Regional and National Significance (PRNS), under which it has established grant
programs for states and communities to address their important substance abuse and mental
health needs. PRNS authorizes each center to fund projects that (1) translate promising new
research findings to community-based prevention and treatment services; (2) provide training and
technical assistance; and (3) target resources to increase service capacity where it is most needed.
In addition, PHSA Title V authorizes a number of specific grant programs, referred to as
categorical grants. The PHSA also directs SAMHSA to conduct data collection and analysis
activities related to mental health and substance abuse. The agency administers the National
Survey on Drug Use and Health (an annual survey that collects information about substance use
and related health topics) and publishes analyses of the survey data.
Most SAMHSA programs are administered by one of the three centers and focus on mental
health, substance abuse treatment, or substance abuse prevention. Some programs receive support
from more than one center. For example, CMHS and CSAT both support SAMHSA’s Behavioral
Health Treatment Court Collaboratives. Additional activities that fall outside the three centers
(e.g., collecting information on the incidence and prevalence of mental illness and substance
abuse) are categorized under Health Surveillance and Program Support.
Congress has not taken up comprehensive legislation to reauthorize SAMHSA since 2000, when
the agency and its programs were last reauthorized as part of the Children’s Health Act.91
However, Congress has added some new authorities to Title V and otherwise expanded a few
SAMHSA programs and activities in the past decade. Although authorizations of appropriations
for most of SAMHSA’s grant programs expired at the end of FY2003, many of these programs
continue to receive annual discretionary appropriations.
FY2010-FY2014 Funding
From FY2010 through FY2014, SAMHSA’s program-level funding increased slightly from
$3.583 billion to $3.631 billion, an increase of $48 million (1.3%). SAMHSA’s discretionary
budget authority, excluding set-aside funds and PPHF transfers, was virtually unchanged over that
period, increasing by just $4 million (0.1%) from $3.431 billion to $3.435 billion (see Table 8).
The agency’s discretionary appropriations declined each year—reaching a low point in FY2013
as a result of sequestration—before rebounding in FY2014 primarily as a result of increased
funding for mental health and the SAPT block grant.
In the Consolidated Appropriations Act, 2012 and the accompanying conference report,92
Congress rejected changes SAMHSA proposed to its budget structure in the FY2012 budget
request. Among other proposed changes, the FY2012 budget request would have combined most
of the existing PRNS activities and programs in the three centers into a single account for
Innovation and Emerging Issues. Congress directed that future budget requests reflect the
structure of the three centers, as well as an account labeled Health Surveillance and Program
Support to fund “program support and cross-cutting activities that supplement activities funded
91 P.L. 106-310, Titles XXXI-XXXIV, 114 Stat. 1168.
92 P.L. 112-74, Division F, Title II, 125 Stat. 1073; H.Rept. 112-331, pp. 1139-1142.
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under [the three centers, and] ... to carry out national surveys on drug abuse and mental health, to
collect and analyze program data, and to conduct public awareness and technical assistance
activities.”93 SAMHSA’s FY2013 and FY2014 budget requests reflected the structure requested
by Congress in P.L. 112-74.
FY2015 President’s Budget Request
The FY2015 request provides SAMHSA with $3,298 million in discretionary budget authority,
which is $137 million (4.0%) below the FY2014 amount of $3,435 million (see Table 8). The
request provides level funding for the mental health and SAPT block grants and other formula
grants, but reduces funding for PRNS activities and programs in the three centers. Those
reductions in discretionary budget authority are partially offset by an increase in set-aside funds.
Overall, the FY2015 request gives SAMHSA a program level total of $3,568 million, which is
$63 million (1.7%) below the FY2014 amount.
Table 8. Substance Abuse and Mental Health Services Administration (SAMHSA)
(Millions of Dollars, by Fiscal Year)
2015
Program or Activity
2010
2011
2012
2013
2014
req.
Center for Mental Health Services (CMHS)
1,005
1,022
994
910
1,080
1,057
Mental
Health
Block
Grant
421 420 460 437 484 484
PHS Evaluation Set-Aside (non-add)
(21) (21) (21) (21) (21) (21)
Programs of Regional & National Significance
361
384
316
267
378
355
PHS Evaluation Set-Aside (non-add)
—
—
—
—
—
(5)
PPHF Transfer (non-add)
(20)
(45) (45) — (12) (38)
Children’s
Mental
Health
Services
121 118 117 111 117 117
PATH
Homeless
Formula
Grant
65 65 65 61 65 65
Protection & Advocacy Formula Grant
36
36
36
34
36
36
Center for Substance Abuse Treatment
2,253
2,214
2,229
2,114
2,181
2,117
Substance Abuse Block Grant
1,799
1,783
1,800
1,710
1,820
1,820
PHS Evaluation Set-Aside (non-add)
(79) (79) (79) (79) (79) (79)
Programs of Regional & National Significance
452
431
429
404
361
297
PHS Evaluation Set-Aside (non-add)
(9)
(2)
(2)
(2)
(2)
(30)
PPHF Transfer (non-add)
—
(25)
(29)
—
(50)
—
Prescription Drug Monitoring (NASPER)a
2 — — — — —
Center for Substance Abuse Prevention
202
186
186
176
176
186
Programs of Regional & National Significance
202
186
186
176
176
186
PHS Evaluation Set-Aside (non-add)
—
—
—
—
—
(16)
Health Surveillance and Program Support
102
177
160
154
194
208
Health Surveillance and Program Support
102 171 124 123 120 122
PHS Evaluation Set-Aside (non-add)
(23) (29) (27) (27) (30) (29)
PPHF Transfer (non-add)
—
(18) (18) (15) — (20)
93 P.L. 112-74; 125 Stat. 1074.
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2015
Program or Activity
2010
2011
2012
2013
2014
req.
Public
Awareness
and
Support
— — 14 14 14 16
PHS Evaluation Set-Aside (non-add)
—
—
—
—
—
(16)
Performance & Quality Information Systems
—
—
13
9
13
13
PHS Evaluation Funds (non-add)
—
—
—
—
—
(13)
Agency-Wide
Initiatives
— 5 9 8 46 56
PHS Evaluation Set-Aside (non-add)
—
—
—
—
—
(1)
Data Request and Publications User Feesb
— — — — 2 2
St. Elizabeths Hospitalc
1 — — — — —
Total, Program Level
3,583
3,599
3,569
3,354
3,631
3,568
Less Funds From Other Sources
PHS
Evaluation
Set-Aside
132 132 130 130 133 211
PPHF
Transfers
20 88 92 15 62 58
Data Request and Publications User Fees
—
—
—
—
2
2
Total, Discretionary Budget Authority
3,431
3,380
3,347
3,210
3,435
3,298
Sources: The funding amounts for FY2010 are taken from SAMHSA’s FY2011 operating plan and FY2012
congressional budget justification document. The amounts for FY2011 are taken from the FY2013 HHS Budget in
Brief. The amounts for FY2012 are taken from SAMHSA’s FY2013 operating plan. The amounts for FY2013,
FY2014 and the FY2015 request are taken from the agency’s FY2015 congressional budget justification
documents. These documents are available at http://www.hhs.gov/budget/.
Notes: Individual amounts may not add to subtotals or totals due to rounding.
a. The Ful -Year Continuing Appropriations Act, 2011 (P.L. 112-10) prohibited the funding of grants original y
authorized under the National Al Schedules Prescription Electronic Reporting Act of 2005 (NASPER, P.L.
109-60) and first funded in FY2009. These grants have not been funded since FY2010. See CRS Report
R42593, Prescription Drug Monitoring Programs, by Kristin Finklea, Lisa N. Sacco, and Erin Bagalman.
b. SAMHSA has received authority to collect Data Request and Publications User Fees for extraordinary
requests that SAMHSA would not otherwise be able to fulfill using existing resources.
c. Upon the transfer of the West Campus of St. Elizabeths Hospital from HHS to the General Services
Administration (GSA) in 2004, HHS and GSA signed a Memorandum of Agreement that required (among
other things) HHS to pay for remediation (clean-up) of hazardous substances found on the site after the
date of transfer. Funding for this purpose has not been needed since FY2010.
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Appendix A. American Recovery and Reinvestment
Act (ARRA): FY2009 Supplemental Appropriations
Through ARRA, Congress appropriated a total of $22.4 billion in supplemental FY2009
discretionary appropriations for health and human services programs administered by HHS. Of
that total amount, $15.1 billion was provided directly to, or allocated for, programs and activities
administered by the PHS agencies (see text box below).94 Generally, the discretionary funds
appropriated under ARRA were intended to be time-limited. In most instances the funding was to
remain available for obligation through the end of FY2010 (i.e., September 30, 2010). Essentially
all the ARRA discretionary funds provided to HHS have been obligated.95
ARRA Funding for PHS Agency Programs
Agency for Healthcare Research and Quality (AHRQ): $1.1 billion
These funds were used to support comparative effectiveness research (now called patient-centered outcomes
research). Of the total amount: $300 million was administered by AHRQ; $400 million was transferred to NIH; and
the remaining $400 million was allocated at the discretion of the HHS Secretary and used primarily to develop the
infrastructure for comparative effectiveness research.
Health Resources and Services Administration (HRSA): $2.5 billion
These funds were used to support HRSA programs as follows: $1.5 billion for health center construction, renovation,
equipment, and health information technology (HIT); $500 million to support new health center delivery sites and
service areas and expand services at existing sites; $300 million for the National Health Service Corps; and $200
million for HRSA’s health workforce programs.
Indian Health Service (IHS): $500 million
These funds were used to support the following IHS facility and infrastructure projects: $227 million for health
facilities construction; $100 million for maintenance and improvement; $85 million for HIT activities; $68 million for
sanitation facilities construction; and $20 million for health equipment, including HIT. [Note: IHS received an
additional $90 million in ARRA discretionary funds from the Environmental Protection Agency for sanitation facilities
construction.]
National Institutes of Health (NIH): $10 billion
These funds were used to support NIH activities as follows: $8.2 billion for intramural and extramural scientific
research; $1.3 billion for extramural research facility construction, renovation, and equipment; and $500 million for
the construction, repair, and improvement of NIH’s facilities. NIH also received a transfer of $400 million from
AHRQ for comparative effectiveness research (see above).
Prevention and Wellness Fund: $1 billion
These funds were used as follows: $300 million for CDC’s immunization program; $50 million for CDC and CMS to
support state and local efforts to reduce health care-associated infections; and $650 million for CDC to support an
evidence-based clinical and community-based prevention and wellness program—Communities Putting Prevention to
Work (CPPW)—focused on increasing levels of physical activity, improving nutrition, reducing obesity rates, and
decreasing smoking prevalence and exposure to secondhand smoke.
94 P.L. 111-5, 123 Stat. 115. The HHS appropriations were included in Title VIII (Labor-HHS-ED) of Division A of
ARRA. In addition to these discretionary appropriations, ARRA included several HHS mandatory spending provisions.
For more information, see CRS Report R40537, American Recovery and Reinvestment Act of 2009 (P.L. 111-5):
Summary and Legislative History, by Clinton T. Brass et al.
95 HHS maintains a Recovery Act website at http://www.hhs.gov/recovery/. It includes detailed implementation plans
for all the ARRA-funded programs, up-to-date information on ARRA obligations and outlays (by state), and links to
the Recovery Act websites maintained by individual HHS agencies.
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Appendix B. Community Health Center Fund
ACA Section 10503 established a Community Health Center Fund (CHCF) to provide
supplemental funding for community and other health centers and the National Health Service
Corps (NHSC). The law provided annual appropriations to the CHCF totaling $11 billion over the
five-year period FY2011 through FY2015. Of that total, $9.5 billion is for health center
operations and the remaining $1.5 billion is for the NHSC.
Table B-1 shows the amounts appropriated for each fiscal year as well as the post-sequestration
levels for FY2013-FY2015. CHCF funds are awarded to the various types of health centers that
are supported by the federal health center program. Those include community health centers and
migrant health centers, as well as facilities that serve the homeless and residents of public
housing. As briefly discussed earlier in the report, OMB determined that sequestration of CHCF
funding for community health centers and migrant health centers is capped at 2%. CHCF funding
for the other types of facilities (i.e., health centers for the homeless and for public housing
residents) and for the NHSC is fully sequestrable at the applicable rate for nonexempt nondefense
mandatory spending (see Table 1).
While CHCF funding may have been intended to supplement—not supplant—annual
discretionary appropriations for the health center program and the NHSC, these mandatory funds
have partially supplanted discretionary funding for the health center program and entirely
replaced discretionary funding for the NHSC (see earlier discussion in the HRSA section of the
report).
Table B-1. Community Health Center Fund, FY2011-FY2015
(Millions of Dollars, by Fiscal Year)
Program
2011
2012
2013
2014
2015
Total
Health
Center
Program
1,000 1,200 1,500 2,200 3,600 9,500
Post-sequestration (non-add)
(1,465)
(2,145)
TBDa
National Health Service Corps
290
295
300
305
310
1,500
Post-sequestration
(non-add)
(285) (283) (287)
Total
1,290
1,495
1,800
2,505
3,910
11,000
Source: Prepared by CRS based on ACA Section 10503 and the HHS FY2015 Budget in Brief, available at
http://www.hhs.gov/budget/.
Note: The ACA also included a one-time appropriation of $1.5 billion for health center construction and
renovation. Those funds are separate from the CHCF and are not included in this table.
a. The post-sequestration amount of FY2015 CHCF funding for health centers will depend on the specific
al ocation of funds to the various types of health centers.
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Appendix C. Prevention and Public Health Fund
(PPHF)
Authority and Funding Allocation
ACA Section 4002 established the Prevention and Public Health Fund (PPHF), administered by
the HHS Secretary, and provided it with a permanent annual appropriation. Under the law,
PPHF’s annual appropriation increases from $500 million in FY2010 to $2 billion in FY2015 and
in each fiscal year thereafter. However, the Middle Class Tax Relief and Job Creation Act of
201296 amended the ACA by reducing the PPHF appropriation from FY2013 through FY2021 as
part of a package of offsets to partly cover the costs of the law. The PPHF annual appropriation is
now $1 billion through FY2017 and will increase to $2 billion in FY2022 and in each subsequent
fiscal year.
The HHS Secretary is instructed to transfer amounts from the PPHF to agencies for prevention,
wellness, and public health activities. The funds are available to the Secretary at the beginning of
each fiscal year. The Administration’s annual budget sets out the intended distribution and use of
PPHF funds for that fiscal year. The Secretary determined the distribution of PPHF funds for
FY2010 through FY2013. For FY2014 funds, Congress explicitly directed the Secretary to
distribute PPHF funds according to the FY2014 Consolidated Appropriation.97
As discussed earlier in the report, the PPHF appropriation is fully sequestrable at the applicable
percentage rate for nonexempt nondefense mandatory spending (see Table 1). Sequestration is
applied to the entire appropriation by the Secretary before funds are transferred to the agencies.
The distribution of PPHF funds to HHS agencies for FY2010 through the FY2015 President’s
budget proposal is presented in Table C-1. Further details regarding PPHF distributions to
AHRQ, CDC, HRSA, and SAMHSA are provided in the respective agency budget tables in the
body of this report.98
Scope of PPHF-Funded Activities
The terms “prevention,” “wellness,” and “public health activities,” which describe allowable
PPHF-funded activities, are not defined in the PHSA, ACA, or elsewhere in federal law. ACA
was not accompanied by committee reports in either chamber. Finally, HHS has not published
regulations, guidance, or other information to clarify the department’s views about the types of
activities that are within scope for PPHF funding.99
96 P.L. 112-96, Section 3205, 126 Stat. 194.
97 “Explanatory Statement Submitted by Mr. Rogers of Kentucky ... Regarding ... H.R. 3547, Consolidated
Appropriations Act, 2014,” Congressional Record, vol. 160, part 9 (January 15, 2014), pp. H-1041-H1042.
98 See also references to the PPHF in text and tables in CRS Report RL33880, Funding for the Older Americans Act
and Other Aging Services Programs, by Angela Napili and Kirsten J. Colello.
99 For more information about federal prevention activities and how they may be defined, see Government
Accountability Office, Available Information on Federal Spending, Cost Savings, and International Comparisons Has
Limitations, GAO-13-49, December 6, 2012, http://gao.gov/products/GAO-13-49.
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HHS published an annual report to Congress on PPHF spending for FY2012, as required by
law.100 The report notes spending (typically through grants or contracts) on the following types of
activities, among others: (1) community prevention activities to improve health and reduce
chronic disease risk factors, to reduce tobacco use, and to improve fitness and reduce obesity; (2)
clinical prevention activities to improve access to important preventive services and definitive
care for a variety of health needs; (3) behavioral health screening and integration with primary
care; (4) public health infrastructure, workforce, and training; and (5) public health research and
data collection. As shown in Table C-1, more than two-thirds of PPHF funds have been
distributed to CDC.
Table C-1. PPHF Transfers to HHS Agencies
(Millions of Dollars, by Fiscal Year)
Agency
Agency
2015
Total
Total (%)
Agency
2010
2011
2012
2013
2014
Proposala
2010-2014
2010-2014
ACL
0 0 20 9 28 28 57 1.3
AHRQ
6 12 12 7 7 0 43 1.0
CDC
192 611 809 463 831 810 2,906 68.4
CMS 0
0
0
454b 0 0 454b 10.7
HRSA
271 20 37 2 0 0 330 7.8
OS
12 19 30 0 0 105 61 1.4
SAMHSA 20 88 92 15 62 58 277 6.5
Sequestered
— — — 51 72 — — —
Total
500
750
1,000
1,000
1,000
1,000
4,250
100
Sources: Prepared by Congressional Research Service based on HHS agency congressional budget justifications
for FY2012 through FY2015, http://www.hhs.gov/budget/; and HHS, “Prevention and Public Health Fund,” funding
distribution tables, http://www.hhs.gov/open/recordsandreports/prevention/index.html.
Notes: Individual amounts may not add to totals due to rounding. ACL is the Administration for Community
Living; OS is the Office of the HHS Secretary.
a. Distribution proposed by the Administration. This is not a budget request, as PPHF funds have already been
appropriated. Amounts do not reflect the 7.3% sequestration (i.e., $73 million) for FY2015 required under
current law; see Table 1.
b. Funds were used for implementation of insurance exchanges under ACA. CMS, Justification of Estimates for
Appropriations Committees, Fiscal Year 2015, p. 349, http://www.hhs.gov/budget/.
Relationship to Annual Appropriations
In some cases, the Secretary has used, or proposed to use, PPHF funds to augment funds from
annual discretionary appropriations. For example, for FY2013, the Administration proposed using
the PPHF to fund almost the entire budget of the CDC Center on Birth Defects and
Developmental Disabilities.101 If PPHF funds were to become unavailable, appropriators would
100 HHS, “The Affordable Care Act and the Prevention and Public Health Fund: Report to Congress for FY2012,”
undated, http://www.hhs.gov/open/recordsandreports/prevention/fy2012_aca_rpt_to_congress.pdf.
101 CDC, Justification of Estimates for Congressional Committees, FY2013, February, 2012, p. 153,
http://www.cdc.gov/fmo.
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face a need to provide additional regular appropriations in order to sustain programmatic
activities.102
Recent funding trends for the CDC Chronic Disease Prevention and Health Promotion account
illustrate this point. This account has received sizeable PPHF distributions since funds first
became available for FY2010. As shown in Figure C-1, budget authority for the account has
decreased from its highest level in FY2009, before PPHF funds were available. However, the
program level increased from FY2010 through FY2012, due to the increasing transfers of PPHF
funds. The program level then decreased for FY2013, in part due to the decrease in budget
authority (BA) as a result of rescission and sequestration, but in larger part to the reduced PPHF
amount that resulted from a large PPHF transfer to CMS for ACA implementation, as shown in
Table C-1.103 Ultimately, the CMS transfer and its effect on the PPHF transfer to CDC had a
greater effect on the FY2013 operating budget for CDC Chronic Disease Prevention and Health
Promotion activities than did sequestration.104 In directing the allocation of FY2014 PPHF funds,
Congress in most cases provided PPHF funds to pre-existing programs and activities rather than
to programs and activities newly authorized under ACA.
102 John Reichard, “Advocates: CDC, Other Agencies Face Big Cuts Fast if Prevention Fund Ends,” CQ HealthBeat,
June 18, 2012.
103 Rachana Dixit, “HHS Sets Aside $454 Million in Prevention Funds for Insurance Enrollment Support,”
InsideHealthPolicy, April 16, 2013.
104 CDC describes the trends in budget authority and PPHF transfers for the agency as a whole in an FY2015 budget
fact sheet (p. 2) at http://www.cdc.gov/fmo/topic/Budget%20Information/FY-2015-Fact-Sheets/CDC-Overview.pdf.
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Figure C-1. Funding for CDC Chronic Disease Prevention and Health Promotion,
FY2008-FY2015
Dollars in millions
Source: Prepared by Congressional Research Service from CDC, Justification of Estimates for Congressional
Committees, FY2013, p. 120; FY2014, p. 138; and FY2015, p. 129, all at http://www.cdc.gov/fmo.
Notes: ARRA is the American Recovery and Reinvestment Act of 2009 (see Appendix A). PPHF is the ACA
Prevention and Public Health Fund. BA is discretionary budget authority. PB is President’s budget. FY2012,
FY2013, FY2014, and FY2015 amounts have been made comparable to reflect a planned budget realignment for
the CDC Working Capital Fund. These amounts are not strictly comparable to amounts for earlier fiscal years.
Amounts for FY2013 and FY2014 reflect sequestration, which affected both BA and PPHF funds for FY2013, and
PPHF funds for FY2014.
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Appendix D. Patient-Centered Outcomes Research
Trust Fund
Section 6301(e) of the ACA established the Patient-Centered Outcomes Research Trust Fund
(PCORTF) to support comparative clinical effectiveness research at both HHS and the Patient-
Centered Outcomes Research Institute (PCORI).105 The law provided annual funding to the
PCORTF over the period FY2010-FY2019 from the following three sources: (1) annual
appropriations; (2) fees on health insurance and self-insured plans; and (3) transfers from the
Medicare Part A and Part B Trust Funds.
Specifically, the ACA appropriated the following amounts to the PCORTF: (1) $10 million for
FY2010; (2) $50 million for FY2011; and (3) $150 million for each of FY2012 through FY2019.
In addition, for each of FY2013 through 2019, the ACA appropriated an amount equivalent to the
net revenues from a new fee that the law imposes on health insurance policies and self-insured
plans. For policy/plan years ending during FY2013, the fee equals $1 multiplied by the number of
covered lives. For policy/plan years ending during each subsequent fiscal year through FY2019,
the fee equals $2 multiplied by the number of covered lives. Finally, transfers to PCORTF from
the Medicare Part A and Part B trust funds are calculated by multiplying the average number of
individuals entitled to benefits under Medicare Part A, or enrolled in Medicare Part B, by $1 (for
FY2013) or by $2 (for each of fiscal years 2014 through 2019).
For each of FY2011 through FY2019, the ACA requires 80% of the PCORTF funds to be made
available to PCORI, and the remaining 20% of funds to be transferred to the HHS Secretary for
carrying out PHSA Section 937.106 Of the total amount transferred to HHS, 80% is to be
distributed to AHRQ. Table D-1 shows the allocation of PCORTF funds through FY2015.
Table D-1. Distribution of PCORTF Funding
(Millions of Dollars, by Fiscal Year)
2014
2015
Funding Recipient
2010
2011
2012
2013
est.
est.
PCORI
10 40 120 289 543 528
HHS
— 10 30 72 136 132
AHRQ (non-add)
—
(8) (24) (58) (109) (106)
Office of the Secretary (non-add)
—
(2) (6) (14) (27) (26)
Total
10
50
150
361
679
660
Source: CRS calculations using data provided in Office of Management and Budget, Fiscal Year 2015, Appendix,
Budget of the U.S. Government, p. 1358.
105 PCORI (established by ACA Section 6301(a), adding new SSA Section 1181) is a non-governmental body
authorized by Congress to evaluate existing research and to conduct original research examining the relative health
outcomes, clinical effectiveness, and appropriateness of different medical treatments.
106 ACA Section 6301(b) added a new PHSA Section 937 requiring the broad dissemination of research findings
published by PCORI.
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Appendix E. FDA User Fee Authorizations
Table E-1. FDA User Fee Authorizations and Revenue
(Dollars in Millions, In Order of FY2014 Anticipated Revenue)
FY2014
User Fee
Initial Authorizing Legislation and Year
Revenue
Prescription drug
Prescription Drug User Fee Act (PDUFA), 1992
760
(P.L. 102-300)
Tobacco product
Family Smoking Prevention and Tobacco Control Act, 2009
534
(P.L. 111-31)
Generic drug
Food and Drug Administration Safety and Innovation Act (FDASIA), 2012
306
(P.L. 112-144)
Medical device
Medical Device User Fee and Modernization Act (MDUFMA), 2002
115
(P.L. 107-250)
Animal drug
Animal Drug User Fee Act (ADUFA), 2003
24
(P.L. 108-130)
Biosimilars
Food and Drug Administration Safety and Innovation Act (FDASIA), 2012
21
(P.L. 112-144)
Mammography Mammography
Quality Standards Act (MQSA), 1992
19
(P.L. 102-539)
Food reinspection
Food Safety Modernization Act (FSMA), 2011
15
(P.L. 111-353)
Food recal
Food Safety Modernization Act (FSMA), 2011
13
(P.L. 111-353)
Color certification
Color Additive Amendments of 1960
7
(P.L. 86-618)
Animal generic drug
Animal Generic Drug User Fee Act (AGDUFA), 2008
7
(P.L. 110-316)
Export certification
FDA Export Reform and Enhancement Act of 1996 [for medical products]
5
(P.L. 104-134);
Food Safety Modernization Act (FSMA), 2011 [for foods]
(P.L. 111-353)
Priority review
Food and Drug Administration Amendments Act (FDAAA), 2007
0
with vouchera
(P.L. 110-85)
Voluntary qualified
Food Safety Modernization Act (FSMA), 2011
0
importer (VQIP)b
(P.L. 111-353)
Total
1,826
Source: Prepared by CRS.
a. The appropriations act for FY2009 was the first to authorize priority review user fees to be assessed when
a sponsor submitted an application using a priority review voucher that FDA had issued after it approved an
New Drug Application (from the same or another sponsor) for a tropical disease. Congress added a second
opportunity for a priority review voucher in return for an approved NDA for a rare pediatric disease. FDA
collected a priority review fee only once, in 2012.
b. No appropriations have yet been authorized for VQIP.
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Public Health Service Agencies: Overview and Funding
Author Contact Information
C. Stephen Redhead, Coordinator
Sarah A. Lister
Specialist in Health Policy
Specialist in Public Health and Epidemiology
credhead@crs.loc.gov, 7-2261
slister@crs.loc.gov, 7-7320
Erin Bagalman
Amanda K. Sarata
Analyst in Health Policy
Specialist in Health Policy
ebagalman@crs.loc.gov, 7-5345
asarata@crs.loc.gov, 7-7641
Elayne J. Heisler
Susan Thaul
Analyst in Health Services
Specialist in Drug Safety and Effectiveness
eheisler@crs.loc.gov, 7-4453
sthaul@crs.loc.gov, 7-0562
Judith A. Johnson
Specialist in Biomedical Policy
jajohnson@crs.loc.gov, 7-7077
Acknowledgments
The figures in the funding tables in this report were by reviewed by Leah Rosenstiel, Research Assistant.
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