Discretionary Spending Under the Affordable
Care Act (ACA)

C. Stephen Redhead, Coordinator
Specialist in Health Policy
Kirsten J. Colello
Specialist in Health and Aging Policy
Elayne J. Heisler
Specialist in Health Services
Sarah A. Lister
Specialist in Public Health and Epidemiology
Amanda K. Sarata
Specialist in Health Policy
October 28, 2014
Congressional Research Service
7-5700
www.crs.gov
R41390


Discretionary Spending Under the Affordable Care Act (ACA)

Summary
The Patient Protection and Affordable Care Act (Affordable Care Act, or ACA) reauthorized
funding for numerous existing discretionary grant programs administered by the Department of
Health and Human Services (HHS). The ACA also created many new discretionary grant
programs and provided for each an authorization of appropriations. Generally, the law authorized
(or reauthorized) appropriations through FY2014 or FY2015. This report summarizes all the
discretionary spending provisions in the ACA. A companion product, CRS Report R41301,
Appropriations and Fund Transfers in the Affordable Care Act (ACA), summarizes all the
mandatory appropriations in the law.
Among the provisions that are intended to strengthen the nation’s health care safety net and
improve access to care, the ACA permanently reauthorized the federal health centers program and
the National Health Service Corps (NHSC). The NHSC provides scholarships and student loan
repayments to individuals who agree to a period of service as a primary care provider in a
federally designated Health Professional Shortage Area. In addition, the ACA addressed concerns
about the current size, specialty mix, and geographic distribution of the health care workforce. It
reauthorized and expanded existing health workforce education and training programs under
Titles VII and VIII of the Public Health Service Act (PHSA). Title VII supports the education and
training of physicians, dentists, physician assistants, and public health workers through grants,
scholarships, and loan repayment. The ACA created several new programs to increase training
experiences in primary care, in rural areas, and in community-based settings, and provided
training opportunities to increase the supply of pediatric subspecialists and geriatricians. It also
expanded the nursing workforce development programs authorized under PHSA Title VIII.
As part of a comprehensive framework for federal community-based public health activities,
including a national strategy and a national education and outreach campaign, the ACA
authorized several new grant programs with a focus on preventable or modifiable risk factors for
disease (e.g., sedentary lifestyle, tobacco use). The new law also leveraged a number of
mechanisms to improve health care quality, including new requirements for quality measure
development, collection, analysis, and public reporting; programs to develop and disseminate
innovative strategies for improving the quality of health care delivery; and support for care
coordination programs such as medical homes and the co-location of primary health care and
mental health services. Additionally, the ACA authorized funding for programs to prevent elder
abuse, neglect, and exploitation; grants to expand trauma care services and improve regional
coordination of emergency services; and demonstration projects to implement alternatives to
current tort litigation for resolving medical malpractice claims, among other provisions.
The Congressional Budget Office estimated that the ACA’s discretionary spending provisions, if
fully funded by appropriations acts, would result in appropriations of approximately $100 billion
over the 10-year period FY2012-FY2021. Much of that funding would be for discretionary
programs that existed prior to, and whose funding was reauthorized by, the ACA. While most of
those existing discretionary programs continue to receive an annual discretionary appropriation,
albeit at levels below the amounts authorized by the law, few of the new grant programs
authorized under the ACA have received any discretionary funding. However, several of the new
programs have received mandatory funds from the ACA. This report is periodically revised and
updated to reflect important legislative and other developments.

Congressional Research Service

Discretionary Spending Under the Affordable Care Act (ACA)

Contents
Introduction ...................................................................................................................................... 1
Discretionary Spending Under the ACA.......................................................................................... 2
Authorizations of Appropriations for Grant Programs .............................................................. 2
Expired or Expiring Authorizations of Appropriations ....................................................... 5
Administrative Spending on Health Insurance Exchanges ........................................................ 5
Recent Actions to Reduce Discretionary Spending ......................................................................... 7
Trends in Nondefense Discretionary Spending ............................................................................... 7

Tables
Table 1. CMS Administrative Funding for Exchange Operations ................................................... 6
Table 2. ACA Discretionary Spending: Health Centers and Clinics ................................................ 9
Table 3. ACA Discretionary Spending: Health Care Workforce .................................................... 11
Table 4. ACA Discretionary Spending: Prevention and Wellness ................................................. 25
Table 5. ACA Discretionary Spending: Maternal and Child Health .............................................. 31
Table 6. ACA Discretionary Spending: Health Care Quality ......................................................... 31
Table 7. ACA Discretionary Spending: Nursing Homes................................................................ 36
Table 8. ACA Discretionary Spending: Health Disparities Data Collection .................................. 37
Table 9. ACA Discretionary Spending: Emergency Care and Trauma Services ............................ 38
Table 10. ACA Discretionary Spending: Elder Justice .................................................................. 39
Table 11. ACA Discretionary Spending: Biomedical Research ..................................................... 41
Table 12. ACA Discretionary Spending: Biologics ....................................................................... 42
Table 13. ACA Discretionary Spending: 340B Drug Pricing ........................................................ 42
Table 14. ACA Discretionary Spending: Medical Malpractice ...................................................... 43
Table 15. ACA Discretionary Spending: Pain Care Management ................................................. 43
Table 16. ACA Discretionary Spending: Medicaid ........................................................................ 44
Table 17. ACA Discretionary Spending: Medicare ........................................................................ 44
Table 18. ACA Discretionary Spending: Private Health Insurance ............................................... 45
Table A-1. Programs with Expired Authorizations of Appropriations ........................................... 46
Table A-2. Programs Whose Authorizations of Appropriations Expire at the End of
FY2015 ....................................................................................................................................... 47

Appendixes
Appendix. Expired and Expiring Authorizations of Appropriations .............................................. 46

Congressional Research Service

Discretionary Spending Under the Affordable Care Act (ACA)

Contacts
Author Contact Information........................................................................................................... 48
Acknowledgments ......................................................................................................................... 48
Key Policy Staff ............................................................................................................................. 48

Congressional Research Service

Discretionary Spending Under the Affordable Care Act (ACA)

Introduction
Implementation of the Patient Protection and Affordable Care Act (Affordable Care Act, or
ACA),1 the health reform law enacted in March 2010, is having a significant impact on federal
mandatory—also known as direct—spending.2 The ACA provided subsidies to help offset the cost
of purchasing private insurance coverage through health insurance exchanges established under
the law and included enhanced federal funding to expand state Medicaid programs. The law also
included numerous mandatory appropriations to fund temporary programs that increase access to
health care for targeted groups, provide funding to states to plan and establish health insurance
exchanges, and support many other research and demonstration programs.3
In addition, the ACA is having an impact on federal discretionary spending, which is subject to
the annual appropriations process.4 The law included many discretionary spending provisions that
authorize the appropriation of funds to support new and existing grant programs and other
activities. Moreover, the two federal agencies that are primarily responsible for the ACA’s
implementation—the Centers for Medicare & Medicaid Services (CMS) within the Department
of Health and Human Services (HHS), and the Internal Revenue Service (IRS) within the
Department of the Treasury—are incurring substantial costs to administer and enforce the law.
Both agencies have requested additional discretionary funding in recent budget cycles to cover
those costs.
This report focuses on the ACA’s effects on discretionary spending. The information is
summarized in a series of spending tables. The report begins with a discussion of the types of
discretionary spending provisions in the ACA, and an explanation of the format and content of the
tables. It also discusses recent actions taken by Congress and the President to reduce the federal
deficit, including enactment of the Budget Control Act of 2011 (and its subsequent amendments).
The impact of these actions on nondefense discretionary spending is briefly summarized.
This report is periodically revised and updated to reflect important legislative and administrative
developments.

1 The ACA was signed into law on March 23, 2010 (P.L. 111-148, 124 Stat. 119). A week later, on March 30, 2010, the
President signed the Health Care and Education Reconciliation Act (HCERA; P.L. 111-152, 124 Stat. 1029), which
amended numerous health care and revenue provisions in the ACA and added multiple new stand-alone provisions.
Congress and the President have since enacted several other bills that have made more targeted changes to specific
ACA provisions. All references to the ACA in this report refer collectively to the ACA, as amended, and to other
related provisions in HCERA.
2 Mandatory, or direct, spending generally refers to outlays from budget authority (i.e., the authority to incur financial
obligations that result in government expenditures such as paying salaries, purchasing services, or awarding grants) that
is provided in authorizing laws, as opposed to annual appropriations acts. Mandatory spending includes spending on
entitlement programs (e.g., Medicare, Social Security).
3 While a detailed examination of the ACA is beyond the scope of this report, numerous CRS products that provide
more in-depth information on the many new programs and activities authorized and funded by the law are available at
http://www.crs.loc.gov (see under “Issues Before Congress: Health”).
4 Discretionary spending refers to outlays from budget authority that is provided in and controlled by annual
appropriations acts. It typically covers the routine costs of running federal agencies, including wages and salaries.
Congressional Research Service
1

Discretionary Spending Under the Affordable Care Act (ACA)

Discretionary Spending Under the ACA
Discretionary spending under the ACA falls into one of two broad categories. First, there are the
amounts provided in appropriations acts for specific grant and other programs pursuant to explicit
authorizations of appropriations in the ACA. Second, there are the costs incurred by federal
agencies to administer and enforce the health insurance reforms and other core requirements of
the law.
Authorizations of Appropriations for Grant Programs
The ACA authorized numerous new discretionary grant programs and provided for each an
authorization of appropriations, generally through FY2014 or FY2015. Many of these provisions
authorize annual appropriations of specified amounts for one or more fiscal years to carry out the
program. Other provisions authorize the appropriation of specified amounts for FY2010 or
FY2011, and unspecified amounts—such sums as may be necessary, or SSAN—for later years. A
few provisions authorize multi-year appropriations, available for obligation for a period in excess
of one fiscal year (e.g., for the period FY2011 through FY2014). Numerous other provisions
simply authorize the appropriation of SSAN, in a few cases without specifying any fiscal years.
In addition, the ACA reauthorized funding—in most instances through FY2014 or FY2015—for
many existing discretionary grant programs, primarily ones authorized under the Public Health
Service Act (PHSA). They include most, but not all, of the federal health workforce programs
administered by Health Resources and Services Administration (HRSA). Funding authorizations
for many of these established programs had expired prior to their reauthorization by the ACA.
However, the programs continued to receive an annual appropriation. Importantly, the ACA
permanently reauthorized appropriations for the federal health centers program, the National
Health Service Corp (NHSC), and many programs and services provided by the Indian Health
Service (IHS).5
The actual funding levels for the discretionary grant programs authorized (or reauthorized) by the
ACA depend on decisions made by the congressional appropriators. That process may lead to
greater or smaller amounts than the sums authorized by the law. With Congress operating under
enforceable discretionary spending limits (see discussion below under “Recent Actions to Reduce
Discretionary Spending”), it can be a challenge to maintain funding levels for long-standing
programs with an established appropriations history, let alone secure initial funding to implement
new programs.
All the ACA’s discretionary spending provisions that include authorizations of appropriations are
summarized in a series of tables below. The provisions are organized by general topic under the
following headings: Health Centers and Clinics (Table 2); Health Care Workforce (Table 3);
Prevention and Wellness (Table 4); Maternal and Child Health (Table 5); Health Care Quality
(Table 6); Nursing Homes (Table 7); Health Disparities Data Collection (Table 8); Emergency

5 ACA reauthorized the Indian Health Care Improvement Act (IHCIA), which includes many discretionary Indian
Health Service (IHS) programs and services, and it extended indefinitely the authorizations of appropriations for these
programs and services. For more information on ACA’s Indian health provisions, which are not included in this report,
see CRS Report R41630, The Indian Health Care Improvement Act Reauthorization and Extension as Enacted by the
ACA: Detailed Summary and Timeline
, by Elayne J. Heisler.
Congressional Research Service
2

Discretionary Spending Under the Affordable Care Act (ACA)

Care (Table 9); Elder Justice (Table 10); Biomedical Research (Table 11); Biologics (Table 12);
340B Drug Pricing (Table 13); Medical Malpractice (Table 14); Pain Care Management (Table
15
); Medicaid (Table 16); Medicare (Table 17); and Private Health Insurance (Table 18).
Each table row provides information on a specific ACA provision, organized across four columns.
The first column shows the ACA section or subsection number. The second column indicates
whether the provision is freestanding (i.e., new statutory authority that is not amending an
existing statute) or amendatory (i.e., amends
an existing statute such as the PHSA).
Acronyms Used in the Tables in
Amendatory provisions either add a new
This Report
program to the statute or modify an existing
Agency for Healthcare Research and Quality (AHRQ)
one. The name of the administering agency or
Centers for Disease Control and Prevention (CDC)
office within HHS is also included, if known.
The third column provides a brief description
Centers for Medicare and Medicaid Services (CMS)
of the program, including the types of entities
Community Health Center Fund (CHCF)
and/or individuals eligible for funding,6 and
Federal Food, Drug, and Cosmetic Act (FFDCA)
gives details of the authorization of
appropriations.
Food and Drug Administration (FDA)
Health Resources and Services Administration (HRSA)
Finally, the fourth column shows the
Indian Health Service (IHS)
program’s actual funding levels for FY2010
through FY2014 if it received any
National Institutes of Health (NIH)
discretionary appropriations (or other funding)
Office of Personnel Management (OPM)
during that period. The FY2015 funding
Office of the Secretary (OS)
request, if applicable, is also provided.7
Prevention and Public Health Fund (PPHF)
Funding from sources other than annual
discretionary appropriations (e.g., ACA
Public Health Service Act (PHSA)
mandatory funds) is shown in parentheses. All
Substance Abuse and Mental Health Services
the discretionary funding listed in the tables in
Administration (SAMHSA)
this report is provided by the Departments of
Social Security Act (SSA)
Labor, Health and Human Services,
Education, and Related Agencies (L-HHS-
ED) annual appropriations act. If CRS was unable to identify specific appropriations for a
program, then that is indicated by the phrase “No appropriations identified.” In some instances a
program may be supported with funds from another budget account.
In each of the larger tables with multiple entries (i.e., Tables 2, 3, 4, 6 and 9), the ACA provisions
are grouped based on whether they reauthorize funding for existing programs or authorize
funding for new programs. Where available, the table entry includes the Catalog of Federal
Domestic Assistance (CFDA) number for the grant program.8 Unless otherwise stated, all
references in the tables to the Secretary refer to the HHS Secretary.

6 Not applicable if the funding is to support programs and activities carried out by the federal agency.
7 The funding amounts in the tables are taken from HHS agency budget documents available at http://www.hhs.gov/
budget/. Congress has yet to complete work on any of the regular appropriations bills for FY2015, which began on
October 1, 2014. The President signed the Continuing Appropriations Resolution, 2015 (P.L. 113-164), on September
19, 2014. P.L. 113-164 provides continuing appropriations through December 11, 2014.
8 CFDA is a government-wide compendium of federal grant and other assistance programs. Each program is assigned a
unique five-digit number, XX.XXX, where the first two digits represent the funding agency and the second three digits
represent the program. Programs funded by the Department of Health and Human Services begin with the number 93.
(continued...)
Congressional Research Service
3

Discretionary Spending Under the Affordable Care Act (ACA)

Most, though not all, of the existing grant programs that were reauthorized under the ACA
continue to receive annual discretionary appropriations. However, these programs typically are
funded at levels below the amounts authorized by the law. The federal health centers program
(see Table 2) and the NHSC (see Table 3) are particularly noteworthy in this regard. Both
programs have seen a significant decrease in their discretionary funding since FY2010 and,
increasingly, are being supported by mandatory ACA funds from the Community Health Center
Fund (CHCF; see text box below). Indeed, CHCF funds have become the sole source of funding
for the NHSC, which has not received an annual discretionary appropriation since FY2011. In
addition, mandatory ACA funds from the Prevention and Public Health Fund (PPHF; see text box
below) have supplemented, and in some cases supplanted, annual discretionary appropriations for
a number of established programs, including ones that were reauthorized by the ACA.9
ACA Mandatory Spending
Most of the mandatory (i.e., direct) spending under the ACA is for expanding health insurance coverage. This
spending includes the premium tax credits and cost-sharing subsidies, the federal government’s share of the costs of
Medicaid expansion, and tax credits for smal employers. The ACA also included numerous appropriations that
provide billions of dollars of mandatory funds for new and existing programs. For example, the law provided funding
for several temporary insurance programs and for grants to states to plan and establish health insurance exchanges. It
also provided a permanent appropriation, available for 10-year periods, for a new Center for Medicare & Medicaid
Innovation within CMS to test and implement innovative health care payment and service delivery models.
Final y, the ACA created four special funds and appropriated amounts to each one:

The Community Health Center Fund (CHCF), to which the ACA appropriated a total of $11 billion over
the five-year period FY2011-FY2015, is providing supplementary funding for the federal health centers program
and the National Health Service Corps (NHSC). Both programs are administered by the HHS Health Resources
and Services Administration (HRSA).

The Prevention and Public Health Fund (PPHF), to which the ACA provided a permanent annual
appropriation, is intended to support prevention, wel ness, and other public health programs and activities
administered by the Centers for Disease Control and Prevention (CDC) and other HHS agencies.

The Patient-Centered Outcomes Research Trust Fund (PCORTF) is supporting patient-centered
comparative clinical 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 plans, as wel as transfers from the Medicare
Part A and Part B trust funds.

The Health Insurance Reform Implementation Fund (HIRIF), to which the ACA appropriated $1 billion,
is helping cover the administrative costs of implementing the law.
For details on al the ACA’s mandatory appropriations and the status of obligation of these funds, see CRS Report
R41301, Appropriations and Fund Transfers in the Affordable Care Act (ACA), by C. Stephen Redhead. Congress also has
rescinded some of the mandatory funds provided by the ACA; see CRS Report R43289, Legislative Actions to Repeal,
Defund, or Delay the Affordable Care Act
, by C. Stephen Redhead and Janet Kinzer.
Few of the new grant programs authorized by the ACA have received any discretionary funding.10
Several of these new programs, however, have received PPHF funds.11

(...continued)
For more information, see https://www.cfda.gov.
9 These programs include (1) Sec. 5301, Primary Care Training and Enhancement Program, see Table 3; (2) Sec.
10501(m)(2), Public Health and Preventive Medicine Programs, see Table 3; (3) Sec. 4003, Clinical and Community
Preventive Services Task Forces, see Table 4; and (4) Sec. 4204, Immunizations Programs, see Table 4.
10 Examples of programs that have received discretionary funding include CDC’s congenital heart disease and breast
health awareness programs (see Table 4) and the Cures Acceleration Network (CAN) program at NIH (see Table 11).
11 These programs include (1) Sec. 5208, Nurse-Managed Health Clinics, see Table 2; (2) Sec. 5306, Mental and
(continued...)
Congressional Research Service
4

Discretionary Spending Under the Affordable Care Act (ACA)

CBO estimated that the ACA’s discretionary spending provisions, if fully funded by future
appropriations acts
, would result in appropriations of almost $100 billion over the period
FY2012-FY2021.12 However, much of that funding—about $85 billion—would be for three
programs that were in existence prior to, and whose funding was reauthorized by, the ACA;
namely, the federal health centers program, the NHSC, and the IHS.
Expired or Expiring Authorizations of Appropriations
It was noted earlier that the ACA generally authorized (or reauthorized) discretionary
appropriations through FY2014 or FY2015. Indeed, a majority of the discretionary grant
programs summarized in the tables in this report have funding authorizations that have expired or
will expire at the end of the current fiscal year. These programs are listed in a pair of tables in the
Appendix. Table A-1 shows the programs with expired authorizations of appropriations. Table
A-2
shows the programs whose authorizations of appropriations expire at the end of FY2015.
Administrative Spending on Health Insurance Exchanges
In addition to funding the discretionary grant programs and other activities that were authorized
(or reauthorized) by the ACA, both CMS and the IRS are incurring significant administrative
costs to implement the law. Table 1 summarizes the sources and amounts of CMS’s
administrative funding for health insurance exchange operations to date. Congress instructed
CMS to provide this information in the agency’s FY2015 budget submission. There is no
comparable ACA funding information publicly available for the IRS, which is administering the
law’s tax provisions including the premium tax credit and other subsidies.
During the period FY2010 through FY2012, CMS obligated a total of $456 million to support
exchange operations. Of that amount, $331 million came from annual discretionary
appropriations that cover the routine costs of running federal agencies, including salaries and
expenses: $307 million from CMS’s Program Management account, and an additional $24
million from the HHS Departmental Management account. The remaining $125 million came
from the HIRIF.
CMS’s administrative costs to support exchange operations totaled $1,545 million in FY2013. In
the FY2013 budget CMS requested an increase of $1,001 million for its Program Management
account for ACA implementation and other activities. However, Congress did not provide any

(...continued)
Behavioral Health Education and Training Grants, see Table 3; (3) Sec. 5102, State Health Care Workforce
Development Grants, see Table 3; (4) Sec. 4201, Community Transformation Grants, see Table 4; (5) Sec. 10408,
Small Business Workplace Wellness Grants, see Table 4; and (6) Sec. 10501(g), National Diabetes Prevention
Program, see Table 4.
12 U.S. Congress, House Committee on Energy and Commerce, Subcommittee on Health, “CBO’s Analysis of the
Major Health Care Legislation Enacted in March 2010,” Statement of Douglas W. Elmendorf, Director, 112th Cong., 1st
sess., March 30, 2011. Available at http://www.cbo.gov/ftpdocs/121xx/doc12119/03-30-HealthCareLegislation.pdf.
See p. 16. Note: CBO’s estimate of ACA discretionary spending includes (1) amounts specified in ACA, plus estimated
amounts for subsequent years (adjusted for anticipated inflation) where ACA specified an amount for the first year
(FY2010 or FY2011) and authorized SSAN for subsequent years; and (2) estimated amounts for subsequent years
(adjusted for anticipated inflation) where there is an appropriation for FY2010 under prior law and ACA authorized the
appropriation of SSAN for later years. The CBO estimate does not include new ACA programs for which the law
provided only an authorization for the appropriation of SSAN.
Congressional Research Service
5

Discretionary Spending Under the Affordable Care Act (ACA)

additional discretionary funds for ACA implementation in FY2013. CMS instead used funds from
other sources to help pay for ongoing administrative costs associated with exchange operations.
Those funds included (1) discretionary funds transferred from other HHS accounts under the
Secretary’s transfer authority;13 (2) expired discretionary funds from the Nonrecurring Expenses
Fund (NEF);14 (3) mandatory funds from the HIRIF; and (4) mandatory funds from the PPHF (see
Table 1).
Table 1. CMS Administrative Funding for Exchange Operations
Dollars in Millions, by Fiscal Year
2010-2012
2013
2014
2015
Funding Source
Actual
Actual
Estimate
Request
Discretionary Appropriations




CMS Program Management
307
520
711a 629
HHS Departmental Management
24



Secretary’s Transfer Authority

114
109

Nonrecurring Expenses Fund (NEF)

300
350

Mandatory and Other Funds




Health Insurance Reform Implementation Fund (HIRIF)
125
158
20

Prevention and Public Health Fund (PPHF)

454


Federally facilitated exchange (FFE) User Fees


200
1,159
Total
456
1,545
1,390
1,788
Source: Table prepared by the Congressional Research Service based on data provided in the Centers for
Medicare & Medicaid Services’ FY2015 congressional budget justification document, available at
http://www.cms.gov/About-CMS/Agency-Information/PerformanceBudget/Downloads/FY2015-CJ-Final.pdf.
Notes: Figures in each column may not add to total due to rounding.
a. Includes $100 million in budget authority that was made available by using NEF funds for non-FFE activities.
In FY2014, CMS’s administrative costs for exchange operations will total an estimated $1,390
million. The agency requested an increase of $1,397 million for its Program Management account
in the FY2014 budget for ACA implementation and other activities. But as in the previous fiscal
year Congress did not give CMS any additional funding. Once again, the agency is relying on
transferred departmental funds as well as NEF and HIRIF funding to help support exchange
operations in FY2014. In addition, CMS will collect an estimated $200 million in exchange user
fees (see Table 1).
The President’s FY2015 budget includes a total of $1,788 for exchange operations. Of that
amount, $629 million is from CMS’s Program Management account, and the remaining $1,159

13 The L-HHS-ED Appropriations Act provides the HHS Secretary with limited authority to transfer funds between
appropriations accounts. No more than 1% of the funds in any given account may be transferred, and recipient accounts
may not be increased by more than 3%. Congressional appropriators must be notified in advance of any transfer.
14 The Nonrecurring Expenses Fund is an account within the Department of the Treasury. The HHS Secretary is
authorized to transfer to the NEF unobligated balances of expired discretionary funds. NEF funds are available until
expended for use by the HHS Secretary for capital acquisitions including facility and information technology
infrastructure. Congressional appropriators must be notified in advance of any planned use of NEF funds.
Congressional Research Service
6

Discretionary Spending Under the Affordable Care Act (ACA)

million is projected to come from exchange user fees. The FY2015 budget does not identify any
other sources of funding to support exchange operations (see Table 1). CMS has requested an
increase of $227 million for its Program Management account in FY2015 to help support ACA
implementation and other activities.
Recent Actions to Reduce Discretionary Spending
Since FY2010, Congress has taken a number of steps to curb federal discretionary spending.
During negotiations to complete the FY2011 appropriations process and avert a government
shutdown in early 2011, lawmakers agreed to cuts in discretionary spending for a broad range of
agencies and programs. Congress and the President then enacted the Budget Control Act (BCA)
of 2011,15 which established enforceable discretionary spending limits, or caps, for each of
FY2012 through FY2021. Operating under BCA-imposed discretionary spending caps, Congress
further reduced funding for many programs during the FY2012, FY2013, and FY2014
appropriations cycles.
The BCA also triggered annual spending reductions beginning in FY2013 for both defense and
nondefense spending. All the spending on programs and activities summarized in this report falls
within the nondefense category. The BCA spending reductions involve a combination of
automatic across-the-board spending cuts to nonexempt programs through a process known as
sequestration, as well as lowering the BCA-imposed discretionary spending caps. More details on
the BCA annual spending reductions are provided in the text box below.
Unless otherwise noted, the FY2010-FY2014 funding figures in the tables in this report represent
final amounts reflecting sequestration and other adjustments. Many of the grant programs listed in
the tables that have received annual appropriations since FY2010 have seen their discretionary
funding decline. As noted earlier, some of these programs are being supported by mandatory
funds provided by the ACA.
Trends in Nondefense Discretionary Spending
According to CBO, nondefense discretionary (NDD) spending has generally ranged between
about 3% and 4% of gross domestic product (GDP) since 1962, the first year for which there are
comparable data. The two exceptions to this trend are the period 1975-1981, when NDD spending
averaged almost 5% of GDP, and the period 2009-2011, when stimulus spending increased NDD
outlays above 4% of GDP. NDD spending as a share of GDP is now declining and fell to 3.5% in
2013, CBO estimates. Under the current deficit-reduction policies, CBO projects that NDD
spending in 2016 will fall to its lowest level as a share of GDP since 1962 and will continue to
decline thereafter.16



15 P.L. 112-25, 125 Stat. 240.
16 CBO, “Options for Reducing the Deficit: Discretionary Spending,” blog post, December 12, 2013,
http://www.cbo.gov/publication/44958.
Congressional Research Service
7

Discretionary Spending Under the Affordable Care Act (ACA)

Annual Spending Reductions Under the Budget Control Act
The BCA amended the Balanced Budget and Emergency Deficit Control Act of 1985 (BBEDCA) by establishing two
budget enforcement mechanisms to reduce federal spending over the 10-year period FY2012 through FY2021. First, it
established enforceable limits, or caps, on discretionary spending for each of those years. Second, the BCA created a
Joint Committee on Deficit Reduction to develop legislation to further limit federal spending. The failure of the Joint
Committee to agree on deficit-reduction legislation triggered automatic annual spending reductions for each of
FY2013 through FY2021. The BCA specified that a total of $109 bil ion must be cut each year from nonexempt
budget accounts. That amount is equal y divided between defense and nondefense spending. Within each category—
defense and nondefense—the spending cuts are divided proportionately between discretionary spending and
nonexempt mandatory (i.e., direct) spending. 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 BCA requires that the mandatory spending reductions in each category—defense and nondefense—must be
executed each year by a sequestration of al nonexempt accounts, subject to the BBEDCA sequestration rules.
Discretionary spending in each category is also subject to sequestration, but only in FY2013. For each of the
remaining fiscal years (i.e., FY2014 through FY2021), discretionary spending reductions are to be achieved by lowering
the discretionary spending caps for defense and nondefense spending by the total dol ar amount of the reduction.
Thus, congressional appropriators get to decide how to apportion the cuts within the lowered spending caps rather
than having the cuts applied across-the-board to all nonexempt accounts through sequestration. 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 rules.
The FY2013 sequestration order reduced spending on nonexempt nondefense mandatory programs by 5.1% and
reduced nonexempt nondefense discretionary (NDD) spending by about 5.0% [Note: These amounts reflect
adjustments made by the American Taxpayer Relief Act of 2012 (ATRA), which reduced the overall dollar amount
that needed to be cut from FY2013 defense and nondefense spending.] For technical reasons, OMB concluded that
cuts in mandatory (i.e., CHCF) funding for community health centers and migrant health centers are capped at 2%.
The FY2014 sequestration order reduced spending on nonexempt nondefense mandatory programs by 7.2%. OMB
also lowered the FY2014 NDD spending cap by $37 billion. However, the Bipartisan Budget Act of 2013 (BBA)
subsequently amended the BCA by establishing new discretionary spending caps for FY2014 and FY2015 and
eliminating the requirement that these caps be lowered pursuant to the BCA’s annual spending reductions. As a
result, the new FY2014 NDD cap is more than $22 billion above the BCA-lowered FY2014 cap that it replaces, and
almost $24 billion above the FY2013 post-sequestration NDD funding level.
The FY2015 sequestration order reduces spending on nonexempt nondefense mandatory programs by 7.3%.
Pursuant to the BBA, the FY2015 NDD spending cap is virtual y unchanged from the final FY2014 level.


Congressional Research Service
8


Table 2. ACA Discretionary Spending: Health Centers and Clinics
Statutory
ACA
Authority
Summary of Provision
Funding (FY2010-FY2015)
Section
(Agency)
Health Centers: Existing Program
5601 Reauthorizes
Health centers. Permanently reauthorizes funding for the program that provides
FY2010 = $2,185 milliona
PHSA Sec. 330
operating grants to health centers serving federally designated medically underserved
FY2011 = $1,581 million (+ $1,000 million CHCF)a
(HRSA)
populations and furnishing comprehensive primary care services, referrals, and other
FY2012 = $1,567 million (+ $1,200 million CHCF)a
services needed to facilitate access to such care, regardless of ability to pay. Eligible
FY2013 = $1,479 million (+ $1,465 million CHCF)a
grantees include community, migrant, public housing, and homeless health centers
FY2014 = $1,495 million (+ $2,145 million CHCF)a
that meet the statutory requirements of PHSA Sec. 330. Authorizes the appropriation FY2015 request = $1,000 million (+ $3,600 million
of $2,989 million for FY2010, $3,862 million for FY2011, $4,991 mil ion for FY2012,
CHCF)a
$6,449 million for FY2013, $7,333 million for FY2014, $8,333 million for FY2015, and,
for each subsequent fiscal year, an amount equal to the previous year’s funding
[Note: In addition to appropriating mandatory funds for
adjusted for any increase in the number of patients served and the per-patient costs.
health center operations for FY2011-FY2015 through the
[CFDA 93.224, 93.527]
CHCF, the ACA also appropriated $1.5 billion for health
center construction and renovation. For more
information on the ACA’s mandatory appropriations, see
CRS Report R41301.]
Health Centers and Clinics: New Programs
4101(b)
New PHSA Sec.
School-based health centers (SBHCs). Requires the Secretary to award grants
No appropriations identified.
399Z-1 (HRSA)
to fund the management and operation of SBHCs that provide comprehensive
physical and behavioral health services to children and adolescents, subject to parental [Note: The ACA appropriated a total of $200 million for
consent. SBHCs that meet certain specified criteria and match 20% of the grant
SBHC construction and renovation. For more
amount with non-federal funds (unless waived). Preference may be given to SBHCs
information on the ACA’s mandatory appropriations, see
serving children and adolescents who have limited access to or difficulty accessing
CRS Report R41301.]
health care. Authorizes the appropriation of SSAN for each of FY2010 through
FY2014.
5208
New PHSA Sec.
Nurse-managed health clinics (NMHCs). Requires the Secretary to award
FY2010 = $15 million (all PPHF)
330A-1 (HRSA)
grants to fund the operation of NMHCs—associated with schools, col eges, federally
qualified health centers (FQHCs), or nonprofit health/social services agencies—that
No appropriations identified for FY2011-FY2014.
provide comprehensive primary health care and wellness services to vulnerable or
underserved populations regardless of income or insurance status. At least one
advanced practice nurse must hold an executive management position in the NMHC.
Authorizes the appropriation of $50 million for FY2010, and SSAN for each of
FY2011 through FY2014. [CFDA 93.515]
CRS-9


Statutory
ACA
Section
Authority
Summary of Provision
Funding (FY2010-FY2015)
(Agency)
10504 New
freestanding
Access to affordable care demonstration program. Within six months of
No appropriations identified.
authority (HRSA)
enactment, requires the Secretary to establish a three-year demonstration project in
up to 10 states—each state may receive up to $2 million—to provide access to
comprehensive health care services to the uninsured. Eligible grantees must be state-
based, nonprofit, public-private partnerships that provide access to comprehensive
health care services to the uninsured at reduced fees. Authorizes the appropriation of
SSAN (no years specified).
Sources: Table prepared by the Congressional Research Service based on the text of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended).
Funding amounts are taken from HRSA’s budget documents, including the FY2014 operating plan, available at http://www.hrsa.gov/about/budget/index.html.
Note: For more information on health centers, see CRS Report R42433, Federal Health Centers, by Elayne J. Heisler.
a. Annual appropriations for health centers include the fol owing amounts for the Federal Tort Claims Act (FTCA) program: FY2010 = $44 million; FY2011 = $100
million; FY2012 = $95 million; FY2013 = $89 million; FY2014 = $95 million; FY2015 request = $89 mil ion. Under the FTCA, health center employees and
contractors are considered federal employees and are immune from medical malpractice lawsuits while acting within the scope of their employment. The federal
government assumes responsibility for such malpractice claims.








CRS-10


Table 3. ACA Discretionary Spending: Health Care Workforce
Statutory
ACA
Authority
Summary of Provision
Funding (FY2010-FY2015)
Section
(Agency)
National Health Service Corps (NHSC)
5207 Reauthorizes
NHSC scholarships and loan repayments. Permanently reauthorizes funding for
FY2010 = $141 million
PHSA Title III,
the NHSC program. In exchange for a commitment to work in a federally designated
FY2011 = $25 million (+ $290 million CHCF)
Part D, Subpart
Health Professional Shortage Area (HPSA), the program provides (1) scholarships to
FY2012 = $295 million (all CHCF)
III (HRSA)
students training in a primary care discipline to cover tuition, fees, other educational
FY2013 = $285 million (all CHCF)
costs, and a stipend; and (2) student loan repayments of up to $50,000 a year to
FY2014 = $283 million (all CHCF)
primary care and mental health clinicians. To be eligible for a scholarship, a student
FY2015 request = $810 million (i.e., $100 million
must be accepted or enrolled in a training program for medicine, dentistry, family
discretionary funds + $310 million CHCF + $400 million
nurse practitioner, nurse midwife, or physician assistant, and agree to two to four
proposed new mandatory funds)
years of service in an NHSC-approved site in a HPSA. Loan repayments are for
primary care, dental, and mental health clinicians who agree to at least two years of
service in an NHSC-approved site in a HPSA. Authorizes the appropriation of $320
mil ion for FY2010, $414 million for FY2011, $535 million for FY2012, $691 million
for FY2013, $893 million for FY2014, and $1,155 billion for FY2015; amounts in
subsequent years based on previous year’s funding, subject to adjustment. [CFDA
93.162, 93.288, 93.547]
CRS-11


Statutory
ACA
Section
Authority
Summary of Provision
Funding (FY2010-FY2015)
(Agency)
Physicians: Existing Program
5301 Amends
and
Primary care training and enhancement program. (1) Authorizes five-year
FY2010 = $39 million (+ $198 million PPHF)
reauthorizes
grants to public and nonprofit private hospitals, medical schools, academically affiliated FY2011 = $39 million
PHSA Sec. 747
physician assistant training programs, and other public and nonprofit private entities
FY2012 = $39 million
(HRSA)
to support training programs in primary care. Funds are to be used to plan, develop,
FY2013 = $37 million
and operate accredited training programs, including residency and internship
FY2014 = $37 million
programs, in family medicine, general internal medicine, and general pediatrics and to
FY2015 request = $37 million
provide financial assistance (e.g., traineeships). (2) Authorizes five-year grants to
medical schools for primary care capacity building. Funds are to be used to create
academic units or programs that improve clinical teaching in the primary care fields,
and (in a separate authorization) to integrate academic units to enhance
interdisciplinary recruitment, training, and faculty development. Funding priority given
to entities proposing innovative approaches to primary care training and with a
record of training primary care providers, among other things. For both grant
programs, authorizes the appropriation of $125 million for FY2010, and SSAN for
each of FY2011 through FY2014. Note: 15% of the amount appropriated must be
used for physician assistant training programs. Separately, authorizes the
appropriation of $750,000 for each of FY2010 through FY2014 for capacity building
grants to integrate academic units. [CFDA 93.510, 93.514, 93.884]
Physicians: New Programs
5203
New PHSA Sec.
Pediatric specialist loan repayment program. Requires the Secretary to
No appropriations identified.
775 (HRSA)
implement a loan repayment program that pays up to $35,000 for each year of service
(for a maximum of three years) to practicing or in-training pediatric specialists and
surgeons, as well as child and adolescent mental health specialists, who agree to at
least two years of service in a HPSA. Authorizes the appropriation of $30 million for
each of FY2010 through FY2014 for loan repayments to pediatric specialists and
surgeons, and $20 million for each of FY2010 through FY2013 for loan repayments to
mental health providers.
5508(a)
New PHSA Sec.
Teaching health centers development grants. Authorizes three-year grants of
No appropriations identified.
749A (HRSA)
up to $500,000 to FQHCs, rural health clinics, Indian health centers, and entities
receiving PHSA Title X (family planning) funds that establish or expand a primary care
residency training program. Authorizes the appropriation of $25 mil ion for FY2010,
$50 million for each of FY2011 and FY2012, and SSAN for each fiscal year thereafter.
CRS-12


Statutory
ACA
Section
Authority
Summary of Provision
Funding (FY2010-FY2015)
(Agency)
10501(l)
New PHSA Sec.
Rural physician training grants. Requires the Secretary to (1) award grants to
No appropriations identified.
749B (HRSA)
medical schools for recruiting students most likely to practice in underserved rural
communities and for providing rural-focused training and experience; and (2) within
60 days of enactment, by regulation, define underserved rural communities. Priority is
given to entities that train students to practice in rural communities, that have
established partnerships with rural community health centers, or who submit a long-
term plan for tracking where graduates practice. Note: HRSA published an interim
final rule on May 26, 2010 (75 Federal Register 29447). Authorizes the appropriation of
$4 million for each of FY2010 through FY2013.
Dentistry: Existing Program
5303
New PHSA Sec.
General, pediatric, and public health dentistry training. Authorizes grants or
FY2010 = $15 million
748; authority
contracts to dental and dental hygiene schools, as well as approved residency or
FY2011 = $17 million
previously part of advanced education programs in general, pediatric, or public health dentistry, for
FY2012 = $20 million
Sec. 747 (HRSA)
dental training activities including faculty development, financial assistance, faculty loan
FY2013 = $20 million
repayment programs, technical assistance for pediatric dental programs, and pre- and
FY2014 = $21 million
post-doctoral training programs in dental primary care. Gives priority to entities that
FY2015 request = $21 million
train individuals from disadvantaged backgrounds, who have a record of placing
graduates in facilities that provide care to the underserved, or whose programs focus
[Note: HRSA also administers a state oral health
on providing care to the underserved through demonstrated partnerships with
workforce grant program (PHSA Sec. 340G): FY2010 =
FQHCs, rural health clinics, or through having programs focused on specific topics,
$17 million; FY2011 = $16 million; FY2012 = $12 million;
such as HIV/AIDs. Authorizes the appropriation of $30 million for FY2010, and SSAN
FY2013 = $11 million; FY2014 = $11 million; FY2015
for each of FY2011 through FY2015. Permits grantees to carry over funds for up to
request = $11 million. CFDA 93.236]
three fiscal years. [CFDA 93.059, 93.884]
Dentistry: New Program
5304
New PHSA Sec.
Alternative dental health care provider demonstration program. Authorizes No appropriations identified.
340G-1 (HRSA)
the Secretary to award 15 five-year grants of not less than $4 million to train or
employ alternative dental health care providers (e.g., community dental health
[Note: A provision in the L-HHS-ED appropriations act
coordinators, dental health aides) to increase access to dental health care services in
for each of the four most recent fiscal years (i.e.,
rural and other underserved communities. Eligible grantees include institutions of
FY2011-FY2014) prohibits HRSA from funding this new
higher education; public-private entities; FQHCs; facilities operated by the IHS or by
demonstration program.]
Indian tribes or organizations; state or county public health clinics; public hospitals or
health systems; and accredited dental education programs. Authorizes the
appropriation of SSAN (no years specified).
CRS-13


Statutory
ACA
Section
Authority
Summary of Provision
Funding (FY2010-FY2015)
(Agency)
Nursing: Existing Programs
5309(a) Amends
and Nurse education, practice, quality, and retention program. Authorizes grants
FY2010 = $40 million
reauthorizes
or contracts to expand enrollment in baccalaureate nursing programs; provide
FY2011 = $40 million
PHSA Sec. 831
training in new technologies; develop cultural competencies; expand nursing practice
FY2012 = $40 million
(HRSA)
arrangements in non-institutional settings; and support nurse retention programs that
FY2013 = $37 million
offer career advancement for nursing personnel, enhance col aboration among nurses
FY2014 = $38 million
and other health professionals, and promote nurse involvement in clinical decision
FY2015 request = $38 million
making. Eligible grantees include nursing schools, health care facilities (including
NMHCs), or partnerships of the two. Authorizes the appropriation of SSAN for each
of FY2010 through FY2014. See also ACA Sec. 5312 below, which authorizes
appropriations for several Title VIII nursing education programs including Sec. 831.
[CFDA 93.359, 93.503]
5311(a) Amends
and Nursing faculty loan program. Authorizes loans to nursing school students
FY2010 = $25 million
reauthorizes
pursuing advanced degrees to become qualified nursing faculty. Sets the annual loan
FY2011 = $25 million
PHSA Sec. 846A
limit at $35,500 for FY2010 and FY2011; for subsequent fiscal years, the loan limit is
FY2012 = $25 million
(HRSA)
subject to a cost-of-attendance adjustment. Students who go on to serve as nursing
FY2013 = $23 million
school faculty may have up to 85% of their loan repayment cancelled. Authorizes the
FY2014 = $25 million
appropriation of SSAN for each of FY2010 through FY2014. [CFDA 93.264]
FY2015 request = $25 million
CRS-14


Statutory
ACA
Section
Authority
Summary of Provision
Funding (FY2010-FY2015)
(Agency)
5312 Amends
PHSA
Authorization of appropriations. Authorizes the appropriation of $338 million
Funding for Sec. 811:
Sec. 871;
for FY2010, and SSAN for each of FY2011 through FY2016, for the nursing workforce FY2010 = $64 million
previously Sec.
programs authorized under PHSA Secs. 811, 821, 831, and new 831A (see ACA Sec.
FY2011 = $64 million
841 (HRSA)
5309(b) below:
FY2012 = $63 million
FY2013 = $60 million

Sec. 811: Advanced nursing education – grants to accredited programs for
FY2014 = $62 million
advanced nurse education including combined registered nurse masters degree
FY2015 request = $62 million
programs, authorized nurse practitioner programs, accredited nurse midwifery
programs, and accredited nurse anesthesia programs. [CFDA 93.124, 93.247,
Funding for Sec. 821:
93.358, 93.513]
FY2010 = $16 million
FY2011 = $16 million

Sec. 821: Nursing workforce diversity – grants to nursing schools, academic
FY2012 = $16 million
health centers, state or local governments, and other appropriate public or
FY2013 = $15 million
private nonprofit entities for stipends and scholarships so as to increase nursing
FY2014 = $15 million
education opportunities for disadvantaged individuals. [CFDA 93.178]
FY2015 request = $15 million

Sec. 831: Nurse education, practice, quality, and retention – see ACA Sec.
See ACA Sec. 5309(a) above for funding for the Sec. 831
5309(a) above.
program.
Note: ACA did not reauthorize funding for the nursing education loan repayment and
scholarship programs authorized under PHSA Sec. 846.a
Nursing: New Programs
5309(b)
New PHSA Sec.
Nurse retention program. New authority that largely duplicates the nurse
No appropriations identified.
831A (HRSA)
retention grant program authorized under PHSA Sec. 831; see ACA Sec. 5309(a)
above. Authorizes the appropriation of SSAN for each of FY2010 through FY2012.
Note: ACA Sec. 5312 also authorizes appropriations for this new program; see
above.
5311(b)
New PHSA Sec.
Nursing faculty loan repayment program. Authorizes a loan repayment
No appropriations identified.
847 (HRSA)
program for qualified nursing students or graduates who agree to serve as nursing
faculty for four to six years. Sets the annual loan limit for FY2010 and FY2011 at
$10,000 for individuals with a master’s or equivalent degree in nursing ($20,000 for
those with a doctorate or equivalent degree in nursing), and an aggregate loan limit of
$40,000 for individuals with a master’s or equivalent degree in nursing ($80,000 for
those with a doctorate or equivalent degree in nursing). Thereafter, the annual and
aggregate loan limits are subject to a cost-of-attendance adjustment. Authorizes the
appropriation of SSAN for each of FY2010 through FY2014.
CRS-15


Statutory
ACA
Section
Authority
Summary of Provision
Funding (FY2010-FY2015)
(Agency)
5316 New
freestanding
Family nurse practitioner demonstration program. Requires the Secretary to
No appropriations identified.
authority
award three-year demonstration grants to FQHCs and NMHCs, not to exceed
$600,000 a year, for programs to train nurse practitioners as primary care providers
(as defined in ACA Sec. 5208). Preference given to bilingual individuals. Authorizes
the appropriation of SSAN for each of FY2011 through FY2014.
Geriatrics and Long-Term Care: Existing Program
5305(c) Amends
and Geriatric nursing education and training. Provides grants for traineeships for
FY2010 = $5 million
reauthorizes
individuals preparing for advanced degrees in geriatric nursing or other nursing areas
FY2011 = $5 million
PHSA Sec. 865;
that specialize in elder care. Eligible grantees include nursing schools, health care
FY2012 = $4 million
previously Sec.
facilities, programs leading to certification as a certified nurse assistant, and
FY2013 = $4 million
855 (HRSA)
partnerships of such schools, facilities, and programs. Authorizes the appropriation of
FY2014 = $4 million
SSAN for each of FY2010 through FY2014. [CFDA 93.265]
FY2015 request = $4 million
Geriatrics and Long-Term Care (LTC): New Programs
5302
New PHSA Sec.
Direct care worker training. Requires the Secretary to establish a grant program
No appropriations identified.
747A (HRSA)
to provide new training opportunities, such as tuition and fee assistance, for direct
care workers employed in LTC settings. Individuals who receive assistance are
required to work in the field of geriatrics, disability services, LTC services and
supports, or chronic care management for a minimum of two years. Eligible grantees
include institutions of higher education that have an established partnership with an
LTC entity, as specified. Authorizes the appropriation of $10 million for the period
FY2011 through FY2013.
CRS-16


Statutory
ACA
Section
Authority
Summary of Provision
Funding (FY2010-FY2015)
(Agency)
5305(a) Amends
PHSA
Geriatric workforce development; geriatric career incentive awards. Sec.
No appropriations identified.
Sec. 753 by
753(d) requires the Secretary to award no more than 24 grants or contracts for
adding new
$150,000 to entities that operate geriatric education centers to support short-term
[Note: The three existing geriatric education and training
subsections (d)-
intensive courses on geriatrics and LTC, and support training for family caregivers and programs authorized under PHSA Sec. 753(a)-(c), which
(e) (HRSA)
direct care workers. Eligible grantees include accredited schools of allied health,
support activities that are broadly comparable to the
medicine, nursing, dentistry, osteopathic medicine, optometry, podiatric medicine,
new programs authorized by the ACA, have received the
veterinary medicine, public health, or chiropractic care; accredited graduate programs following amounts: FY2010 = $34 million; FY2011 = $34
in clinical psychology, clinical social work, health administration, marriage and family
mil ion; FY2012 = $31 million, FY2013 = $29 million (+
therapy, and counseling; and physician assistant programs. Sec. 753(e) requires the
$2 million PPHF); FY2014 = $33 million; FY2015 request
Secretary to award grants or contracts to advance practice nurses, clinical social
= $33 million.]
workers, pharmacists, and psychologists pursuing an advanced degree in geriatrics or
a related field, in return for agreeing to teach or practice in the field of geriatrics,
LTC, or chronic care management for a minimum of five years upon completion of
the degree. Authorizes the appropriation of $10.8 million for the period FY2011
through FY2014 for Sec. 753(d), and $10 million for the period FY2011 through
FY2013 for Sec. 753(e). [CFDA 93.156, 93.250, 93.969]
Pain Care: New Program
4305(c)
New PHSA Sec.
Education and training in pain care. Authorizes a grant program to train health
No appropriations identified.
759 (HRSA)
professionals in pain care. Eligible grantees include health professions schools,
hospices, and other public and private entities. Applicants must agree to include
training and education on recognizing the signs and symptoms of pain; applicable laws
and policies on controlled substances; interdisciplinary approaches to pain care
delivery; barriers to care in underserved populations; and recent developments in
pain care. Authorizes the appropriation of SSAN for each of FY2010 through FY2012,
to remain available until expended. [See also Table 15.]
CRS-17


Statutory
ACA
Section
Authority
Summary of Provision
Funding (FY2010-FY2015)
(Agency)
Public Health: Existing Programs
10501(m)(2) Amends
PHSA
Public health and preventive medicine programs. Reauthorizes funding for the
FY2010 = $10 million (+ $15 million PPHF)
Sec. 770 (HRSA)
public health workforce programs authorized under PHSA Secs. 765-769. They
FY2011 = $10 million (+ $20 million PPHF)
include grants for public health training centers; tuition, fees, and stipends for
FY2012 = $8 million (+ $25 million PPHF)
traineeships in public health and in health administration; and residency programs in
FY2013 = $8 million
preventive medicine and dental public health. Several programs mention preference
FY2014 = $18 million
for underserved communities or underrepresented minorities. Eligible grantees
FY2015 request = $18 million
include accredited academic institutions, as well as state, local, and tribal public health
departments. Authorizes the appropriation of $43 million for FY2011, and SSAN for
each of FY2012 through FY2015. [CFDA 93.117, 93.249, 93.516, 93.964]
Public Health: New Programs
5204
New PHSA Sec.
Public health workforce loan repayment program. Requires the Secretary to
No appropriations identified.
776 (HRSA)
establish a student loan repayment program that pays up to $35,000 a year, or one-
third of total debt, whichever is less, to increase the supply of public health
professionals. Eligible individuals must agree to work for at last three years in a public
health agency or related training fel owship. Authorizes the appropriation of $195
mil ion for FY2010, and SSAN for each of FY2011 through FY2015.
5206(b)
New PHSA Sec.
Public health and allied health scholarship program. Authorizes grants to
No appropriations identified.
777 (HRSA)
accredited institutions for scholarships to help support the training of mid-career
professionals in public health and allied health. Available grant funds are to be divided
50:50 between supporting public health and allied health professionals. Authorizes the
appropriation of $60 million for FY2010, and SSAN for each of FY2011 through
FY2015.
5313
New PHSA Sec.
Community health worker (CHW) program. Requires CDC to award grants
No appropriations identified.
399V (CDC)
to promote healthy behaviors and outcomes for populations in medical y underserved
communities through programs of training and supervision of CHWs. Eligible grantees
include states and subdivisions, health departments, free clinics, hospitals, and FQHCs.
Priority is to be given to applicants that target areas with a high proportion of
uninsured or underinsured individuals, or with high rates of chronic illness or infant
mortality. Authorizes the appropriation of SSAN for each of FY2010 through FY2014.
CRS-18


Statutory
ACA
Section
Authority
Summary of Provision
Funding (FY2010-FY2015)
(Agency)
5314
New PHSA Sec.
CDC training fellowships. Authorizes the Secretary to expand existing CDC
Funding for CDC’s public health workforce and career
778 (CDC)
training fellowships in epidemiology, laboratory science, and informatics; the Epidemic
development programs:
Intelligence Service (EIS); and other training programs that meet similar objectives.
FY2010 = $38 million (+ $7 million PPHF)
Participants may be placed in state and local health agencies, and states can receive
FY2011 = $36 million (+ $25 million PPHF)
federal assistance for loan repayment programs for such participants. Authorizes the
FY2012 = $36 million (+ $25 million PPHF)
appropriation of $39.5 million for each of FY2010 through FY2013 ($24.5 million for
FY2013 = $48 million (+ $16 million PPHF)
EIS, and $5 million each for epidemiology, laboratory science, and informatics).
FY2014 = $52 million
[CFDA 93.065]
FY2015 request = $52 million (+ $15 million PPHF)
5315
New PHSA Title
United States Public Health Sciences Track. Authorizes the establishment of a
No appropriations identified.
II, Part D – Secs.
science track at academic sites selected by the Secretary to award degrees that
271-274 (U.S.
emphasize team-based service, public health, epidemiology, and emergency
Surgeon General) preparedness/response. Funds may be used for program development and for tuition
and stipends for students who meet a service obligation, including in the United States
Public Health Service (USPHS) Commissioned Corps. Requires the Secretary to
transfer SSAN from the Public Health and Social Services Emergency Fund for FY2010
and each fiscal year thereafter. Note: P.L. 112-10 prohibited any such transfer of
funds.b
5210 Amends
PHSA
USPHS Commissioned Corps. Establishes a Ready Reserve Corps of officers who No appropriations identified.
Sec. 203 (U.S.
are subject to involuntary cal to active duty (and training) by the Surgeon General, in
Surgeon General) order to bolster the available workforce for both routine and emergency public
health missions. Authorizes the appropriation of $17.5 million for each of FY2010
through FY2014 ($5 million for recruitment and training, $12.5 million for the Ready
Reserve Corps).
CRS-19


Statutory
ACA
Section
Authority
Summary of Provision
Funding (FY2010-FY2015)
(Agency)
Workforce Diversity, Health Disparities, Cultural Competency: Existing Programs
5307(a) Amends
and Cultural competency, prevention, public health, disparities, and individuals
No appropriations identified.
reauthorizes
with disability training. Authorizes grants, contracts, or cooperative agreements
PHSA Sec. 741
for the development and evaluation of research, demonstration projects, and model
(HRSA)
curricula that provide training in cultural competency, prevention, public health
proficiency, reducing health disparities, and aptitude for working with individuals with
disabilities. Requires the Secretary to coordinate this program with the one
authorized under PHSA Sec. 807 (see below). Authorizes the appropriation of SSAN
for each of FY2010 through FY2015.
5307(b) Amends
and Cultural competency, prevention, public health, disparities, and individuals
No appropriations identified.
reauthorizes
with disability training. Authorizes grants, contracts, or cooperative agreements
PHSA Sec. 807
for the development and evaluation of research, demonstration projects, and model
(HRSA)
curricula that provide training in cultural competency, prevention, public health
proficiency, reducing health disparities, and aptitude for working with individuals with
disabilities. The Secretary is required to coordinate this program with the one
authorized under PHSA Sec. 741 (see above). Authorizes the appropriation of SSAN
for each of FY2010 through FY2015.
5401 Amends
and
Centers of excellence (COE). Requires the Secretary to fund COEs at health
FY2010 = $25 million
reauthorizes
professions schools that recruit, enroll, and graduate underrepresented minorities or
FY2011 = $24 million
PHSA Sec. 736
that recruit underrepresented minorities serving in faculty or administrative positions. FY2012 = $23 million
(HRSA)
Authorizes the appropriation of $50 million for each of FY2010 through FY2015, and
FY2013 = $21 million
SSAN for each subsequent fiscal year. [CFDA 93.157]
FY2014 = $22 million
FY2015 request = $22 million
CRS-20


Statutory
ACA
Section
Authority
Summary of Provision
Funding (FY2010-FY2015)
(Agency)
5402 Amends
PHSA
Authorization of appropriations. Authorizes appropriations for the workforce
Funding for Sec. 737:
Sec. 740 (HRSA)
diversity programs authorized under PHSA Secs. 737, 738, and 739:
FY2010 = $49 million
FY2011 = $49 million

Authorizes the appropriation of $51 million for FY2010, and SSAN for each of
FY2012 = $47 million
FY2011 through FY2014, for Sec. 737, Scholarships for Disadvantaged Students,
FY2013 = $44 million
which provides grants to health professions schools for awarding scholarships to
FY2014 = $45 million
students from disadvantaged backgrounds with financial need. [CFDA 93.925]
FY2015 request = $45 million

Authorizes the appropriation of $5 million for each of FY2010 through FY2014
Funding for Sec. 738:
for Sec. 738, Faculty Loan Repayment Program, which helps repay loans for
FY2010 = $1 million
health profession graduates from disadvantaged backgrounds who serve as
FY2011 = $1 million
faculty at an eligible health professions college for at least two years. [CFDA
FY2012 = $1 million
93.923]
FY2013 = $1 million

Authorizes the appropriation of $60 million for FY2010, and SSAN for each of
FY2014 = $1 million
FY2011 through FY2014 for Sec. 739, Health Careers Opportunity Program,
FY2015 request = $1 million
which provides grants to health professions schools and other educational
Funding for Sec. 739:
institutions to improve recruitment and academic preparation of students from
FY2010 = $22 million
disadvantaged backgrounds. [CFDA 93.822]
FY2011 = $22 million
FY2012 = $15 million
FY2013 = $14 million
FY2014 = $14 million
FY2015 request = $0
5403(a) Amends
and Area Health Education Centers (AHECs). Requires the Secretary to award
Funding for AHECs:
reauthorizes
grants (with a matching requirement) to medical and nursing schools of at least
FY2010 = $33 million
PHSA Sec. 751
$250,000 to (1) plan, develop, and operate AHEC programs; and (2) to maintain and
FY2011 = $33 million
(HRSA)
improve the effectiveness of existing AHEC programs. AHECs recruit, train, and
FY2012 = $27 million
prepare individuals from minority populations or from disadvantaged or rural
FY2013 = $28 million
backgrounds to work in medical y underserved areas. Authorizes the appropriation of
FY2014 = $30 million
$125 million for each of FY2010 through FY2014; funds may be carried over for up to FY2015 request = $0
three fiscal years. [CFDA 93.107, 93.824]
CRS-21


Statutory
ACA
Section
Authority
Summary of Provision
Funding (FY2010-FY2015)
(Agency)
Workforce Diversity, Health Disparities, Cultural Competency: New Program
5403(b)
New PHSA Sec.
Continuing educational support for health professionals serving in
No appropriations identified.
752 (HRSA)
underserved communities. Requires the Secretary to award grants to enhance
education through distance learning, continuing education, col aborative conferences,
and telehealth, with a focus on primary care. Eligible grantees include health
professions schools, academic health centers, state or local governments, or other
public or nonprofit entities participating in training activities. Authorizes the
appropriation of $5 million for each of FY2010 through FY2014, and SSAN for each
subsequent fiscal year. [CFDA 93.189]
Mental and Behavioral Health: New Program
5306 Redesignates
Mental and behavioral health education and training grants. Authorizes
FY2012 = $10 million (all PPHF)
PHSA Sec. 756 as grants for the recruitment and education of students in social work, interdisciplinary
Sec. 757, and
psychology training, and internships or other field placement programs related to
No appropriations identified since FY2012.
adds a new Sec.
child and adolescent mental health. Priority for social work grants given to schools of
[Note: (1) HRSA’s graduate psychology education
756 (HRSA)
social work meeting certain criteria such as recruiting from and placing graduates into
program, which predates ACA, received the fol owing
areas with a high-need and high-demand population. Priority for psychology grants
amounts: FY2010 = $3 million; FY2011 = $3 million;
given to institutions focusing on the needs of specified vulnerable groups. Priority for
FY2012 = $3 million; FY2013 = $3 million; FY2014 = $8
grants to train professional and paraprofessional child and adolescent mental health
mil ion; FY2015 request = $8 million. (2) SAMHSA
workers given to applicants that can, among other things, assess workforce needs and
received $35 million in FY2014 to expand the mental and
that have programs designed to increase the number of child and adolescent mental
behavioral health workforce, through a partnership with
health workers serving high-priority populations. Authorizes the appropriation of $35
HRSA. SAMHSA requested the same amount for FY2015
million for the period of FY2010 through FY2013 (i.e., $8 million for training in social
to continue the program.]
work, $12 million for training in graduate psychology, $10 million for training in
professional child and adolescent mental health, and $5 million for training in

paraprofessional child and adolescent mental health). [CFDA 93.732]
CRS-22


Statutory
ACA
Section
Authority
Summary of Provision
Funding (FY2010-FY2015)
(Agency)
Policy and Planning: Existing Program
5103 Amends
and
Health care workforce program assessment. Requires the Secretary to
FY2010 = $3 million
reauthorizes
establish a National Center for Health Care Workforce Analysis, award grants to
FY2011 = $3 million
PHSA Sec. 761
support state and regional centers for health workforce analysis, and increase funding
FY2012 = $3 million
(HRSA)
for longitudinal evaluations of specified individuals who have received education,
FY2013 = $3 million
training, or financial assistance from programs under PHSA Title VII. Authorizes the
FY2014 = $5 million
appropriation of the following amounts: $7.5 million for each of FY2010 through
FY2015 request = $5 million
FY2014 for the National Center; $4.5 million for each of FY2010 through FY2014 for
state and regional centers; and SSAN for FY2010 through FY2014 for the longitudinal
[Note: These amounts also include funding for PHSA
evaluations. [CFDA 93.300]
Sec. 792 (health professions data) and Sec. 806 (nursing
grant program data).]
Policy and Planning: New Programs
5101 New
freestanding
National Health Care Workforce Commission. Establishes a 15-member
No appropriations identified.
authority
commission focused on evaluating and meeting the need for health care workers in
the United States. The commission is required to conduct studies, produce annual
reports beginning in 2011, and make recommendations on high-priority topics related
to the health care workforce. Authorizes the appropriation of SSAN (no years
specified).
5102 New
freestanding
State health care workforce development grants. Establishes a matching grants FY2010 = $6 million (all PPHF)
authority (HRSA)
program for state partnerships to plan and implement activities leading to coherent
and comprehensive health care workforce development strategies at the state and
No appropriations identified since FY2012.
local levels. Planning grants of up to $150,000 are for up to one year and require a
15% match. Implementation grants are for up to two years (with up to one additional
year of funding) and require a 25% match. Authorizes the appropriation of $8 million
for FY2010, and SSAN for each subsequent fiscal year, for planning grants; and $150
mil ion for FY2010, and SSAN for each subsequent fiscal year, for implementation
grants. [CFDA 93.509]
Sources: Table prepared by the Congressional Research Service based on the text of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended).
Funding amounts are taken from HRSA’s budget documents, including the FY2014 operating plan, available at http://www.hrsa.gov/about/budget/index.html.
a. The nursing education loan repayment program repays 60% of a registered nurse’s educational loans in return for a two-year commitment to work in a health care
facility with a critical shortage of nurses. Participants may have an additional 25% of their loan repaid in exchange for one more year of service. The nurse
scholarship program offers scholarships to individuals attending nursing school in exchange for at least two years working in a health care facility with a critical
shortage of nurses. Together the two programs, which are authorized under PHSA Sec. 846 and col ectively known as NURSE Corps, received $94 million in
CRS-23


FY2010, $93 million in FY2011, $83 million in FY2012, and $78 million in FY2013. The FY2014 request is for $83 million. The authorization of appropriations for
Sec. 846 expired at the end of FY2007 and was not reauthorized by ACA.
b. The Department of Defense and Ful -Year Continuing Appropriations Act, 2011 (P.L. 112-10, Div. B, Sec. 1828) prohibited the transfer of funds from the Public
Health and Social Services Emergency Fund (PHSSEF) to support the U.S. Public Health Sciences Track. The PHSSEF is an HHS account administered by the
Secretary. Congress has historical y used the PHSSEF to provide one-time funding for non-routine activities. Each fiscal year, Congress appropriates amounts to the
PHSSEF for specified purposes. ACA did not authorize or appropriate funds to the PHSSEF.
CRS-24


Table 4. ACA Discretionary Spending: Prevention and Wellness
Statutory
ACA
Authority
Summary of Provision
Funding (FY2010-FY2015)
Section
(Agency)
Community-Based Prevention: Existing Programs
3509/3511
New PHSA Secs.
Offices on Women’s Health. Establishes within OS an Office on Women’s Health,
Funding for OS Office on Women’s Health:
229 (OS), 310A
headed by a Deputy Assistant Secretary for Women’s Health, and transfers all
FY2010 = $34 million
(CDC), 925
functions and personnel from the existing Office on Women’s Health of the Public
FY2011 = $34 million
(AHRQ); new
Health Service to the new office. Requires the OS Office on Women’s Health to
FY2012 = $34 million
SSA Sec. 713
establish an HHS Coordinating Committee on Women’s Health and a National
FY2013 = $33 million
(HRSA); and new
Women’s Health Information Center, among other things. Authorizes the
FY2014 = $34 million
FFDCA Sec. 1011 appropriation of SSAN for each of FY2010 through FY2014.
FY2015 request = $30 million
(FDA). Amends
PHSA Secs.
Amends the existing authorities for NIH’s Office of Research on Women’s Health
Funding for NIH Office of Research on Women’s Health:
486(a) (NIH) and
(ORWH) and SAMHSA’s Associate Administrator for Women’s Services by specifying FY2010 = $43 million
501(f)
that the ORWH director and the Associate Administrator are to report directly to
FY2011 = $42 million
(SAMHSA).
the NIH Director and the SAMHSA Administrator, respectively. Authorizes the
FY2012 = $42 million
appropriation of SSAN (no years specified).
FY2013 = $40 million
FY2014 = $41 million
Establishes Offices of Women’s Health at CDC, AHRQ, HRSA, and FDA to make
FY2015 request = $41 million
recommendations regarding grant-making through other agency accounts. Authorizes
the appropriation of SSAN for each of FY2010 through FY2014.
4003 Amends
PHSA
Clinical and community preventive services task forces. Reauthorizes and
AHRQ funding for USPSTF:
Sec. 915(a)
expands the authority for the U.S. Preventive Services Task Force (USPSTF) to review FY2010 = $4 million (+ $5 million PPHF)
(AHRQ). New
and recommend effective clinical preventive services. Provides explicit statutory
FY2011 = $4 million (+ $7 million PPHF)
PHSA Sec. 399U
authority for the existing Task Force on Community Preventive Services (TFCPS) to
FY2012 = $4 million (+ $7 million PPHF)
(CDC).
review and recommend effective community-based interventions. Authorizes the
FY2013 = $5 million (+ $6 million PPHF)
appropriation of SSAN for each fiscal year to carry out the activities of the USPSTF
FY2014 = $4 million (+ $7 million PPHF)
and the TFCPS.
FY2015 request = $11 million
CDC funding for TFCPS:
FY2010 = $5 million (all PPHF)
FY2011 = $7 million (all PPHF)
FY2012 = $10 million (all PPHF)
FY2013 = $7 million (all PPHF)
FY2014 = $0
FY2015 request = $8 million (al PPHF)
CRS-25


Statutory
ACA
Section
Authority
Summary of Provision
Funding (FY2010-FY2015)
(Agency)
4102(b) Amends
PHSA
School-based dental sealant program. Amends the existing school-based dental
Funding for all of CDC’s existing oral health programs
Sec. 317M(c)
sealant grant program, which was discretionary, by requiring the Secretary to award
under PHSA Sec. 317M:
(CDC, HRSA)
grants to the 50 states and to Indian tribes for school-based dental sealant programs.
FY2010 = $15 million
Note: The authorization of appropriations for the school-based dental sealant
FY2011 = $15 million
program expired at the end of FY2005. ACA did not reauthorize appropriations for
FY2012 = $16 million
the program.
FY2013 = $15 million
FY2014 = $16 million
FY2015 request = $16 million
[Note: Amounts below the line reflect realignment for
the CDC Working Capital Fund (WCF) and are not
comparable to amounts above the line.]
4204 Amends
PHSA
Immunization programs. Provides explicit authority for states to purchase
Funding for the Sec. 317 immunization program
Sec. 317 and adds vaccines at prices negotiated by Secretary. Authorizes the appropriation of SSAN (no
(including program implementation and accountability):
a new subsection
years specified) for state immunization grants. Establishes a new immunization
FY2010 = $561 million
(m) (CDC)
demonstration grant, for which is authorized the appropriation of SSAN for each of
FY2011 = $361 million (+ $100 million PPHF)
FY2010 through FY2014. [CFDA 93.185, 93.268, 93.533, 93.539]
FY2012 = $452 million (+ $190 million PPHF)
FY2013 = $461 million (+ $91 million PPHF)
FY2014 = $452 million (+ $160 million PPHF)
FY2015 request = $433 million (+ $127 million PPHF)
[Note: Amounts below the line reflect realignment for
the CDC WCF and are not comparable to amounts
above the line.]
CRS-26


Statutory
ACA
Section
Authority
Summary of Provision
Funding (FY2010-FY2015)
(Agency)
10334 Amends
PHSA
Offices of Minority Health. Establishes within OS an Office of Minority Health,
Funding for OS Office of Minority Health:
Sec. 1707 (OS)
headed by a Deputy Assistant Secretary for Minority Health, and transfers all
FY2010 = $56 million
and PHSA Title
functions and personnel from the existing Office of Minority Health of the Public
FY2011 = $56 million
IV (NIH), and
Health Service to the new office. Authorizes the appropriation of SSAN for each of
FY2012 = $56 million
adds new PHSA
FY2011 through FY2016.
FY2013 = $40 million
Sec. 1707A
FY2014 = $57 million
(AHRQ, CDC,
Renames NIH’s National Center on Minority Health and Health Disparities
FY2015 request = $36 million
CMS, FDA,
(NCMHD) as the National Institute on Minority Health and Health Disparities
HRSA, SAMHSA)
(NIMHD). Specifies that the NIMHD Director is responsible for the coordination of
Funding for NIH/NIMHD:
all NIH research on minority health and health disparities.
FY2010 = $211 million
FY2011 = $276 million
Establishes an Office of Minority Health in AHRQ, CDC, CMS, FDA, HRSA, and
FY2012 = $276 million
SAMHSA. Requires the Secretary to designate an appropriate amount of each
FY2013 = $260 million
agency’s funding to support the activities of its Office of Minority Health.
FY2014 = $268 million
FY2015 request = $268 million
10412 Reauthorizes
Rural access to emergency devices. Authorizes the appropriation of $25 million
FY2010 = $3 million
PHSA Sec. 312
for each of FY2003 through FY2014 for a program of grants to community
FY2011 = $0.2 million
(HRSA)
partnerships to purchase and distribute automatic external defibrillators (AEDs) in
FY2012 = $1 million
rural communities, and to provide AED training for first responders. [CFDA 93.259]
FY2013 = $2 million
FY2014 = $3 million
FY2015 = $0
Community-Based Prevention: New Programs
4004 New
freestanding
Education and outreach regarding prevention. Requires the Secretary to carry
Note: Education and outreach for health promotion are
authority
out various specified communications activities regarding health promotion and
core public health activities and a part of many HHS
disease prevention, for common and serious chronic health problems. They include
programs, authorized in broad language in the PHSA.
establishing, within one year of enactment, a national media campaign on health
Thus, it is not possible to identify total funding for Sec.
promotion and disease prevention. Authorizes the appropriation of SSAN for each
4004 implementation. However, HHS reported using $30
fiscal year; no more than $500 mil ion total.
mil ion in FY2012 PPHF funds for tobacco prevention
media activities and prevention education and outreach,
and continues to use a portion of annual PPHF funds for
education, awareness, and outreach activities for various
other disease prevention and health promotion
purposes.
CRS-27


Statutory
ACA
Section
Authority
Summary of Provision
Funding (FY2010-FY2015)
(Agency)
4102(a)
New PHSA Secs.
Oral health activities. Requires CDC, subject to appropriations, to fund a five-year
No appropriations identified.
399LL, 399LL-1,
national oral health education campaign, and award grants to community-based
and 399LL-2
providers of dental services for dental caries disease management programs, among
(CDC)
other things. Authorizes the appropriation of SSAN (no years specified).
4102(c) Amends
PHSA
Oral health infrastructure. Requires the Secretary to enter into cooperative
No appropriations identified.
Sec. 317M by
agreements with states and tribal entities to establish oral health leadership and
adding a new
programs to improve oral health. Authorizes the appropriation of SSAN for FY2010
subsection (d)
through FY2014.
(CDC)
4102(d) New
freestanding
Oral health surveillance. Requires the Secretary to expand the fol owing
No appropriations identified.
authority (CDC,
surveillance systems to include more information on oral health: Pregnancy Risk
AHRQ)
Assessment Monitoring System (PRAMS); National Health and Nutrition Examination
Survey (NHANES); National Oral Health Surveillance System (NOHSS); and Medical
Expenditure Panel Survey (MEPS). Authorizes the appropriation of SSAN (no years
specified) for PRAMS, and SSAN for each of FY2010 through FY2014 for NOHSS; no
explicit authorization of appropriations for NHANES/MEPS expansion.
4201 New
freestanding
Community transformation grants. Requires CDC to fund competitive grants
FY2011 = $145 million (all PPHF)
authority (CDC)
for the implementation, evaluation, and dissemination of evidence-based community
FY2012 = $226 million (all PPHF)
preventive health activities. Authorizes the appropriation of SSAN for each of FY2010
FY2013 = $146 million (all PPHF)
through FY2014. [CFDA 93.531]
FY2014 = $0
FY2015 request = $0
4202(a) New
freestanding
Community wellness pilot program. Requires CDC to award grants to state and No appropriations identified.
authority (CDC)
local health departments, and to Indian tribes, for five-year pilot programs to provide
community prevention interventions, screenings, and clinical referrals for individuals
between 55 and 64 years of age. Authorizes the appropriation of SSAN for each of
FY2010 through FY2014.
4206 Amends
PHSA
Individualized wellness plan demonstration program. Requires the Secretary
No appropriations identified.
Sec. 330 by
to establish a pilot program in not more than 10 community health centers to test the
adding a new
impact of providing at-risk individuals who use the centers with individualized wel ness
subsection (s)
plans. Authorizes the appropriation of SSAN (no years specified).
CRS-28


Statutory
ACA
Section
Authority
Summary of Provision
Funding (FY2010-FY2015)
(Agency)
4304
New PHSA Sec.
Epidemiology and laboratory capacity grants. Codifies existing grant programs
Funding for CDC’s Epidemiology and Laboratory
2821 (CDC)
to strengthen national epidemiology, laboratory, and information management
Capacity (ELC) program and Emerging Infections
capacity for the response to infectious diseases and other conditions of public health
Program (EIP) grants:
importance. Authorizes the appropriation of $190 million for each of FY2010 through
FY2010 = $20 million (all PPHF)
FY2013. [Note: ACA requires a specific distribution of funds among epidemiology,
FY2011 = $40 million (all PPHF)
information management, and laboratory grants. A provision in annual appropriations
FY2012 = $40 million (all PPHF)
acts nullifies this distribution directive.]
FY2013 = $40 million (PPHF + transfers)
FY2014 = $40 million (all PPHF)
FY2015 request = $40 million (all PPHF)
10407 New
freestanding
Diabetes activities. Requires CDC to conduct several diabetes prevention activities No appropriations identified.
authority (CDC)
including state assessments, vital statistics, physician education, and funding of an
Institute of Medicine (IOM) report. Authorizes the appropriation of SSAN (no years
specified).
10411
New PHSA Secs.
Congenital heart disease programs. Authorizes CDC to establish a National
Funding for CDC’s congenital heart disease program:
399V-2 (CDC)
Congenital Heart Disease Surveillance System (NCHDSS), or to award one grant to
FY2012 = $2 million
and 425 (NIH)
establish such a system. Authorizes NIH to expand and coordinate research on
FY2013 = $2 million
congenital heart disease. Authorizes the appropriation of SSAN for each of FY2011
FY2014 = $3 million
through FY2015 for both the surveillance system and the expanded research
FY2015 request = $3 million (al PPHF)
program.
10413
New PHSA Sec.
Young women’s breast health awareness. Among other things, requires CDC
FY2010 = $5 million
399NN (OS,
to conduct an education campaign and award grants for a media campaign regarding
FY2011 = $5 million
CDC)
breast health in young women, and to conduct prevention research; requires the
FY2012 = $5 million
Secretary to award grants to provide education and assistance to young women
FY2013 = $5 million
diagnosed with breast disease. Authorizes the appropriation of $9 million for each of
FY2014 = $5 million
FY2010 through FY2014.
FY2015 request amount not specified
CRS-29


Statutory
ACA
Section
Authority
Summary of Provision
Funding (FY2010-FY2015)
(Agency)
10501(g)
New PHSA Sec.
National diabetes prevention program (NDPP). Among other things, requires
FY2010 = $0
399V-3 (CDC)
the Secretary to award grants for community-based diabetes prevention program
FY2011 = $0
model sites. Authorizes the appropriation of SSAN for each of FY2010 through
FY2012 = $10 million (all PPHF)
FY2014. [Note: NDPP is a component of CDC’s broader diabetes prevention
FY2013 = $3*
activities.]
FY2014 = $10 million
FY2015 request = $10 million
*NDPP did not receive dedicated funding for FY2013.
CDC used internal transfers to continue program
activities.
Workplace Wellness: New Program
10408 New
freestanding
Small business wellness program. Requires the Secretary to award grants to
FY2010 = $0
authority (CDC)
employers to provide their employees with access to comprehensive workplace
FY2011 = $10 million (all PPHF)
wellness programs. Eligible employers are those with fewer than 100 employees, who
FY2012 = $10 million (all PPHF)
work at least 25 hours per week. Authorizes the appropriation of $200 million for
FY2013 = $0
the period of FY2011 through FY2015, to remain available until expended.
FY2014 = $10 (all PPHF)
FY2015 request = $0
Sources: Table prepared by the Congressional Research Service based on the text of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended).
Funding amounts are taken from agency budget documents, including operating plans for certain fiscal years, available at http://www.hhs.gov/budget/, and communications
with the CDC Washington Office.

CRS-30


Table 5. ACA Discretionary Spending: Maternal and Child Health
Statutory
ACA
Authority
Summary of Provision
Funding (FY2010-FY2015)
Section
(Agency)
2952(b)
New SSA Sec.
Services to individuals with a postpartum condition. Authorizes grants to
No appropriations identified.
512 (HRSA)
establish, operate and coordinate effective and cost-efficient systems for the delivery
of essential services to individuals with, or at risk of, postpartum depression and their
families. Eligible grantees include public or nonprofit private entities, state or local
government public-private partnerships, recipients of Healthy Start grants, public or
nonprofit private hospitals, community-based organizations, hospices, ambulatory care
facilities, community health centers, and primary care centers. Authorizes the
appropriation of $3 million for FY2010, and SSAN for each of FY2011 and FY2012.
Source: Table prepared by the Congressional Research Service based on the text of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended).

Table 6. ACA Discretionary Spending: Health Care Quality
ACA
Statutory
Authority
Section
Summary of Provision
Funding (FY2010-FY2015)
(Agency)
Quality Measure Development, Analysis, and Public Reporting: New Programs
3013(a)&(c)
New PHSA 931
Quality measure development. Requires the Secretary, in consultation with
No appropriations identified.
(AHRQ)
AHRQ and CMS, to (1) identify gaps where no quality measures exist or where
existing measures need improvement, updating or expansion consistent with the
National Strategy for Quality Improvement; and (2) fund or enter into agreements
with eligible entities that have demonstrated expertise in measure development to
develop, improve, update, or expand quality measures in areas identified as gap areas.
Authorizes the appropriation of $75 million for each of FY2010 through FY2014, to
remain available until expended. At least 50% of the amounts appropriated must be
used pursuant to SSA Sec. 1890A(e), as added by ACA Sec. 3013(b). See below.
CRS-31


Statutory
ACA
Section
Authority
Summary of Provision
Funding (FY2010-FY2015)
(Agency)
3013(b)
Amends new SSA Quality and efficiency measures development. Requires CMS, in consultation
See ACA Sec. 3013(a)&(c) above.
Sec. 1890A, as
with AHRQ, through contracts, to develop quality and efficiency measures as
added by ACA
determined appropriate for use under the SSA.
Sec. 3014(b), by
adding a new
subsection (e)
(CMS)
3015
New PHSA Sec.
Collection and analysis of data for quality and resource use measures.
No appropriations identified.
399II
Requires the Secretary to establish and implement an overall strategic framework to
carry out the public reporting of performance information. Requires the Secretary to
collect and aggregate consistent data on quality and resource use measures, and
authorizes the Secretary to award grants or contracts for this purpose. Authorizes
the Secretary to award grants or contracts to multi-stakeholder entities to support
new, or improve existing, efforts to collect and aggregate quality and resource use
measures. Authorizes the appropriation of SSAN for each of FY2010 through FY2014.
3015
New PHSA Sec.
Public reporting of performance information. Requires the Secretary to make
No appropriations identified.
399JJ
available to the public, through standardized websites, performance information
summarizing data on quality measures. The information must include clinical
conditions to the extent such data are available and, where appropriate, be provider-
specific and sufficiently disaggregated and specific to meet the needs of patients with
different clinical conditions. Authorizes the appropriation of SSAN for each of FY2010
through FY2014.
Quality Improvement Research, Training, and Implementation: New Programs
3501
New PHSA Sec.
Health care delivery system research. Requires AHRQ to (1) identify, develop,
FY2014 = $5 million
933 (AHRQ)
evaluate, and disseminate innovative strategies for quality improvement practices in
the delivery of health care services that represent best practice; (2) support research
No appropriations identified prior to FY2014.
on health care delivery improvement and facilitate adoption of best practices; and (3)
make the research findings available to the public; among other specified functions.
Authorizes the appropriation of $20 million for FY2010 through FY2014.
CRS-32


Statutory
ACA
Section
Authority
Summary of Provision
Funding (FY2010-FY2015)
(Agency)
3501/3511
New PHSA Sec.
Quality improvement technical assistance and implementation. Requires
No appropriations identified.
934 (AHRQ)
AHRQ to award grants (with a matching requirement) to eligible entities for
providing technical support to health care providers in order to help them
understand, adapt, and implement the models and practices identified by the research
conducted by the agency. Grantees must have demonstrated expertise in providing
information and technical support and assistance to health care providers regarding
quality improvement. Authorizes the appropriation of SSAN (no years specified).
3508/3511 New
freestanding
Quality and patient safety training. Authorizes the Secretary to award
No appropriations identified.
authority
demonstration grants (with a matching requirement) to eligible health professions
schools or consortia to develop and implement academic curricula that integrate
quality improvement and patient safety into clinical education of health professionals.
Authorizes the appropriation of SSAN (no years specified).
Health Care Coordination: Existing Program
3510 Amends
and
Patient navigator program. Prohibits the Secretary from awarding a grant to an
FY2010 = $5 million
reauthorizes
entity under this section unless the entity provides assurances that patient navigators
FY2011 = $5 million
PHSA Sec. 340A
recruited, assigned, trained, or employed using these grant funds meet certain
(HRSA)
minimum core proficiencies. Eligible grantees include public or nonprofit private
No appropriations identified since FY2011.
health centers (including FQHCs), IHS facilities, hospitals, cancer centers, rural health

clinics, academic health centers, and nonprofit entities that partner or coordinate
referrals with such a facility to provide patient navigator services. Authorizes the
appropriation of $3.5 million for FY2010, and SSAN for each of FY2011 through
FY2015. [CFDA 93.191]
CRS-33


Statutory
ACA
Section
Authority
Summary of Provision
Funding (FY2010-FY2015)
(Agency)
Health Care Coordination: New Programs
3502/3511 New
freestanding
Community health team grants to support medical homes. Requires the
No appropriations identified.
authority
Secretary to award grants to or enter into contracts with states, state-designated
entities, and tribal organizations to support community-based interdisciplinary,
interprofessional health teams in assisting primary care practices. Funding must be
used to establish the health teams and to provide capitated payments to the
providers. Authorizes the appropriation of SSAN (no years specified).
3503/3511
New PHSA Sec.
Medication therapy management (MTM) grants. Requires the Secretary, not
No appropriations identified.
935 (AHRQ)
later than May 1, 2010, to provide grants to support MTM services provided by
licensed pharmacists that are targeted at patients who take four or more prescribed
medications, take high-risk medications, have two or more chronic diseases, or have
undergone a transition of care or other factors that are likely to create a high risk for
medication-related problems. Authorizes the appropriation of SSAN (no years
specified).
3506
New PHSA Sec.
Program to facilitate shared decision making. Requires the Secretary, through
No appropriations identified.
936 (AHRQ)
a contract, to develop and identify standards for patient decision aids, to review
patient decision aids, and develop a certification process for determining whether
patient decision aids meet those standards. The contract is to be awarded to the
entity that holds the contract under SSA Sec. 1890 (currently the National Quality
Forum). Further requires the Secretary to (1) award grants or contracts to develop,
update, and produce patient decision aids, to test such materials to ensure they are
balanced and evidence-based, and to educate providers on their use; and (2) to award
grants for establishing Shared Decision Making Resource Centers to develop and
disseminate best practices to speed adoption and effective use of patient decision aids
and shared decision making. Also requires the Secretary to award grants to providers
for the development and implementation of shared decision-making techniques.
Authorizes the appropriation of SSAN for FY2010 and each subsequent fiscal year.
CRS-34


Statutory
ACA
Section
Authority
Summary of Provision
Funding (FY2010-FY2015)
(Agency)
5405
New PHSA Sec.
Primary care extension program. Requires the Secretary to establish a Primary
No appropriations identified.
399V-1 (AHRQ)
Care Extension Program to award state planning and implementation grants for
Primary Care Extension Program State Hubs, consisting of the state health
department and other specified entities. State hubs must contract with and provide
grant funds to county and local entities to serve as Primary Care Extension Agencies
that assist primary care providers in implementing patient-centered medical homes
and develop and support primary care learning communities, among other functions.
Authorizes the appropriation of $120 million for each of FY2011 and FY2012, and
SSAN for each of FY2013 and FY2014.
5604
New PHSA Sec.
Co-locating primary and specialty care in community-based mental health
Note: SAMHSA’s Primary & Behavioral Health Care
520K (SAMHSA)
settings. Requires the Secretary to fund demonstration projects for providing
Integration (PBHCI) program, authorized under PHSA
coordinated and integrated services to individuals with mental illness and co-occurring Sec. 520A, predates ACA and has received the fol owing
chronic diseases through the co-location of primary and specialty care services in
amounts: FY2011 = $28 million (+ $35 million PPHF);
community-based mental and behavioral health settings. Authorizes the appropriation
FY2012 = $31 million (+ $35 million PPHF); FY2013 =
of $50 million for FY2010, and SSAN for each of FY2011 through FY2014.
$29 million; FY2014 = $50 million; FY2015 request =
$26 million (+ $8 million PPHF).
10333
New PHSA Sec.
Community-based collaborative care network program. Authorizes the
No appropriations identified.
340H
Secretary to award grants to support community-based col aborative care networks
(CCN). An eligible CCN is a consortium of health care providers with a joint
governance structure that provides comprehensive coordinated and integrated health
care services (as defined by the Secretary) for low-income populations. CCNs must
include a safety net hospital and all FQHCs in the community, as specified. Authorizes
the appropriation of SSAN for each of FY2011 through FY2015.
10410
New PHSA Sec.
Centers of excellence for depression. Requires SAMHSA to award five-year
No appropriations identified.
520B (SAMHSA)
grants (with a matching requirement) on a competitive basis to eligible institutions of
higher education or research institutions to establish national centers of excel ence
for depression. One grantee is to be designated as the coordinating center and
required to establish and maintain a national database. Centers of excel ence may
receive a grant of up to $5 million; the coordinating center may receive a grant of up
to $10 million. Authorizes the appropriation of $100 million for each of FY2011
through FY2015, and $150 million for each of FY2016 through FY2020.
Sources: Table prepared by the Congressional Research Service based on the text of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended).
Funding amounts are taken from agency budget documents, including the FY2014 operating plans, available at http://www.hhs.gov/budget/.
CRS-35


Table 7. ACA Discretionary Spending: Nursing Homes
Statutory
ACA
Authority
Summary of Provision
Funding (FY2010-FY2015)
Section
(Agency)
6112 New
freestanding
National independent monitor demonstration program. Requires the
No appropriations identified.
authority
Secretary, within one year of enactment, to implement a two-year demonstration to
develop, test, and implement an independent monitoring program to oversee
interstate and large intrastate chains of skilled nursing facilities (SNFs) and nursing
facilities (NFs). Authorizes the appropriation of SSAN (no years specified); a
monitored chain must contribute a portion of costs of the demonstration, as
determined by the Secretary.
6114 New
freestanding
Culture change and information technology demonstration programs.
No appropriations identified.
authority
Requires the Secretary, within one year of enactment, to award one or more
competitive grants to support each of the fol owing three-year demonstration
projects for SNFs and NFs: (1) develop best practices for culture change (i.e., patient-
centric models of care); and (2) develop best practices for the use of health
information technology. Authorizes the appropriation of SSAN (no years specified).
Source: Table prepared by the Congressional Research Service based on the text of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended).
CRS-36


Table 8. ACA Discretionary Spending: Health Disparities Data Collection
Statutory
ACA
Authority
Summary of Provision
Funding (FY2010-FY2015)
Section
(Agency)
4302(a)
New PHSA Title
Health disparities data collection and analysis. Not later than two years after
No appropriations identified.
XXXI; new Sec.
enactment, requires federally conducted and supported health programs and surveys,
3101
to the extent practicable, to col ect and report data on race, ethnicity, sex, primary
language, and disability status, as well as other demographic data on health disparities
as deemed appropriate by the Secretary. Requires the Secretary to adopt standards for
the measurement and col ection of such data. Requires the Secretary to analyze the
data col ected on health disparities; provide for the public reporting and dissemination
of the data and analyses; and safeguard the privacy of the information. Authorizes the
appropriation of SSAN for each of FY2010 through FY2014; however, data may not be
col ected unless funds are directly appropriated for such purpose. [Note: On October
31, 2011, HHS published final standards for collecting and reporting health disparities
data. See http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlid=208.]
5605 New
freestanding
Key national indicators. Establishes a Commission on Key National Indicators
No appropriations identified.
authority
composed of eight members appointed by Congress. [Note: The commission members
were appointed in Dec. 2010. See http://www.stateoftheusa.org/content/commission-
on-key-national-ind.php.] Requires the commission to contract with the National
Academy of Sciences to review available public and private sector research on key
national indicator set selection and determine how best to establish a key national
indicator system, among other things. Mandates a Government Accountability Office
(GAO) study of previous efforts by public, private, or foreign entities to develop best
practices for a key national indicator system. Authorizes the appropriation of $10
mil ion for FY2010, and $7.5 million for each of FY2011 through FY2018, with amounts
appropriated to remain available until expended. [Note: GAO released its study in
March 2011. See http://www.gao.gov/new.items/d11396.pdf.]
Source: Table prepared by the Congressional Research Service based on the text of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended).
CRS-37


Table 9. ACA Discretionary Spending: Emergency Care and Trauma Services
Statutory
ACA
Authority
Summary of Provision
Funding (FY2010-FY2015)
Section
(Agency)
Emergency Care and Trauma Services: Existing Programs
3505(a) Amends
and Trauma care centers. Requires the Secretary to establish separate grant programs
No appropriations identified.
reauthorizes
for IHS and tribal trauma care centers to (1) help defray substantial uncompensated
PHSA Secs. 1241-
care costs, (2) further the core missions of trauma care centers, and (3) provide
1245 (HRSA)
emergency relief to ensure the continued availability of trauma services. Authorizes
the appropriation of $100 million for FY2009, and SSAN for each of FY2010 through
FY2015.
5603 Amends
and
Children’s emergency medical services demonstration grants. Expands
FY2010 = $21 million
reauthorizes
emergency services for children who need treatment for trauma or critical care by
FY2011 = $21 million
PHSA Sec. 1910
lengthening the period for demonstration grants to four years (with an optional fifth
FY2012 = $21 million
(HRSA)
year). Authorizes the appropriation of $25 million for FY2010, $26.3 million for
FY2013 = $20 million
FY2011, $27.6 million for FY2012, $28.9 million for FY2013, and $30.4 million for
FY2014 = $20 million
FY2014. [CFDA 93.127]
FY2015 request = $20 million
Emergency Care and Trauma Services: New Programs
3504(a)
New PHSA Sec.
Regional systems for emergency care. Requires the Assistant Secretary for
Note: In addition to authorizing funding for the new
1204 (OS)
Preparedness and Response to award at least four multi-year contracts or grants
program, this ACA provision reauthorized funding for
(with matching requirement) to states and Indian tribes for pilot projects to improve
several existing trauma care grant programs in PHSA
regional coordination of emergency services. Priority given to entities serving a
Title XII Parts A and B (i.e., Secs. 1202, 1203, and 1211-
medically underserved population. Authorizes the appropriation of $24 million for
1222). No appropriations identified for any of the
each of FY2010 through FY2014.
programs.
3504(b)
New PHSA Sec.
Emergency medicine research. Requires the Secretary to expand and accelerate
No appropriations identified.
498D (NIH,
basic, translational, and service delivery research on emergency medical care systems
AHRQ, HRSA,
and emergency medicine, including pediatric emergency medical care. Also requires
CDC)
the Secretary to support research on the economic impact of coordinated emergency
care systems. Authorizes the appropriation of SSAN for each of FY2010 through
FY2014.
3505(b)
New PHSA Secs.
Trauma service availability grants. Requires the Secretary to award grants to
No appropriations identified.
1281-1282
states for the purpose of supporting trauma-related physician specialties and
broadening access to and availability of trauma care services. States must use at least
40% of the funds for grants to safety net trauma centers. Authorizes the
appropriation of $100 million for each of FY2010 through FY2015.
Sources: Table prepared by the Congressional Research Service based on the text of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended).
Funding amounts are taken from HRSA’s budget documents, including the FY2014 operating plan, available at http://www.hrsa.gov/about/budget/index.html.
CRS-38


Table 10. ACA Discretionary Spending: Elder Justice
Statutory
ACA
Authority
Summary of Provision
Funding (FY2010-FY2015)
Section
(Agency)
6703(a)
New SSA Sec.
Elder Justice Coordinating Council. Establishes an Elder Justice Coordinating
No appropriations identified.
2021 (OS)
Council to include the Secretary as chair and the U.S. Attorney General, as well as
the head of each federal department or agency, identified by the chair, as having
administrative responsibility or administering programs related to elder abuse,
neglect, and exploitation. Authorizes the appropriation of SSAN (no years specified).
See also new SSA Sec. 2024 below.
6703(a)
New SSA Sec.
Advisory Board on Elder Abuse, Neglect, and Exploitation. Establishes an
No appropriations identified.
2022
advisory board to create a short- and long-term multidisciplinary plan for
development of the field of elder justice and to make recommendations to the Elder
Justice Coordinating Council. Authorizes the appropriation of SSAN (no years
specified). See also new SSA Sec. 2024 below.
6703(a)
New SSA Sec.
Authorization of appropriations. Authorizes funding for new SSA Secs. 2021
No appropriations identified.
2024
(Coordinating Council), 2022 (Advisory Board), and 2023 (human subject protection
guidelines for researchers). Authorizes the appropriation of $6.5 mil ion for FY2011,
and $7.0 million for each of FY2012 through FY2014.
6703(a)
New SSA Sec.
Forensic centers and expertise. Requires the Secretary to award grants to eligible No appropriations identified.
2031
entities to establish and operate stationary and mobile forensic centers and to
develop forensic expertise pertaining to elder abuse, neglect, and exploitation.
Authorizes the appropriation of $4 million for FY2011, $6 million for FY2012, and $8
mil ion for each of FY2013 and FY2014.
6703(a)
New SSA Sec.
Incentives for LTC staffing. Requires the Secretary to award grants to LTC
No appropriations identified.
2041(a)
facilities for them to offer continuing training and varying levels of certification to
employees providing direct care to residents and to improve management practices
so as to promote retention of direct care workers. Authorizes the appropriation of
$20 million for FY2011, $17.5 mil ion for FY2012, and $15 million for each of FY2013
and FY2014 for new SSA Sec. 2041.
6703(a)
New SSA Sec.
Certified EHR technology grant program. Authorizes grants to LTC facilities
No appropriations identified.
2041(b)
for specified activities that would assist such entities in offsetting costs related to
purchasing, leasing, developing, and implementing certified electronic health record
technology. See above authorization of appropriations for new SSA Sec. 2041.
CRS-39


ACA
Statutory
Section
Authority
Summary of Provision
Funding (FY2010-FY2015)
(Agency)
6703(a)
New SSA Sec.
Standards for transactions involving clinical data by LTC facilities. Requires
No appropriations identified.
2041(c)
the Secretary to adopt electronic standards for the exchange of clinical data by LTC
facilities and, within 10 years, to have in place procedures to accept the optional
electronic submission of clinical data by LTC facilities pursuant to such standards. See
above authorization of appropriations for new SSA Sec. 2041.
6703(a)
New SSA Sec.
Adult protective service functions. Requires the Secretary to undertake various
No appropriations identified.
2042(a)
activities with respect to adult protective services, including providing funding,
col ecting and disseminating data on elder abuse, disseminating information on best
practices and training, conducting research, and providing technical assistance to
states and other entities. Authorizes the appropriation of $3 million for FY2011, and
$4 million for each of FY2012 through FY2014.
6703(a)
New SSA Sec.
Grants to enhance provision of adult protective services. Requires the
No appropriations identified.
2042(b)
Secretary to award formula grants to states to enhance adult protective services
programs provided by states and local governments. Authorizes the appropriation of
$100 million for each of FY2011 through FY2014.
6703(a)
New SSA Sec.
Adult protective services demonstration grants. Requires the Secretary to
No appropriations identified.
2042(c)
fund state demonstration programs for adult protective services that test methods to
prevent and detect elder abuse. Authorizes the appropriation of $25 million for each
of FY2011 through FY2014.
6703(a)
New SSA Sec.
Long-term care ombudsman program grants. Requires the Secretary to award
No appropriations identified.
2043(a)
grants to improve the capacity of state LTC ombudsman programs to address abuse
and neglect complaints, conduct pilot programs, and provide support for such
programs. Authorizes the appropriation of $5 million for FY2011, $7.5 million for
FY2012, and $10 million for each of FY2013 and FY2014.
6703(a)
New SSA Sec.
Ombudsman training programs. Requires the Secretary to establish programs to
No appropriations identified.
2043(b)
provide and improve ombudsman training with respect to elder abuse, neglect, and
exploitation for national organizations and state LTC ombudsman programs.
Authorizes the appropriation of $10 million for each of FY2011 through FY2014.
6703(b) New
freestanding
National Training Institute for Surveyors. Requires that the Secretary enter
No appropriations identified.
authority
into a contract with an entity to establish and operate a National Training Institute for
Federal and State Surveyors to train surveyors who investigate allegations of abuse in
programs and LTC facilities that receive payments under Medicare or Medicaid.
Authorizes the appropriation of $12 million for the period of FY2011 through
FY2014.
CRS-40


ACA
Statutory
Section
Authority
Summary of Provision
Funding (FY2010-FY2015)
(Agency)
6703(b) New
freestanding
Grants to state survey agencies. Requires the Secretary to award grants to state
No appropriations identified.
authority
survey agencies that perform surveys of Medicare or Medicaid participating nursing
facilities to design and implement complaint investigation systems. Authorizes the
appropriation of $5 million for each of FY2011 through FY2014.
6703(c) New
freestanding
National nurse aide registry study and report. Requires the Secretary, in
No appropriations identified.
authority
consultation with appropriate government agencies and private sector organizations,
to conduct a study on establishing a national nurse aide registry and report on its
findings. Authorizes the appropriation of SSAN (no years specified) to carry out these
activities, with funding not to exceed $500,000.
Source: Table prepared by the Congressional Research Service based on the text of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended).

Table 11. ACA Discretionary Spending: Biomedical Research
ACA
Statutory
Authority
Section
Summary of Provision
Funding (FY2010-FY2015)
(Agency)
10409 Amends
PHSA
Cures Acceleration Network (CAN). Establishes a CAN program within the
FY2012 = $10 million
Secs. 402(b) and
Office of the NIH Directora to award grants, contracts, or cooperative agreements to FY2013 = $9 million
499(c); new
support the development of treatments for diseases or conditions that are rare, and
FY2014 = $10 million
PHSA Sec. 402Ca for which market incentives are inadequate. Eligible grantees include public or private
FY2015 request = $30 million
(NIH)
entities, which may include private or public research institutions, institutions of
higher education, medical centers, biotechnology companies, pharmaceutical
companies, disease advocacy organizations, patient advocacy organizations, and
academic research institutions. Authorizes the appropriation of $500 million for
FY2010, and SSAN for subsequent fiscal years. Other funds appropriated under the
PHSA may not be allocated to CAN.
Sources: Table prepared by the Congressional Research Service based on the text of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended).
Funding amounts are taken from NIH’s budget documents, including the FY2014 operating plan, available at http://officeofbudget.od.nih.gov/br.html.
a. P.L. 112-74 created the National Center for Advancing Translational Sciences (NCATS) within NIH and transferred the CAN program from the Office of the NIH
Director to NCATS. It also redesignated PHSA Sec. 402C as Sec. 480.
CRS-41


Table 12. ACA Discretionary Spending: Biologics
Statutory
ACA
Authority
Summary of Provision
Funding (FY2010-FY2015)
Section
(Agency)
7002 Amends
PHSA
FDA approval of biosimilar biologics. Creates an abbreviated regulatory pathway No appropriations identified (FY2010-FY2012).
Sec. 351 (FDA)
for approving biological products that are demonstrated to be biosimilar to, or
interchangeable with, an FDA-licensed biological product. Provides for the collection
FY2013 = $1 million (user fees)
of user fees, subject to congressional authorization, to cover regulatory costs
FY2014 = $1 million (user fees)
beginning in FY2013. Authorizes the appropriation of SSAN for each of FY2010
FY2015 request = $1 million (user fees)
through FY2012. For more information on FDA regulation of biosimilar biological
products, see http://www.fda.gov/Drugs/DevelopmentApprovalProcess/
HowDrugsareDevelopedandApproved/ApprovalApplications/
TherapeuticBiologicApplications/Biosimilars/default.htm.
Source: Table prepared by the Congressional Research Service based on the text of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended).
Funding amounts are taken from FDA’s budget documents, including the FY2014 operating plan, available at http://www.fda.gov/AboutFDA/ReportsManualsForms/
Reports/BudgetReports/default.htm.

Table 13. ACA Discretionary Spending: 340B Drug Pricing
ACA
Statutory
Authority
Section
Summary of Provision
Funding (FY2010-FY2015)
(Agency)
7102 Amends
PHSA
Improvements to 340B program integrity. Requires the Secretary to develop
FY2010 = $2 million
Sec. 340B(d)
systems to improve compliance and program integrity to (1) increase transparency
FY2011 = $4 million
(HRSA)
and strengthen monitoring, oversight, and investigation of the prices that
FY2012 = $4 million
manufacturers charge covered entities; and (2) ensure covered entities do not divert
FY2013 = $4 million
drugs or obtain multiple discounts. Further requires the Secretary to establish a new
FY2014 = $10 million
administrative dispute resolution process to mediate and resolve covered entity
FY2015 request = $17 million (includes $7 million from a
overpayment claims and manufacturer claims against covered entities for drug
proposed new user fee program)
diversion or multiple discounts. Authorizes the appropriation of SSAN for FY2010
and each succeeding fiscal year.
Sources: Table prepared by the Congressional Research Service based on the text of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended).
Funding amounts are taken from HRSA’s budget documents, including the FY2014 operating plan, available at http://www.hrsa.gov/about/budget/index.html.
CRS-42


Table 14. ACA Discretionary Spending: Medical Malpractice
Statutory
ACA
Authority
Summary of Provision
Funding (FY2010-FY2015)
Section
(Agent)
10607
New PHSA Sec.
Liability reform demonstration program. Authorizes five-year demonstration
No appropriations identified.
399V-4 (HRSA)
grants to states for the implementation and evaluation of alternatives to current tort
litigation for resolving disputes over injuries allegedly caused by health care providers
or organizations. Planning grants of up to $500,000 may be awarded to states for the
development of demonstration project applications. To receive a grant, a state must
develop an alternative system that allows for the resolution of disputes caused by
health care providers or organizations, and reduces medical errors by encouraging
the col ection and analysis of patient safety data related to the resolved disputes.
Authorizes the appropriation of $50 million for the period FY2011 through FY2015.
Source: Table prepared by the Congressional Research Service based on the text of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended).

Table 15. ACA Discretionary Spending: Pain Care Management
ACA
Statutory
Authority
Section
Summary of Provision
Funding (FY2010-FY2015)
(Agency)
4305(a)
New freestanding Conference on pain. Requires the Secretary, within one year of appropriating
No appropriations identified.
authority
funds, to contract with the IOM to convene a Conference on Pain for the purpose of
assessing the public health impact of pain, reviewing pain research, care, and
education, and identifying barriers to improved pain care. A report summarizing the
Conference’s findings must be submitted to Congress by June 30, 2011. Authorizes
the appropriation of SSAN for each of FY2010 and FY2011. [Note: IOM released its
report on June 29, 2011. See http://painconsortium.nih.gov/.]
Source: Table prepared by the Congressional Research Service based on the text of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended).
CRS-43


Table 16. ACA Discretionary Spending: Medicaid
Statutory
ACA
Authority
Summary of Provision
Funding (FY2010-FY2015)
Section
(Agency)
2705 New
freestanding
Global payment system demonstration program. Requires the Secretary, in
No appropriations identified.
authority (CMS)
coordination with the Center for Medicare and Medicaid Innovation, to fund up to
five Medicaid demonstrations during the period FY2010 through FY2012 under which
a participating state will adjust payments made to a large safety net hospital system or
network from a fee-for-service model to a global capitated payment model.
Authorizes the appropriation of SSAN (no years specified).
2706 New
freestanding
Pediatric accountable care organization demonstration program. Requires
No appropriations identified.
authority (CMS)
the Secretary to conduct a five-year Medicaid demonstration (Jan. 1, 2012, through
Dec. 31, 2016) under which a participating state is allowed to recognize pediatric
providers as an accountable care organization (ACO) for the purpose of receiving
incentive payments. Eligible pediatric providers must meet certain performance
guidelines established by the Secretary to be recognized as an ACO, and must achieve
a specified minimum level of Medicaid savings to receive an incentive payment.
Authorizes the appropriation of SSAN (no years specified).
Source: Table prepared by the Congressional Research Service based on the text of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended).

Table 17. ACA Discretionary Spending: Medicare
ACA
Statutory
Authority
Section
Summary of Provision
Funding (FY2010-FY2015)
(Agency)
3129 Amends
and
Rural hospital flexibility grant program. Extends authorization of appropriations
FY2010 = $41 million
reauthorizes SSA
for the rural hospital flexibility (Flex) grants that support a range of performance and
FY2011 = $41 million
Sec. 1820 (HRSA) quality improvement activities at small rural hospitals. Permits the funding to be used
FY2012 = $41 million
to help rural hospitals participate in delivery system reform programs authorized
FY2013 = $38 million
under ACA. Authorizes the appropriation of SSAN for each of FY2011 and FY2012,
FY2014 = $41 million
to remain available until expended. [CFDA 93.241]
FY2015 request = $26 million
Sources: Table prepared by the Congressional Research Service based on the text of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended).
Funding amounts are taken from HRSA’s budget documents, including the FY2014 operating plan, available at http://www.hrsa.gov/about/budget/index.html.
CRS-44


Table 18. ACA Discretionary Spending: Private Health Insurance
Statutory
ACA
Authority
Summary of Provision
Funding (FY2010-FY2015)
Section
(Agency)
1334 New
freestanding
Multi-state health plans. Requires OPM to contract with health insurers to offer
No appropriations identified.
authority (OPM)
at least two multi-state health plans (at least one nonprofit) through exchanges in
each state. Authorizes OPM to prohibit multi-state plans that do not meet standards
for medical loss ratios, profit margins, and premiums. Requires multi-state plans to
cover essential health benefits and meet all the requirements of a qualified health plan.
Authorizes the appropriation of SSAN (no years specified). [Note: On March 11,
2013, OPM published a final rule to implement the multi-state plan program (78
Federal Register 15560).]
Source: Table prepared by the Congressional Research Service based on the text of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended).

CRS-45

Discretionary Spending Under the Affordable Care Act (ACA)

Appendix. Expired and Expiring Authorizations of
Appropriations

Table A-1. Programs with Expired Authorizations of Appropriations
Listed by Topic Area, Program Name, and ACA Section Number
Health Centers and Clinics (Table 2)

School-Based Health Centers (Sec. 4101(b))
Nurse-Managed Health Clinics (Sec. 5208)
Health Care Workforce (Table 3)

Primary Care Training & Enhancement (Sec. 5301)
Community Health Worker Program (Sec. 5313)
Pediatric Specialist Loan Repayment Program (Sec. 5203)
CDC Training Fel owships (Sec. 5314)
Rural physician Training Grants (Sec. 10501(l))
USPHS Commissioned Corps Ready Reserve (Sec. 5210)
Nurse Faculty Loan Program (Sec. 5311(a))
Scholarships for Disadvantaged Students (Sec. 5402)
Nurse Faculty Loan Repayment Program (Sec. 5311(b)
Faculty Loan Repayment Program (Sec. 5402)
Family Nurse Practitioner Demonstration (Sec. 5316)
Health Careers Opportunity Program (Sec. 5402)
Geriatric Nursing Education and Training (Sec. 5305(c))
Area Health Education Centers (Sec. 5403(a))
Direct Care Worker Training (Sec. 5302)
Mental/Behavioral Health Education and Training (Sec. 5306)
Geriatric Workforce Development (Sec. 5305(a))
National Center for Health Care Workforce Analysis
(Sec. 5103)
Education and Training In Pain Care (Sec. 4305(c))

Prevention and Wellness (Table 4)

Offices of Women’s Health (Sec. 3509/3511)
Community Transformation Grants (Sec. 4201)
School-Based Dental Sealant Program (Sec. 4102(b))
Community Wellness Pilot Program (Sec. 4202(a))
Immunization Demonstration Grants (Sec. 4204(b))
Epidemiology & Laboratory Capacity Grants (Sec. 4304)
Rural Access to Emergency Devices (Sec. 10412)
Young Women’s Breast Health Awareness (Sec. 10413)
Oral Health Infrastructure (Sec. 4102(c))
National Diabetes Prevention Program (Sec. 10501(g))
Oral Health Surveillance (Sec. 4102(d))

Maternal and Child Health (Table 5)

Individuals with Postpartum Depression (Sec. 2952(b))

Health Care Quality (Table 6)

Quality and Efficiency Measures Development (Sec. 3013)
Health Care Delivery System Research (Sec. 3501)
Collection and Analysis of Quality Data (Sec. 3015)
Primary Care Extension Program (Sec. 5405)
Public Reporting of Quality Measures (Sec. 3015)
Co-Locating Primary and Specialty Care (Sec. 5604)
Health Disparities (Table 8)

Data Collection and Analysis (Sec. 4302(a))

Emergency Care and Trauma Services (Table 9)

Children’s Emergency Medical Services (Sec. 5603)
Emergency Medicine Research (Sec. 3504(b))
Regional Systems for Emergency Use (Sec. 3504(a))

Congressional Research Service
46

Discretionary Spending Under the Affordable Care Act (ACA)

Elder Justice (Table 10)

Elder Justice Coordinating Council (Sec. 6703(a))
LTC Ombudsman Program & Training (Sec. 6703(a))
Forensic Centers and Expertise (Sec. 6703(a))
National Training Institute of Surveyors (Sec. 6703(b))
LTC Facility Staffing & Information Technology (Sec. 6703(a))
Grants to State Survey Agencies (Sec. 6703(b))
Adult Protective Services (Sec. 6703(a))

Medicare (Table 17)

Rural Hospital Flexibility Grant Program (Sec. 3129)

Source: Table prepared by the Congressional Research Service based on the text of the Patient Protection and
Affordable Care Act (ACA; P.L. 111-148, as amended).
Notes: Programs listed in roman type have received annual discretionary appropriations. Programs for which
CRS could not identify any specific discretionary appropriations are listed in italic type. In some cases a program
may receive funding from another budget account; see Tables 2-18 for additional details on program funding.
Table A-2. Programs Whose Authorizations of Appropriations Expire at the End of
FY2015
Listed by Topic Area, Program Name, and ACA Section Number
Health Care Workforce (Table 3)

General and Pediatric Dentistry Training (Sec. 5303)
Public Health & Allied Health Scholarships (Sec. 5206(b))
Public Health & Preventive Medicine (Sec. 10501(m)(2))
Cultural Competency, Prevention, Public Health, Disparities,
and Individuals with Disability Training (Secs. 5307(a)&(b))

Public Health Workforce Loan Repayment Program (Sec.
5204)

Prevention and Wellness (Table 4)

Congenital Heart Disease Program (Sec. 10411)
Smal Business Wel ness Program (Sec. 10408)
Health Care Quality (Table 6)

Patient Navigator Program (Sec. 3510)
Community-Based Collaborative Care Network (Sec. 10333)
Emergency Care and Trauma Services (Table 9)

Trauma Care Centers (Sec. 3505(a))
Trauma Service Availability Grants (Sec. 3505(b))
Medical Malpractice (Table 14)

Liability Reform Demonstration Program (Sec. 10607)

Source: Table prepared by the Congressional Research Service based on the text of the Patient Protection and
Affordable Care Act (ACA; P.L. 111-148, as amended).
Notes: Programs listed in roman type have received annual discretionary appropriations. Programs for which
CRS could not identify any specific discretionary appropriations are listed in italic type. In some cases, a program
may receive funding from another budget account; see Tables 2-18 for additional details on program funding.




Congressional Research Service
47

Discretionary Spending Under the Affordable Care Act (ACA)

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
Kirsten J. Colello
Amanda K. Sarata
Specialist in Health and Aging Policy
Specialist in Health Policy
kcolello@crs.loc.gov, 7-7839
asarata@crs.loc.gov, 7-7641
Elayne J. Heisler

Specialist in Health Services
eheisler@crs.loc.gov, 7-4453


Acknowledgments
Kirsten J. Colello, Elayne J. Heisler, Sarah A. Lister, and Amanda K. Sarata helped prepare the tables in the
initial version of this report. They continue to provide and review revised funding information for each
report update.
Key Policy Staff
Area of Expertise

Name
Phone
Email
Health Centers and Clinics (Table 2)
Elayne J. Heisler
7-4453
eheisler@crs.loc.gov
C. Stephen Redhead
7-2261
credhead@crs.loc.gov
Health Care Workforce (Table 3)
Elayne J. Heisler
7-4453
eheisler@crs.loc.gov
Bernice Reyes-Akinbileje
7-2260
breyes@crs.loc.gov
Long-Term Care (Table 3)
Kirsten J. Colello
7-7839
kcolello@crs.loc.gov
Prevention and Wellness (Table 4)
Sarah A. Lister
7-7320
slister@crs.loc.gov
Maternal and Child Health (Table 5) Emilie
Stoltzfus
7-2324
estoltzfus@crs.loc.gov
Health Care Quality (Table 6)
Amanda K. Sarata
7-7641
asarata@crs.loc.gov
Nursing Homes (Table 7)
Cliff Binder
7-7965
cbinder@crs.loc.gov
Health Disparities (Table 8)
C. Stephen Redhead
7-2261
credhead@crs.loc.gov
Emergency Care (Table 9)
Elayne J. Heisler
7-4453
eheisler@crs.loc.gov
Elder Justice (Table 10)
Kirsten J. Colello
7-7839
kcolello@crs.loc.gov
Biomedical Research (Table 11)
Judith A. Johnson
7-7077
jajohnson@crs.loc.gov
Biologics (Table 12)
Judith A. Johnson
7-7077
jajohnson@crs.loc.gov
340B Drug Pricing (Table 13) Cliff
Binder
7-7965
cbinder@crs.loc.gov
Medical Malpractice (Table 14)
Vivian S. Chu
7-4576
vchu@crs.loc.gov
Pain Care Management (Table 15)
Kirsten J. Colello
7-7839
kcolello@crs.loc.gov
Medicaid (Table 16) Cliff
Binder
7-7965
cbinder@crs.loc.gov
Medicare (Table 17) Sibyl
Tilson
7-7368
stilson@crs.loc.gov
Private Health Insurance (Table 18) Bernadette Fernandez
7-0322
bfernandez@crs.loc.gov
Annie Mach
7-7825
amach@crs.loc.gov


Congressional Research Service
48