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

CRS Report for Congress
Prepared for Members and Committees of Congress
Discretionary Spending in the Patient
Protection and Affordable Care Act (ACA)
C. Stephen Redhead, Coordinator
Specialist in Health Policy
Sarah A. Lister
Specialist in Public Health and Epidemiology
Kirsten J. Colello
Specialist in Health and Aging Policy
Amanda K. Sarata
Specialist in Health Policy/Acting Section Research Manager
Elayne J. Heisler
Analyst in Health Services
January 15, 2013
Congressional Research Service
7-5700
www.crs.gov
R41390
Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)
Congressional Research Service
Summary
The Patient Protection and Affordable Care Act (ACA) reauthorized funding for numerous
existing discretionary grant programs and other activities. ACA also created multiple new
discretionary grant programs and provided for each an authorization of appropriations. Funding
for all these discretionary programs is subject to action by congressional appropriators. This
report summarizes all the discretionary spending provisions in ACA. A companion product, CRS
Report R41301, Appropriations and Fund Transfers in the Patient Protection and Affordable
Care Act (ACA), summarizes all the mandatory appropriations in the law.
Among the provisions that are intended to strengthen the nation’s health care safety net and
improve access to care, ACA permanently reauthorized the federal health centers program and the
National Health Service Corps (NHSC). The NHSC provides scholarships and student loan
repayments to individuals who agree to a period of service as a primary care provider in a
federally designated Health Professional Shortage Area. In addition, ACA addressed concerns
about the current size, specialty mix, and geographic distribution of the health care workforce. It
reauthorized and expanded existing health workforce education and training programs under
Titles VII and VIII of the Public Health Service Act (PHSA). Title VII supports the education and
training of physicians, dentists, physician assistants, and public health workers through grants,
scholarships, and loan repayment. ACA created several new programs to increase training
experiences in primary care, in rural areas, and in community-based settings, and provided
training opportunities to increase the supply of pediatric subspecialists and geriatricians. It also
expanded the nursing workforce development programs authorized under PHSA Title VIII.
As part of a comprehensive framework for federal community-based public health activities,
including a national strategy and a national education and outreach campaign, ACA authorized
several new grant programs with a focus on preventable or modifiable risk factors for disease
(e.g., sedentary lifestyle, tobacco use). The new law also leveraged a number of mechanisms to
improve the quality of health care, including new requirements for quality measure development,
collection, analysis, and public reporting; programs to develop and disseminate innovative
strategies for improving the quality of health care delivery; and support for care coordination
programs such as medical homes, patient navigators, and the co-location of primary health care
and mental health services. Additionally, ACA authorized funding for programs to prevent elder
abuse, neglect, and exploitation; grants to expand trauma care services and improve regional
coordination of emergency services; and demonstration projects to implement alternatives to
current tort litigation for resolving medical malpractice claims, among other provisions.
The Congressional Budget Office estimated that ACA’s discretionary spending provisions, if fully
funded by future appropriations acts, would result in appropriations of approximately $100 billion
over the 10-year period FY2012-FY2021. Most of that funding would be for programs that
existed prior to, and whose funding was reauthorized by, ACA. Few new programs created by
ACA received funding in FY2011 or FY2012. ACA also appropriated $1 billion to help cover the
initial administrative costs of implementing the new law. All those funds were obligated by the
end of FY2012. The President’s FY2013 budget requested more than $1 billion in discretionary
funding for ongoing ACA administrative costs at the Department of Health and Human Services
and the Internal Revenue Service, though none of these funds were included in the FY2013
continuing resolution under which the government is currently operating. It remains to be seen
whether Congress will provide all of the requested ACA administrative funds.
Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)
Congressional Research Service
Contents
Introduction ...................................................................................................................................... 1
Discretionary Spending in ACA ...................................................................................................... 3
ACA Administrative Costs and Funding ................................................................................... 4
Mandatory Appropriations in ACA .................................................................................................. 5
Potential Impact of Spending Cuts Under the Budget Control Act ................................................. 6
BCA Background ....................................................................................................................... 7
FY2013 Nondefense Discretionary Spending Reductions ........................................................ 8
Tables
Table 1. ACA Discretionary Spending: Health Centers and Clinics ................................................ 9
Table 2. ACA Discretionary Spending: Health Care Workforce .................................................... 10
Table 3. ACA Discretionary Spending: Prevention and Wellness ................................................. 21
Table 4. ACA Discretionary Spending: Maternal and Child Health .............................................. 24
Table 5. ACA Discretionary Spending: Health Care Quality ......................................................... 25
Table 6. ACA Discretionary Spending: Nursing Homes................................................................ 29
Table 7. ACA Discretionary Spending: Health Disparities Data Collection .................................. 30
Table 8. ACA Discretionary Spending: Emergency Care and Trauma Services ............................ 31
Table 9. ACA Discretionary Spending: Elder Justice .................................................................... 32
Table 10. ACA Discretionary Spending: Biomedical Research ..................................................... 34
Table 11. ACA Discretionary Spending: Biologics........................................................................ 34
Table 12. ACA Discretionary Spending: 340B Drug Pricing ........................................................ 35
Table 13. ACA Discretionary Spending: Medical Malpractice ...................................................... 35
Table 14. ACA Discretionary Spending: Pain Care Management ................................................. 36
Table 15. ACA Discretionary Spending: Medicaid ........................................................................ 36
Table 16. ACA Discretionary Spending: Medicare ........................................................................ 37
Table 17. ACA Discretionary Spending: Private Health Insurance ............................................... 37
Contacts
Author Contact Information........................................................................................................... 38
Acknowledgments ......................................................................................................................... 38
Key Policy Staff ............................................................................................................................. 38
Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)
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Introduction
The Patient Protection and Affordable Care Act (ACA)1 makes significant changes to the way
health care is financed, organized, and delivered in the United States. Among its many provisions,
ACA restructures the private health insurance market, sets minimum standards for health
coverage, and, beginning in 2014, mandates that most U.S. residents obtain health insurance
coverage or pay a penalty. The law provides for the establishment by 2014 of state-based health
insurance exchanges for the purchase of private health insurance. Qualifying individuals and
families will be able to receive federal subsidies to reduce the cost of purchasing coverage
through the exchanges.
In addition to expanding private health insurance coverage, ACA, as enacted, requires state
Medicaid programs to expand coverage to all eligible nonelderly, non-pregnant individuals under
age 65 with incomes up to 133% of the federal poverty level (FPL). States that elect not to
expand their Medicaid programs risk losing their existing federal Medicaid matching funds.
Under ACA, the federal government will initially cover 100% of the expansion costs, phasing
down to 90% of the costs by 2020. On June 28, 2012, the U.S. Supreme Court, in National
Federation of Independent Business v. Sebelius, found that the Medicaid expansion violated the
Constitution by threatening states with the loss of their existing federal Medicaid matching
funds.2 The Court precluded the Secretary of Health and Human Services (HHS) from penalizing
states that choose not to participate in the Medicaid expansion (see text box below). ACA also
amends the Medicare program in an effort to reduce the rate of its projected growth; imposes an
excise tax on insurance plans found to have high premiums; and makes many other changes to the
tax code, Medicare, Medicaid, the State Children’s Health Insurance Program (CHIP), and other
federal programs.
Implementation of ACA is projected to have a significant impact on federal revenues and direct
(also referred to as mandatory) spending.3 The law includes direct spending to subsidize the
purchase of health insurance coverage through the exchanges, as well as increased outlays for the
expansion of the Medicaid program. ACA also includes numerous mandatory appropriations to
fund temporary programs to increase access and funding for targeted groups, provide funding to
states to plan and establish exchanges, and support many other research and demonstration
programs and activities (see discussion below under “Mandatory Appropriations in ACA”). The
costs of expanding public and private health insurance coverage and other mandatory spending
are offset by revenues from new taxes and industry fees, and by savings from payment and health
1 ACA was signed into law on March 23, 2010 (P.L. 111-148, 124 Stat. 119). A week later, on March 30, 2010, the
President signed the Health Care and Education Reconciliation Act (HCERA; P.L. 111-152, 124 Stat. 1029), which
amended multiple health care and revenue provisions in ACA. Several other bills that were subsequently enacted
during the 111th and 112th Congresses made more targeted changes to specific ACA provisions. All references to ACA
in this report refer to the law as amended. Note that previous CRS reports on the Patient Protection and Affordable
Care Act used the acronym PPACA to refer to the law. CRS is now using the more common acronym ACA.
2 NFIB v. Sebelius, No. 11-393, slip op. (June 28, 2012), available at http://www.supremecourt.gov/opinions/11pdf/11-
393c3a2.pdf.
3 Direct, or mandatory, spending generally refers to budget authority (i.e., the authority to incur financial obligations
that result in government expenditures, such as purchasing services or awarding grants) that is provided in laws other
than the annual appropriations acts. Mandatory spending includes entitlement authority (e.g., Medicare, Social
Security).
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care delivery system reforms designed to slow the growth in spending on Medicare and other
federal health care programs.4
U.S. Supreme Court Decision on ACA (June 28, 2012)
In National Federation of Independent Business v. Sebelius (NFIB) the Court ruled on the constitutionality of both the
individual mandate, which requires most U.S. residents (beginning in 2014) to carry health insurance or pay a penalty,
and the Medicaid expansion. The Court upheld the individual mandate as a constitutional exercise of Congress’s
authority to levy taxes. The penalty is to be paid by taxpayers when they file their tax returns and enforced by the
Internal Revenue Service.
In a separate opinion, the Court found that compelling states to participate in the ACA Medicaid expansion—which
the Court determined to be essentially a new program—or risk losing their existing federal Medicaid matching funds
was coercive and unconstitutional under the Spending Clause of the Constitution and the Tenth Amendment. The
Court’s remedy for this constitutional violation was to prohibit HHS from penalizing states that choose not to
participate in the expansion by withholding any federal matching funds for their existing Medicaid program. However,
if a state accepts the new ACA expansion funds (initially a 100% federal match), it must abide by all the expansion
coverage rules.
Under NFIB, all other provisions of ACA remain fully intact and operative. For more information, see CRS Report
R42698, NFIB v. Sebelius: Constitutionality of the Individual Mandate, by Erika K. Lunder and Jennifer Staman, and CRS
Report R42367, Medicaid and Federal Grant Conditions After NFIB v. Sebelius: Constitutional Issues and Analysis, by Kenneth
R. Thomas.
ACA implementation affects not only direct spending and revenues but also discretionary
spending, which is subject to the annual appropriations process.5 The law includes numerous
discretionary spending provisions that authorize the appropriation of funds to implement grant
programs and other activities. These provisions are of two kinds:
• Authorizations of appropriations for new discretionary grant and other programs
created by ACA.
• Authorizations of appropriations for existing programs, primarily ones
authorized under the Public Health Service Act (PHSA). In most instances, the
appropriation authorizations for these established programs expired prior to their
reauthorization by ACA. However, almost all of them continued to receive an
annual appropriation.6
Many of the ACA discretionary spending provisions authorize annual appropriations of specified
amounts for one or more fiscal years to carry out the program or activity. Other provisions
authorize the appropriation of specified amounts for FY2010 or FY2011 and unspecified
amounts—such sums as may be necessary, or SSAN—for later years. A few provisions authorize
multi-year appropriations, available for obligation for a period in excess of one fiscal year (e.g.,
4 For more information on ACA’s provisions and its projected impact on federal revenues and direct spending, see CRS
Report R41664, ACA: A Brief Overview of the Law, Implementation, and Legal Challenges, coordinated by C. Stephen
Redhead.
5 Discretionary spending refers to outlays from budget authority that is provided in and controlled by annual
appropriations acts.
6 ACA also reauthorized the Indian Health Care Improvement Act (IHCIA), which includes many discretionary Indian
Health Service (IHS) programs and services. It extended indefinitely the authorizations of appropriations for those
programs and services. For more information on ACA’s Indian health provisions, which are not included in this report,
see CRS Report R41630, The Indian Health Care Improvement Act Reauthorization and Extension as Enacted by the
ACA: Detailed Summary and Timeline, by Elayne J. Heisler.
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for the period FY2011 through FY2014). Numerous other provisions simply authorize the
appropriation of SSAN, in a few cases without specifying any fiscal years.
Funding for all discretionary programs in ACA depends on actions taken by congressional
appropriators, a process that may lead to greater or smaller amounts than the sums authorized by
the law. With Congress now operating under discretionary spending limits set by the Budget
Control Act,7 it may prove difficult to secure funding for new programs and activities (see
discussion below under “Potential Impact of Spending Cuts Under the Budget Control Act”).
Even maintaining current funding levels for existing programs with an established appropriations
history may prove a challenge under growing pressure to reduce federal discretionary spending.
This report, which is periodically revised and updated to reflect important legislative and other
developments, summarizes all the discretionary spending provisions in ACA that authorize (or
reauthorize) appropriations for grant programs and other activities. It also includes a brief
discussion of two trust funds for which ACA provided mandatory appropriations to help support
several discretionary programs summarized in the tables below. Finally, the report provides some
analysis of the impact that a sequestration triggered by the Budget Control Act might have on
ACA-related discretionary spending in FY2013.
Discretionary Spending in ACA
The law’s discretionary spending provisions are organized by general topic in a series of tables
with the following headings: Health Centers and Clinics (Table 1); Health Care Workforce (Table
2); Prevention and Wellness (Table 3); Maternal and Child Health (Table 4); Health Care Quality
(Table 5); Nursing Homes (Table 6); Health Data Collection (Table 7); Emergency Care (Table
8); Elder Justice (Table 9); Biomedical Research (Table 10); Biologics (Table 11); 340B Drug
Pricing (Table 12); Medical Malpractice (Table 13); Pain Care Management (Table 14);
Medicaid (Table 15); Medicare (Table 16); and Private Health Insurance (Table 17).
Each table row provides information on a specific ACA provision, organized across four columns.
The first column shows the ACA section or subsection number. The second column indicates
whether the provision is freestanding (i.e., new statutory authority that is not amending an
existing statute) or amendatory (i.e., amends an existing statute such as the PHSA, either by
adding a new program or amending an existing one). The name of the administering agency or
office within HHS is also included, if known. The third column provides a brief description of the
program or activity, including the types of entities and/or individuals eligible for funding.8 The
fourth column gives details of the authorization of appropriations, along with the FY2011 and
FY2012 amounts for programs and activities that received funding, and, if applicable, the
FY2013 funding request.9 The federal government currently is operating under a six-month
continuing resolution (see discussion below under “ACA Administrative Costs and Funding”).
Note that in several of the larger tables with multiple entries (i.e., Tables 1, 2, 3, 5 and 8), the
ACA provisions are grouped based on whether they reauthorize funding for existing programs or
7 P.L. 112-25, 125 Stat. 240.
8 Not applicable if the funding is to support programs and activities carried out by the federal agency.
9 The FY2011, FY2012, and FY2013 (request) funding amounts are taken from HHS agency FY2013 congressional
justification documents, available at http://www.hrsa.gov/about/budget/index.html.
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authorize funding for new programs. Where available, the table entry includes the Catalog of
Federal Domestic Assistance (CFDA) number for the grant program.10 Unless otherwise stated,
all references in the tables to the Secretary refer to the HHS Secretary.
The Congressional Budget Office (CBO) estimated that ACA’s discretionary spending provisions,
if fully funded by future appropriations acts, would result in appropriations of almost $100 billion
over the period FY2012-FY2021.11 However, much of that funding—about $85 billion—would
be for three programs that were in existence prior to, and were reauthorized by, ACA; namely, the
National Health Service Corps, the federal health centers program, and the Indian Health Service
(IHS).
Most, though not all, of the existing grant
programs that were reauthorized under ACA
received a discretionary appropriation for
FY2011 and FY2012, as well as a FY2013
request for continued funding. In contrast, few
of the new grant programs authorized under
ACA have received annual discretionary
appropriations.12 However, several of the new
programs have received mandatory funds
from ACA’s Prevention and Public Health
Fund (see discussion below under “Mandatory
Appropriations in ACA”).
ACA Administrative Costs and
Funding
In addition to the costs of fully funding ACA’s
discretionary grant programs and other
activities, CBO projected that both HHS and
the Internal Revenue Service (IRS) will incur
substantial administrative costs to implement
the law’s private health insurance reforms and
its changes to the federal health care
10 CFDA is a government-wide compendium of federal grant and other assistance programs. Each program is assigned
a unique five-digit number, XX.XXX, where the first two digits represent the funding agency and the second three
digits represent the program. Programs funded by the Department of Health and Human Services begin with the
number 93. For more information, see https://www.cfda.gov.
11 U.S. Congress, House Committee on Energy and Commerce, Subcommittee on Health, “CBO’s Analysis of the
Major Health Care Legislation Enacted in March 2010,” Statement of Douglas W. Elmendorf, Director, 112th Cong., 1st
sess., March 30, 2011. Available at http://www.cbo.gov/ftpdocs/121xx/doc12119/03-30-HealthCareLegislation.pdf.
See p. 16. CBO’s estimate of ACA discretionary spending includes (1) amounts specified in ACA, plus estimated
amounts for subsequent years (adjusted for anticipated inflation) where ACA specified an amount for the first year
(FY2010 or FY2011) and authorized SSAN for subsequent years; and (2) estimated amounts for subsequent years
(adjusted for anticipated inflation) where there is an appropriation for FY2010 under prior law and ACA authorized the
appropriation of SSAN for later years. The CBO estimate does not include new ACA programs for which the law
provided only an authorization for the appropriation of SSAN.
12 Examples include CDC’s congenital heart disease and breast health awareness programs (see Table 3) and the Cures
Acceleration Network (CAN) program at NIH (see Table 10).
Acronyms Used in the Tables in
This Report
Agency for Healthcare Research and Quality (AHRQ)
Centers for Disease Control and Prevention (CDC)
Centers for Medicare and Medicaid Services (CMS)
Community Health Center Fund (CHCF)
Federal Food, Drug, and Cosmetic Act (FFDCA)
Food and Drug Administration (FDA)
Health Resources and Services Administration (HRSA)
Indian Health Service (IHS)
National Institutes of Health (NIH)
Office of Personnel Management (OPM)
Office of the Secretary (OS)
Prevention and Public Health Fund (PPHF)
Public Health Service Act (PHSA)
Substance Abuse and Mental Health Services
Administration (SAMHSA)
Social Security Act (SSA)
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programs. CBO estimated that the costs to the IRS of implementing the eligibility determination,
documentation, and verification processes for the health insurance subsidies will probably total
between $5 billion and $10 billion over 10 years. It further estimated that the costs to HHS of
implementing the changes in Medicare, Medicaid, and CHIP, as well as some of the reforms to
the private insurance market, will require similar amounts over 10 years.13
The Health Care and Education Reconciliation Act (HCERA) established, and appropriated $1
billion to, the Health Insurance Reform Implementation Fund (HIRIF)—one of many sources of
mandatory funding for ACA programs and activities (see discussion below under “Mandatory
Appropriations in ACA”).14 HIRIF funds are for administrative expenses associated with
implementing the new law. While HHS has used HIRIF to cover its own ACA administrative
costs, a significant portion of HIRIF funding were transferred to the IRS. HHS projected that all
the HIRIF funds would be obligated by the end of FY2012. Thereafter, ACA administrative costs
will have to be funded through annual discretionary appropriations.
The President’s FY2013 budget requested more than $1 billion in new discretionary funding for
HHS and the IRS to pay for ongoing administrative costs associated with ACA implementation. It
remains to be seen whether congressional appropriators will provide any or all of those funds in
FY2013. Congress has yet to complete action on any of the FY2013 appropriations bills and has
instead passed, and the President has signed, a continuing resolution to provide temporary
funding authority for the first six months of FY2013. The requested ACA administrative funding
was not included in the FY2013 continuing resolution.15
Mandatory Appropriations in ACA
Separate from the discretionary spending authorizations summarized in the tables in this report,
ACA included numerous mandatory appropriations that provide billions of dollars to fund new
and existing grant programs and activities within HHS.16
Of particular note, ACA established two multi-billion dollar funds that are helping support several
of the discretionary grant programs authorized (or reauthorized) under ACA:
• The Community Health Center Fund (CHCF) will provide a total of $11
billion over the period FY2011-FY2015 for the federal health centers program
and the National Health Service Corps (NHSC).17 While CHCF funding may
13 CBO, March 30, 2011, see footnote 11.
14 HCERA Section 1105; see footnote 1.
15 The Continuing Appropriations Resolution, 2013 (P.L. 112-175, 126 Stat. 1313) funds government operations for
most discretionary programs at an estimated annualized rate of $1.047 trillion in discretionary budget authority, which
equals the FY2013 discretionary spending cap set by the BCA. It increases funding for most federal agencies and
programs by 0.612% over the FY2012 levels. P.L. 112-175 does not incorporate any of the new ACA-related policies
or funding that were included in the President’s FY2013 budget. For more information, see CRS Report R42782,
FY2013 Continuing Resolution: Analysis of Components and Congressional Action, by Jessica Tollestrup.
16 All these mandatory spending provisions are summarized in a companion product, CRS Report R41301,
Appropriations and Fund Transfers in the Patient Protection and Affordable Care Act (ACA), by C. Stephen Redhead.
17 ACA Section 10503(a)-(b). The CHCF provides the following amounts for health center operating grants: FY2011 =
$1 billion; FY2012 = $1.2 billion; FY2013 = $1.5 billion; FY2014 = $2.2 billion; and FY2015 = $3.6 billion. It also
provides the following amounts for the National Health Service Corps: FY2011 = $290 million; FY2012 = $295
million; FY2013 = $300 million; FY2014 = $305 million; and FY2015 = $310 million.
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have been intended to supplement annual discretionary appropriations for health
centers and the NHSC program, the funds have partially supplanted discretionary
health center appropriations and have become the sole source of funding for the
NHSC program, which received no discretionary funds in FY2012 (see Table 1
and Table 2). Note: A separate ACA appropriation provided $1.5 billion for
health center construction and renovation (see Table 1).18
• The Prevention and Public Health Fund (PPHF), for which ACA provided a
permanent annual appropriation, is intended to fund prevention, wellness, and
other public health-related programs and activities authorized under the PHSA.19
PPHF funds have been used to support at least six new discretionary grant
programs authorized under ACA.20 In addition, PPHF funds are supplementing,
and in some cases supplanting, annual discretionary appropriations for several
established programs (see Table 2, Table 3, and Table 5).
Potential Impact of Spending Cuts Under the
Budget Control Act
The Budget Control Act of 2011 (BCA) included procedures and a timetable for enactment of a
bill to reduce the federal deficit.21 In the event that Congress and the President failed to enact
such legislation, as was the case, the BCA required the President to order across-the-board
spending cuts—a process known as sequestration—for all nonexempt direct (i.e., mandatory) and
discretionary spending programs on January 2, 2013. That deadline was delayed for two months,
until March 1, 2013, by the American Taxpayer Relief Act of 2012 (ATRA).22 ATRA also reduced
the total amount of spending cuts for FY2013 by $24 billion, from $109.33 billion to $85.33
billion. This final section of the report provides an overview of the BCA’s mechanisms for
reducing spending. As discussed below, a FY2013 sequestration would impact the ACA-related
discretionary appropriations summarized in this report.
18 ACA Section 10503(c). See also CRS Report R42433, Federal Health Centers, by Elayne J. Heisler.
19 ACA Section 4002. As originally enacted, ACA appropriated the following amounts to the PPHF: FY2010 = $500
million; FY2011 = $750 million; FY2012 = $1 billion; FY2013 = $1.25 billion; FY2014 = $1.5 billion; and FY2015
and each fiscal year thereafter = $2 billion. The Middle Class Tax Relief and Job Creation Act of 2012 (P.L. 112-96,
Sec. 3205) amended Section 4002 and reduced the amounts appropriated over the period FY2013-FY2021 by a total of
$6.25 billion. The reduced appropriations for each of those fiscal years are as follows: FY2013 = $1 billion; FY2014 =
$1 billion; FY2015 = $1 billion; FY2016 = $1 billion; FY2017 = $1 billion; FY2018 = $1.25 billion; FY2019 = $1.25
billion; FY2020 = $1.5 billion; and FY2021 = $1.5 billion.
20 Those programs include (1) Sec. 5208, Nurse-Managed Health Clinics, see Table 1; (2) Sec. 5306, Mental and
Behavioral Health Education and Training Grants, see Table 2; (3) Sec. 5102, State Health Care Workforce
Development Grants, see Table 2; (4) Sec. 4201, Community Transformation Grants, see Table 3; (5) Sec. 10408,
Small Business Workplace Wellness Grants, see Table 3; and (6) Sec. 10501(g), National Diabetes Prevention
Program, see Table 3.
21 P.L. 112-25, 125 Stat. 240.
22 P.L. 112-240, 126 Stat. 2313.
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BCA Background
The BCA authorized the President to increase the nation’s debt limit by at least $2.1 trillion (and
up to $2.4 trillion under certain conditions) in three installments and established procedures
designed to reduce future federal spending by a comparable amount.23 To achieve the spending
reductions, the law placed enforceable limits, or caps, on discretionary spending for each of
FY2012 through FY2021. CBO estimated that adhering to these limits, which grow by
approximately 2% each year, would reduce federal spending by $917 billion through FY2021,
compared to the projected level of spending if annual appropriations were to grow at the rate of
inflation.24
In addition, the BCA created a Joint Select Committee on Deficit Reduction (Joint Committee)
and instructed it to develop deficit-reduction legislation for Congress to consider under expedited
floor procedures. If, by January 15, 2012, Congress and the President failed to enact a Joint
Committee bill reducing the deficit by an amount greater than $1.2 trillion over the period
FY2012-FY2021, then automatic annual spending reductions would be triggered beginning in
FY2013. On November 21, 2011, the Joint Committee announced that it was unable to agree on a
deficit-reduction bill. This meant that automatic spending reductions totaling $1.2 trillion were set
to take effect, pursuant to the procedures and timetable established in the BCA, unless new
legislation to modify or repeal the law was enacted.
Based on the formula in the BCA, the automatic spending reductions would cut $109.33 billion
for each fiscal year over the period FY2013-FY2021. [Note: ATRA’s $24 billion adjustment for
FY2013 is discussed below.] Each year’s cut would be equally divided between defense and
nondefense spending. The annual spending reduction in each of these two categories (i.e., $54.67
billion) would be further divided proportionately between discretionary spending and nonexempt
direct (i.e., mandatory) spending. In FY2013, both the discretionary and the direct spending
reductions in the two categories would be achieved through sequestration—a largely across-theboard
cancellation of budgetary resources in nonexempt accounts. In each of the remaining fiscal
years through FY2021, discretionary spending reductions would be achieved through a downward
adjustment of the BCA spending limits, while direct spending reductions would continue to be
executed through sequestration.
Under the sequestration rules, reductions in Medicare payments to health care providers and
health plans (which account for most of Medicare spending) are capped at 2%. Many other
federal direct spending programs, accounting for most of the government’s entitlement and other
direct spending (excluding Medicare), are exempt from sequestration altogether.25
Discretionary spending reductions in FY2013 also would be achieved through a sequestration of
nonexempt discretionary appropriations. The sequestration rules exempt some discretionary
spending, notably for veterans’ health care and Pell grants.26 For each of the remaining fiscal
23 For a more detailed examination of all the provisions in the BCA, see CRS Report R41965, The Budget Control Act
of 2011, by Bill Heniff Jr., Elizabeth Rybicki, and Shannon M. Mahan. The President has exercised the authority
provided him in the BCA and raised the debt ceiling by a total of $2.1 trillion, from $14.294 trillion to $16.394 trillion.
24 U.S. Congressional Budget Office, Analysis of Budget Control Act, August 1, 2011. Available at
http://www.cbo.gov/publication/41626.
25 For more information, see CRS Report R42050, Budget “Sequestration” and Selected Program Exemptions and
Special Rules, coordinated by Karen Spar.
26 Ibid. Note that all veterans programs, mandatory and discretionary, are exempt from sequestration.
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years (i.e., FY2014-FY2021), however, discretionary spending reductions would be achieved by
lowering the BCA discretionary spending caps. There would be no across-the-board cuts through
sequestration. Instead, the Appropriations Committees would decide how to apportion the cuts
within the reduced cap.
The BCA requires the OMB to calculate, and the President to order, a sequestration of nonexempt
discretionary appropriations for FY2013 and nonexempt direct spending for each of FY2013
through FY2021. As already noted, the sequestration for FY2013 was to be ordered on January 2,
2013. However, ATRA amended the BCA by delaying the sequestration order by two months. The
President is now instructed to order a FY2013 sequestration on March 1, 2013. The BCA requires
the sequestrations for subsequent fiscal years (i.e., FY2014-FY2021) to occur at the time of the
President’s annual budget submission in early February.
FY2013 Nondefense Discretionary Spending Reductions
On September 14, 2012, OMB released a report on the potential impact of a sequestration
triggered by the failure of the Joint Committee to propose, and Congress and the President to
enact, legislation to reduce the deficit by an amount greater than $1.2 trillion.27 The OMB report
provides a breakdown of exempt and nonexempt budget accounts, and includes estimates of the
FY2013 funding reductions in nonexempt accounts. OMB calculated that sequestration would
result in an 8.2% reduction in nonexempt nondefense discretionary spending. That reduction
would generally apply to the discretionary spending summarized in the tables in this report.28
OMB emphasized that the estimates and budget account classifications in the report are
preliminary. The agency noted that “[i]f the sequestration were to occur, the actual results would
differ based on changes in law and ongoing legal, budgetary, and technical analysis.”29
In addition to delaying the FY2013 sequestration order, ATRA reduced the FY2013 sequestration
by $24 billion, from $109.33 billion to $85.33 billion. Because the sequestration is divided
equally between defense and nondefense spending, each of these two spending categories would
be subject to $12 billion less in spending cuts (i.e., $42.67 billion, instead of $54.67 billion).
OMB’s preliminary estimates of the potential impact of a FY2013 sequestration predate ATRA’s
enactment and, therefore, do not take into account the $24 billion reduction. Applying that
adjustment to OMB’s calculations significantly reduced the estimated percentage reduction in
nonexempt nondefense discretionary spending under a FY2013 sequestration order.
Importantly, the reductions in nondefense (and defense) discretionary spending under the BCA
would largely occur in the first year (i.e., FY2013) through sequestration, rather than phasing in
gradually over the entire period. In each subsequent fiscal year (i.e., FY2014-FY2021), the level
of nondefense (and defense) discretionary spending would be tied to the adjusted (i.e., lowered)
cap, which would actually grow by about 2% annually over that period.
27 U.S. Office of Management and Budget, OMB Report Pursuant to the Sequestration Transparency Act of 2012 (P.L.
112-155), http://www.whitehouse.gov/sites/default/files/omb/assets/legislative_reports/stareport.pdf.
28 For more discussion and analysis of the potential impact of spending reductions triggered by the BCA, see CRS
Report R42051, Budget Control Act: Potential Impact of Sequestration on Health Reform Spending, by C. Stephen
Redhead.
29 Ibid., p. 1.
Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)
CRS-9
Table 1. ACA Discretionary Spending: Health Centers and Clinics
ACA
Section
Statutory
Authority
(Agency) Summary of Provision
Authorization of Appropriations
Funding (FY2011-FY2013)
Health Centers: Existing Program
5601 Reauthorizes
PHSA Sec. 330
(HRSA)
Health centers. Permanently reauthorizes funding for the program
that provides operating grants to health centers serving federally
designated medically underserved populations and furnishing
comprehensive primary care services, referrals, and other services
needed to facilitate access to such care, regardless of ability to pay.
Eligible grantees include community, migrant, public housing, and
homeless health centers that meet the statutory requirements of PHSA
Sec. 330.
$3.0 billion for FY2010, $3.9 billion for FY2011, $5.0 billion for FY2012,
$6.5 billion for FY2013, $7.3 billion for FY2014, and $8.3 billion for
FY2015; amounts in subsequent years based on previous year’s funding,
subject to adjustment.
FY2011 funding = $2.6 billion (includes $1.0 billion from the CHCF),
FY2012 funding = $2.8 billion (includes $1.2 billion from the CHCF),
FY2013 request = $3.1 billion (includes $1.5 billion from the
CHCF).a [CFDA 93.224, 93.527]
Note: ACA Sec. 10503(c) appropriated $1.5 billion for the period
FY2011 through FY2015 for health center construction and renovation;
see CRS Report R41301.
Health Centers and Clinics: New Programs
4101(b) New PHSA Sec.
399Z-1 (HRSA)
School-based health centers (SBHCs). Requires the Secretary to
award grants to fund the management and operation of SBHCs that
provide comprehensive physical and behavioral health services to
children and adolescents, subject to parental consent. SBHCs that meet
certain specified criteria and match 20% of the grant amount with nonfederal
funds (unless waived). Preference may be given to SBHCs serving
children and adolescents who have limited access to or difficulty
accessing health care.
SSAN for each of FY2010 through FY2014.
Note: ACA Sec. 4101(a) appropriated a total of $200 million for SBHC
construction and renovation; see CRS Report R41301.
5208 New PHSA Sec.
330A-1 (HRSA)
Nurse-managed health clinics (NMHCs). Requires the Secretary to
award grants to fund the operation of NMHCs—associated with
schools, colleges, federally qualified health centers (FQHCs), or
nonprofit health/social services agencies—that provide comprehensive
primary health care and wellness services to vulnerable or underserved
populations regardless of income or insurance status. At least one
advanced practice nurse must hold an executive management position in
the NMHC.
$50 million for FY2010, and SSAN for each of FY2011 through FY2014.
Note: This new program received $15 million in FY2010 funds from the
PPHF but has not received any funding since that time. [CFDA 93.515]
Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)
CRS-10
ACA
Section
Statutory
Authority
(Agency) Summary of Provision
Authorization of Appropriations
Funding (FY2011-FY2013)
10504 New authority
(HRSA)
Access to affordable care demonstration program. Within six
months of enactment, requires the Secretary to establish a three-year
demonstration project in up to 10 states—each state may receive up to
$2 million—to provide access to comprehensive health care services to
the uninsured. Eligible grantees must be state-based, nonprofit, publicprivate
partnerships that provide access to comprehensive health care
services to the uninsured at reduced fees.
SSAN (no years specified).
Sources: Table prepared by the Congressional Research Service based on the text of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended).
FY2011, FY2012 and requested FY2013 funding amounts are taken from HRSA’s FY2013 budget justification document for Congress, available at http://www.hrsa.gov/
about/budget/index.html.
a. Annual funding totals for health centers include the following amounts for the Federal Tort Claims Act (FTCA) program: FY2011 = $100 million; FY2012 = $95 million;
FY2013 request = $95 million. Under the FTCA, health center employees and contractors are considered federal employees immune from medical malpractice
lawsuits while acting within the scope of their employment. The federal government assumes responsibility for such malpractice claims.
Table 2. ACA Discretionary Spending: Health Care Workforce
ACA
Section
Statutory
Authority
(Agency) Summary of Provision
Authorization of Appropriations
Funding (FY2011-FY2013)
National Health Service Corps (NHSC)
5207 Reauthorizes
PHSA Title III,
Part D, Subpart III
(HRSA)
NHSC scholarships and loan repayments. Permanently
reauthorizes funding for the NHSC program. In exchange for a
commitment to work in a federally designated Health Professional
Shortage Area (HPSA), the program provides (1) scholarships to
students training in a primary care discipline to cover tuition, fees, other
educational costs, and a stipend; and (2) student loan repayments of up
to $50,000 a year to primary care and mental health clinicians. To be
eligible for a scholarship, a student must be accepted or enrolled in a
training program for medicine, dentistry, family nurse practitioner, nurse
midwife, or physician assistant, and agree to two to four years of service
in an NHSC-approved site in a HPSA. Loan repayments are for primary
care, dental, and mental health clinicians who agree to at least two years
of service in an NHSC-approved site in a HPSA.
$320 million for FY2010, $414 million for FY2011, $535 million for
FY2012, $691 million for FY2013, $893 million for FY2014, and $1,155
billion for FY2015; amounts in subsequent years based on previous
year’s funding, subject to adjustment.
FY2011 funding = $315 million (includes $290 million from the
CHCF), FY2012 funding = $295 million (all CHCF), FY2013 request
= $300 million (all CHCF). [CFDA 93.162, 93.288, 93.547]
Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)
CRS-11
ACA
Section
Statutory
Authority
(Agency) Summary of Provision
Authorization of Appropriations
Funding (FY2011-FY2013)
Physicians: Existing Program
5301 Amends and
reauthorizes
PHSA Sec. 747
(HRSA)
Primary care training and enhancement program. (1) Authorizes
five-year grants to public and nonprofit private hospitals, medical
schools, academically affiliated physician assistant training programs, and
other public and nonprofit private entities to support training programs
in primary care. Funds are to be used to plan, develop and operate
accredited training programs, including residency and internship
programs, in family medicine, general internal medicine, and general
pediatrics and to provide financial assistance (e.g., traineeships). (2)
Authorizes five-year grants to medical schools for primary care capacity
building. Funds are to be used to create academic units or programs that
improve clinical teaching in the primary care fields, and (in a separate
authorization) to integrate academic units to enhance interdisciplinary
recruitment, training, and faculty development. Funding priority given to
entities proposing innovative approaches to primary care training and
with a record of training primary care providers, among other things.
For both grant programs, $125 million for FY2010, and SSAN for each
of FY2011 through FY2014. Note: 15% of the amount appropriated must
be use for physician assistant training programs.
A separate authorization of $750,000 for each of FY2010 through
FY2014 is provided for capacity building grants to integrate academic
units.
FY2011 funding = $39 million, FY2012 funding = $39 million, FY2013
request = $51 million. [CFDA 93.510, 93.514, 93.884]
Note: For FY2010, this program received $198 million in PPHF funds in
addition to its annual discretionary appropriation of $39 million.
Physicians: New Programs
5203 New PHSA Sec.
775 (HRSA)
Pediatric specialist loan repayment program. Requires the
Secretary to implement a loan repayment program that pays up to
$35,000 for each year of service (for a maximum of three years) to
practicing or in-training pediatric specialists and surgeons, as well as
child and adolescent mental health specialists, who agree to at least two
years of service in a HPSA.
$30 million for each of FY2010 through FY2014 for loan repayments to
pediatric specialists and surgeons; $20 million for each of FY2010
through FY2013 for loan repayments to mental health providers.
FY2013 request = $5 million.
5508(a) New PHSA Sec.
749A (HRSA)
Teaching health centers development grants. Authorizes threeyear
grants of up to $500,000 to FQHCs, rural health clinics, Indian
health centers, and entities receiving PHSA Title X (family planning)
funds that establish or expand a primary care residency training
program.
$25 million for FY2010, $50 million for each of FY2011 and FY2012, and
SSAN for each fiscal year thereafter.
10501(l) New PHSA Sec.
749B (HRSA)
Rural physician training grants. Requires the Secretary to (1) award
grants medical schools for recruiting students most likely to practice in
underserved rural communities and for providing rural-focused training
and experience; and (2) within 60 days of enactment, by regulation,
define underserved rural communities. Priority is given to entities that
train students to practice in rural communities, that have established
partnerships with rural community health centers, or who submit a longterm
plan for tracking where graduates practice. [Note: HRSA published
an interim final rule on May 26, 2010 (75 Federal Register 29447).]
$4 million for each of FY2010 through FY2013.
Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)
CRS-12
ACA
Section
Statutory
Authority
(Agency) Summary of Provision
Authorization of Appropriations
Funding (FY2011-FY2013)
Dentistry: Existing Program
5303 New PHSA Sec.
748; authority
previously part of
Sec. 747 (HRSA)
General, pediatric, and public health dentistry training.
Authorizes grants or contracts to dental and dental hygiene schools, as
well as approved residency or advanced education programs in general,
pediatric, or public health dentistry, for dental training activities including
faculty development, financial assistance, faculty loan repayment
programs, technical assistance for pediatric dental programs, and preand
post-doctoral training programs in dental primary care. Gives
priority to entities that train individuals from disadvantaged backgrounds,
who have a record of placing graduates in facilities that provide care to
the underserved, or whose programs focus on providing care to the
underserved through demonstrated partnerships with FQHCs, rural
health clinics, or through having programs focused on specific topics,
such as HIV/AIDs.
$30 million for FY2010, and SSAN for each of FY2011 through FY2015;
permits grantees to carry over funds for up to three fiscal years.
FY2011 funding = $17 million, FY2012 funding = $20 million, FY2013
request = $20 million. [CFDA 93.059, 93.884]
Note: HRSA also administers a state oral health workforce grant
program (PHSA Sec. 340G): FY2011 funding = $16 million, FY2012
funding = $12 million, FY2013 request = $11 million. [CFDA 93.236]
Dentistry: New Program
5304 New PHSA Sec.
340G-1 (HRSA)
Alternative dental health care provider demonstration
program. Authorizes the Secretary to award 15 five-year grants of not
less than $4 million to train or employ alternative dental health care
providers (e.g., community dental health coordinators, dental health
aides) to increase access to dental health care services in rural and other
underserved communities. Eligible grantees include institutions of higher
education; public-private entities; FQHCs; facilities operated by the IHS
or by Indian tribes or organizations; state or county public health clinics;
public hospitals or health systems; and accredited dental education
programs.
SSAN (no years specified).
FY2013 request = $1 million.
Note: The Consolidated Appropriations Act, 2012 (P.L. 112-74)
prohibited HRSA funding for this new program in FY2012.
Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)
CRS-13
ACA
Section
Statutory
Authority
(Agency) Summary of Provision
Authorization of Appropriations
Funding (FY2011-FY2013)
Nursing: Existing Programs
5309(a) Amends and
reauthorizes
PHSA Sec. 831
(HRSA)
Nurse education, practice, quality, and retention program.
Authorizes grants or contracts to expand enrollment in baccalaureate
nursing programs; provide training in new technologies; develop cultural
competencies; expand nursing practice arrangements in non-institutional
settings; and support nurse retention programs that offer career
advancement for nursing personnel, enhance collaboration among nurses
and other health professionals, and promote nurse involvement in
clinical decision making. Eligible grantees include nursing schools, health
care facilities (including NMHCs), or partnerships of the two.
SSAN for each of FY2010 through FY2014. See also ACA Sec. 5312
below, which reauthorized appropriations for several Title VIII nursing
education programs, including Sec. 831.
FY2011 funding = $40 million, FY2012 funding = $39 million, FY2013
request = $39 million. [CFDA 93.359, 93.503]
5311(a) Amends and
reauthorizes
PHSA Sec. 846A
(HRSA)
Nursing faculty loan program. Authorizes loans to nursing school
students pursuing advanced degrees to become qualified nursing faculty.
Sets the annual loan limit at $35,500 for FY2010 and FY2011; for
subsequent fiscal years, the loan limit is subject to a cost-of-attendance
adjustment. Students who go on to serve as nursing school faculty may
have up to 85% of their loan repayment cancelled.
SSAN for each of FY2010 through FY2014.
FY2011 funding = $25 million, FY2012 funding = $25 million, FY2013
request = $25 million. [CFDA 93.264]
5312 Amends PHSA
Sec. 871;
previously Sec.
841 (HRSA)
Authorization of appropriations. Reauthorizes funding for the
following PHSA Title VIII nursing workforce programs:
1. Advanced nursing education (PHSA Sec. 811) – grants to accredited
programs for advanced nurse education including combined registered
nurse masters degree programs, authorized nurse practitioner
programs, accredited nurse midwifery programs, and accredited nurse
anesthesia programs.
2. Nursing workforce diversity (PHSA Sec. 821) – grants to nursing
schools, academic health centers, state or local governments, and other
appropriate public or private nonprofit entities for stipends and
scholarships so as to increase nursing education opportunities for
disadvantaged individuals.
3. Nurse education, practice, quality, and retention (PHSA Sec. 831) –
see ACA Sec. 5309(a) above.
Note: ACA did not reauthorize funding for the nursing education loan
repayment and scholarship programs authorized under PHSA Sec. 846.b
For PHSA Secs. 811, 821, 831, and new 831A (see ACA Sec. 5309(b)
below), $338 million for FY2010, and SSAN for each of FY2011 through
FY2016.
Sec. 811: FY2011 funding = $64 million, FY2012 funding = $64
million, FY2013 request = $84 million (includes $20 million in PHS
evaluation funds).a [CFDA 93.124, 93.247, 93.358, 93.513]
Sec. 821: FY2011 funding = $16 million, FY2012 funding = $16
million, FY2013 request = $16 million. [CFDA 93.178]
Sec. 831: see ACA Sec. 5309(a) above for funding amounts.
Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)
CRS-14
ACA
Section
Statutory
Authority
(Agency) Summary of Provision
Authorization of Appropriations
Funding (FY2011-FY2013)
Nursing: New Programs
5309(b) New PHSA Sec.
831A (HRSA)
Nurse retention program. New authority that largely duplicates the
nurse retention grant program authorized under PHSA Sec. 831; see
ACA Sec. 5309(a) above.
SSAN for each of FY2010 through FY2012. See also ACA Sec. 5312
above.
5311(b) New PHSA Sec.
847 (HRSA)
Nursing faculty loan repayment program. Authorizes a loan
repayment program for qualified nursing students or graduates who
agree to serve as nursing faculty for four to six years. Sets the annual
loan limit for FY2010 and FY2011 at $10,000 for individuals with a
master’s or equivalent degree in nursing ($20,000 for those with a
doctorate or equivalent degree in nursing), and an aggregate loan limit of
$40,000 for individuals with a master’s or equivalent degree in nursing
($80,000 for those with a doctorate or equivalent degree in nursing).
Thereafter, the annual and aggregate loan limits are subject to a cost-ofattendance
adjustment.
SSAN for each of FY2010 through FY2014.
5316 New authority Family nurse practitioner demonstration program. Requires the
Secretary to award three-year demonstration grants to FQHCs and
NMHCs, not to exceed $600,000 a year, for programs to train nurse
practitioners as primary care providers (as defined in ACA Sec. 5208).
Preference given to bilingual individuals.
SSAN for each of FY2011 through FY2014.
Geriatrics and Long-Term Care: Existing Program
5305(c) Amends and
reauthorizes
PHSA Sec. 865;
previously Sec.
855 (HRSA)
Geriatric nursing education and training. Provides grants for
traineeships for individuals preparing for advanced degrees in geriatric
nursing or other nursing areas that specialize in elder care. Eligible
grantees include nursing schools, health care facilities, programs leading
to certification as a certified nurse assistant, and partnerships of such
schools, facilities, and programs.
SSAN for each of FY2010 through FY2014.
FY2011 funding = $5 million, FY2012 funding = $4 million, FY2013
request = $4 million. [CFDA 93.265]
Geriatrics and Long-Term Care (LTC): New Programs
5302 New PHSA Sec.
747A (HRSA)
Direct care worker training. Requires the Secretary to establish a
grant program to provide new training opportunities, such as tuition and
fee assistance, for direct care workers employed in LTC settings.
Individuals who receive assistance are required to work in the field of
geriatrics, disability services, LTC services and supports, or chronic care
management for a minimum of two years. Eligible grantees include
institutions of higher education that have an established partnership with
an LTC entity, as specified.
$10 million for the period FY2011 through FY2013.
Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)
CRS-15
ACA
Section
Statutory
Authority
(Agency) Summary of Provision
Authorization of Appropriations
Funding (FY2011-FY2013)
5305(a) Amends PHSA
Sec. 753 by
adding new
subsections (d)-
(e) (HRSA)
Geriatric workforce development; geriatric career incentive
awards. (1) Requires the Secretary to award no more than 24 grants or
contracts for $150,000 to entities that operate geriatric education
centers to support short-term intensive courses on geriatrics and LTC,
and support training for family caregivers and direct care workers.
Eligible grantees include accredited schools of allied health, medicine,
nursing, dentistry, osteopathic medicine, optometry, podiatric medicine,
veterinary medicine, public health, or chiropractic care; accredited
graduate programs in clinical psychology, clinical social work, health
administration, marriage and family therapy, and counseling; and
physician assistant programs. (2) Requires the Secretary to award grants
or contracts to advance practice nurses, clinical social workers,
pharmacists, and psychologists pursuing an advanced degree in geriatrics
or a related field, in return for agreeing to teach or practice in the field
of geriatrics, LTC, or chronic care management for a minimum of five
years upon completion of the degree.
(1) $10.8 million for the period FY2011 through FY2014. (2) $10 million
for the period FY2011 through FY2013.
Note: Funding for the three existing geriatric education and training
programs under PHSA Sec. 753(a)-(c) is as follows: FY2011 funding =
$34 million; FY2012 funding = $31 million, FY2013 request = $31
million. [CFDA 93.156, 93.250, 93.969]
Pain Care: New Program
4305(c) New PHSA Sec.
759 (HRSA)
Education and training in pain care. Authorizes a grant program to
train health professionals in pain care. Eligible grantees include health
professions schools, hospices, and other public and private entities.
Applicants must agree to include training and education on recognizing
the signs and symptoms of pain; applicable laws and policies on
controlled substances; interdisciplinary approaches to pain care delivery;
barriers to care in underserved populations; and recent developments in
pain care. [See also Table 14.]
SSAN for each of FY2010 through FY2012, to remain available until
expended.
Public Health: Existing Programs
10501(m)(2) Amends PHSA
Sec. 770 (HRSA)
Public health and preventive medicine programs. Reauthorizes
funding for the public health workforce programs authorized under
PHSA Secs. 765-769. They include grants for public health training
centers; tuition, fees, and stipends for traineeships in public health and in
health administration; and residency programs in preventive medicine
and dental public health. Several programs mention preference for
underserved communities or underrepresented minorities. Eligible
grantees include accredited academic institutions, as well as state, local
and tribal public health departments.
$43 million for FY2011, and SSAN for each of FY2012 through FY2015.
FY2011 funding = $30 million (includes $20 million from the PPHF),
FY2012 funding = $33 million (includes $25 million from the PPHF),
FY2013 request = $20 million (includes $10 million from the PPHF).
[CFDA 93.117, 93.249, 93.516, 93.964]
Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)
CRS-16
ACA
Section
Statutory
Authority
(Agency) Summary of Provision
Authorization of Appropriations
Funding (FY2011-FY2013)
Public Health: New Programs
5204 New PHSA Sec.
776 (HRSA)
Public health workforce loan repayment program. Requires the
Secretary to establish a student loan repayment program that pays up to
$35,000 a year, or one-third of total debt, whichever is less, to increase
the supply of public health professionals. Eligible individuals must agree
to work for at last three years in a public health agency or related
training fellowship.
$195 million for FY2010, and SSAN for each of FY2011 through FY2015.
5206(b) New PHSA Sec.
777 (HRSA)
Public health and allied health scholarship program. Authorizes
grants to accredited institutions for scholarships to help support the
training of mid-career professionals in public health and allied health.
Available grant funds are to be divided 50:50 between supporting public
health and allied health professionals.
$60 million for FY2010, and SSAN for each of FY2011 through FY2015.
5313 New PHSA Sec.
399V (CDC)
Community health worker (CHW) program. Requires CDC to
award grants to promote healthy behaviors and outcomes for
populations in medically underserved communities through programs of
training and supervision of CHWs. Eligible grantees include states and
subdivisions, health departments, free clinics, hospitals, and FQHCs.
Priority is to be given to applicants that target areas with a high
proportion of uninsured or underinsured individuals, or with high rates
of chronic illness or infant mortality.
SSAN for each of FY2010 through FY2014.
5314 New PHSA Sec.
778 (CDC)
CDC training fellowships. Authorizes the Secretary to expand
existing CDC training fellowships in epidemiology, laboratory science,
and informatics; the Epidemic Intelligence Service (EIS); and other
training programs that meet similar objectives. Participants may be
placed in state and local health agencies, and states can receive federal
assistance for loan repayment programs for such participants. [CFDA
93.065]
$39.5 million for each of FY2010 through FY2013 ($24.5 million for EIS,
and $5 million each for epidemiology, laboratory science, and
informatics).
5315 New PHSA Title
II, Part D – Secs.
271-274 (U.S.
Surgeon General)
United States Public Health Sciences Track. Authorizes the
establishment of a science track at academic sites selected by the
Secretary to award degrees that emphasize team-based service, public
health, epidemiology, and emergency preparedness and response. Funds
may be used for program development and for tuition and stipends for
student who meet a service obligation, including in the United States
Public Health Service (USPHS) Commissioned Corps.
Requires the Secretary to transfer SSAN from the Public Health and
Social Services Emergency Fund for FY2010 and each fiscal year
thereafter. Note: P.L. 112-10 prohibited any such transfer of funds.c
Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)
CRS-17
ACA
Section
Statutory
Authority
(Agency) Summary of Provision
Authorization of Appropriations
Funding (FY2011-FY2013)
5210 Amends PHSA
Sec. 203 (U.S.
Surgeon General)
USPHS Commissioned Corps. Establishes a Ready Reserve Corps
of officers who are subject to involuntary call to active duty (including
for training) by the Surgeon General, in order to bolster the available
workforce for both routine and emergency public health missions.
$17.5 million for each of FY2010 through FY2014 ($5 million for
recruitment and training, $12.5 million for the Ready Reserve Corps).
Workforce Diversity, Health Disparities, Cultural Competency: Existing Programs
5307(a) Amends and
reauthorizes
PHSA Sec. 741
(HRSA)
Cultural competency, prevention, public health, disparities, and
individuals with disability training. Authorizes grants, contracts, or
cooperative agreements under PHSA Title VII (Health Professions
Education) for the development and evaluation of research,
demonstration projects, and model curricula that provide training in
cultural competency, prevention, public health proficiency, reducing
health disparities, and aptitude for working with individuals with
disabilities. The Secretary is required to coordinate this program with
the one authorized under PHSA Sec. 807.
SSAN for each of FY2010 through FY2015.
5307(b) Amends and
reauthorizes
PHSA Sec. 807
(HRSA)
Cultural competency, prevention, public health, disparities, and
individuals with disability training. Authorizes grants, contracts, or
cooperative agreements under PHSA Title VIII (Nursing Workforce
Development) for the development and evaluation of research,
demonstration projects, and model curricula that provide training in
cultural competency, prevention, public health proficiency, reducing
health disparities, and aptitude for working with individuals with
disabilities. The Secretary is required to coordinate this program with
the one authorized under PHSA Sec. 741.
SSAN for each of FY2010 through FY2015.
5401 Amends and
reauthorizes
PHSA Sec. 736
(HRSA)
Centers of excellence (COE). Requires the Secretary to fund COEs
at health professions schools that recruit, enroll and graduate
underrepresented minorities or that recruit underrepresented
minorities serving in faculty or administrative positions.
$50 million for each of FY2010 through FY2015, and SSAN for each
subsequent fiscal year.
FY2011 funding = $24 million, FY2012 funding = $23 million, FY2013
request = $23 million. [CFDA 93.157]
Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)
CRS-18
ACA
Section
Statutory
Authority
(Agency) Summary of Provision
Authorization of Appropriations
Funding (FY2011-FY2013)
5402 Amends PHSA
Sec. 740 (HRSA)
Authorization of appropriations. Reauthorizes funding for the
following PHSA Title VII workforce diversity programs:
1. Scholarships for disadvantaged students (PHSA Sec. 737) – grants
to health professions schools for awarding scholarships to students from
disadvantaged backgrounds with financial need.
2. Faculty loan repayment program (PHSA Sec. 738) – loan repayment
program for health profession graduates from disadvantaged
backgrounds who serve as faculty at an eligible health professions college
for at least two years.
3. Health careers opportunity program (PHSA Sec. 739) – grants to
health professions schools and other educational institutions to improve
recruitment and academic preparation of students from disadvantaged
backgrounds.
For Sec. 737, $51 million for FY2010, and SSAN for each of FY2011
through FY2014. For Sec. 738, $5 million for each of FY2010 through
FY2014. For Sec. 739, $60 million for FY2010, and SSAN for each of
FY2011 through FY2014.
Sec. 737: FY2011 funding = $49 million, FY2012 funding = $47
million, FY2013 request = $47. [CFDA 93.925]
Sec. 738: FY2011 funding = $1 million, FY2012 funding = $1 million,
FY2013 request = $1 million. [CFDA 93.923]
Sec. 739: FY2011 funding = $22 million, FY2012 funding = $15
million, FY2013 request = $0. [CFDA 93.822]
5403(a) Amends and
reauthorizes
PHSA Sec. 751
(HRSA)
Area Health Education Centers (AHECs). Requires the Secretary
to award grants (with a matching requirement) to medical and nursing
schools of at least $250,000 to (1) plan, develop, and operate AHEC
programs; and (2) to maintain and improve the effectiveness of existing
AHEC programs. AHECs recruit, train, and prepare individuals from
minority populations or from disadvantaged or rural backgrounds to
work in medically underserved areas.
$125 million for each of FY2010 through FY2014; funds may be carried
over for up to three fiscal years.
FY2011 funding = $33 million, FY2012 funding = $27 million, FY2013
request = $0. [CFDA 93.107, 93.824]
Workforce Diversity, Health Disparities, Cultural Competency: New Program
5403(b) New PHSA Sec.
752 (HRSA)
Continuing educational support for health professionals serving
in underserved communities. Requires the Secretary to award
grants to enhance education through distance learning, continuing
education, collaborative conferences, and telehealth, with a focus on
primary care. Eligible grantees include health professions schools,
academic health centers, state or local governments, or other public or
nonprofit entities participating in training activities. [CFDA 93.189]
$5 million for each of FY2010 through FY2014, and SSAN for each
subsequent fiscal year.
Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)
CRS-19
ACA
Section
Statutory
Authority
(Agency) Summary of Provision
Authorization of Appropriations
Funding (FY2011-FY2013)
Mental and Behavioral Health: New Program
5306 Redesignates
PHSA Sec. 756 as
Sec. 757, and
adds a new Sec.
756 (HRSA)
Mental and behavioral health education and training grants.
Authorizes grants for the recruitment and education of students in
social work, interdisciplinary psychology training, and internships or
other field placement programs related to child and adolescent mental
health. Priority for social work grants given to schools of social work
meeting certain criteria such as recruiting from and placing graduates
into areas with a high-need and high-demand population. Priority for
psychology grants given to institutions that focus on the needs of
specified vulnerable groups. Priority for grants to train professional and
paraprofessional child and adolescent mental health workers given to
applicants that can, among other things, assess workforce needs and that
have programs designed to increase the number of child and adolescent
mental health workers serving high-priority populations.
$35 million for the period of FY2010 through FY2013 ($8 million for
training in social work, $12 million for training in graduate psychology,
$10 million for training in professional child and adolescent mental
health, and $5 million for training in paraprofessional child and
adolescent mental health).
FY2012 funding = $10 million from the PPHF, FY2013 request = $5
million in PHS evaluation funds.a [CFDA 93.732]
Note: The existing graduate psychology education program received $3
million in FY2011 and in FY2012; the FY2013 request is for the same
amount.
Policy and Planning: Existing Program
5103 Amends and
reauthorizes
PHSA Sec. 761
(HRSA)
Health care workforce program assessment. Requires the
Secretary to establish a National Center for Health Care Workforce
Analysis, award grants to support state and regional centers for health
workforce analysis, and increase funding for longitudinal evaluations of
specified individuals who have received education, training, or financial
assistance from programs under PHSA Title VII.
For the National Center, $7.5 million for each of FY2010 through
FY2014; for state and regional centers, $4.5 million for each of FY2010
through FY2014; and for longitudinal evaluations, SSAN for FY2010
through FY2014.
FY2011 funding = $3 million, FY2012 funding = $3 million, FY2013
request = $10 million. Note: Includes funding for Sec. 792 (health
professions data) and Sec. 806 (nursing grant program data). FY2013
request is all PHS evaluation funds.a [CFDA 93.300]
Policy and Planning: New Programs
5101 New authority National Health Care Workforce Commission. Establishes a 15-
member commission focused on evaluating and meeting the need for
health care workers in the United States. The commission is required to
conduct studies, produce annual reports beginning in 2011, and make
recommendations on high-priority topics related to the health care
workforce.
SSAN (no years specified).
Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)
CRS-20
ACA
Section
Statutory
Authority
(Agency) Summary of Provision
Authorization of Appropriations
Funding (FY2011-FY2013)
5102 New authority
(HRSA)
State health care workforce development grants. Establishes a
matching grants program for state partnerships to plan and implement
activities leading to coherent and comprehensive health care workforce
development strategies at the state and local levels. Planning grants of up
to $150,000 are for up to one year and require a 15% match.
Implementation grants are for up to two years (with up to one
additional year of funding) and require a 25% match.
For planning grants, $8 million for FY2010, and SSAN for each
subsequent fiscal year. For implementation grants, $150 million for
FY2010, and SSAN for each subsequent fiscal year.
Note: This program received $6 million in FY2010 funds from the PPHF.
[CFDA 93.509]
Sources: Table prepared by the Congressional Research Service based on the text of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended).
FY2011, FY2012 and requested FY2013 funding amounts are taken from HHS FY2013 budget justification documents for Congress, available at http://www.hrsa.gov/about/
budget/index.html.
a. PHSA Sec. 241 authorizes the Secretary to use a portion of the funds appropriated for PHSA programs to evaluate their implementation and effectiveness. Under this
authority a number of HHS agencies and offices are subject to a budget tap, called the PHS Program Evaluation Set-Aside. The tapped evaluation funds are
redistributed and used for evaluation and other specific programs within HHS.
b. The nursing education loan repayment program repays 60% of a registered nurse’s educational loans in return for a two-year commitment to work in a health care
facility with a critical shortage of nurses. Participants may have an additional 25% of their loan repaid in exchange for one more year of service. The nurse scholarship
program offer scholarships to individuals attending nursing school in exchange for at least two years working in a health care facility with a critical shortage of nurses.
Together the two programs, authorized under PHSA Sec. 846, received $94 million in FY2010 and $93 million in FY2011. The authorization of appropriations for Sec.
846 expired at the end of FY2007 and was not reauthorized by ACA.
c. The Department of Defense and Full-Year Continuing Appropriations Act, 2011 (P.L. 112-10, Div. B, Sec. 1828) prohibited the transfer of funds from the Public Health
and Social Services Emergency Fund (PHSSEF) to support the U.S. Public Health Sciences Track. The PHSSEF is an HHS account administered by the Secretary.
Congress has historically used the PHSSEF to provide one-time funding for non-routine activities. Each fiscal year, Congress appropriates amounts to the PHSSEF for
specified purposes. ACA did not authorize or appropriate funds to the PHSSEF.
Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)
CRS-21
Table 3. ACA Discretionary Spending: Prevention and Wellness
ACA
Section
Statutory
Authority
(Agency) Summary of Provision
Authorization of Appropriations
Funding (FY2011-FY2013)
Community-Based Prevention: Existing Programs
3509/3511 New PHSA Secs.
229 (OS), 310A
(CDC), 925
(AHRQ); new
SSA Sec. 713
(HRSA); and new
FFDCA Sec. 1011
(FDA).
Reauthorizes
PHSA Secs.
486(a) (NIH) and
501(f) (SAMHSA).
Offices on Women’s Health. Establishes or reauthorizes offices of
women’s health in OS, CDC, AHRQ, HRSA, FDA, NIH, and SAMHSA.
Grants, agreements, or contracts may be awarded for activities of the
OS office to establish an information center and coordinating
committee. Activities of other offices include recommendations
regarding grant-making through other agency accounts, not direct grantmaking.
For most offices, SSAN for each of FY2010 through FY2014. For NIH
and SAMHSA offices, SSAN (no years specified).
OS Office on Women’s Health: FY2011 funding = $34 million,
FY2012 funding = $34 million, FY2013 request = $29 million.
NIH Office of Research on Women’s Health: FY2011 funding = $42
million, FY2012 funding = $42 million, FY2013 request = $42 million.
4003 Amends PHSA
Sec. 915(a)
(AHRQ). New
PHSA Sec. 399U
(CDC).
Clinical and community preventive services task forces.
Reauthorizes and expands the authority for the U.S. Preventive Services
Task Force (USPSTF) to review and recommend effective clinical
preventive services. Provides explicit statutory authority for the existing
Task Force on Community Preventive Services (TFCPS) to review and
recommend effective community-based interventions.
SSAN for each fiscal year to carry out the activities of the USPSTF and
the TFCPS.
USPSTF: Funding for each of FY2011, FY2012, and the FY2013
request = $11 million (includes $7 million from the PPHF).
4102(b) Amends PHSA
Sec. 317M(c)
(CDC, HRSA)
School-based dental sealant program. Amends the existing schoolbased
dental sealant grant program, which was discretionary, by
requiring the Secretary to award grants to the 50 states and to Indian
tribes for school-based dental sealant programs.
Authority expired at end of FY2005; ACA does not authorize new
funding.
Funding for all CDC’s existing oral health programs under Sec.
317M: FY2011 = $15 million; FY2012 = $15 million, FY2013 request
= $15 million.
4204 Amends PHSA
Sec. 317 and adds
a new subsection
(m) (CDC)
Immunization programs. Provides explicit authority for states to
purchase vaccines at prices negotiated by Secretary. Permanently
reauthorizes state immunization grants. Requires new immunization
demonstration grants.
SSAN for each of FY2010 through FY2014 for demonstration grants;
SSAN (no years specified) for other authorities.
Funding for the Sec. 317 vaccination program: FY2011 = $589
million (includes $100 million from the PPHF), FY2012 = $620
million (includes $190 million from the PPHF), FY2013 request =
$562 million (includes $72 million from the PPHF). [CFDA 93.185,
93.268, 93.533, 93.539]
Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)
CRS-22
ACA
Section
Statutory
Authority
(Agency) Summary of Provision
Authorization of Appropriations
Funding (FY2011-FY2013)
10334 Amends PHSA
Sec. 1707 (OS)
and PHSA Title IV
(NIH)
Offices of Minority Health. Elevates the existing OS Office of
Minority Health and NIH National Center on Minority Health and
Health Disparities (NCMHD); instructs the OS office to award grants
and undertake other activities to improve minority health status; and
gives the new NIH National Institute on Minority Health and Health
Disparities (NIMHD) responsibility for minority health disparities
research and other health disparities research at NIH.
SSAN for each of FY2011 through FY2016 for OS office.
NIMHD: FY2011 funding = $276 million, FY2012 funding = $276
million, FY2013 request = $279 million.
OS Office of Minority Health: FY2011 funding = $56 million,
FY2012 funding = $56 million, FY2013 request = $41 million.
10412 Reauthorizes
PHSA Sec. 312
(HRSA)
Rural access to emergency devices. Reauthorizes a program of
grants to community partnerships for the purchase and distribution of
automatic external defibrillators (AEDs) in rural communities, and to
support AED training for first responders.
$25 million for each of FY2003 through FY2014.
FY2011 funding = $236,000, FY2012 funding = $1 million, FY2013
request = $0. [CFDA 93.259]
Community-Based Prevention: New Programs
4004 New authority Education and outreach regarding prevention. Requires the
Secretary to carry out various specified communications activities
regarding health promotion and disease prevention, for common and
serious chronic health problems. They include establishing, within one
year of enactment, a national media campaign on health promotion and
disease prevention.
SSAN for each fiscal year; no more than $500 million total.
4102(a) New PHSA Secs.
399LL, 399LL-1,
and 399LL-2
(CDC)
Oral health activities. Requires CDC, subject to appropriations, to
fund a five-year national oral health education campaign, and award
grants to community-based providers of dental services for dental caries
disease management programs, among other things.
SSAN (no years specified).
4102(c) Amends PHSA
Sec. 317M by
adding a new
subsection (d)
(CDC)
Oral health infrastructure. Requires the Secretary to enter into
cooperative agreements with states and tribal entities to establish oral
health leadership and programs to improve oral health.
SSAN for FY2010 through FY2014.
4102(d) New authority
(CDC, AHRQ)
Oral health surveillance. Requires the Secretary to expand the
following surveillance systems to include more information on oral
health: Pregnancy Risk Assessment Monitoring System (PRAMS);
National Health and Nutrition Examination Survey (NHANES); National
Oral Health Surveillance System (NOHSS); and Medical Expenditure
Panel Survey (MEPS).
SSAN (no years specified) for PRAMS; SSAN for each of FY2010
through FY2014 for NOHSS; no explicit authorization of appropriations
for NHANES/MEPS expansion.
Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)
CRS-23
ACA
Section
Statutory
Authority
(Agency) Summary of Provision
Authorization of Appropriations
Funding (FY2011-FY2013)
4201 New authority
(CDC)
Community transformation grants. Requires CDC to fund
competitive grants for the implementation, evaluation, and dissemination
of evidence-based community preventive health activities.
SSAN for each of FY2010 through FY2014.
FY2011 funding = $145 million, FY2012 funding = $226 million,
FY2013 request = $146 million; all funds are from the PPHF. [CFDA
93.531]
4202(a) New authority
(CDC)
Community wellness pilot program. Requires CDC to award
grants state and local health departments, and to Indian tribes, for fiveyear
pilot programs to provide community prevention interventions,
screenings, and clinical referrals for individuals between 55 and 64 years
of age.
SSAN for each of FY2010 through FY2014.
4206 Amends PHSA
Sec. 330 by
adding a new
subsection (s)
Individualized wellness plan demonstration program. Requires
the Secretary to establish a pilot program in not more than 10
community health centers to test the impact of providing at-risk
individuals who use the centers with individualized wellness plans.
SSAN (no years specified).
4304 New PHSA Sec.
2821 (CDC)
Epidemiology and laboratory capacity grants. Codifies existing
grant programs to strengthen national epidemiology, laboratory, and
information management capacity for the response to infectious diseases
and other conditions of public health importance.
$190 million for each of FY2010 through FY2013 (at least $95 million
for epidemiology, $60 million for information management, and $32
million for laboratories).
Funding for Epidemiology and Laboratory Capacity (ELC) and
Emerging Infections Program (EIP): FY2011 = $49 million (includes
$40 million from the PPHF), FY2012 = $53 million (includes $40
million from the PPHF), FY2013 request = $53 million (includes $40
million from the PPHF.
10407 New authority
(CDC)
Diabetes activities. Requires CDC to conduct several diabetes
prevention activities including state assessments, vital statistics, physician
education, and funding of an Institute of Medicine (IOM) report.
SSAN (no years specified).
10411 New PHSA Secs.
399V-2 (CDC)
and 425 (NIH)
Congenital heart disease programs. Authorizes CDC to establish a
National Congenital Heart Disease Surveillance System (NCHDSS), or
to award one grant to establish such a system. Authorizes NIH to
expand and coordinate research on congenital heart disease.
SSAN for each of FY2011 through FY2015 for both the surveillance
system and the expanded research program.
FY2012 funding = $2million, FY2013 request amount not specified.
10413 New PHSA Sec.
399NN (OS,
CDC)
Young women’s breast health awareness. Among other things,
requires CDC to conduct an education campaign and award grants for a
media campaign regarding breast health in young women, and to conduct
prevention research; requires the Secretary to award grants to provide
education and assistance to young women diagnosed with breast disease.
$9 million for each of FY2010 through FY2014.
FY2011 funding = $5 million, FY2012 funding = $5 million, FY2013
request = $5 million.
Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)
CRS-24
ACA
Section
Statutory
Authority
(Agency) Summary of Provision
Authorization of Appropriations
Funding (FY2011-FY2013)
10501(g) New PHSA Sec.
399V-3 (CDC)
National diabetes prevention program. Among other things,
requires the Secretary to award grants for community-based diabetes
prevention program model sites.
SSAN for each of FY2010 through FY2014.
FY2011 funding = $10 million, FY2012 funding = $10 million (all
PPHF), FY2013 request = $10 million (all PPHF).
Workplace Wellness: New Program
10408 New authority
(CDC)
Small business wellness program. Requires the Secretary to award
grants to employers to provide their employees with access to
comprehensive workplace wellness programs. Eligible employers are
those with fewer than 100 employees, who work at least 25 hours per
week.
$200 million for the period of FY2011 through FY2015, to remain
available until expended.
FY2011 funding = $10 million, FY2012 funding = $10 million, FY2013
request = $4 million; all funds are from the PPHF.
Sources: Table prepared by the Congressional Research Service based on the text of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended).
FY2011, FY2012 and requested FY2013 funding amounts are taken from HHS FY2013 budget justification documents for Congress, available at http://www.hrsa.gov/about/
budget/index.html.
Table 4. ACA Discretionary Spending: Maternal and Child Health
ACA
Section
Statutory
Authority
(Agency) Summary of Provision
Authorization of Appropriations
Funding (FY2011-FY2013)
2952(b) New SSA Sec.
512 (HRSA)
Services to individuals with a postpartum condition. Authorizes
grants to establish, operate and coordinate effective and cost-efficient
systems for the delivery of essential services to individuals with, or at
risk of, postpartum depression and their families. Eligible grantees
include public or nonprofit private entities, state or local government
public-private partnerships, recipients of Healthy Start grants, public or
nonprofit private hospitals, community-based organizations, hospices,
ambulatory care facilities, community health centers, and primary care
centers.
$3 million for FY2010, and SSAN for each of FY2011 and FY2012.
Source: Table prepared by the Congressional Research Service based on the text of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended).
Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)
CRS-25
Table 5. ACA Discretionary Spending: Health Care Quality
ACA
Section
Statutory
Authority
(Agency) Summary of Provision
Authorization of Appropriations
Funding (FY2011-FY2013)
Quality Measure Development, Analysis, and Public Reporting: New Programs
3013(a)&(c) New PHSA 931
(AHRQ)
Quality measure development. Requires the Secretary, in
consultation with AHRQ and CMS, to (1) identify gaps where no quality
measures exist or where existing measures need improvement, updating
or expansion consistent with the National Strategy for Quality
Improvement; and (2) fund or enter into agreements with eligible
entities that have demonstrated expertise in measure development to
develop, improve, update or expand quality measures in areas identified
as gap areas.
$75 million for each of FY2010 through FY2014, to remain available until
expended. At least 50% of the amounts appropriated must be used
pursuant to SSA Sec. 1890A(e), as added by ACA Sec. 3013(b). See
below.
3013(b) Amends new SSA
Sec. 1890A, as
added by ACA
Sec. 3014(b), by
adding a new
subsection (e)
(CMS)
Quality and efficiency measures development. Requires CMS, in
consultation with AHRQ, through contracts, to develop quality and
efficiency measures as determined appropriate for use under the SSA.
See ACA Sec. 3013(a)&(c) above.
3015 New PHSA Sec.
399II
Collection and analysis of data for quality and resource use
measures. Requires the Secretary to establish and implement an
overall strategic framework to carry out the public reporting of
performance information. Requires the Secretary to collect and
aggregate consistent data on quality and resource use measures, and
authorizes the Secretary to award grants or contracts for this purpose.
Authorizes the Secretary to award grants or contracts to multistakeholder
entities to support new, or improve existing, efforts to
collect and aggregate quality and resource use measures.
SSAN for each of FY2010 through FY2014.
3015 New PHSA Sec.
399JJ
Public reporting of performance information. Requires the
Secretary to make available to the public, through standardized websites,
performance information summarizing data on quality measures. The
information must include clinical conditions to the extent such data is
available and, where appropriate, be provider-specific and sufficiently
disaggregated and specific to meet the needs of patients with different
clinical conditions.
SSAN for each of FY2010 through FY2014.
Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)
CRS-26
ACA
Section
Statutory
Authority
(Agency) Summary of Provision
Authorization of Appropriations
Funding (FY2011-FY2013)
Quality Improvement Research, Training, and Implementation: New Programs
3501 New PHSA Sec.
933 (AHRQ)
Health care delivery system research. Requires AHRQ to (1)
identify, develop, evaluate, and disseminate innovative strategies for
quality improvement practices in the delivery of health care services that
represent best practice; (2) support research on health care delivery
improvement and facilitate adoption of best practices; and (3) make the
research findings available to the public; among other specified functions.
$20 million for FY2010 through FY2014.
3501/3511 New PHSA Sec.
934 (AHRQ)
Quality improvement technical assistance and implementation.
Requires AHRQ to award grants (with a matching requirement) to
eligible entities for providing technical support to health care providers
in order to help them understand, adapt, and implement the models and
practices identified by the research conducted by the agency. Grantees
must have demonstrated expertise in providing information and
technical support and assistance to health care providers regarding
quality improvement.
SSAN (no years specified).
3508/3511 New authority Quality and patient safety training. Authorizes the Secretary to
award demonstration grants (with a matching requirement) to eligible
health professions schools or consortia to develop and implement
academic curricula that integrate quality improvement and patient safety
into clinical education of health professionals.
SSAN (no years specified).
Health Care Coordination: Existing Program
3510 Amends and
reauthorizes
PHSA Sec. 340A
(HRSA)
Patient navigator program. Prohibits the Secretary from awarding a
grant to an entity under this section unless the entity provides
assurances that patient navigators recruited, assigned, trained, or
employed using these grant funds meet certain minimum core
proficiencies. Eligible grantees include public or nonprofit private health
centers (including an FQHCs), IHS facilities, hospitals, cancer centers,
rural health clinics, academic health centers, and nonprofit entities that
partner or coordinate referrals with such a facility to provide patient
navigator services.
$3.5 million for FY2010, and SSAN for each of FY2011 through FY2015.
FY2011 funding = $5 million, FY2012 funding = $0, FY2013 request
= $0. [CFDA 93.191]
Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)
CRS-27
ACA
Section
Statutory
Authority
(Agency) Summary of Provision
Authorization of Appropriations
Funding (FY2011-FY2013)
Health Care Coordination: New Programs
3502/3511 New authority Community health team grants to support medical homes.
Requires the Secretary to award grants to or enter into contracts with
states, state-designated entities, and tribal organizations to support
community-based interdisciplinary, interprofessional health teams in
assisting primary care practices. Funding must be used to establish the
health teams and to provide capitated payments to the providers.
SSAN (no years specified).
3503/3511 New PHSA Sec.
935 (AHRQ)
Medication therapy management (MTM) grants. Requires the
Secretary, not later than May 1, 2010, to provide grants to support
MTM services provided by licensed pharmacists that are targeted at
patients who take four or more prescribed medications, take high-risk
medications, have two or more chronic diseases, or have undergone a
transition of care or other factors that are likely to create a high risk for
medication-related problems.
SSAN (no years specified).
3506 New PHSA Sec.
936 (AHRQ)
Program to facilitate shared decision making. Requires the
Secretary, through a contract, to develop and identify standards for
patient decision aids, to review patient decision aids, and develop a
certification process for determining whether patient decision aids meet
those standards. The contract is to be awarded to the entity that holds
the contract under SSA Sec. 1890 (currently the National Quality
Forum). Further requires the Secretary to (1) award grants or contracts
to develop, update, and produce patient decision aids, to test such
materials to ensure they are balanced and evidence-based, and to
educate providers on their use; and (2) to award grants for establishing
Shared Decision Making Resource Centers to develop and disseminate
best practices to speed adoption and effective use of patient decision
aids and shared decision making. Also requires the Secretary to award
grants to providers for the development and implementation of shared
decision-making techniques.
SSAN for FY2010 and each subsequent fiscal year.
Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)
CRS-28
ACA
Section
Statutory
Authority
(Agency) Summary of Provision
Authorization of Appropriations
Funding (FY2011-FY2013)
5405 New PHSA Sec.
399V-1 (AHRQ)
Primary care extension program. Requires the Secretary to
establish a Primary Care Extension Program to award state planning and
implementation grants for Primary Care Extension Program State Hubs,
consisting of the state health department and other specified entities.
State hubs must contract with and provide grant funds to county and
local entities to serve as Primary Care Extension Agencies that assist
primary care providers in implementing patient-centered medical homes
and develop and support primary care learning communities, among
other functions.
$120 million for each of FY2011 and FY2012, and SSAN for each of
FY2013 and FY2014.
5604 New PHSA Sec.
520K (SAMHSA)
Co-locating primary and specialty care in community-based
mental health settings. Requires the Secretary to fund
demonstration projects for providing coordinated and integrated
services to individuals with mental illness and co-occurring chronic
diseases through the co-location of primary and specialty care services in
community-based mental and behavioral health settings.
$50 million for FY2010, and SSAN for each of FY2011 through FY2014.
Note: SAMHSA’s Primary & Behavioral Health Care Integration (PBHCI)
program, authorized under PHSA Sec. 520A, predates ACA and has
received the following amounts: FY2011 funding = $63 million (includes
$35 million from the PPHF), FY2012 = $68 (includes $35 million from
the PPHF), FY2013 request = $28 million (all PPHF).
10333 New PHSA Sec.
340H
Community-based collaborative care network program.
Authorizes the Secretary to award grants to support community-based
collaborative care networks (CCN). An eligible CCN is a consortium of
health care providers with a joint governance structure that provides
comprehensive coordinated and integrated health care services (as
defined by the Secretary) for low-income populations. CCNs must
include a safety net hospital and all FQHCs in the community, as
specified.
SSAN for each of FY2011 through FY2015.
10410 New PHSA Sec.
520B (SAMHSA)
Centers of excellence for depression. Requires SAMHSA to award
five-year grants (with a matching requirement) on a competitive basis to
eligible institutions of higher education or research institutions to
establish national centers of excellence for depression. One grantee is to
be designated as the coordinating center and required to establish and
maintain a national database. Centers of excellence may receive a grant
of up to $5 million; the coordinating center may receive a grant of up to
$10 million.
$100 million for each of FY2011 through FY2015, and $150 million for
each of FY2016 through FY2020.
Sources: Table prepared by the Congressional Research Service based on the text of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended).
FY2011, FY2012 and requested FY2013 funding amounts are taken from HHS FY2013 budget justification documents for Congress, available at http://www.hrsa.gov/about/
budget/index.html.
Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)
CRS-29
Table 6. ACA Discretionary Spending: Nursing Homes
ACA
Section
Statutory
Authority
(Agency) Summary of Provision
Authorization of Appropriations
Funding (FY2011-FY2013)
6112 New authority National independent monitor demonstration program.
Requires the Secretary, within one year of enactment, to implement a
two-year demonstration to develop, test, and implement an independent
monitoring program to oversee interstate and large intrastate chains of
skilled nursing facilities (SNFs) and nursing facilities (NFs).
SSAN (no years specified); a monitored chain must contribute a portion
of costs of the demonstration, as determined by the Secretary.
6114 New authority Culture change and information technology demonstration
programs. Requires the Secretary, within one year of enactment, to
award one or more competitive grants to support each of the following
two three-year demonstration projects for SNFs and NFs: (1) develop
best practices for culture change (i.e., patient-centric models of care);
and (2) develop best practices for the use of health information
technology.
SSAN (no years specified).
Source: Table prepared by the Congressional Research Service based on the text of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended).
Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)
CRS-30
Table 7. ACA Discretionary Spending: Health Disparities Data Collection
ACA
Section
Statutory
Authority
(Agency) Summary of Provision
Authorization of Appropriations
Funding (FY2011-FY2013)
4302(a) New PHSA Title
XXXI; new Sec.
3101
Health disparities data collection and analysis. Not later than two
years after enactment, requires federally conducted and supported
health programs and surveys, to the extent practicable, to collect and
report data on race, ethnicity, sex, primary language, and disability
status, as well as other demographic data on health disparities as
deemed appropriate by the Secretary. Requires the Secretary to adopt
standards for the measurement and collection of such data. Requires the
Secretary to analyze the data collected on health disparities; provide for
the public reporting and dissemination of the data and analyses; and
safeguard the privacy of the information. [Note: On October 31, 2011,
HHS published final standards for collecting and reporting health
disparities data. See http://minorityhealth.hhs.gov/templates/
browse.aspx?lvl=2&lvlid=208.]
SSAN for each of FY2010 through FY2014; however, data may not be
collected unless funds are directly appropriated for such purpose.
5605 New authority Key national indicators. Establishes a Commission on Key National
Indicators composed of eight members appointed by Congress. [Note:
The Commission members were appointed in Dec. 2010. See
http://www.stateoftheusa.org/content/commission-on-key-nationalind.
php.] Requires the commission to contract with the National
Academy of Sciences to review available public and private sector
research on key national indicator set selection and determine how best
to establish a key national indicator system, among other things.
Mandates a Government Accountability Office (GAO) study of previous
efforts by public, private, or foreign entities to develop best practices for
a key national indicator system. [Note: GAO released its study in March
2011. See http://www.gao.gov/new.items/d11396.pdf.]
$10 million for FY2010, and $7.5 million for each of FY2011 through
FY2018, with amounts appropriated to remain available until expended.
Source: Table prepared by the Congressional Research Service based on the text of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended).
Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)
CRS-31
Table 8. ACA Discretionary Spending: Emergency Care and Trauma Services
ACA
Section
Statutory
Authority
(Agency) Summary of Provision
Authorization of Appropriations
Funding (FY2011-FY2013)
Emergency Care and Trauma Services: Existing Programs
3505(a) Amends and
reauthorizes
PHSA Secs. 1241-
1245 (HRSA)
Trauma care centers. Requires the Secretary to establish separate
grant programs for IHS and tribal trauma care centers to (1) help defray
substantial uncompensated care costs, (2) further the core missions of
trauma care centers, and (3) provide emergency relief to ensure the
continued availability of trauma services.
$100 million for FY2009, and SSAN for each of FY2010 through FY2015.
5603 Amends and
reauthorizes
PHSA Sec. 1910
(HRSA)
Children’s emergency medical services demonstration grants.
Expands emergency services for children who need treatment for
trauma or critical care by lengthening the period for demonstration
grants to four years (with an optional fifth year).
$25 million for FY2010, $26.3 million for FY2011, $27.6 million for
FY2012, $28.9 million for FY2013, and $30.4 million for FY2014.
FY2011 funding = $21 million, FY2012 funding = $21 million, FY2013
request = $21 million. [CFDA 93.127]
Emergency Care and Trauma Services: New Programs
3504(a) New PHSA Sec.
1204 (OS)
Regional systems for emergency care. Requires the Assistant
Secretary for Preparedness and Response to award at least four multiyear
contracts or grants (with matching requirement) to states and
Indian tribes for pilot projects to improve regional coordination of
emergency services. Priority given to entities that serve a medically
underserved population.
$24 million for each of FY2010 through FY2014.
Note: This provision reauthorized funding for several existing trauma
care grant programs in PHSA Title XII Parts A and B (i.e., Secs. 1202,
1203, and 1211-1222), as well as for the new program (i.e., Sec. 1204).
3504(b) New PHSA Sec.
498D (NIH,
AHRQ, HRSA,
CDC)
Emergency medicine research. Requires the Secretary to expand
and accelerate basic, translational, and service delivery research on
emergency medical care systems and emergency medicine, including
pediatric emergency medical care. Also requires the Secretary to
support research on the economic impact of coordinated emergency
care systems.
SSAN for each of FY2010 through FY2014.
3505(b) New PHSA Secs.
1281-1282
Trauma service availability grants. Requires the Secretary to award
grants to states for the purpose of supporting trauma-related physician
specialties and broadening access to and availability of trauma care
services. States must use at least 40% of the funds for grants to safety
net trauma centers.
$100 million for each of FY2010 through FY2015.
Sources: Table prepared by the Congressional Research Service based on the text of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended).
FY2011, FY2012 and requested FY2013 funding amounts are taken from HRSA’s FY2013 budget justification document for Congress, available at http://www.hrsa.gov/
about/budget/index.html.
Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)
CRS-32
Table 9. ACA Discretionary Spending: Elder Justice
ACA
Section
Statutory
Authority
(Agency) Summary of Provision
Authorization of Appropriations
Funding (FY2011-FY2013)
6703(a) New SSA Sec.
2021 (OS)
Elder Justice Coordinating Council. Establishes an Elder Justice
Coordinating Council to include the Secretary as chair and the U.S.
Attorney General, as well as the head of each federal department or
agency, identified by the chair, as having administrative responsibility or
administering programs related to elder abuse, neglect, and exploitation.
SSAN (no years specified). See also new SSA Sec. 2024 below.
6703(a) New SSA Sec.
2022
Advisory Board on Elder Abuse, Neglect, and Exploitation.
Establishes an advisory board to create a short- and long-term
multidisciplinary plan for development of the field of elder justice and to
make recommendations to the Elder Justice Coordinating Council.
SSAN (no years specified). See also new SSA Sec. 2024 below.
6703(a) New SSA Sec.
2024
Authorization of appropriations. Authorizes funding for new SSA
Secs. 2021 (Coordinating Council), 2022 (Advisory Board), and 2023
(human subject protection guidelines for researchers).
$6.5 million for FY2011, and $7.0 million for each of FY2012 through
FY2014.
6703(a) New SSA Sec.
2031
Forensic centers and expertise. Requires the Secretary to award
grants to eligible entities to establish and operate stationary and mobile
forensic centers and to develop forensic expertise pertaining to elder
abuse, neglect, and exploitation.
$4 million for FY2011, $6 million for FY2012, and $8 million for each of
FY2013 and FY2014.
6703(a) New SSA Sec.
2041(a)
Incentives for LTC staffing. Requires the Secretary to award grants
to LTC facilities for them to offer continuing training and varying levels
of certification to employees providing direct care to residents, and to
improve management practices so as to promote retention of direct
care workers.
For new SSA Sec. 2041: $20 million for FY2011, $17.5 million for
FY2012, and $15 million for each of FY2013 and FY2014.
6703(a) New SSA Sec.
2041(b)
Certified EHR technology grant program. Authorizes grants to
LTC facilities for specified activities that would assist such entities in
offsetting costs related to purchasing, leasing, developing, and
implementing certified electronic health record technology.
See above authorization of appropriations for SSA Sec. 2041.
6703(a) New SSA Sec.
2041(c)
Standards for transactions involving clinical data by LTC
facilities. Requires the Secretary to adopt electronic standards for the
exchange of clinical data by LTC facilities and, within 10 years, to have in
place procedures to accept the optional electronic submission of clinical
data by LTC facilities pursuant to such standards.
See above authorization of appropriations for SSA Sec. 2041.
6703(a) New SSA Sec.
2042(a)
Adult protective service functions. Requires the Secretary to
undertake various activities with respect to adult protective services,
including providing funding, collecting and disseminating data on elder
abuse, disseminating information on best practices and training,
conducting research, and providing technical assistance to states and
other entities.
$3 million for FY2011, and $4 million for each of FY2012 through
FY2014.
Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)
CRS-33
ACA
Section
Statutory
Authority
(Agency) Summary of Provision
Authorization of Appropriations
Funding (FY2011-FY2013)
6703(a) New SSA Sec.
2042(b)
Grants to enhance provision of adult protective services.
Requires the Secretary to award formula grants to states to enhance
adult protective services programs provided by states and local
governments.
$100 million for each of FY2011 through FY2014.
6703(a) New SSA Sec.
2042(c)
Adult protective services demonstration grants. Requires the
Secretary to fund state demonstration programs for adult protective
services that test methods to prevent and detect elder abuse.
$25 million for each of FY2011 through FY2014.
6703(a) New SSA Sec.
2043(a)
Long-term care ombudsman program grants. Requires the
Secretary to award grants to improve the capacity of state LTC
ombudsman programs to address abuse and neglect complaints, conduct
pilot programs, and provide support for such programs.
$5 million for FY2011, $7.5 million for FY2012, and $10 million for each
of FY2013 and FY2014.
6703(a) New SSA Sec.
2043(b)
Ombudsman training programs. Requires the Secretary to establish
programs to provide and improve ombudsman training with respect to
elder abuse, neglect, and exploitation for national organizations and state
LTC ombudsman programs.
$10 million for each of FY2011 through FY2014.
6703(b) New authority National Training Institute for Surveyors. Requires that the
Secretary enter into a contract with an entity to establish and operate a
National Training Institute for Federal and State Surveyors to provide
and improve training of surveyors investigating allegations of abuse in
programs and LTC facilities that receive payments under Medicare or
Medicaid.
$12 million for the period of FY2011 through FY2014.
6703(b) New authority Grants to state survey agencies. Requires the Secretary to award
grants to state survey agencies that perform surveys of Medicare or
Medicaid participating nursing facilities to design and implement
complaint investigation systems.
$5 million for each of FY2011 through FY2014.
6703(c) New authority National nurse aide registry study and report. Requires the
Secretary, in consultation with appropriate government agencies and
private sector organizations, to conduct a study on establishing a
national nurse aide registry and report on its findings.
SSAN (no years specified) to carry out these activities, with funding not
to exceed $500,000.
Source: Table prepared by the Congressional Research Service based on the text of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended).
Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)
CRS-34
Table 10. ACA Discretionary Spending: Biomedical Research
ACA
Section
Statutory
Authority
(Agency) Summary of Provision
Authorization of Appropriations
Funding (FY2011-FY2013)
10409 Amends PHSA
Secs. 402(b) and
499(c); new
PHSA Sec. 402C
(NIH)
Cures Acceleration Network (CAN). Establishes a CAN program
within the Office of the NIH Director to award grants, contracts, or
cooperative agreements to support the development of treatments for
diseases or conditions that are rare, and for which market incentives are
inadequate. Eligible grantees include public or private entity, which may
include a private or public research institution, an institution of higher
education, a medical center, a biotechnology company, a pharmaceutical
company, a disease advocacy organization, a patient advocacy
organization, or an academic research institution.
$500 million for FY2010, and SSAN for subsequent fiscal years. Other
funds appropriated under the PHSA may not be allocated to CAN.
FY2012 funding = $10 million, FY2013 request = $50 million.
Source: Table prepared by the Congressional Research Service based on the text of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended).
Table 11. ACA Discretionary Spending: Biologics
ACA
Section
Statutory
Authority
(Agency) Summary of Provision
Authorization of Appropriations
Funding (FY2011-FY2013)
7002 Amends PHSA
Sec. 351 (FDA)
FDA approval of follow-on biologics. Creates an abbreviated
regulatory pathway for approving biological products that are
demonstrated to be biosimilar to, or interchangeable with, an FDAlicensed
biological product. Provides for the collection of user fees,
subject to congressional authorization, to cover regulatory costs
beginning in FY2013. [Note: On February 9, 2012, FDA released three
guidance documents to assist industry in developing biosimilar products
and submitting them to the agency for approval. See http://www.fda.gov/
Drugs/DevelopmentApprovalProcess/
HowDrugsareDevelopedandApproved/ApprovalApplications/
TherapeuticBiologicApplications/Biosimilars/default.htm.]
SSAN for each of FY2010 through FY2012.
Source: Table prepared by the Congressional Research Service based on the text of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended).
Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)
CRS-35
Table 12. ACA Discretionary Spending: 340B Drug Pricing
ACA
Section
Statutory
Authority
(Agency) Summary of Provision
Authorization of Appropriations
Funding (FY2011-FY2013)
7102 Amends PHSA
Sec. 340B(d)
(HRSA)
Improvements to 340B program integrity. Requires the Secretary
to develop systems to improve compliance and program integrity to (1)
increase transparency and strengthen monitoring, oversight, and
investigation of the prices that manufacturers charge covered entities;
and (2) ensure covered entities do not divert drugs or obtain multiple
discounts. Further requires the Secretary to establish a new
administrative dispute resolution process to mediate and resolve
covered entity overpayment claims and manufacturer claims against
covered entities for drug diversion or multiple discounts.
SSAN for FY2010 and each succeeding fiscal year.
FY2011 funding = $4 million, FY2012 funding = $4 million, FY2013
request = $6 million (proposed new user fee program).
Sources: Table prepared by the Congressional Research Service based on the text of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended).
FY2011, FY2012 and requested FY2013 funding amounts are taken from HRSA’s FY2013 budget justification document for Congress, available at http://www.hrsa.gov/
about/budget/index.html.
Table 13. ACA Discretionary Spending: Medical Malpractice
ACA
Section
Statutory
Authority
(Agent) Summary of Provision
Authorization of Appropriations
Funding (FY2011-FY2013)
10607 New PHSA Sec.
399V-4 (HRSA)
Liability reform demonstration program. Authorizes five-year
demonstration grants to states for the implementation and evaluation of
alternatives to current tort litigation for resolving disputes over injuries
allegedly caused by health care providers or organizations. Planning
grants of up to $500,000 may be awarded to states for the development
of demonstration project applications. To receive a grant, a state must
develop an alternative system that allows for the resolution of disputes
caused by health care providers or organizations, and reduces medical
errors by encouraging the collection and analysis of patient safety data
related to the resolved disputes.
$50 million for the period FY2011 through FY2015.
Source: Table prepared by the Congressional Research Service based on the text of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended).
Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)
CRS-36
Table 14. ACA Discretionary Spending: Pain Care Management
ACA
Section
Statutory
Authority
(Agency) Summary of Provision
Authorization of Appropriations
Funding (FY2011-FY2013)
4305(a) New authority Conference on pain. Requires the Secretary, within one year of
appropriating funds, to contract with the IOM to convene a Conference
on Pain for the purpose of assessing the public health impact of pain,
reviewing pain research, care, and education, and identifying barriers to
improved pain care. A report summarizing the Conference’s findings
must be submitted to Congress by June 30, 2011. [Note: IOM released
its report on June 29, 2011. See http://painconsortium.nih.gov/.]
SSAN for each of FY2010 and FY2011.
Source: Table prepared by the Congressional Research Service based on the text of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended).
Table 15. ACA Discretionary Spending: Medicaid
ACA
Section
Statutory
Authority
(Agency) Summary of Provision
Authorization of Appropriations
Funding (FY2011-FY2013)
2705 New authority
(CMS)
Global payment system demonstration program. Requires the
Secretary, in coordination with the Center for Medicare and Medicaid
Innovation, to fund up to five Medicaid demonstrations during the
period FY2010 through FY2012 under which a participating state will
adjust payments made to a large safety net hospital system or network
from a fee-for-service model to a global capitated payment model.
SSAN (no years specified).
2706 New authority
(CMS)
Pediatric accountable care organization demonstration
program. Requires the Secretary to conduct a five-year Medicaid
demonstration (Jan. 1, 2012 through Dec. 31, 2016) under which a
participating state is allowed to recognize pediatric providers as an
accountable care organization (ACO) for the purpose of receiving
incentive payments. Eligible pediatric providers must meet certain
performance guidelines established by the Secretary to be recognized as
an ACO, and must achieve a specified minimum level of Medicaid savings
to receive an incentive payment.
SSAN (no years specified).
Source: Table prepared by the Congressional Research Service based on the text of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended).
Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)
CRS-37
Table 16. ACA Discretionary Spending: Medicare
ACA
Section
Statutory
Authority
(Agency) Summary of Provision
Authorization of Appropriations
Funding (FY2011-FY2013)
3129 Amends and
reauthorizes SSA
Sec. 1820 (HRSA)
Rural hospital flexibility grant program. Extends authorization of
appropriations for the rural hospital flexibility (Flex) grants that support
a range of performance and quality improvement activities at small rural
hospitals. Permits the funding to be used to help rural hospitals
participate in delivery system reform programs authorized under ACA.
SSAN for each of FY2011 and FY2012, to remain available until
expended.
FY2011 funding = $41 million, FY2012 funding = $41 million, FY2013
request = $26 million. [CFDA 93.241]
Sources: Table prepared by the Congressional Research Service based on the text of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended).
FY2011, FY2012 and requested FY2013 funding amounts are taken from HRSA’s FY2013 budget justification document for Congress, available at http://www.hrsa.gov/
about/budget/index.html.
Table 17. ACA Discretionary Spending: Private Health Insurance
ACA
Section
Statutory
Authority
(Agency) Summary of Provision
Authorization of Appropriations
Funding (FY2011-FY2013)
1334 New authority
(OPM)
Multi-state health plans. Requires OPM to contract with health
insurers to offer at least two multi-state health plans (at least one
nonprofit) through exchanges in each state. Authorizes OPM to prohibit
multi-state plans that do not meet standards for medical loss ratios,
profit margins, and premiums. Requires multi-state plans to cover
essential health benefits and meet all the requirements of a qualified
health plan.
SSAN (no years specified).
Note: On December 5, 2012, OPM published a proposed rule to
implement the multi-state plan program (77 Federal Register 72582).
Source: Table prepared by the Congressional Research Service based on the text of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended).
Discretionary Spending in the Patient Protection and Affordable Care Act (ACA)
Congressional Research Service 38

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