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From Health Law Daily, April 9, 2014

Congressional actions affecting the ACA summarized, federal spending impacted

By Harold M. Bishop, JD

The Congressional Research Service (CRS) has issued a report summarizing legislative actions that have been taken to repeal, defund, delay, or otherwise amend the Patient Protection and Affordable Care Act (PPACA) (P.L. 111-148) and the Health Care and Education Reconciliation Act (HCERA) (P.L. 111-152), collectively the Affordable Care Act (ACA), since their enactment. The CRS report also describes the impact of ACA implementation on federal spending.

Legislative actions. To date, 12 bills containing provisions to amend the ACA have actually attracted sufficient bipartisan support to have been approved in both the House and the Senate and signed into law. These 12 bills have resulted in 18 amendments to ACA provisions. Some lawmakers, however, have used the annual appropriations process in an effort to eliminate funding for the ACA and address other concerns they have with the law.

The CRS report contains three tables which summarize these legislative actions. The tables summarize:

  • authorizing legislation to amend the ACA that has been approved by both chambers and enacted into law (Table A-1 in Appendix A);

  • ACA provisions in authorizing legislation that passed the House in the 112th Congress (2011-2012) but were not approved by the Senate, and the ACA-related legislation that the House has passed to date in the 113th Congress (2013-2014), but which has not been taken up by the Senate (Table B-1 in Appendix B); and

  • ACA-related provisions in enacted annual appropriations acts for each of FY 2011 through FY 2014, and a brief overview of all the ACA-related provisions added to appropriations bills considered, and in most cases reported, by the House and Senate Appropriations Committees since FY 2011 (Table C-1 in Appendix C).

Federal spending. CRS groups federal spending on ACA implementation into the following categories: (1) mandatory spending to expand insurance coverage through the Exchanges and Medicaid, (2) mandatory spending provided in the ACA for other programs and activities, and (3) discretionary spending on new grant programs authorized by the ACA and on administration and enforcement of the law.

Mandatory spending to expand insurance coverage. This category, according to CRS, accounts for most of the federal spending under the ACA. It includes the Exchange subsidies (i.e., premium tax credits and cost-sharing subsidies), the federal government’s share of the costs of Medicaid expansion, and tax credits for small employers. CRS reports that the

Congressional Budget Office estimates that this mandatory spending will be fully offset by revenues from new taxes and fees established in the law, and by savings from the law’s changes slowing the growth of Medicare payments.

Mandatory spending for other programs and activities. The ACA includes numerous appropriations that provide billions of dollars of mandatory funding to support grant programs and other activities authorized by the law. According to the CRS report, the ACA also created: (1) the Community Health Center Fund, which provides $11 billion from FY 2011- FY 2015 to help support community health center operations and the National Health Service Corps.; (2) the Patient-Centered Outcomes Research Trust Fund, which supports comparative effectiveness research through FY 2019 with a mix of appropriations, fees on health plans, and transfers from the Medicare trust funds; (3) the Prevention and Public Health Fund (PPHF), for which the ACA provided a permanent annual appropriation, and is intended to support prevention, wellness, and other public health-related programs and activities; and (4) the Health Insurance Reform Implementation Fund (HIFIF), for which the ACA appropriated $1 billion, and that helps cover the administrative costs of implementing the law.

Discretionary spending. CRS reports that the ACA is affecting discretionary spending in two ways: (1) through the creation of numerous new discretionary grant programs and providing each of them with an authorization of appropriations; and (2) by CMS and the Internal Revenue Service (IRS) incurring significant costs in connection with administration and enforcement of the law.

According to CRS, CMS will spend an estimated $3.391 billion on the operation of the Federally Facilitated Exchanges (FFEs) and providing technical assistance to state run exchanges by the end of FY 2014. Of that total, $2.435 billion is discretionary funding, including transfers from other HHS accounts ($223 million) and expired discretionary funds from the HIRIF ($303 million), the PPHF ($454 million), as well as FFE user fees ($200 million). For FY 2015, CRS reports that CMS has budgeted $1.8 billion for Exchange operations, with $1.2 billion of that funding projected to come from FFE user fees.

CRS reports that the IRS, which is responsible for administering and enforcing the ACA’s tax provisions, including the premium tax credit, has also requested additional discretionary funding for ACA implementation. However, as with CMS, Congress has not appropriated any additional discretionary funds.

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