Department of Health and Human Services: FY2020 Budget Request

Historically, the U.S. Department of Health and Human Services (HHS) has been one of the larger federal departments in terms of budgetary resources. Estimates by the Office of Management and Budget (OMB) indicate that HHS has accounted for at least 20% of all federal outlays in each year since FY1995. Most recently, HHS is estimated to have accounted for 27% of all federal outlays in FY2018.

Final FY2019 appropriations had not been enacted for a few HHS operating divisions and accounts prior to the development of the FY2020 President’s budget request. As a result, the FY2019 estimates contained in FY2020 President’s budget materials (and this report) are based on annualized amounts provided in the FY2019 continuing resolution for this subset of HHS accounts. The remainder of the HHS estimates for FY2019 are based on enacted full-year appropriations contained in Division B of P.L. 115-245, along with current services estimates for mandatory spending.

Under the FY2020 President’s budget request, HHS would spend an estimated $1.286 trillion in outlays in FY2020. This is $56 billion (+5%) more than estimated HHS spending in FY2019 and $166 billion (+15%) more than actual HHS spending in FY2018. Mandatory spending typically comprises the majority of the HHS budget. Two programs—Medicare and Medicaid—are expected to account for 86% of all estimated HHS spending in FY2020, according to the President’s budget request. Medicare and Medicaid are “entitlement” programs, meaning the federal government is required to make mandatory payments to individuals, states, or other entities based on criteria established in authorizing law.

Discretionary spending accounts for about 8% of HHS outlays in the FY2020 President’s budget request. Although discretionary spending represents a relatively small share of total HHS spending, the department nevertheless receives more discretionary money than most federal departments. According to OMB data, HHS accounted for 7% of all discretionary budget authority across the government in FY2018.

This report provides information about the FY2020 HHS budget request. It begins with a review of the department’s mission and structure. Next, the report provides some context for the FY2020 President’s budget request. It then discusses the concept of the HHS budget as a whole, in comparison to how funding is provided to HHS through the annual appropriations process. The report continues with a breakdown of the HHS request by operating division. An appendix summarizes the mission of each HHS operating division and identifies additional agency-level resources related to the FY2020 budget request.

Department of Health and Human Services: FY2020 Budget Request

July 17, 2019 (R45820)
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Summary

Historically, the U.S. Department of Health and Human Services (HHS) has been one of the larger federal departments in terms of budgetary resources. Estimates by the Office of Management and Budget (OMB) indicate that HHS has accounted for at least 20% of all federal outlays in each year since FY1995. Most recently, HHS is estimated to have accounted for 27% of all federal outlays in FY2018.

Final FY2019 appropriations had not been enacted for a few HHS operating divisions and accounts prior to the development of the FY2020 President's budget request. As a result, the FY2019 estimates contained in FY2020 President's budget materials (and this report) are based on annualized amounts provided in the FY2019 continuing resolution for this subset of HHS accounts. The remainder of the HHS estimates for FY2019 are based on enacted full-year appropriations contained in Division B of P.L. 115-245, along with current services estimates for mandatory spending.

Under the FY2020 President's budget request, HHS would spend an estimated $1.286 trillion in outlays in FY2020. This is $56 billion (+5%) more than estimated HHS spending in FY2019 and $166 billion (+15%) more than actual HHS spending in FY2018. Mandatory spending typically comprises the majority of the HHS budget. Two programs—Medicare and Medicaid—are expected to account for 86% of all estimated HHS spending in FY2020, according to the President's budget request. Medicare and Medicaid are "entitlement" programs, meaning the federal government is required to make mandatory payments to individuals, states, or other entities based on criteria established in authorizing law.

Discretionary spending accounts for about 8% of HHS outlays in the FY2020 President's budget request. Although discretionary spending represents a relatively small share of total HHS spending, the department nevertheless receives more discretionary money than most federal departments. According to OMB data, HHS accounted for 7% of all discretionary budget authority across the government in FY2018.

This report provides information about the FY2020 HHS budget request. It begins with a review of the department's mission and structure. Next, the report provides some context for the FY2020 President's budget request. It then discusses the concept of the HHS budget as a whole, in comparison to how funding is provided to HHS through the annual appropriations process. The report continues with a breakdown of the HHS request by operating division. An appendix summarizes the mission of each HHS operating division and identifies additional agency-level resources related to the FY2020 budget request.


About the U.S. Department of Health and Human Services (HHS)

The mission of HHS is to "enhance the health and well-being of Americans by providing for effective health and human services and by fostering sound, sustained advances in the sciences underlying medicine, public health, and social services."1

HHS is currently organized into 11 main agencies, called "operating divisions" (listed below), which are responsible for administering a wide variety of health and human services programs, and conducting related research. In addition, HHS has a number of "staff divisions" within the Office of the Secretary (OS). These staff divisions fulfill a broad array of management, research, oversight, and emergency preparedness functions in support of the entire department.

HHS Operating Divisions

ACF

Administration for Children and Families

ACL

Administration for Community Living

AHRQ

Agency for Healthcare Research and Quality

ATSDR

Agency for Toxic Substances and Disease Registry

CDC

Centers for Disease Control and Prevention

CMS

Centers for Medicare & Medicaid Services

FDA

Food and Drug Administration

HRSA

Health Resources and Services Administration

IHS

Indian Health Service

NIH

National Institutes of Health

SAMHSA

Substance Abuse and Mental Health Services Administration

Eight of the HHS operating divisions are part of the U.S. Public Health Service (PHS). PHS agencies have diverse missions in support of public health, including the provision of health care services and supports (e.g., IHS, HRSA, SAMHSA); the advancement of health care quality and medical research (e.g., AHRQ, NIH); the prevention and control of disease, injury, and environmental health hazards (e.g., CDC, ATSDR); and the regulation of food and drugs (e.g., FDA).2

The three remaining HHS operating divisions—ACF, ACL, and CMS—are not PHS agencies. ACF and ACL largely administer human services programs focused on the well-being of vulnerable children, families, older Americans, and individuals with disabilities. CMS—which accounts for the largest share of the HHS budget by far—is responsible for administering Medicare, Medicaid, and the State Children's Health Insurance Program (CHIP), in addition to some aspects of the private health insurance market.

(For a summary of each operating division's mission and links to agency resources related to the FY2020 budget request, see the Appendix.)

Context for the FY2020 President's Budget Request

The initial President's budget request for FY2020 was submitted to Congress on March 11, 2019, about five weeks after the statutory deadline.3 (Additional components of the FY2020 request were released in subsequent weeks.) The delay in the budget submission was attributable, in part, to protracted negotiations over seven of the FY2019 annual appropriations acts, which resulted in a five-week partial government shutdown.4 (Five of the 12 annual appropriations acts had already received full-year appropriations for FY2019 when the shutdown commenced.)

At HHS, the FY2019 shutdown primarily affected FDA, IHS, and ATSDR.5 The remaining HHS operating and staff divisions generally had already received full-year FY2019 funding prior to the start of the fiscal year (Division B of P.L. 115-245). Full-year appropriations for FDA, IHS, and ATSDR were ultimately enacted on February 15, 2019, almost five months after the start of the fiscal year (P.L. 116-6).

FY2020 HHS Budget Amendments

The focus of this report is the FY2020 President's budget request for HHS, as submitted to Congress in March 2019. However, it should be noted that a President may decide to make changes to the annual budget request after its initial submission to Congress. Such changes are commonly referred to as budget amendments. (The President may also submit additional funding requests for the current fiscal year. These are typically referred to as supplementals and are beyond the scope of this report.)

On May 13, the President submitted three FY2020 budget amendments that would affect portions of the initial request for FDA, NIH, and OS. None of these amendments would affect the net budget authority totals proposed in the initial FY2020 request. The FDA amendment would allow requested appropriations within the FDA salaries and expenses account to be used to carry out certain activities specified in the 21st Century Cures Act (P.L. 114-255). The NIH amendment would authorize the National Institute on Minority Health and Health Disparities to implement a reorganization plan. The OS amendment would authorize certain funds in the General Departmental Management account to be available for specified activities carried out by the Departmental Appeals Board.

In light of this delay, the source of the FY2019 numbers contained in the FY2020 President's budget materials varies by HHS agency. In the case of FDA, IHS, and ATSDR, amounts shown for FY2019 were estimated based on annualized funding levels under the FY2019 continuing resolution (Division C of P.L. 115-245, as amended), not final full-year enacted levels. By contrast, amounts shown for the remaining HHS agencies generally reflect enacted full-year appropriations provided in Division B of P.L. 115-245.6

Overview of the FY2020 HHS Budget Request

Under the President's budget request, HHS would spend an estimated $1.286 trillion in outlays7 in FY2020 (see Table 1).8 This is $56 billion (+5%) more than estimated HHS spending in FY2019 and about $166 billion (+15%) more than actual HHS spending in FY2018.

Historical estimates by the Office of Management and Budget (OMB) indicate that HHS has accounted for at least 20% of all federal outlays in each year since FY1995.9 Most recently, OMB estimated that HHS accounted for 27% of all federal outlays in FY2018.10

Table 1. FY2020 President's Budget Request for HHS

(dollars in billions)

 

FY2017 Actual

FY2018 Actual

FY2019 Estimatea

FY2020 Request

Budget Authority

1,144

1,177

1,274

1,293

Outlays

1,117

1,121

1,231

1,286

Sources: For FY2017 actual, see "HHS Budget by Operating Division" in HHS FY2019 Budget in Brief, pp. 8-9 https://www.hhs.gov/sites/default/files/fy-2019-budget-in-brief.pdf. For FY2018 actual, FY2019 estimate, and FY2020 request, see "HHS Budget by Operating Division" in HHS FY2020 Budget in Brief, pp. 7-8, https://www.hhs.gov/sites/default/files/fy-2020-budget-in-brief.pdf.

Notes: Budget authority is the amount of money a federal agency is legally authorized to commit or spend; an outlay occurs when funds are actually expended from the Treasury. Amounts for FY2020 reflect all proposals in the President's budget for both mandatory and discretionary spending programs. Amounts in this table reflect mandatory sequestration in FY2017-FY2019, but do not reflect estimated effects of sequestration for FY2020.

a. The FY2019 estimate was calculated based on full-year enacted levels for most HHS agencies, except that amounts for FDA, IHS, ATSDR, and Superfund-related amounts at NIH reflect annualized funding levels under the FY2019 continuing resolution. (FY2019 mandatory spending levels are as enacted or estimated in the current services baseline.)

Figure 1 displays proposed FY2020 HHS outlays by major program or spending category in the President's request. As this figure shows, mandatory spending typically accounts for the vast majority of the HHS budget.11 In fact, two programs—Medicare and Medicaid—are expected to account for 86% of all estimated HHS spending in FY2020. Medicare and Medicaid are "entitlement" programs, meaning the federal government is required to make mandatory payments to individuals, states, or other entities based on criteria established in authorizing law.12

This figure also shows that discretionary spending accounts for about 8% of estimated FY2020 HHS outlays in the President's request. Although discretionary spending represents a relatively small share of total HHS spending, the department nevertheless receives more discretionary money than most federal departments. According to OMB data, HHS accounted for 7% of all discretionary budget authority across the government in FY2018, the same as the Department of Homeland Security.13 The Department of Defense was the only federal agency to account for a larger share of all discretionary budget authority in that year (47%).

Figure 1. Proposed FY2020 HHS Outlays by Major Program and Spending Category

Source: Prepared by the Congressional Research Service (CRS) based on data presented on pp. 10-11 of the HHS FY2020 Budget in Brief, https://www.hhs.gov/sites/default/files/fy-2020-budget-in-brief.pdf.

Notes: Percentages may not sum due to rounding. For mandatory spending, outlays reflect proposed law spending levels, not the current services baseline.

Budgetary Resources Versus Appropriations

Readers should be aware that the HHS budget includes a broader set of budgetary resources than the amounts provided to HHS through the annual appropriations process. As a result, certain amounts shown in FY2020 HHS budget materials (including amounts for prior years) will not match amounts provided to HHS by annual appropriations acts and displayed in accompanying congressional documents. There are several reasons for this:

  • Mandatory spending makes up a large portion of the HHS budget, and much of that spending is provided directly by authorizing laws, not through appropriations acts. All discretionary spending is controlled and provided through the annual appropriations process. By contrast, all mandatory spending is controlled by the program's authorizing statute. In most cases, that authorizing statute also provides the funding for the program. However, the budget authority for some mandatory programs (including Medicaid), while controlled by criteria in the authorizing statute, must still be provided through the annual appropriations process; such programs are commonly referred to as "appropriated entitlements" or "appropriated mandatories."
  • The HHS budget request takes into account the department as a whole, while the appropriations process divides HHS funding across three different appropriations bills. Most of the discretionary funding for the department is provided through the Departments of Labor, Health and Human Services, and Education, and Related Agencies (LHHS) Appropriations Act. However, funding for certain HHS agencies and activities is appropriated in two other bills—the Departments of the Interior, Environment, and Related Agencies Appropriations Act (INT) and the Agriculture, Rural Development, Food and Drug Administration, and Related Agencies Appropriations Act (AG). Table 2 lists HHS agencies by appropriations bill.

Table 2. HHS Agencies by Appropriations Bill

Appropriations Bill

HHS Agencies Funded in the Bill

Departments of Labor, Health and Human Services, and Education, and Related Agencies (LHHS)

  • Administration for Children and Families
  • Administration for Community Living
  • Agency for Healthcare Research and Quality
  • Centers for Disease Control and Prevention
  • Centers for Medicare & Medicaid Services
  • Health Resources and Services Administration
  • National Institutes of Healtha
  • Office of the Secretary
  • Substance Abuse and Mental Health Services Administration

Departments of the Interior, Environment, and Related Agencies (INT)a

  • Agency for Toxic Substances and Disease Registry
  • Indian Health Service

Agriculture, Rural Development, Food and Drug Administration, and Related Agencies (AG)

  • Food and Drug Administration

Source: See CRS Report R40858, Locate an Agency or Program Within Appropriations Bills, by Justin Murray.

a. Funding for NIH comes primarily from the LHHS appropriations bill, with an additional amount for Superfund-related activities provided as part of the INT appropriations bill.

  • The Administration may choose to follow different conventions than those of congressional scorekeepers for its estimates of HHS programs. For example, certain transfers of funding between HHS agencies (or from HHS to other federal agencies) that occurred in prior fiscal years, or are expected to occur in the current fiscal year, may be accounted for in the Administration's estimates but not necessarily in the congressional documents.
  • HHS budget materials include two different estimates for mandatory spending programs in FY2019 when appropriate: proposed law and current law. Proposed law estimates take into account changes in mandatory spending proposed in the FY2020 HHS budget request. Such proposals would need to be enacted into law to affect the budgetary resources ultimately available to the mandatory spending program.14 HHS materials may also show a current law or current services estimate for mandatory spending programs. These estimates assume that no changes will be made to existing policies, and instead estimate mandatory spending for programs based on criteria established in current authorizing law. The HHS budget estimates in this report reflect the proposed law estimates for mandatory spending programs, but readers should be aware that other HHS, OMB, or congressional estimates might reflect current law instead.
  • In some cases, agencies within HHS have the authority to expend user fees and other types of collections that effectively supplement their appropriations. In addition, agencies may receive transfers of budgetary resources from other sources, such as from the Public Health Service Evaluation Set-Aside (also referred to as the PHS Tap) or one of the mandatory funds established by the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended).15 Budgetary totals that account for these sorts of resources in the Administration estimates are referred to as being at the "program level." HHS agencies that have historically had notable differences between the amounts in the appropriations bills and their program level include FDA (due to user fees) and AHRQ (due to transfers). The program level for each agency is listed in the table entitled "Composition of the HHS Budget Discretionary Programs" in the HHS FY2020 Budget in Brief.16

HHS Budget by Operating Division

Figure 2 provides a breakdown of the FY2020 HHS budget request by operating division. When taking into account both mandatory and discretionary budget authority (i.e., total budget authority shown in Figure 2), CMS accounts for the largest share of the request (nearly $1.17 trillion). The majority of the CMS budget request would go toward mandatory spending programs, such as Medicare and Medicaid.

When looking exclusively at discretionary budget authority, funding for CMS is comparatively smaller, accounting for just $3.6 billion of the HHS discretionary request. The largest share of the discretionary request would go to the PHS agencies (roughly $59.4 billion in combined funding for FDA, HRSA, IHS, CDC, ATSDR, NIH, and SAMHSA; no funds would go to AHRQ under the request17). NIH would receive the largest amount ($33.5 billion) of discretionary budget authority of any HHS operating division, and ACF would receive the second-largest amount ($18.3 billion).

Figure 2. FY2020 President's Request for HHS by Operating Division

Source: Prepared by the Congressional Research Service (CRS) based on data presented on pp. 7-10 of the HHS FY2020 Budget in Brief (BIB), https://www.hhs.gov/sites/default/files/fy-2020-budget-in-brief.pdf. The amounts displayed as total budget authority include mandatory and discretionary funds. The HHS BIB sources the OMB Budget Appendix for the total budget authority amounts shown above and cautions that these amounts "potentially differ from the levels displayed" elsewhere in the BIB. HHS does not use the same disclaimer for the discretionary budget authority levels shown in the BIB and above, meaning that the methodology used to calculate and present these numbers may differ from that used by HHS in calculating total budget authority. For this reason, the figure should be viewed as illustrative.

Notes: Amounts for mandatory spending programs are based on the President's proposed law baseline, not the current services baseline. Amounts for discretionary spending programs have not been adjusted to reflect the effects of proposed rescissions or other cancelations of budget authority. Amounts in this figure exclude funding for the HHS staff divisions within the Office of the Secretary.

Table 3 puts the FY2020 request for each HHS operating division and the Office of the Secretary into context, displaying it along with estimates of funding provided over the three prior fiscal years (FY2017-FY2019). These totals are inclusive of both mandatory and discretionary funding.

The amounts in this table are shown in terms of budget authority (BA) and outlays. BA is the authority provided by federal law to enter into contracts or other financial obligations that will result in immediate or future expenditures involving federal government funds. Outlays occur when funds are actually expended from the Treasury; they could be the result of either new budget authority enacted in the current fiscal year or unexpended budget authority that was enacted in previous fiscal years. As a consequence, the BA and outlays in this table represent two different ways of accounting for the funding that is provided to each HHS agency through the federal budget process. For example, Table 3 shows $0 in FY2020 BA for AHRQ because the President's budget proposes to eliminate this agency; however, the table shows an estimated $299 million in FY2020 AHRQ outlays, reflecting the expected expenditure of funds previously provided to the agency.

Table 3. HHS Budget by Operating and Staff Division

(mandatory and discretionary spending combined, dollars in millions)

Operating Division

FY2017 Actual

FY2018 Actual

FY2019 Estimatea

FY2020 Request

Food and Drug Administration

Budget Authority (BA)

3,215

2,397

2,956

3,329

Outlays

3,312

2,057

2,766

2,837

Health Resources and Services Administration

BA

10,732

11,703

11,995

11,004

Outlays

10,894

11,058

11,488

11,864

Indian Health Service

BA

5,107

5,741

5,815

6,104

Outlays

4,775

5,003

6,358

5,970

Centers for Disease Control and Prevention (including ATSDR)b

BA

7,653

8,741

7,909

6,767

Outlays

7,999

7,976

7,595

7,877

National Institutes of Healthc

BA

33,448

36,396

38,201

33,669

Outlays

31,062

32,716

35,454

36,652

Substance Abuse and Mental Health Services Administration

BA

4,123

5,539

5,609

5,535

Outlays

3,414

3,833

4,912

5,684

Agency for Healthcare Research and Qualityc

BA

323

333

338

0

Outlays

318

324

230

299

Centers for Medicare & Medicaid Servicesd

BA

1,021,127

1,042,407

1,137,937

1,169,091

Outlays

998,556

999,392

1,098,072

1,156,333

Administration for Children and Families

BA

54,481

58,618

58,299

52,121

Outlays

51,990

53,897

56,267

53,208

Administration for Community Living

BA

1,940

2,115

2,148

1,997

Outlays

1,896

1,942

2,223

2,238

Office of the Secretarye

BA

1,864

2,513

3,035

2,905

Outlays

2,563

2,449

5,249

3,472

Total, Health and Human Services

BA

1,144,013

1,176,503

1,274,242

1,292,523

Outlays

1,116,779

1,120,647

1,230,614

1,286,434

Sources: For FY2017 actual, see "HHS Budget by Operating Division" in FY2019 HHS Budget in Brief (BIB), https://www.hhs.gov/sites/default/files/fy-2019-budget-in-brief.pdf. For FY2018 actual, FY2019 estimate, and FY2020 request, see "HHS Budget by Operating Division" in FY2020 HHS BIB, https://www.hhs.gov/sites/default/files/fy-2020-budget-in-brief.pdf. The HHS BIBs source the Budget Appendix prepared by the Office of Management and Budget for the BA amounts shown in these particular BIB tables. HHS cautions that these amounts "potentially differ from the levels displayed in the individual Operating or Staff Division Chapters."

Notes: Totals are as reported in the applicable HHS BIBs. Totals may not sum due to rounding and, in prior years, may reflect some adjustments for comparability. Amounts for FY2020 reflect all proposals in the President's budget for both mandatory and discretionary spending programs. Amounts in this table reflect sequestration for mandatory spending programs in FY2017-FY2019, but do not reflect estimated effects of mandatory sequestration for FY2020.

a. FY2019 estimates were calculated based on enacted levels for most HHS agencies, except that amounts for FDA, IHS, ATSDR, and Superfund-related amounts at NIH reflect annualized funding levels under the FY2019 continuing resolution. (FY2019 mandatory spending levels are as enacted or estimated in the current services baseline.)

b. By HHS convention, the amounts shown for CDC include funding for ATSDR.

c. The FY2020 President's budget proposes to consolidate certain AHRQ functions into a new National Institute for Research on Safety and Quality (NIRSQ) at NIH. For consistency with source materials, this table includes the amounts requested for the newly proposed NIRSQ within the NIH totals for FY2020, but it displays FY2017-FY2019 AHRQ funding separately.

d. Per source materials, the budget authority for CMS includes non-CMS budget authority for Hospital Insurance and Supplementary Medical Insurance for the Social Security Administration and the Medicare Payment Advisory Commission (MedPAC).

e. The amounts of budget authority and outlays listed for the Office of the Secretary are the total of funding for the following staff divisions, accounts, or activities: Departmental Management (including funding for the Pregnancy Assistance Fund, the Health Insurance Reform Implementation Fund, transfers from the Patient-Centered Outcomes Research Trust Fund, and payments to the State Response to the Opioid Abuse Crisis Account), Nonrecurring Expenses Fund, Office of Medicare Hearings and Appeals, Office of the National Coordinator for Health Information Technology, Office for Civil Rights, Office of Inspector General, Public Health and Social Services Emergency Fund, Program Support Center (including retirement pay, medical benefits, and miscellaneous trust funds), and certain collections that are credited to that office or the department. For a breakdown of funding by staff division or activity, see the sources noted above.

Appendix. HHS Operating Divisions: Missions and FY2020 Budget Resources

This appendix provides for each operating division a brief summary of its mission,18 the applicable appropriations bill, the FY2020 budget request level, and links to additional resources related to that request.

Food and Drug Administration (FDA)

The FDA mission is focused on regulating the safety, efficacy, and security of human foods, dietary supplements, cosmetics, and animal foods; and the safety and effectiveness of human drugs, biological products (e.g., vaccines), medical devices, radiation-emitting products, and animal drugs. It also regulates the manufacture, marketing, and sale of tobacco products.19

Relevant Appropriations Bill:

  • AG

FY2020 Request:

  • BA: $3.329 billion
  • Outlays: $2.837 billion

Additional Resources Related to the FY2020 Request:

Health Resources and Services Administration (HRSA)

The HRSA mission is focused on "improving health care to people who are geographically isolated, economically or medically vulnerable."20 Among its many programs and activities, HRSA supports health care workforce training; the National Health Service Corps; and the federal health centers program, which provides grants to nonprofit entities that provide primary care services to people who experience financial, geographic, cultural, or other barriers to health care.

Relevant Appropriations Bill:

  • LHHS

FY2020 Request:

  • BA: $11.004 billion
  • Outlays: $11.864 billion

Additional Resources Related to the FY2020 Request:

Indian Health Service (IHS)

The IHS mission is to provide "a comprehensive health service delivery system for American Indians and Alaska Natives" and "raise the physical, mental, social, and spiritual health of American Indians and Alaska Natives to the highest level."21 IHS provides health care for approximately 2.2 million eligible American Indians and Alaska Natives through a system of programs and facilities located on or near Indian reservations, and through contractors in certain urban areas.

Relevant Appropriations Bill:

  • INT

FY2020 Request:

  • BA: $6.104 billion
  • Outlays: $5.970 billion

Additional Resources Related to the FY2020 Request:

Centers for Disease Control and Prevention (CDC) and Agency for Toxic Substances and Disease Registry (ATSDR)

The CDC mission is focused on "disease prevention and control, environmental health, and health promotion and health education."22 CDC is organized into a number of centers, institutes, and offices, some focused on specific public health challenges (e.g., injury prevention) and others focused on general public health capabilities (e.g., surveillance and laboratory services).

In addition, the Agency for Toxic Substances and Disease Registry (ATSDR) is headed by the CDC director. For that reason, the ATSDR budget is often shown within CDC. Following the conventions of the FY2020 HHS BIB, ATSDR's budget request is included in the CDC totals shown in this report. ATSDR's work is focused on preventing or mitigating adverse effects resulting from exposure to hazardous substances in the environment.

Relevant Appropriations Bills:

  • LHHS (CDC)
  • INT (ATSDR)

FY2020 Request (CDC and ATSDR combined):

  • BA: $6.767 billion
  • Outlays: $7.877 billion

Additional Resources Related to the FY2020 Request:

National Institutes of Health (NIH)

The NIH mission is focused on conducting and supporting research "in causes, diagnosis, prevention, and cure of human diseases" and "in directing programs for the collection, dissemination, and exchange of information in medicine and health."23 NIH is organized into 27 research institutes and centers, headed by the NIH Director.24 (The FY2020 President's budget assumes that AHRQ's functions will be consolidated within NIH, in the new National Institute for Research on Safety and Quality (NIRSQ). This assumption is reflected in the figures below.25)

Relevant Appropriations Bill:

  • LHHS

FY2020 Request:

  • BA: $33.669 billion
  • Outlays: $36.652 billion

Additional Resources Related to the FY2020 Request:

Substance Abuse and Mental Health Services Administration (SAMHSA)

The SAMHSA mission is focused on reducing the "impact of substance abuse and mental illness on America's communities."26 SAMHSA coordinates behavioral health surveillance to improve understanding of the impact of substance abuse and mental illness on children, individuals, and families, and the costs associated with treatment.

Relevant Appropriations Bill:

  • LHHS

FY2020 Request:

  • BA: $5.535 billion
  • Outlays: $5.684 billion

Additional Resources Related to the FY2020 Request:

Agency for Healthcare Research and Quality (AHRQ)

The AHRQ mission is focused on research to make health care "safer, higher quality, more accessible, equitable, and affordable."27 Specific AHRQ research efforts are aimed at reducing the costs of care, promoting patient safety, measuring the quality of health care, and improving health care services, organization, and financing. The FY2020 President's budget proposes eliminating AHRQ and consolidating certain key AHRQ functions within NIH, in the new National Institute for Research on Safety and Quality (NIRSQ).

Relevant Appropriations Bill:

  • LHHS

FY2020 Request:

  • BA: $0
  • Outlays: $0.299 billion

Additional Resources Related to the FY2020 Request:

Centers for Medicare & Medicaid Services (CMS)

The CMS mission is focused on supporting "innovative approaches to improve quality, accessibility, and affordability" of Medicare, Medicaid, the State Children's Health Insurance Program (CHIP), and private insurance, and on supporting private insurance market reform programs.28 The President's budget estimates that in FY2020, "over 145 million Americans will rely on the programs CMS administers including Medicare, Medicaid, the Children's Health Insurance Program (CHIP), and the [Health Insurance] Exchanges."29

Relevant Appropriations Bill:

  • LHHS

FY2020 Request:

  • BA: $1,169.091 billion
  • Outlays: $1,156.333 billion

Additional Resources Related to the FY2020 Request:

Administration for Children and Families (ACF)

The ACF mission is focused on promoting the "economic and social well-being of children, youth, families, and communities."30 ACF administers a wide array of human services programs, including Temporary Assistance for Needy Families (TANF), Head Start, child care, the Social Services Block Grant (SSBG), and various child welfare programs.

Relevant Appropriations Bill:

  • LHHS

FY2020 Request:

  • BA: $52.121 billion
  • Outlays: $53.208 billion

Additional Resources Related to the FY2020 Request:

Administration for Community Living (ACL)

The ACL mission is focused on maximizing the "independence, well-being, and health of older adults, people with disabilities across the lifespan, and their families and caregivers."31 ACL administers a number of programs targeted at older Americans and the disabled, including Home and Community-Based Supportive Services and State Councils on Developmental Disabilities.

Relevant Appropriations Bill:

  • LHHS

FY2020 Request:

  • BA: $1.997 billion
  • Outlays: $2.238 billion

Additional Resources Related to the FY2020 Request:

Author Contact Information

Karen E. Lynch, Specialist in Social Policy ([email address scrubbed], [phone number scrubbed])
Jessica Tollestrup, Specialist in Social Policy ([email address scrubbed], [phone number scrubbed])
Ada S. Cornell, Senior Research Librarian ([email address scrubbed], [phone number scrubbed])

Footnotes

1.

Introduction to the HHS Strategic Plan FY2018-FY2022, available at https://www.hhs.gov/about/strategic-plan/introduction/index.html.

2.

For further information, see CRS Report R44916, Public Health Service Agencies: Overview and Funding (FY2016-FY2018).

3.

For more information on the timing or content of the President's budget, see CRS Report R43163, The President's Budget: Overview of Structure and Timing of Submission to Congress.

4.

For more information, see CRS Report RS20348, Federal Funding Gaps: A Brief Overview.

5.

In addition, Superfund-related appropriations for NIH were affected by the funding gap. See the FY2019 HHS contingency staffing plan at https://www.hhs.gov/about/budget/fy-2019-hhs-contingency-staffing-plan/index.html.

6.

There are limited exceptions. For instance, while FY2019 estimates for NIH are primarily based on FY2019 enacted levels, a small amount of Superfund-related funding was estimated based on the continuing resolution levels for the NIH National Institute of Environmental Health Sciences. Additionally, for certain mandatory spending programs (e.g., Temporary Assistance for Needy Families), FY2019 estimates were based on annualized levels provided in the most recent short-term funding extension.

7.

Budget authority is the amount of funding a federal agency is legally authorized to commit or spend; an outlay occurs when funds are actually expended from the Treasury. These terms are discussed in the "HHS Budget by Operating Division" section of this report.

8.

This does not account for expected reductions to nonexempt mandatory spending due to sequestration. For further information, see OMB, OMB Report to the Congress on the Joint Committee Reductions for Fiscal Year 2020, March 18, 2018, https://www.whitehouse.gov/wp-content/uploads/2019/03/2020_JC_Sequestration_Report_3-18-19.pdf.

9.

OMB Historical Tables of the FY2020 President's Budget, Table 4.2, "Percentage Distribution of Outlays by Agency: 1962–2024," https://www.whitehouse.gov/omb/historical-tables/.

10.

Ibid.

11.

The terms "mandatory spending" and "discretionary spending" are discussed in the "Budgetary Resources Versus Appropriations" section of this report.

12.

For more information on how these entitlement programs are financed, see CRS Report R40425, Medicare Primer; and CRS Report R42640, Medicaid Financing and Expenditures.

13.

OMB Historical Tables of the FY2020 President's Budget, Table 5.5, "Percentage Distribution of Discretionary Budget Authority by Agency: 1976–2024," https://www.whitehouse.gov/omb/historical-tables/.

14.

For a list of some HHS legislative proposals for mandatory spending programs in the FY2020 President's budget, see pp. 116-124 of Summary Table S-6 in OMB, Budget of the United States Government, Fiscal Year 2020, https://www.whitehouse.gov/wp-content/uploads/2019/03/budget-fy2020.pdf. This table lists mandatory proposals (but not discretionary proposals) by federal department and shows the estimated dollar change from current law levels should the proposal be enacted (the table does not show the actual proposed funding level). For additional information, see the applicable operating division chapters of the HHS Budget in Brief or congressional justifications.

15.

For further information, see CRS Report R44916, Public Health Service Agencies: Overview and Funding (FY2016-FY2018).

16.

The FY2020 HHS Budget in Brief (BIB) is available at https://www.hhs.gov/sites/default/files/fy-2020-budget-in-brief.pdf (hereinafter, FY2020 BIB).

17.

The FY2020 President's budget proposes eliminating AHRQ as an HHS operating division. Certain high-priority AHRQ functions would be transferred to NIH under this proposal.

18.

The mission summaries below exclude the Office of the Secretary, which comprises multiple staff divisions whose goals are to "provide leadership, direction, and policy guidance to the Department." See HHS Strategic Plan FY2018-FY2022, Introduction, https://www.hhs.gov/about/strategic-plan/introduction/index.html.

19.

FDA, What We Do, https://www.fda.gov/aboutfda/whatwedo.

20.

HRSA, About HRSA, https://www.hrsa.gov/about/index.html.

21.

IHS, Agency Overview, https://www.ihs.gov/aboutihs/overview/.

22.

CDC, Official Mission Statements & Organizational Charts, https://www.cdc.gov/maso/pdf/cdcmiss.pdf.

23.

NIH, Mission and Goals, https://www.nih.gov/about-nih/what-we-do/mission-goals.

24.

NIH, Organization, https://www.nih.gov/about-nih/who-we-are/organization.

25.

NIH chapter in the FY2020 BIB, https://www.hhs.gov/sites/default/files/fy-2020-budget-in-brief.pdf.

26.

SAMHSA, About Us, https://www.samhsa.gov/about-us.

27.

AHRQ, About AHRQ, https://www.ahrq.gov/cpi/about/index.html.

28.

CMS, Homepage, https://www.cms.gov/.

29.

CMS, Fiscal Year 2020 Justification of Estimates for Appropriations Committees, March 2019, https://www.cms.gov/About-CMS/Agency-Information/PerformanceBudget/FY2020-CJ-Final.pdf.

30.

ACF, What We Do, https://www.acf.hhs.gov/about/what-we-do.

31.

ACL, About ACL, https://acl.gov/about-acl.