Legislative Actions to Modify the Affordable Care Act in the 111th-115th Congresses

June 27, 2018 R45244

The Patient Protection and Affordable Care Act (ACA; P.L. 111-148) was signed into law on March 23, 2010. The law comprises numerous provisions in 10 titles. The provisions in Titles I-VIII largely relate to how health care in the United States is financed, organized, and delivered. Title IX contains revenue provisions. Title X reauthorizes the Indian Health Care Improvement Act, establishes some new programs and requirements, and amends provisions included in the other nine titles of the ACA. On March 30, 2010, the Health Care and Education Reconciliation Act (HCERA; P.L. 111-152) was signed into law, which included new provisions and amended several ACA provisions.

Since enactment of the ACA and HCERA, lawmakers have repeatedly debated the laws’ implementation and considered bills to repeal, defund, or otherwise amend them. This report summarizes legislative actions taken during the 111th-115th Congresses to modify the health care-related provisions of the ACA and HCERA.

The first part of the report provides a brief overview of the laws’ core provisions and their impact on federal spending and health insurance coverage as context for the other material presented in the report. The second part of the report includes Table 2, which summarizes laws enacted during the 111th-115th Congresses that modified ACA or HCERA provisions. The third part of the report lists bills passed in the House or the Senate during the 111th-115th Congresses that would have modified ACA or HCERA provisions, had they been enacted.

Identifying legislation that modifies the ACA and HCERA has become increasingly difficult over the years. This is because of the vast number of ACA and HCERA provisions, their complexity, and the fact that these provisions are codified in many different parts of the U.S. Code. As a result, the legislation presented in this report’s tables may not include all enacted legislation that modifies the ACA or HCERA, or all House- or Senate-passed legislation that would have modified the ACA or HCERA, had it been enacted. Due to the increasing complexity of tracking such legislation and concerns about the ability to do so authoritatively, the Congressional Research Service (CRS) does not intend to update this report.

Legislative Actions to Modify the Affordable Care Act in the 111th-115th Congresses

June 27, 2018 (R45244)
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Summary

The Patient Protection and Affordable Care Act (ACA; P.L. 111-148) was signed into law on March 23, 2010. The law comprises numerous provisions in 10 titles. The provisions in Titles I-VIII largely relate to how health care in the United States is financed, organized, and delivered. Title IX contains revenue provisions. Title X reauthorizes the Indian Health Care Improvement Act, establishes some new programs and requirements, and amends provisions included in the other nine titles of the ACA. On March 30, 2010, the Health Care and Education Reconciliation Act (HCERA; P.L. 111-152) was signed into law, which included new provisions and amended several ACA provisions.

Since enactment of the ACA and HCERA, lawmakers have repeatedly debated the laws' implementation and considered bills to repeal, defund, or otherwise amend them. This report summarizes legislative actions taken during the 111th-115th Congresses to modify the health care-related provisions of the ACA and HCERA.

The first part of the report provides a brief overview of the laws' core provisions and their impact on federal spending and health insurance coverage as context for the other material presented in the report. The second part of the report includes Table 2, which summarizes laws enacted during the 111th-115th Congresses that modified ACA or HCERA provisions. The third part of the report lists bills passed in the House or the Senate during the 111th-115th Congresses that would have modified ACA or HCERA provisions, had they been enacted.

Identifying legislation that modifies the ACA and HCERA has become increasingly difficult over the years. This is because of the vast number of ACA and HCERA provisions, their complexity, and the fact that these provisions are codified in many different parts of the U.S. Code. As a result, the legislation presented in this report's tables may not include all enacted legislation that modifies the ACA or HCERA, or all House- or Senate-passed legislation that would have modified the ACA or HCERA, had it been enacted. Due to the increasing complexity of tracking such legislation and concerns about the ability to do so authoritatively, the Congressional Research Service (CRS) does not intend to update this report.

Legislative Actions to Modify the Affordable Care Act in the 111th-115th Congresses

The Patient Protection and Affordable Care Act (ACA; P.L. 111-148) was signed into law on March 23, 2010. On March 30, 2010, the Health Care and Education Reconciliation Act (HCERA; P.L. 111-152) was signed into law, which included new provisions and amended several ACA provisions. Collectively, the laws comprise numerous provisions, most of which relate to how health care in the United States is financed, organized, and delivered. Since enactment of the ACA and HCERA, lawmakers have repeatedly debated the laws' implementation and considered bills to repeal, defund, or otherwise amend them. This report summarizes legislative actions taken during the 111th-115th Congresses to modify the health care-related provisions of the ACA and HCERA.1 (From this point forward, all references to the ACA in this report refer collectively to the law and to the changes made by HCERA, unless otherwise noted.)

The first part of the report provides a brief overview of the ACA's core provisions and its impact on federal spending and health insurance coverage as context for the other material presented in the report. The second part of the report includes Table 2, which summarizes laws enacted during the 111th-115th Congresses that modified ACA provisions. The third part of the report lists bills passed in the House or the Senate during the 111th-115th Congresses that would have modified ACA provisions, had they been enacted.

Identifying legislation that modifies the ACA has become increasingly difficult over the years. This is because of the vast number of ACA provisions, their complexity, and the fact that these provisions are codified in many different parts of the U.S. Code. As a result, the legislation presented in this report's tables may not include all enacted legislation that modifies the ACA or all House- or Senate-passed legislation that would have modified the ACA, had it been enacted. Due to the increasing complexity of tracking such legislation and concerns about the ability to do so authoritatively, the Congressional Research Service (CRS) does not intend to update this report.

A Brief Overview of the ACA

The ACA has 10 titles (Table 1), and each title has many provisions. The provisions in Titles I-VIII largely relate to how health care in the United States is financed, organized, and delivered. Title IX contains revenue provisions. Title X reauthorizes the Indian Health Care Improvement Act, establishes some new programs and requirements, and amends provisions included in the other nine titles of the ACA.

Table 1. Patient Protection and Affordable Care Act (ACA) Titles

ACA Titles

Title I: Quality, Affordable Health Care for All Americans

Title II: Role of Public Programs

Title III: Improving the Quality and Efficiency of Health Care

Title IV: Prevention of Chronic Disease and Improving Public Health

Title V: Health Care Workforce

Title VI: Transparency and Program Integrity

Title VII: Improving Access to Innovative Medical Therapies

Title VIII: Class Act

Title IX: Revenue Provisions

Title X: Strengthening Quality, Affordable Health Care For All Americans

Source: ACA (P.L. 111-148), as amended by the Health Care and Education Reconciliation Act (HCERA; P.L. 111-152).

A primary goal of the ACA was to increase access to affordable health care for the medically uninsured and underinsured. To that end, the law includes a complex set of interconnected provisions that address the private health insurance market and the Medicaid program.2 For instance, the law established financial subsidies for eligible individuals purchasing private insurance through health insurance exchanges and expanded eligibility for Medicaid.

The costs to the federal government of expanding access to private insurance and Medicaid coverage were projected to be offset by increased taxes and revenues and by reduced spending on Medicare and other federal health programs. The ACA established several new taxes on firms in the health care sector and expanded existing taxes on individuals.3 The law includes many different provisions affecting the Medicare program, such as provisions concerning payment and program modifications to Medicare's fee-for-service program, the Medicare Advantage program, and the outpatient prescription drug program.4

In addition, the ACA contains hundreds of other provisions that address health care access, costs, and quality.5 The ACA includes provisions intended to increase the primary care and public health workforce, promote preventive services, and strengthen quality measurement, among other things. Other ACA provisions include programs to prevent elder abuse, neglect, and exploitation; a new regulatory pathway for licensing biological drugs shown to be biosimilar or interchangeable with a licensed biologic; and new nutrition labeling requirements for chain restaurant menus and vending machines.

The Congressional Budget Office (CBO) and the Joint Committee on Taxation (JCT) issued the first cost estimate of the ACA on March 20, 2010.6 They issued an updated estimate in February 2011.7 According to the February 2011 estimate, the ACA would reduce federal deficits by $210 billion over the 10-year period FY2012-FY2021, and the number of non-elderly uninsured individuals would be reduced by about 34 million in CY2021.

CBO and JCT have not issued an updated cost estimate of the ACA in its entirety since February 2011; however, they have issued many other ACA-related cost estimates and analyses.8 The estimates have changed over time due to changes in the economy, the effects of enacted legislation, technical changes in the agencies' analyses (e.g., new survey and agency data on enrollment in health care programs), and the effects of administrative and judicial decisions (e.g., the 2012 U.S. Supreme Court decision effectively making state participation in the ACA Medicaid expansion voluntary).

ACA Provisions in Enacted Laws

Table 2 summarizes legislation amending the ACA that has been enacted since March 30, 2010.9 Each table entry identifies the Congress in which the law was enacted, provides the public law number and date of enactment, and offers a brief description of the change(s) made to the ACA. The laws are listed in reverse chronological order, beginning with the most recently enacted legislation and extending back to the first measure signed into law following enactment of the ACA and the accompanying package of amendments in the HCERA.

During the 111th Congress, a number of clarifications and technical adjustments to the ACA were enacted. In the 112th-115th Congresses, several more substantive ACA amendments were signed into law. For example, Title VIII of the ACA—the Community Living Assistance Services and Supports (CLASS) Act—which would have established a voluntary, long-term care insurance program to pay for community-based services and supports for individuals with functional limitations was repealed. Lawmakers also repealed a tax-filing provision (IRS Form 1099) that had been included in the ACA. In multiple separate legislative actions, lawmakers both appropriated funding for programs established under the ACA (e.g., the Community Health Center Fund) and rescinded funding for other programs established under the ACA (e.g., the Prevention and Public Health Fund).

In compiling Table 2, CRS made decisions about which laws—or which specific provisions in a particular law—to include. CRS elected to include only those provisions that made changes (including funding extensions or rescissions) to new programs and activities first authorized and funded by the ACA. CRS generally excluded provisions addressing established programs and activities that predate the ACA but were extended or amended in a non-substantive way by the law. For example, the ACA extended multiple existing Medicare and Medicaid program payments and activities that since have been further extended and/or modified by provisions in more recently enacted laws. The ACA also extended funding for a number of existing grant programs whose funding has been further extended by provisions in newer laws. None of these types of provisions are included in Table 2.

In addition to considering ACA repeal or amendment in authorizing legislation, lawmakers have used the annual appropriations process to eliminate or provide funding for ACA provisions and to modify provisions of the law. Table 2 includes provisions in appropriations legislation that have the effect of making new law or changing existing law. As an example, the Consolidated Appropriations Act, 2016 (P.L. 114-113), included a temporary moratorium on the ACA's medical device tax and the annual fee on health insurance providers, as well as a two-year delay of the ACA's excise tax on high-cost employer-sponsored health plans (often referred to as the Cadillac tax). However, Table 2 does not include provisions in appropriations legislation that

  • address administrative spending for covering the costs of ACA implementation (e.g., denial of agency requests for new funding to help support ACA implementation);
  • limit or restrict the use of funds provided under a bill for a specific purpose (e.g., language prohibiting an agency from using any of the funds appropriated to the agency for ACA implementation activities); or
  • establish reporting or other administrative requirements regarding implementation of the ACA (e.g., language instructing an agency to provide an accounting of administrative funding on ACA implementation).

As noted, identifying legislation that modifies the ACA has become increasingly difficult over the years. As a result, Table 2 may not provide a comprehensive list of enacted legislation that has modified the ACA.

Table 2. Enacted Legislation in the 111th – 115th Congresses That Repealed, Modified, Extended, or Rescinded Funding for Programs Established by the ACA

Congress

Public Law

Date of Enactment

Summary of Repealed or Amended ACA Provisionsa

Similar Provisions or Interactions with Other Laws

ACA Section [U.S. Code]

115th

P.L. 115-123:

Bipartisan Budget Act of 2018

Feb. 9, 2018

Repealed the Independent Payment Advisory Board (IPAB).

N.A.

ACA §3403
[42 U.S.C. §1395kkk]
 

  

  

Appropriated $3.8 billion for FY2018 and $4.0 billion for FY2019 in mandatory funds to the Community Health Center Fund (CHCF) for the health centers program and $310 million for each of FY2018 and FY2019 to the CHCF for the National Health Service Corps (NHSC).

Superseded the appropriation included in P.L. 115-96. An appropriation also was made under P.L. 114-10.

ACA §10503
[42 U.S.C. §254b-2]
 

  

  

Appropriated $126.5 million for each of FY2018 and FY2019 for graduate medical education (GME) payments to teaching health centers and made other amendments to the program.

Superseded the appropriation included in P.L. 115-96, which superseded the appropriation included in P.L. 115-63. An appropriation also was made under P.L. 114-10.

ACA §5508
[42 U.S.C. §256h]
 

  

  

Appropriated $85 million for each of FY2018 and FY2019 for the Health Profession Opportunity Grant (HPOG) program.

This is one of three laws that appropriated funding for the HPOG program. See, also, entries for P.L. 114-10 and P.L. 113-93.

ACA §5507(a) [42 U.S.C. §1397g]
 

  

  

Reduced Prevention and Public Health Fund (PPHF) annual appropriations over the period FY2019-FY2027 by $1.35 billion.

This is one of four laws that reduced PPHF appropriations. See, also, entries for P.L. 112-96, P.L. 114-255, and P.L. 115-96.

ACA §4002

[42 U.S.C. §300u-11]
 

  

  

Appropriated $400 million for each of FY2017 through FY2022 for the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program and made other amendments to the program.

An appropriation also was made under P.L. 113-93, which was superseded by an appropriation for the program in P.L. 114-10.

ACA §2951
[42 U.S.C. §711]
 

  

  

Appropriated $75 million for each of FY2018 and FY2019 for the Personal Responsibility Education Program (PREP) and made other amendments to the program.

This is one of three laws that appropriated funding for PREP. See, also, entries for P.L. 114-10 and P.L. 113-93.

ACA §2953
[42 U.S.C. §713]
 

  

  

Eliminated the Medicaid disproportionate share hospital (DSH) reductions for FY2018 and FY2019 and increased the aggregate Medicaid DSH reduction amounts.

This is one of six laws that modified the Medicaid DSH reductions. See, also, entries for P.L. 114-10, P.L. 113-93, P.L. 113-67, P.L. 112-240, and P.L. 112-96.

ACA §2551
[42 U.S.C. §1396r-4]
 

  

  

Required states to consider qualified lottery winnings and/or qualified lump-sum income when determining eligibility for Medicaid based on modified adjusted gross income (MAGI).

N.A.

ACA §2001
[42 U.S.C.1396a(e)]
 

  

  

Extended the Medicaid and the State Children's Health Insurance Program (CHIP) Maintenance of Effort (MOE) requirements for children for the period FY2024-FY2027 for certain children

Previously, P.L. 115-120 had extended the requirements for the same category of children for the period FY2019-FY2024.

ACA §2001
[42 U.S.C. §1396a(gg)(2); 42 U.S.C. 1397ee(d)(3)]

115th

P.L. 115-120:

Making further continuing appropriations for the fiscal year ending September 30, 2018, and for other purposes

Jan. 22, 2018

Extended the moratorium on the medical device excise tax for an additional two years—through Dec. 31, 2019.

The moratorium was first established under P.L. 114-113, beginning Jan. 1, 2016, and ending Dec. 31, 2017.

HCERA §1405 [26 U.S.C. §4191]
 

  

  

Delayed implementation of the excise tax on high-cost employer-sponsored insurance (often referred to as the Cadillac tax) until TY2022.

Implementation of the Cadillac tax was first delayed from TY2018 until TY2020 under P.L. 114-113.

ACA §9001
[26 U.S.C. §4980I]
 

  

  

Suspended collection of the annual fee on insurers for CY2019.

Previously, P.L. 114-113 suspended collection of the fee for CY2017.

ACA §9010
 

  

  

Modified the definition of minimum essential coverage (MEC) to provide that a qualified CHIP look-alike program constitutes MEC, effective TY2018.b

N.A.

ACA §1501
[26 U.S.C. §5000A]
 

  

  

Extended the increased enhanced federal medical assistance percentage (E-FMAP) for CHIP for one year at 11.5 percentage points.

N.A.

ACA §2101
[42 U.S.C. §1397ee]
 

  

  

Extended the Medicaid and CHIP MOE requirements for children for the period of FY2019-FY2024, but only for children in families with annual income less than 300% of the FPL.

Subsequently, P.L. 115-123 extended the requirements for the same category of children through FY2027.

ACA §2001
[42 U.S.C. §1396a(gg)(2); 42 U.S.C. 1397ee(d)(3)]
 

  

  

Excluded compensation from Medicaid outreach and enrollment grants for parent mentors when determining income eligibility based on MAGI.

N.A.

ACA §2001
[42 U.S.C. §1396a(e)]

115th

P.L. 115-97:

An Act to provide for reconciliation pursuant to titles II and V of the concurrent resolution on the budget for fiscal year 2018

Dec. 22, 2017

Effectively eliminated the individual mandate penalty beginning TY2019.

N.A.

ACA §1501
[26 U.S.C. §5000A]
 

  

  

Reduced the adjusted gross income (AGI) threshold from 10% to 7.5% for individual taxpayers claiming an itemized deduction for unreimbursed medical and dental expenses in 2017 and 2018.

N.A.

ACA §9013
[26 U.S.C. §213(a)]

115th

P.L. 115-96:

Third Continuing Appropriations for Fiscal Year 2018, Missile Defense, Health Provisions, Other Matters, and Budgetary Effects.

Dec. 22, 2017

Appropriated $550 million to the CHCF for health centers and $65 million to the CHCF for the NHSC for the first and second quarters of FY2018.

This appropriation was superseded by the appropriation in P.L. 115-123. An appropriation also was made under P.L. 114-10.

ACA §10503
[42 U.S.C. §254b-2]
 

  

  

Appropriated $30 million for the first and second quarters of FY2018 for GME payments to teaching health centers.

This appropriation superseded the appropriations included in P.L. 115-63 and was superseded by the appropriation in P.L. 115-123. An appropriation also was made under P.L. 114-10.

ACA §5508
[42 U.S.C. §256h]
 

  

  

Reduced PPHF annual appropriations over the period FY2019-FY2022 by $750 million.

This is one of four laws that reduced PPHF appropriations. See, also, entries for P.L. 112-96, P.L. 114-255, and P.L. 115-123.

ACA §4002
[42 U.S.C. §300u-11]

115th

P.L. 115-63:

Disaster Tax Relief and Airport and Airway Extension Act of 2017

Sep. 29, 2017

Appropriated $15 million for the first quarter of FY2018 for GME payments to teaching health centers.

This appropriation was superseded by the appropriation in P.L. 115-96, and that appropriation was superseded by an appropriation in P.L. 115-123. An appropriation also was made under P.L. 114-10.

ACA §5508
[42 U.S.C. §256h]

115th

P.L. 115-31:

Consolidated Appropriations Act, 2017

May 5, 2017

Rescinded $15 million from the IPAB funds made available for FY2017.

This was one of six laws that rescinded IPAB funds. See, also, entries for P.L. 114-113, P.L. 113-235, P.L. 113-76, P.L. 113-6, and P.L. 112-74.

ACA §3403
[42 U.S.C. §1395kkk]
 

  

  

Rescinded all unobligated amounts of the $1 billion appropriation for U.S. territories that elected to establish a health insurance exchange.c

This is one of three laws that rescinded funds from this appropriation. See, also, entries for P.L. 114-25 and P.L. 114-223.

ACA §1323(c)
[42 U.S.C. §18043(c)]

114th

P.L. 114-301:

GAO Mandates Revision Act of 2016

Dec. 16, 2016

Amended requirements of state demonstration programs to evaluate alternatives to current medical tort litigation. Amendments relate to a panel established to review demonstration grant applications and the designation of a chairperson for this panel.

N.A.

ACA §10607
[42 U.S.C. §280g-15]

114th

P.L. 114-255:

21st Century Cures Act

Dec. 13, 2016

Amended provisions in order to improve states' ability to identify health care providers who have been terminated from participating in Medicare or in another state's Medicaid or CHIP program, by (1) requiring providers participating in Medicaid and CHIP managed care to enroll with the state and (2) increasing state oversight and reporting requirements.

N.A.

ACA §6401(b)(2) [42 U.S.C. §1395cc note]
 

  

  

Reduced PPHF annual appropriations over the period FY2018-FY2024 by $3.5 billion.

This is one of four laws that reduced PPHF appropriations. See, also, entries for P.L. 112-96, P.L. 115-96, and P.L. 115-123.

ACA §4002
[42 U.S.C. §300u-11]
 

  

  

Instructed the HHS Secretary to collect certain specified information from each state that has participated in the Medicaid Emergency Psychiatric Demonstration program and, within two years, to submit to Congress a report that summarizes and analyzes that information.

N.A.

ACA §2707

[42 U.S.C. §1396a]
 

  

  

Rescinded $464 million from unobligated amounts of the $1 billion appropriation for U.S. territories that elected to establish a health insurance exchange.c

This is one of three laws that rescinded funds from this appropriation. See, also, entries for P.L. 115-31 and P.L. 114-223.

ACA §1323(c)
[42 U.S.C. §18043(c)]

114th

P.L. 114-223:

Continuing Appropriations and Military Construction, Veterans Affairs, and Related Agencies Appropriations Act, 2017, and Zika Response and Preparedness Act

Dec. 10, 2016

Rescinded $168 million from unobligated amounts of the $1 billion appropriation for U.S. territories that elected to establish a health insurance exchange.c

This is one of three laws that rescinded funds from this appropriation. See, also, entries for P.L. 115-31 and P.L. 114-225.

ACA §1323(c)
[42 U.S.C. §18043(c)]

114th

P.L. 114-113:

Consolidated Appropriations Act, 2016

Dec. 18, 2015

Rescinded $15 million of IPAB's FY2016 appropriation.

This was one of six laws that rescinded IPAB funds. See, also, entries for P.L. 115-31, P.L. 113-235, P.L. 113-76, P.L. 113-6, and P.L. 112-74.

ACA §3403
[42 U.S.C. §1395kkk]
 

  

  

Allowed the excise tax on high-cost employer-sponsored insurance (often referred to as the Cadillac tax) to be deducted as a business expense.

N.A.

ACA §9001
[26 U.S.C. §4980I(f)(10)]
 

  

  

Delayed implementation of the high-cost employer-sponsored insurance tax (often referred to as the Cadillac tax) until TY2020.

Subsequently, P.L. 115-120 delayed implementation of the Cadillac tax until TY2022.

ACA §9001
[26 U.S.C §49801]
 

  

  

Suspended collection of the annual fee on insurers for CY2017.

P.L. 115-120 suspended collection of the fee again for CY2019.

ACA §9010
 

  

  

Established a two-year moratorium on the medical device excise tax beginning Jan. 1, 2016, and ending Dec. 31, 2017.

Subsequently, P.L. 115-120 extended the moratorium through Dec. 31, 2019.

HCERA §1405 [26 U.S.C. §4191]

114th

P.L. 114-97:

Improving Access to Emergency Psychiatric Care Act

Dec. 11, 2015

Extended the Medicaid Emergency Psychiatric Demonstration program through December 31, 2019, provided it meets budget-neutrality requirements.

N.A.

ACA §2707
[42 U.S.C. §1396a]

114th

P.L. 114-74:

Bipartisan Budget Act of 2015

Nov. 2, 2015

Repealed the requirement that employers with more than 200 employees automatically enroll new full-time employees in health insurance and continue coverage for current employees.

N.A.

ACA §1511
[29 U.S.C. §218a]

114th

P.L. 114-60:

Protecting Affordable Coverage for Employees (PACE) Act

Oct. 7, 2015

Amended the definition of small employer to mean employers with up to 50 employees, while giving states the option to expand the definition to include employers with up to 100 employees.d

N.A.

ACA §1304(b)(2), (3) [42 U.S.C. §18024(b)(2), (3)]

114th

P.L. 114-41:

Surface Transportation and Veterans Health Care Choice Improvement Act of 2015

Jul. 31, 2015

Amended the definition of applicable large employer to exclude hours worked by individuals receiving care under the TRICARE program or individuals enrolled and receiving coverage through certain Department of Veterans Affairs health care.e

N.A.

ACA §1513(a) [26 U.S.C. §4980H(c)(2)(F)]

114th

P.L. 114-10:

Medicare Access and CHIP Reauthorization Act of 2015

Apr. 16, 2015

Eliminated Medicare's value-based payment modifier (VBM) and combined measures established for the VBM with measures from other existing programs into four components that determine a physician or practitioner's composite score under the new Merit-Based Incentive Payment System, which will affect Medicare fee-for-service payments to physicians and practitioners beginning January 1, 2019.

N.A.

ACA §3007
[42 U.S.C. §1395w-4]
 

  

  

Appropriated a total of $3.9 billion to the CHCF for each of FY2016 and FY2017: $3.6 billion for the health centers program and $310 million for the NHSC.

An appropriation also was made under P.L. 115-96, which was superseded by an appropriation made under P.L. 115-123.

ACA §10503
[42 U.S.C. §254b-2]
 

  

  

Appropriated $60 million for each of FY2016 and FY2017 for GME payments to teaching health centers.

An appropriation also was made under P.L. 115-63, which was superseded by an appropriation made under P.L. 115-96, which was then superseded by an appropriation made under P.L. 115-123.

ACA §5508(c) [42 U.S.C. §256h]
 

  

  

Appropriated $400 million for each of FY2015 through FY2017 for the MIECHV program.

Superseded the appropriation in P.L. 113-93. An appropriation also was made under P.L. 115-123.

ACA §2951
[42 U.S.C. §711]
 

  

  

Appropriated $75 million for each of FY2016 and FY2017 for PREP.

This is one of three laws that appropriated funding for PREP. See, also, entries for P.L. 115-123 and P.L. 113-93.

ACA §2953
[42 U.S.C. §713]
 

  

  

Appropriated $85 million for each of FY2016 and FY2017 for the HPOG program.

This is one of three laws that appropriated funding for the HPOG program. See, also, entries for P.L. 115-123 and P.L. 113-93.

ACA §5507(a) [42 U.S.C. §1397g]
 

  

  

Eliminated the FY2017 Medicaid DSH reductions, increased the aggregate reduction amounts, and extended the reductions by one year through FY2025.

This is one of six laws that modified the Medicaid DSH reductions. See, also, entries for P.L. 115-123, P.L. 113-93, P.L. 113-67, P.L. 112-240, and P.L. 112-96.

ACA §2551
[42 U.S.C. §1396r-4]

113th

P.L. 113-235:

Consolidated and Further Continuing Appropriations Act, 2015

Dec. 16, 2014

Rescinded $10 million of IPAB's FY2015 appropriation.

This was one of six laws that rescinded IPAB funds. See, also, entries for P.L. 115-31, P.L. 114-113, P.L. 113-76, P.L. 113-6, and P.L. 112-74.

ACA §3403
[42 U.S.C. §1395kkk]
 

  

  

Exempted expatriate health plans from certain ACA requirements.

N.A.

NAf

113th

P.L. 113-93:

Protecting Access to Medicare Act of 2014

Apr. 1, 2014

Repealed the cap on deductibles for small-group health plans, which was to be $2,000 for self-only plans and $4,000 for family plans in plan year 2014 (and indexed to average per capita premium costs in subsequent years).

N.A.

ACA §1302(c)(2) [42 U.S.C. §18022(c)(2)]
 

  

  

Appropriated $400 million for the first half of FY2015 for the MIECHV program.

Superseded by the appropriation in P.L. 114-10. An appropriation also was made under P.L. 115-123.

ACA §2951
[42 U.S.C. §711]
 

  

  

Appropriated $85 million for FY2015 for the HPOG program.

This is one of three laws that appropriated funding for the HPOG program. See, also, entries for P.L. 115-123 and P.L. 114-10.

ACA §5507(a) [42 U.S.C. §1397g]
 

  

  

Appropriated $75 million for FY2015 for PREP.

This is one of three laws that appropriated funding for PREP. See, also, entries for P.L. 115-123 and P.L. 114-10.

ACA §2953
[42 U.S.C. §713]
 

  

  

Required that no less than $15 million of the funds appropriated under 42 U.S.C. §1320b-9b(e) be used to carry out the Pediatric Quality Measures Program for FY2014.

N.A.

ACA §2701
[42 U.S.C. §1320b-9b]
 

  

  

Eliminated the FY2016 Medicaid DSH reductions; increased the aggregate reduction amounts; and extended the reductions by one year through FY2024.

This is one of six laws that modified the Medicaid DSH reductions. See, also, entries for P.L. 115-123, P.L. 114-10, P.L. 113-67, P.L. 112-240, and P.L. 112-96.

ACA §2551
[42 U.S.C. §1396r-4]

113th

P.L. 113-76:

Consolidated Appropriations Act, 2014

Jan. 17, 2014

Rescinded $10 million of IPAB's FY2014 appropriation.

This was one of six laws that rescinded IPAB funds. See, also, entries for P.L. 115-31, P.L. 114-113, P.L. 113-235, P.L. 113-6, and P.L. 112-74.

ACA §3403
[42 U.S.C. §1395kkk]

113th

P.L. 113-67: Bipartisan Budget Act of 2013

Dec. 26, 2013

Eliminated the Medicaid DSH reductions for FY2014 and FY2015, increased the FY2016 Medicaid DSH reduction amount, and extended the Medicaid DSH reductions by one year through FY2023.

This is one of six laws that modified the Medicaid DSH reductions. See, also, entries for P.L. 115-123, P.L. 114-10, P.L. 113-93, P.L. 112-240, and P.L. 112-96.

ACA §2551
[42 U.S.C. §1396r-4]

113th

P.L. 113-6:

Consolidated and Further Continuing Appropriations Act, 2013

Mar. 26, 2013

Rescinded $10 million of IPAB's FY2013 appropriation.

This was one of six laws that rescinded IPAB funds. See, also, entries for P.L. 115-31, P.L. 114-113, P.L. 113-235, P.L. 113-76, and P.L. 112-74.

ACA §3403
[42 U.S.C. §1395kkk]
 

  

  

Rescinded $200 million of the $500 million transfer from the Medicare Part A and Part B trust funds for the five-year Community-Based Care Transition Program.

N.A.

ACA §3026
[42 U.S.C. §1395b–1 note]

112th

P.L. 112-240:

American Taxpayer Relief Act of 2012

Jan. 2, 2013

Transferred 10% of the remaining unobligated Consumer Operated and Oriented Plan (CO-OP) program funds to a new CO-OP contingency fund (to provide assistance and oversight to CO-OP loan recipients) and rescinded the other 90% of these funds.

This was one of three laws that rescinded funds from the CO-OP program. See, also, entries for P.L. 112-74 and P.L. 112-10.

ACA §1322(g) [42 U.S.C. §18042(g)]
 

  

  

Repealed Title VIII of the ACA, the Community Living Assistance Services and Supports (CLASS) Act.

N.A.

ACA Title VIII
 

  

  

Extended the Medicaid DSH allotment reductions by one year through FY2022.

This is one of six laws that modified the Medicaid DSH reductions. See, also, entries for P.L. 115-123, P.L. 114-10, P.L. 113-93, P.L. 113-67, and P.L. 112-96.

ACA §2551
[42 U.S.C. §1396r-4]

112th

P.L. 112-141:

Moving Ahead for Progress in the 21st Century Act, or "MAP-21"

Jul. 6, 2012

Modified the Medicaid disaster-recovery federal medical assistance percentage (FMAP) adjustment by changing the adjustment factor and effective date.

This was one of two laws to adjust the Medicaid disaster-recovery FMAP. See, also, the entry for P.L. 112-96.

ACA §2006
[42 U.S.C. §1396d]

112th

P.L. 112-96:

Middle Class Tax Relief and Job Creation Act of 2012

Feb. 22, 2012

Reduced PPHF annual appropriations over the period FY2013-FY2021 by $6.25 billion.

This is one of four laws that reduced PPHF appropriations. See, also, entries for P.L. 114-255, P.L. 115-96, and P.L. 115-123.

ACA §4002
[42 U.S.C. §300u-11]
 

  

  

Extended the Medicaid DSH allotment reductions by one year through FY2021.

This is one of six laws that modified the Medicaid DSH reductions. See, also, entries for P.L. 115-123, P.L. 114-10, P.L. 113-93, P.L. 113-67, and P.L. 112-240.

ACA §2551
[42 U.S.C. §1396r-4]
 

  

  

Made a technical correction to the formula to phase down the Medicaid disaster-recovery FMAP adjustment as originally intended. g

This was one of two laws to adjust the Medicaid disaster-recovery FMAP. See, also, the entry for P.L. 112-141.

ACA §2006
[42 U.S.C. §1396d]

112th

P.L. 112-74:

Consolidated Appropriations Act, 2012

Dec. 23, 2011

Rescinded $400 million of the remaining $3.8 billion for the CO-OP program.

This was one of three laws that rescinded funds from the CO-OP program. See, also, entries for P.L. 112-240 and P.L. 112-10.

ACA §1322(g) [42 U.S.C. 18042(g)]
 

  

  

Rescinded $10 million of the FY2012 appropriation for the IPAB.

This was one of six laws that rescinded IPAB funds. See, also, entries for P.L. 115-31, P.L. 114-113, P.L. 113-235, P.L. 113-76, and P.L. 113-6.

ACA §3403
[42 U.S.C. §1395kkk]

112th

P.L. 112-56:

Three Percent Withholding Repeal and Job Creation Act

Nov. 21, 2011

Modified the calculation of MAGI to include nontaxable Social Security benefits for purposes of determining eligibility for the premium tax credits.

N.A.

ACA §1401
[26 U.S.C. §36B]

112th

P.L. 112-10:

Department of Defense and Full-Year Continuing Appropriations Act, 2011

Apr. 15, 2011

Rescinded $2.2 billion of the $6 billion appropriation for the CO-OP program.

This was one of three laws that rescinded funds from the CO-OP program. See, also, entries for P.L. 112-240 and P.L. 112-74.

ACA §1322(g) [42 U.S.C. 18042(g)]
 

  

  

Repealed the free-choice voucher program, which would have required certain employers to provide vouchers to qualified employees for purchasing coverage through a health insurance exchange.

N.A.

ACA §10108
[26 U.S.C. §139D]
 

  

  

Repealed the MOE requirement for use of monies in the CHCF for FY2011.

N.A.

ACA §10503(d) [42 U.S.C. §254b-2]

112th

P.L. 112-9:

Comprehensive 1099 Taxpayer Protection and Repayment of Exchange Subsidy Overpayments Act of 2011

Apr. 14, 2011

Repealed the requirement that businesses file an information report (IRS Form 1099) whenever they pay a vendor more than $600 for goods in a single year.

N.A.

ACA §9006
[26 U.S.C. §6041]
 

  

  

Modified the sliding scale that determines the amount of excess advance premium tax credits that individuals have to repay based on household income.

This is one of two laws to modify the scale. See, also, the entry for P.L. 111-309.

ACA §1401
[26 U.S.C. §36B]

111th

P.L. 111-309:

Medicare and Medicaid Extenders Act of 2010

Dec. 15, 2010

Modified the sliding scale that determines the amount of excess advance premium tax credits that individuals have to repay based on household income to increase repayment amounts.

This is one of two laws to modify the scale. See, also, the entry for P.L. 112-9.

ACA §1401
[26 U.S.C. §36B]
 

  

  

Repealed the requirement that state Medicaid programs exclude individuals or entities from participating in the state Medicaid program when the individuals or entities had unpaid overpayments, were suspended or terminated by Medicaid, or were affiliated with an individual or entity who was suspended or terminated by Medicaid.

N.A.

ACA §6502
[42 U.S.C. §1396a(a)]

111th

P.L. 111-226:

FAA Air Transportation Modernization and Safety Improvement Act

Aug. 10, 2010

Modified the definition of average manufacturer price to include inhalation, infusion, implanted, or injectable drugs that generally are not dispensed through a retail community pharmacy.

N.A.

ACA §2503(a)(2)(B) [42 U.S.C. §1396r–8(k)(1)]

111th

P.L. 111-173 [No title.]

May 27, 2010

Amended the definition of MEC to include health care provided by the Department of Veterans Affairs.

N.A.

ACA §1501(b) [26 U.S.C. §5000A(f)(1)(A)]

111th

P.L. 111-159:

TRICARE Affirmation Act

Apr. 26, 2010

Amended the definition of MEC to include health care provided under TRICARE, TRICARE for Life, and the Department of Defense's Nonappropriated Fund Health Benefits.

N.A.

ACA §1501(b) [26 U.S.C. §5000A(f)(1)(A)]

Source: Prepared by the Congressional Research Service.

Notes: N.A. = not applicable. Table 2 shows laws enacted through June 11, 2018, not through the entire 115th Congress. Table 2 may not provide a comprehensive list of enacted legislation that has modified the ACA.

a. The term ACA refers to the Patient Protection and Affordable Care Act (P.L. 111-148), as amended by the Health Care and Education Reconciliation Act (HCERA; P.L. 111-152).

b. A qualified CHIP look-alike program is defined as a state-only program (i.e., financed with nonfederal funds, including premiums) that is available for purchase for certain specified children and that provides benefits that are at least identical to CHIP.

c. No U.S. territory elected to establish a health insurance exchange.

d. The definition is used to determine whether employers purchase health insurance in the small-group or large-group market.

e. The term applicable large employer is used for determining the applicability of the ACA's employer shared responsibility provision (commonly referred to as the employer mandate). The mandate applies only to applicable large employers.

f. This is the only provision included in this table that does not repeal or amend an ACA provision. It is included because it impacts how several ACA provisions (such as the individual mandate) apply to expatriate health plans.

g. The purpose of the adjustment was to help Louisiana avoid a significant reduction in its federal Medicaid match (i.e., FMAP) in the aftermath of Hurricane Katrina. As written in ACA §2006, the formula for the disaster-recovery FMAP adjustment unintentionally caused the FMAP adjustment to increase, rather than phase down, each year the state qualifies for the adjustment.

ACA Provisions in House-Passed and Senate-Passed Bills

The tables in this section list legislation that passed the House (Table 3) or the Senate (Table 4) in the 111th-115th Congresses that would have modified health care-related provisions of the ACA.10 None of the bills listed in Tables 3 or 4 became law (although provisions included in the bills may have been added to other legislation that became law).11 Generally, Tables 3 and 4 list only legislation that, if enacted, would have had a direct impact on the ACA and its implementation; measures that would not have had such an effect are not included. Thus, budget resolutions, which are binding only on certain procedural matters before Congress, are not included.12

The House-passed legislation included stand-alone bills as well as provisions in broader, often unrelated measures. Four of the House-passed bills listed in Table 3 would have repealed the ACA in its entirety:

The other House-passed bills listed in Table 3 would have (1) repealed, restricted, or otherwise limited, specific provisions in the ACA; (2) eliminated appropriations provided by the ACA and rescinded all unobligated funds;13 (3) replaced the mandatory appropriations for one or more ACA programs with authorizations of (discretionary) appropriations and rescinded all unobligated funds; or (4) blocked or otherwise delayed implementation of specific ACA provisions.

The Senate passed considerably fewer bills that would have modified the health care-related provisions of the ACA than did the House in the 111th-115th Congresses (Table 4). None of the Senate-passed bills listed in Table 4 would have repealed the ACA in its entirety. Two of the three bills listed in Table 4 would have repealed or amended specific provisions in the ACA, and the third bill would have extended a program that was modified under the ACA.

As noted elsewhere in this report, identifying bills that would modify the ACA has become increasingly difficult. As a result, Tables 3 and 4 may not provide comprehensive lists of House-passed and Senate-passed bills that would modify the ACA.

Table 3. ACA Provisions in Bills Approved by the House in the 111th-115th Congresses

Bill

House Vote

115th Congress

H.R. 2372: VETERAN Act—Veterans Equal Treatment Ensures Relief and Access Now Act

Passed the House by voice vote on June 15, 2017.

H.R. 2581: Verify First Act

Passed the House by a vote of 238-184 on June 13, 2017.

H.R. 1628: American Health Care Act of 2017

Passed the House by a vote of 217-213 on May 4, 2017.

H.R. 2192: To amend the Public Health Service Act to eliminate the non-application of certain State waiver provisions to Members of Congress and congressional staff

Passed the House by a vote of 429-0 on May 4, 2017.

H.R. 3922: CHAMPIONING HEALTHY KIDS Act

Passed the House by a vote of 242-174 on Nov. 3, 2017.

H.R. 849: Protecting Seniors Access to Medicare Act

Passed the House by a vote of 307-111 on Nov. 2, 2017.

H.R. 7: No Taxpayer Funding for Abortion and Abortion Insurance Full Disclosure Act of 2017

Passed the House by a vote of 238-183 on Jan. 24, 2017.

114th Congress

H.R. 954: CO-OP Consumer Protection Act of 2016

Passed the House by a vote of 258-165 on Sept. 27, 2016.

H.R. 1270: Restoring Access to Medication and Improving Health Savings Act of 2016

Passed the House by a vote of 243-164 on July 6, 2016.

H.R. 5447: Small Business Health Care Relief Act of 2016

Passed the House by voice vote on June 21, 2016.

H.R. 3762: Restoring Americans' Healthcare Freedom Reconciliation Act of 2015

Passed the House by vote of 240-189 on Oct. 23, 2015.

H.R. 2061: Equitable Access to Care and Health (EACH) Act

Passed the House by voice vote on Sept. 28, 2015.

H.J.Res. 61: Hire More Heroes Act of 2015

Passed the House by voice vote on July 27, 2015.

H.R. 1190: Protecting Seniors' Access to Medicare Act of 2015

Passed the House by a vote of 244-154 on June 23, 2015.

H.R. 160: Protect Medical Innovation Act of 2015

Passed the House by a vote of 280-140 on June 18, 2015.

H.R. 1191: Protecting Volunteer Firefighters and Emergency Responders Act

Passed the House by a vote of 415-0 on Mar. 17, 2015.

H.R. 596: A bill to repeal the Patient Protection and Affordable Care Act

Passed the House by a vote of 239-186 on Feb. 3, 2015.

H.R. 7: No Taxpayer Funding for Abortion and Abortion Insurance Full Disclosure Act of 2015

Passed the House by a vote of 242-179 on Jan. 22, 2015.

H.R. 33: Protecting Volunteer Firefighters and Emergency Responders Act

Passed the House by a vote of 401-0 on Jan. 12, 2015.

H.R. 30: Save American Workers Act of 2015

Passed the House by a vote of 252-172 on Jan. 8, 2015.

H.R. 22: Hire More Heroes Act of 2015

Passed the House by a vote of 412-0 on Jan. 6, 2015.

113th Congress

H.R. 3522: Employer Health Care Protection Act of 2014

Passed the House by a vote of 247-167 on Sept. 11, 2014.

H.R. 4414: Expatriate Health Coverage Clarification Act of 2014

Passed the House by a vote of 268-150 on Apr. 29, 2014.

H.R. 4194: Government Reports Elimination Act of 2014

Passed the House by voice vote on Apr. 28, 2014.

H.R. 2575: Save American Workers Act of 2014

Passed the House by a vote of 248-179 on Apr. 3, 2014.

H.R. 4015: SGR Repeal and Medicare Provider Payment Modernization Act of 2014

Passed the House by a vote of 238-181 on Mar. 14, 2014.

H.R. 3979: Protecting Volunteer Firefighters and Emergency Responders Act of 2014

Passed the House by a vote of 410-0 on Mar. 11, 2014.

H.R. 3474: Hire More Heroes Act of 2014

Passed the House by a vote of 406-1 on Mar. 11, 2014.

H.R. 1814: Equitable Access to Care and Health (EACH) Act

Passed the House by voice vote on Mar. 11, 2014.

H.R. 4118: Suspending the Individual Mandate Penalty Law Equals (SIMPLE) Fairness Act

Passed the House by a vote of 250-160 on Mar. 5, 2014.

H.R. 7: No Taxpayer Funding for Abortion and Abortion Insurance Full Disclosure Act of 2014

Passed the House by a vote of 227-188 on Jan. 28, 2014.

H.R. 3362: Exchange Information Disclosure Act

Passed the House by a vote of 259-154 on Jan. 16, 2014.

H.R. 3811: Health Exchange Security and Transparency Act of 2014

Passed the House by a vote of 291-122 on Jan. 10, 2014.

H.R. 3350: Keep Your Health Plan Act of 2013

Passed the House by a vote of 261-157 on Nov. 15, 2013.

H.R. 2775: No Subsidies Without Verification Act

Passed the House by a vote of 235-191 on Sept. 12, 2013.

H.R. 2009: Keep the IRS Off Your Health Care Act of 2013

Passed the House by a vote of 232-185 on Aug. 2, 2013.

H.R. 2668: Fairness for American Families Act

Passed the House by a vote of 251-174 on July 17, 2013.

H.R. 2667: Authority for Mandate Delay Act

Passed the House by a vote of 264-161 on July 17, 2013.

H.R. 45: A bill to repeal the Patient Protection and Affordable Care Act

Passed the House by a vote of 229-195 on May 16, 2013.

112th Congress

H.R. 6684: Spending Reduction Act of 2012

Passed the House by a vote of 215-209 on Dec. 20, 2012.

H.R. 6079: Repeal of Obamacare Act

Passed the House by a vote of 244-185 on July 11, 2012.

H.R. 436: Health Care Cost Reduction Act of 2012

Passed the House by a vote of 270-146 on June 7, 2012.

H.R. 5652: Sequester Replacement Reconciliation Act of 2012

Passed the House by a vote of 218-199 on May 10, 2012.

H.R. 4628: Interest Rate Reduction Act

Passed the House by a vote of 215-195 on Apr. 27, 2012.

H.R. 5: Protecting Access to Healthcare Act

Passed the House by a vote of 223-181 on Mar. 22, 2012.

H.R. 1173: Fiscal Responsibility and Retirement Security Act of 2012

Passed the House by a vote of 267-159 on Feb. 1, 2012.

H.R. 358: Protect Life Act

Passed the House by a vote of 251-172 on Oct. 13, 2011.

H.R. 1216: A bill to convert funding for graduate medical education (GME) in qualified teaching health centers (THCs) to an authorization of appropriations

Passed the House by a vote of 234-185 on May 25, 2011.

H.R. 1214: A bill to repeal ACA funding for school-based health center (SBHC) construction

Passed the House by a vote of 235-191 on May 4, 2011.

H.R. 1213: A bill to repeal ACA funding for health insurance exchanges

Passed the House by a vote of 238-183 on May 3, 2011.

H.R. 1217: A bill to repeal the Prevention and Public Health Fund (PPHF)

Passed the House by a vote of 236-183 on Apr. 13, 2011.

H.R. 2: Repealing the Job-Killing Health Care Law Act

Passed the House by a vote of 245-189 on Jan. 19, 2011.

111th Congress

H.R. 5281: Removal Clarification Act of 2010

Passed the House by voice vote on July 27, 2010.

H.R. 5013: Implementing Management for Performance and Related Reforms to Obtain Value in Every Acquisition Act of 2010

Passed the House by a vote of 417-3 on Apr. 28, 2010.

Source: Prepared by the Congressional Research Service.

Notes: Table 3 shows House-passed bills through June 11, 2018, not through the entire 115th Congress. Table 3 may not provide a comprehensive list of all House-passed bills that would modify the ACA.

Table 4. ACA Provisions in Bills Approved by the Senate in the 111th-115th Congresses

Congress

Bill

Senate Vote

115th

No relevant bills passed the Senate in this Congress.

114th

H.R. 3762: To provide for reconciliation pursuant to section 2002 of the concurrent resolution on the budget for fiscal year 2016

Passed Senate with an amendment by yea-nay vote 52-47 on Dec. 3, 2015.

114th

S. 607: Rural Community Hospital Demonstration Extension Act of 2015

Passed Senate with an amendment and an amendment to the title by unanimous consent on Jan. 20, 2016.

113th

No relevant bills passed the Senate in this Congress.

112th

S. 223: FAA Air Transportation Modernization and Safety Improvement Act

Passed Senate with amendments by yea-nay vote 87-8 on Feb. 17, 2011.

111th

No relevant bills passed the Senate in this Congress.

Source: Prepared by the Congressional Research Service.

Notes: Table 4 shows Senate-passed bills through June 11, 2018, not through the entire 115th Congress. Table 4 may not provide a comprehensive list of all Senate-passed bills that would modify the ACA.

Author Contact Information

[author name scrubbed], Specialist in Health Care Financing ([email address scrubbed], [phone number scrubbed])
[author name scrubbed], Senior Research Librarian ([email address scrubbed], [phone number scrubbed])

Footnotes

1.

The second title of the Health Care and Education Reconciliation Act (HCERA; P.L. 111-152) includes amendments to the Higher Education Act of 1965 (P.L. 89-329), which authorizes most of the federal programs involving postsecondary education. The education provisions included in HCERA are not covered in this report.
2.

For details about the Medicaid provisions included in the Patient Protection and Affordable Care Act (ACA; P.L. 111-148), see CRS Report R41210, Medicaid and the State Children's Health Insurance Program (CHIP) Provisions in ACA: Summary and Timeline. Please note that this report reflects the Medicaid and CHIP provisions at the time of the ACA's enactment and is meant to serve as a historical reference.
3.

For information about the new or expanded taxes, see CRS Report R41128, Health-Related Revenue Provisions in the Patient Protection and Affordable Care Act (ACA). Please note that this report reflects the ACA revenue provisions as of the date of the report (January 18, 2012).
4.

For details about the Medicare provisions included in the ACA, see CRS Report R41196, Medicare Provisions in the Patient Protection and Affordable Care Act (PPACA): Summary and Timeline. Please note that this report reflects Medicare provisions at the time of the ACA's enactment and is meant to serve as a historical reference.

5.

For more information about these provisions, see CRS Report R41278, Public Health, Workforce, Quality, and Related Provisions in ACA: Summary and Timeline. Please note that this report reflects the described provisions at the time of the ACA's enactment and is meant to serve as a historical reference.
6.

Congressional Budget Office (CBO), H.R. 4872, Reconciliation Act of 2010 (Final Health Care Legislation), March 20, 2010, at https://www.cbo.gov/publication/21351.
7.

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, at http://www.cbo.gov/ftpdocs/121xx/doc12119/03-30-HealthCareLegislation.pdf. See Table 1.
8.

CBO and the Joint Committee on Taxation have not issued an updated cost estimate of the ACA in its entirety since February 2011; however, they have issued many other ACA-related cost estimates and analyses. To access CBO's reports on the ACA, go to https://www.cbo.gov/taxonomy/term/45/latest.

9.

The date the HCERA was enacted. It should be noted that Table 2 summarizes enacted legislation through June 11, 2018, not through the entire 115th Congress.
10.

Tables 3 and 4 list legislation passed through June 11, 2018, not through the entire 115th Congress.
11.

For example, the House passed H.R. 849 on November 2, 2017, which would have repealed the ACA's Independent Payment Advisory Board (IPAB). Although H.R. 849 was not enacted, repeal of the IPAB was included in a different bill that became law on February 9, 2018 (P.L. 115-123).

12.

Budget resolutions are concurrent resolutions that apply only to Congress. They are not presented to the President for his signature and do not have the force of law.
13.

Appropriations bills provide agencies with budget authority, which is the legal authority to incur financial obligations (e.g., hire employees, purchase services, award grants, or sign contracts) that result in immediate or future government expenditures (or outlays). Budget authority generally is made available for obligation during a specified time period, typically the upcoming fiscal year. Once budget authority reaches the end of that time period, it "expires," meaning that it is no longer available for obligation. A rescission is a provision of law that cancels budget authority prior to when it otherwise would expire, making the budget authority unavailable for future obligation. For further explanations of these terms, see Government Accountability Office (GAO), A Glossary of Terms Used in the Federal Budget Process, GAO-05-734SP, September 2005, pp. 85-86, at http://www.gao.gov.