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CRS Examines Efforts to Block ACA Through Appropriations Process

JUL. 8, 2015

R44100

DATED JUL. 8, 2015
DOCUMENT ATTRIBUTES
Citations: R44100

 

C. Stephen Redhead

 

Specialist in Health Policy

 

 

Ada S. Cornell

 

Information Research Specialist

 

 

July 8, 2015

 

 

Congressional Research Service

 

 

7-5700

 

www.crs.gov

 

 

R44100

 

 

Summary

Congress remains deeply divided over implementation of the Patient Protection and Affordable Care Act (ACA), the health reform law enacted in March 2010. Since the ACA's enactment, lawmakers opposed to specific provisions in the ACA or the entire law have repeatedly debated its implementation and considered bills to repeal, defund, delay, or otherwise amend the law.

In addition to considering ACA repeal or amendment in authorizing legislation, some lawmakers have used the annual appropriations process in an effort to eliminate funding for the ACA's implementation and address other aspects of the law. ACA-related provisions have been included in enacted appropriations acts each year since the ACA became law. In October 2013, disagreement between the Republican-led House and Democratic-controlled Senate over the inclusion of ACA language in a temporary spending bill for the new fiscal year (i.e., FY2014) resulted in a partial shutdown of government operations that lasted 16 days.

The House Appropriations Committee has added numerous ACA -- related provisions to annual appropriations acts since the Republicans regained control of the House in 2011. Most of these provisions were included in the Departments of Labor, Health and Human Services, Education, and Related Agencies ("Labor-HHS-ED") Appropriations Act, which funds the Centers for Medicare & Medicaid Services (CMS). A few were incorporated in the Financial Services and General Government ("Financial Services") Appropriations Act, which funds the Internal Revenue Service (IRS). By comparison, the Labor-HHS-ED and Financial Services appropriations bills drafted by the Senate Appropriations Committee were largely free of any ACA-related provisions while the committee remained under Democratic control through 2014.

Congressional appropriators have used a number of legislative options available to them through the appropriations process in an effort to defund, delay, or otherwise address implementation of the ACA. First, they have denied CMS and the IRS any new funding to cover the administrative costs of ACA implementation. Second, House appropriators repeatedly have added limitations (often referred to as riders) to the Labor-HHS-ED and Financial Services appropriations bills to prohibit CMS and the IRS from using discretionary funds provided in the bills for ACA implementation activities. To date, the ACA limitation provisions added by House appropriators have been removed during negotiations with the Senate. None of them have been included in any of the enacted appropriations acts.

Third, House appropriators have incorporated ACA-related legislative language in the Labor-HHS-ED appropriations bills. For example, appropriators have included language to rescind (i.e., cancel) certain mandatory funding provided by the ACA.

Finally, congressional appropriators have added to recent Labor-HHS-ED appropriations acts several reporting and other administrative requirements regarding implementation of the ACA. These include instructing the HHS Secretary to establish a website with information on the allocation of funding from the Prevention and Public Health Fund and to provide an accounting of administrative spending on ACA implementation.

                            Contents

 

 

 Introduction

 

 Brief Overview of the ACA

 

 ACA's Impact on Federal Spending

 

 

      Mandatory Spending on Expanding Insurance Coverage

 

      Mandatory Spending on Other Programs

 

      Discretionary Spending

 

 

 ACA Provisions in Enacted Appropriations Acts

 

 Government Shutdown

 

 ACA Provisions in FY2016 Appropriations Legislation

 

 

 Tables

 

 

 Table 1. ACA-Related Provisions in Appropriations Acts, FY2011-FY2016

 

 

 Contacts

 

 

 Author Contact Information

 

 

Introduction

Congress remains deeply divided over implementation of the Patient Protection and Affordable Care Act (ACA), the health reform law enacted in March 2010.1 Since the ACA's enactment, lawmakers opposed to specific provisions in the ACA or the entire law have repeatedly debated its implementation and considered bills to repeal, defund, delay, or otherwise amend the law.

To date, most of this legislative activity has taken place in the House, which reverted to Republican control in 2011. Over the past four years, the Republican-led House has passed numerous ACA-related bills, including legislation that would repeal the entire law. There has been far less debate in the Senate, which remained under Democratic control through 2014. Most of the ACA legislation that passed the House during this period was not considered in the Senate. However, a few bills to amend specific elements of the ACA that attracted sufficiently broad and bipartisan support were approved by both the House and the Senate and signed into law. Now that Republicans control both chambers of Congress, opponents of the ACA see new opportunities to pass and send to the President legislation that would change the law.

In addition to considering ACA repeal or amendment in authorizing legislation, some lawmakers have used the annual appropriations process in an effort to eliminate funding for the ACA's implementation and address other concerns they have with the law. ACA-related provisions have been included in enacted appropriations acts each year since the ACA became law. In October 2013, disagreement between the House and Senate over the inclusion of ACA language in a temporary spending bill for the new fiscal year (i.e., FY2014) resulted in a partial shutdown of government operations that lasted 16 days.

This report summarizes the ACA-related language added to annual appropriations legislation by congressional appropriators since the ACA was signed into law. The information is presented in Table 1. While a detailed examination of the ACA itself is beyond the scope of this report, a brief overview of the ACA's core provisions and its impact on federal spending is provided as context for the material in the table.2 This report will be updated to reflect key developments in the annual appropriations process.

A companion report, CRS Report R43289, Legislative Actions to Repeal, Defund, or Delay the Affordable Care Act, summarizes the authorizing legislation to amend the ACA that has been enacted since 2010. It also reviews all the ACA legislation taken up and passed by the House during this period.

A Brief Overview of the ACA

The ACA made significant changes to the way U.S. health care is financed, organized, and delivered. Its primary goal is to increase access to affordable health care for the medically uninsured and underinsured. To that end, the law included a complex set of interconnected provisions that address the private health insurance market.

First, the ACA requires health insurers to comply with a set of federal standards ("market reforms") to ensure that individuals may purchase, keep, and renew coverage that provides a minimum level of benefits and consumer protections, with some limits on costs. Second, the law establishes competitive private health insurance exchanges (also known as marketplaces) through which individuals and small employers are able to compare and enroll in qualified health plans.

Exchanges operate in every state and the District of Columbia. They are administered by states or by the federal government, or through a partnership between the state and federal governments. Qualified individuals who enroll in exchange plans may receive financial assistance if they meet income and certain other requirements. Refundable tax credits are available to individuals and families with incomes between 100% and 400% of the federal poverty level (FPL) to help pay the insurance premium. The premium tax credits are available upon enrollment so that eligible individuals and families can choose to receive the subsidy immediately rather than wait until they file taxes the following year. In addition, certain individuals and families receiving the tax credit may be eligible for cost-sharing subsidies to reduce their out-of-pocket costs (e.g., deductibles, copays) when receiving health services. Small employers with fewer than 25 full-time equivalent employees (FTEs) may also use the exchanges to purchase insurance coverage for their employees and may qualify for a tax credit to help cover the cost of providing that coverage.

In June 2015, the U.S. Supreme Court in King v. Burwell ruled that the premium tax credits are available to all qualified individuals who enroll in exchange plans and meet the necessary income and other requirements, regardless of whether the exchange is administered by the state or the federal government.3

Third, the ACA's "individual mandate" requires most U.S. citizens and legal residents to obtain coverage. Those who remain uninsured may have to pay a penalty unless they qualify for an exemption. The individual mandate is intended to encourage healthy individuals to participate in the insurance market and not wait until they get sick to buy coverage. Finally, the law requires larger employers with 50 or more FTEs to offer health coverage that meets affordability and adequacy standards for their full-time employees and those workers' dependents. Employers who do not comply with these requirements may be subject to a tax if one or more of their employees purchase coverage through an exchange and receive a subsidy. The purpose of the ACA's employer requirements is to encourage larger firms to maintain affordable and adequate coverage for their employees.

The ACA coupled its private insurance provisions with the requirement that states expand their Medicaid programs to cover all nonelderly individuals with incomes up to 138% FPL. Those with higher incomes, up to 400% FPL, may be eligible to get subsidized coverage through an exchange. In June 2012, the U.S. Supreme Court in NFIB v. Sebelius found the Medicaid expansion to be unconstitutionally coercive and prohibited the federal government from enforcing it.4 The Court's decision made Medicaid expansion optional for states.

In addition to expanding access to insurance coverage, the ACA contains hundreds of other provisions that address health care access, costs, and quality. They include new programs to test alternative ways of delivering and paying for health care. The law also includes new taxes and fees as well as adjustments to Medicare payments to hospitals and other health care providers. These provisions are designed to offset the federal spending on exchange subsidies and Medicaid expansion.

ACA's Impact on Federal Spending

Implementation of the ACA is affecting both mandatory and discretionary spending. Mandatory spending -- also referred to as direct spending -- is controlled through authorizing laws.5 It includes spending on entitlement programs such as Medicare and Social Security. Authorizing laws may provide permanent or temporary appropriations or other forms of budget authority for such spending. When the authorizing law contains no appropriations, mandatory programs may be funded through the annual appropriations process. This is sometimes referred to as "appropriated mandatory" or "appropriated entitlement" spending.6Discretionary spending is both controlled and funded through the annual appropriations process. It typically covers the routine costs of running federal agencies and offices, including wages and salaries.7

Federal spending on ACA implementation can be grouped into three categories: (1) mandatory spending on expanding insurance coverage, (2) mandatory spending on other programs, and (3) discretionary spending. Each of these categories is briefly discussed below.

Mandatory Spending on Expanding Insurance Coverage

This category 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. The Congressional Budget Office (CBO) and the Joint Committee on Taxation (JCT) projected that this and other ACA mandatory spending (discussed in the second category, below) would be more than offset by (1) revenues from the ACA's new taxes and fees, and (2) savings from the law's adjustments to Medicare provider payments that are projected to slow the rate of growth of Medicare spending.8

Mandatory Spending on Other Programs

The ACA authorized new Medicare and Medicaid spending. For example, it phased out the Medicare prescription drug benefit "donut hole" through a combination of subsidies and manufacturer discounts, and it increased Medicare payments for primary care services and medical education. The ACA also included numerous appropriations that are providing billions of dollars of mandatory funding to support grant programs and other activities authorized by the law.9 For example, the law funded temporary insurance programs for targeted groups prior to the exchanges becoming operational, and it provided funding for grants to states to plan and establish health insurance exchanges. The ACA included a permanent appropriation, available for 10-year periods, for the Center for Medicare & Medicaid Innovation (CMMI), within the Centers for Medicare & Medicaid Services (CMS), to test and implement innovative health care payment and service delivery models.

In addition, the ACA created four special funds and appropriated amounts to each one. First, the Community Health Center Fund (CHCF) has provided almost $11 billion over five years (FY2011-FY2015) for the federal health centers program and the National Health Service Corps.10 Second, the Patient-Centered Outcomes Research Trust Fund (PCORTF) is supporting patient-centered comparative clinical effectiveness research through FY2019 with a mix of appropriations, fees on health plans, and transfers from the Medicare trust funds. Third, the Prevention and Public Health Fund (PPHF), for which the ACA provided a permanent annual appropriation, is supporting prevention, wellness, and other public health-related programs and activities. Finally, the Health Insurance Reform Implementation Fund (HIRIF), for which the ACA appropriated $1 billion, helped pay for the initial administrative costs of implementing the law.

Discretionary Spending

The ACA is affecting discretionary spending in two ways. First, the law created numerous new discretionary grant programs and provided each of them with an authorization of appropriations. To date, however, few of these programs have received discretionary funding through annual appropriations acts, though several of them have been supported with mandatory funds from the PPHF.11 Second, the two agencies primarily responsible for implementing the ACA's provisions to expand insurance coverage -- CMS's Center for Consumer Information and Insurance Oversight (CCIIO) and the Internal Revenue Service (IRS) -- are incurring significant costs in connection with administering and enforcing the law. Both agencies requested increases in funding in each of their past four budget submissions (i.e., FY2013-FY2016) to help pay for ACA implementation. But congressional appropriators have not provided either agency with any additional discretionary funds. CMS instead has relied on discretionary fund transfers from other accounts, amounts from the Non-recurring Expenses Fund (NEF),12 and ACA mandatory funds (i.e., HIRIF, PPHF) to support its ACA implementation activities. CMS also has transferred HIRIF funds to the IRS.

ACA Provisions in Enacted Appropriations Acts

The House Appropriations Committee has added numerous ACA -- related provisions to annual appropriations acts since the Republicans regained control of the House in 2011. Most of these provisions were included in the Departments of Labor, Health and Human Services, Education, and Related Agencies ("Labor-HHS-ED") Appropriations Act, which funds CMS. A few were incorporated in the Financial Services and General Government ("Financial Services") Appropriations Act, which funds the IRS. By comparison, the Labor-HHS-ED and Financial Services appropriations bills drafted by the Senate Appropriations Committee, which was under Democratic control over the past four years, were largely free of any ACA-related provisions with one key exception. Each year, the Senate Labor-HHS-ED appropriations bill included instructions on the allocation of PPHF funding.

Congressional appropriators have used a number of legislative options available to them through the appropriations process in an effort to defund, delay, or otherwise address implementation of the ACA. First, they have denied CMS and the IRS any new funding to cover the administrative costs of ACA implementation. CMS requested substantial increases in funding for its Program Management account in the FY2013, FY2014, and FY2015 budgets. These new funds were to help support operation of the federally facilitated exchanges and other ACA-related activities. Congress, however, did not provide any additional discretionary funds for CMS in the enacted Labor-HHS-ED appropriations acts for FY2013-FY2015. Similarly, the IRS requested additional discretionary funds for each of those three years to support administration and enforcement of the ACA's tax provisions, including the premium tax credits and the individual mandate penalties. Again, congressional appropriators did not give the IRS the extra funds it requested.13 Both agencies have asked for additional ACA funding in the FY2016 budget.

Second, House appropriators repeatedly have added limitations (often referred to as riders) to the Labor-HHS-ED and Financial Services appropriations bills. Limitation provisions within appropriations measures are provisions that restrict the use of discretionary funds provided by the bill. They do this either by capping the amount of funding that may be used for a particular purpose or by prohibiting the use of any funds for a specific purpose. For example, appropriators on multiple occasions added language prohibiting an agency from using any of the discretionary funds in its appropriations bill for ACA implementation activities. Limitation provisions also may be used to restrict the availability of funds for transfer.14 To date, the ACA limitation provisions added by House appropriators have been removed during negotiations with the Senate. None of them have been incorporated into the final appropriations legislation agreed to by both chambers and signed into law.

Third, House appropriators have incorporated ACA-related legislative language in the Labor-HHS-ED appropriations bills. Unlike limitations, legislative provisions have the effect of making new law or changing existing law.15 As an example, appropriators included language to rescind (i.e., cancel) certain mandatory funding provided by the ACA. House rules prohibit legislative provisions in appropriations acts, while the rules of the Senate allow exceptions under some circumstances. However, special rules in the House (approved by the Rules Committee) and unanimous consent agreements in the Senate can be used to set aside each chamber's rules, including those that relate to legislating in appropriations measures.

Finally, congressional appropriators have added to recent Labor-HHS-ED appropriations acts several reporting and other administrative requirements regarding implementation of the ACA. These include instructing the HHS Secretary to establish a website with information on the allocation of PPHF funds and to provide an accounting of administrative spending on ACA implementation.

Table 1 summarizes the ACA-related legislative and other provisions that were incorporated in the enacted Labor-HHS-ED and Financial Services appropriations acts for each of FY2011-FY2015. For each fiscal year, the table also provides a brief overview of any legislative action taken by the House and Senate Appropriations Committees on their respective versions of the two appropriations bills prior to the two chambers reaching agreement on the final version of the legislation. This discussion lists all the ACA language added to the bills by the committees. As already noted, none of the ACA limitations added by the House appropriators were included in the enacted Labor-HHS-ED and Financial Services appropriations acts.

Government Shutdown

Disagreement between the Republican-controlled House and the Democrat-led Senate on whether to include ACA provisions in the FY2014 continuing resolution (CR) shut down programs and activities across the federal government in October 2013. Congress took up consideration of the FY2014 CR to ensure continued funding for the government at the start of the new fiscal year (i.e., October 1) after lawmakers failed to complete legislative action on any of the FY2014 annual appropriations acts. The House tried three times to attach provisions to the CR to defund or delay ACA implementation. Each time the Senate rejected the House language. With no agreement in place at the start of FY2014, the resulting lapse in discretionary funding led to a partial shutdown of government operations.

Lawmakers finally reached agreement on legislative language on October 16, and the President signed the Continuing Appropriations Act, 2014, the following day to reopen the government.16 The measure funded the federal government through January 15, 2014, and did not include any provisions to defund or delay ACA implementation. Instead, it required the HHS Secretary to certify to Congress that the ACA health insurance exchanges were verifying the eligibility of individuals applying for subsidies to help cover the cost of purchasing insurance coverage. In January 2014, Congress completed action on the FY2014 appropriations process by approving the Consolidated Appropriations Act, 2014, which included all 12 annual appropriations acts for FY2014.17

ACA Provisions in FY2016 Appropriations

Legislation

With Republicans now in control of both chambers, House and Senate appropriators may find it easier to coordinate their efforts to include ACA-related provisions in appropriations bills. The two appropriations committees have reported their respective FY2016 Labor-HHS-ED appropriations bills, and both measures include multiple ACA limitations, legislative provisions, and reporting requirements. The bills incorporate most of the ACA language that was in the enacted FY2015 Labor-HHS-ED appropriations act. They also include other ACA funding rescissions, as well as limitation provisions that would prohibit using any of the funds provided by the bill for ACA implementation.

ACA opponents face challenges in getting these provisions enacted into law. Senate Republicans may need to persuade a handful of Democrats to join them to get to the 60 votes needed to debate and pass appropriations bills if the Democrats decide to filibuster the legislation. Moreover, an appropriations bill that contains limitations or other language intended to defund or otherwise impede ACA implementation is likely to be vetoed by the President. In that case, each chamber would require a two-thirds vote to override the veto.

Another option for ACA opponents would be to use the threat of a government shutdown at the beginning of the new fiscal year as leverage to try and get ACA limitations and other legislative provisions included in appropriations measures. However, that option appears less likely in the 114th Congress. Republican leaders in both chambers have made it clear that they will not support another shutdown, like the one that occurred in 2013, suggesting that lawmakers on both sides of the issue may have to find areas of compromise.18

Table 1 summarizes the legislative action taken to date by House and Senate appropriators on the FY2016 Labor-HHS-ED and Financial Services appropriations bills and lists all the ACA language added to the bills.

    Table 1. ACA-Related Provisions in Appropriations Acts, FY2011-FY2016

 

 ______________________________________________________________________________

 

 

 Public Law and Date of                       Summary of Provisions

 

 Enactment

 

 ______________________________________________________________________________

 

 

                                FY2011

 

 ______________________________________________________________________________

 

 

 P.L. 112-10            Department of Defense and Full-Year

 

 Apr. 15, 2011                 Continuing Appropriations Act,

 

                               2011. Division B, Title VIII of P.L. 112-10

 

                               provided full-year continuing appropriations for

 

                               Labor-HHS-ED for FY2011 generally at FY2010

 

                               levels, but with numerous spending reductions

 

                               for specified agencies and programs.

 

                               It included the following ACA-related provisions:

 

 

                               o Permanently canceled $2.2 billion of the $6

 

                                 billion appropriation for Consumer Operated

 

                                 and Oriented Plan (CO-OP) program, which was

 

                                 established and funded by ACA Section 1322.

 

 

                               o Repealed the free choice voucher program,

 

                                 established by ACA Section 10108, which would

 

                                 have required certain employers to provide

 

                                 vouchers to qualified employees for

 

                                 purchasing coverage through a health

 

                                 insurance exchange.

 

 

                               o Prohibited transfers from the Public Health

 

                                 and Social Services Emergency Fund to support

 

                                 the U.S. Public Health Sciences Track,

 

                                 pursuant to ACA Section 5315.

 

 

                               o Removed the maintenance of effort requirement

 

                                 for use of monies in the Community Health

 

                                 Center Fund (CHCF), which was established and

 

                                 funded by ACA Section 10503 (as amended by

 

                                 HCERA Section 2303).

 

 

                               o Mandated a Government Accountability Office

 

                                 (GAO) study of the costs and processes of ACA

 

                                 implementation, and a Medicare actuarial

 

                                 analysis of the impact of the ACA's private

 

                                 insurance reforms on employer-sponsored

 

                                 health insurance premiums.

 

 

                          Note: After it passed the Department of Defense and

 

                          Full-Year Continuing Appropriations Act, 2011 (H.R.

 

                          1473) on April 14, 2011, the House approved an

 

                          accompanying concurrent resolution (H.Con.Res. 35).

 

                          The resolution instructed the House clerk, during

 

                          enrollment of the bill, to insert a provision that

 

                          would have prohibited using any of the funds provided

 

                          by H.R. 1473 or any previous Act to implement the

 

                          ACA. The Senate rejected H.Con.Res. 35.

 

 ______________________________________________________________________________

 

 

 Legislative activity prior to enactment of P.L. 112-10. The Senate

 

 Appropriations Committee reported its version of the FY2011 Labor-HHS-ED

 

 appropriations bill (S. 3686) on August 2, 2010. The measure would have

 

 instructed the HHS Secretary to allocate the Prevention and Public Health Fund

 

 (PPHF) funds for FY2011 to the accounts specified, in the amounts specified,

 

 and for the activities specified in a table included in the accompanying

 

 committee report (S.Rept. 111-243). The House Appropriations Subcommittee on

 

 Labor-HHS-ED also approved a draft (unnumbered) FY2011 bill, but the full

 

 committee took no further action on it.

 

 

 On February 19, 2011, the House by a vote of 235-189 passed its version of a

 

 full-year continuing resolution for FY2011 (H.R. 1). The bill included nine

 

 separate but overlapping provisions that would have prohibited using any of

 

 the discretionary funds provided in the bill to implement specific ACA

 

 provisions or the entire law. The Senate subsequently rejected H.R. 1 by a

 

 vote of 44-56 on March 9, 2011.

 

 ______________________________________________________________________________

 

 

                                FY2012

 

 ______________________________________________________________________________

 

 

 P.L. 112-74            Consolidated Appropriations Act, 2012.

 

 Dec. 23, 2011                 Division F of P.L. 112-74 -- the FY2012 Labor-

 

                               HHS-ED Appropriations Act -- included the

 

                               following ACA-related provisions:

 

 

                               o Rescinded $400 million of the remaining $3.8

 

                                 billion for the CO-OP program; see P.L. 112-

 

                                 10, above.

 

 

                               o Rescinded $10 million of the FY2012

 

                                 appropriation for the Independent Payment

 

                                 Advisory Board (IPAB), which was authorized

 

                                 and funded by ACA Section 3403.

 

 

                               o Required the HHS Secretary to establish a

 

                                 website with detailed information on the

 

                                 allocation and use of PPHF funds.

 

 

                               o Prohibited the use of PPHF funds for lobbying,

 

                                 publicity, or propaganda purposes.

 

 ______________________________________________________________________

 

 

 Legislative activity prior to enactment of P.L. 112-74. The chairman of

 

 the House Appropriations Subcommittee on Labor-HHS-Education introduced a

 

 chairman's bill (H.R. 3070) on September 29, 2011, but the subcommittee did

 

 not mark up or report the measure to the full committee. The bill received no

 

 full committee action. H.R. 3070, as introduced, would have (1) rescinded the

 

 entire FY2012 appropriations for Community Health Center Fund (CHCF), PPHF,

 

 IPAB, the pregnancy assistance grants, the home visitation program, state

 

 Aging and Disability Resource Centers (ADRCs), and the health workforce

 

 demonstration grants; (2) rescinded all the remaining CO-OP funds (i.e., $3.8

 

 billion); (3) rescinded $1.862 billion of the $10 billion appropriation for

 

 the Center for Medicare and Medicaid Innovation (CMMI) for the period FY2011-

 

 FY2019; and (4) prohibited using any of the discretionary funds provided in

 

 the bill to implement and administer the ACA until 90 days after all ACA legal

 

 challenges are complete.

 

 

 The House Appropriations Committee reported the FY2012 Financial Services

 

 appropriations bill (H.R. 2434, H.Rept. 112-136) on July 7, 2011. The would

 

 have (1) prohibited the IRS from using any of the discretionary funds provided

 

 in the bill to implement the ACA individual mandate; and (2) prohibited the

 

 transfer of any ACA funds to the IRS.

 

 

 The Senate Appropriations Committee reported its version of the FY2012 Labor-

 

 HHS-ED appropriations bill (S. 1599) on September 22, 2011. Similar to the

 

 previous year's bill, S. 1599 would have instructed the HHS Secretary to

 

 allocate the PPHF funds for FY2012 to the accounts specified, in the amounts

 

 specified, and for the activities specified in a table included in the

 

 accompanying committee report (S.Rept. 112-84). In addition, S.Rept. 112-84

 

 included language directing the HHS Secretary to submit a detailed report on

 

 all the recipients of PPHF funding.

 

 

 The Senate Appropriations Committee reported its FY2012 Financial Services

 

 appropriations bill (S. 1573) on September 15, 2011. The measure did not

 

 include any ACA provisions. However, the accompanying committee report

 

 (S.Rept. 112-79) directed the IRS to submit a detailed table itemizing each

 

 fund transfer from HHS to the IRS for the purpose of ACA implementation.

 

 ______________________________________________________________________________

 

 

                                FY2013

 

 ______________________________________________________________________________

 

 

 P.L. 113-6                    Consolidated and Further Continuing

 

 Mar. 26, 2013                 Appropriations Act, 2013.

 

                               Division F, Title V of P.L. 113-6 provided full-

 

                               year continuing appropriations for Labor-HHS-ED

 

                               for FY2013 generally at FY2012 levels, but with

 

                               some spending adjustments -- reductions and

 

                               increases -- for specified programs. It included

 

                               the following ACA-related provisions: o

 

                               Rescinded $200 million of the $500 million

 

                               transfer from the Medicare Part A and Part B

 

                               trust funds for the 5-year Community-Based Care

 

                               Transition Program, which was established and

 

                               funded by ACA Section 3026.

 

 

                               o Rescinded $10 million of IPAB's FY2013

 

                                 appropriation. [Note: A similar rescission was

 

                                 included in the FY2012 appropriations act; see

 

                                 above.]

 

 

                               o Required the HHS Secretary to establish a

 

                                 website with detailed information on the

 

                                 allocation and use of PPHF funds. [Note: This

 

                                 provision first appeared in the FY2012

 

                                 appropriations act and remained in effect in

 

                                 FY2013 under P.L. 113-6; see above.]

 

 

                               o Prohibited the use of PPHF funds for lobbying,

 

                                 publicity, or propaganda purposes. [Note: This

 

                                 provision first appeared in the FY2012

 

                                 appropriations act and remained in effect in

 

                                 FY2013 under P.L. 113-6; see above.]

 

 _____________________________________________________________________________

 

 

 Legislative activity prior to enactment of P.L. 113-6. The House

 

 Appropriations Subcommittee on Labor-HHS-ED approved an unnumbered draft bill

 

 for FY2013 on July 18, 2012, but no further action was taken. The measure did

 

 not provide CMS with any of the requested $1.0 billion increase in funding for

 

 FY2013 to help pay for ACA implementation and related activities, and it would

 

 have prohibited using any of the discretionary funding provided in the bill to

 

 support CMS's Center for Consumer Information and Insurance Oversight (CCIIO).

 

 The draft bill also would have (1) rescinded the entire FY2013 appropriations

 

 for PPHF and IPAB, and rescinded the FY2013 base appropriation of $150 million

 

 for the Patient-Centered Outcomes Research Trust Fund (PCORTF); (2) rescinded

 

 $3 billion of the remaining $3.4 billion for the CO-OP funds (see P.L. 112-74,

 

 above); (3) rescinded $1.590 billion of the $10 billion appropriation for CMI

 

 for the period FY2011-FY2019; (4) rescinded $300 million of the $1.5 billion

 

 CHCF appropriation in FY2013 for community health centers; (5) prohibited

 

 using any of the discretionary funds provided in the bill to implement and

 

 administer the ACA; (6) instructed the HHS Secretary to establish a website

 

 with detailed information on the allocation and use of FY2013 PPHF funds; and

 

 (7) prohibited the use of PPHF funds for lobbying, publicity, or propaganda

 

 purposes.

 

 

 The House Appropriations Committee reported its FY2013 Financial Services

 

 appropriations bill (H.R. 6020, H.Rept. 112-550) on June 26, 2012. The measure

 

 did not include the IRS's requested funding increase of $360 million for

 

 FY2013 for ACA implementation. Moreover, H.R. 6020 would have prohibited the

 

 IRS from using any of the discretionary funds provided in the bill to carry

 

 out the transfer of ACA funds to the agency.

 

 

 The Senate Appropriations Committee reported its version of the FY2013 Labor-

 

 HHS-ED appropriations bill (S. 3295) on June 14, 2012. The measure included

 

 about half of the funding increase requested by CMS for ACA implementation. As

 

 with the Senate's Labor-HHS-ED appropriations bills for the previous two

 

 fiscal years, S. 3295 would have instructed the HHS Secretary to allocate the

 

 PPHF funds for FY2013 to the accounts specified, in the amounts specified, and

 

 for the activities specified in a table included in the accompanying committee

 

 report (S.Rept. 112-176). In addition, the bill would have directed the HHS

 

 Secretary to establish a website with detailed information on the allocation

 

 and use of PPHF funds.

 

 

 The Senate Appropriations Committee reported the FY2013 Financial Services

 

 appropriations bill (S. 3301) on June 14, 2012. The measure did not include

 

 any ACA-related provisions. However, the accompanying committee report

 

 (S.Rept. 112-177) directed the IRS to submit a detailed table itemizing each

 

 fund transfer from the Health Insurance Reform Implementation Fund (HIRIF) to

 

 the IRS for the purpose of ACA implementation.

 

 ______________________________________________________________________________

 

 

                                FY2014

 

 ______________________________________________________________________________

 

 

 P.L. 113-76            Consolidated Appropriations Act, 2014.

 

 Jan. 17, 2014                 Division Jan. 17, 2014  H of P.L. 113-76 -- the

 

                               FY2014 L-HHS-ED Appropriations Act -- included

 

                               the following ACA related provisions:

 

 

                               o Rescinded $10 million of IPAB's FY2014

 

                                 appropriation. [Note: A similar rescission was

 

                                 included in both the FY2012 and FY2013

 

                                 appropriations acts; see above.]

 

 

                               o Required the HHS Secretary to transfer the

 

                                 FY2014 PPHF funds to the accounts specified,

 

                                 in the amounts specified, and for the

 

                                 activities specified in a table included in

 

                                 the explanatory statement to accompany P.L.

 

                                 113-76 (Congressional Record, January 15,

 

                                 2014, p. H1041). Prohibited the Secretary from

 

                                 making further transfers. [Note: The

 

                                 requirement to transfer PPHF funds in

 

                                 accordance with the allocations specified by

 

                                 the committee was included in each of the

 

                                 FY2011, FY2012, and FY2013 L-HHS-ED

 

                                 appropriations bills reported by the Senate

 

                                 Appropriations Committee, but the provision

 

                                 was not included in the final enacted

 

                                 appropriations legislation for those years;

 

                                 see above.]

 

 

                               o Required the HHS Secretary to establish a

 

                                 website with detailed information on the

 

                                 allocation and use of PPHF funds, organized by

 

                                 program or by state. [Note: A similar, but

 

                                 less detailed, provision was included in the

 

                                 FY2012 appropriations act and remained in

 

                                 effect in FY2013 under P.L. 113-6; see above.]

 

 

                               o Prohibited the use of PPHF funds for lobbying,

 

                                 publicity, or propaganda purposes. [Note: This

 

                                 provision first appeared in the FY2012

 

                                 appropriations act and remained in effect in

 

                                 FY2013 under P.L. 113-6; see above.]

 

 

                               o Authorized the HHS Secretary to transfer up to

 

                                 $305 million from the Medicare trust funds to

 

                                 the CMS Program Management account for

 

                                 Medicare operations, but prohibited the use of

 

                                 such transferred funds for ACA implementation.

 

 

                               o Required the HHS Secretary to include in the

 

                                 FY2015 budget justification and on the HHS

 

                                 website a detailed breakdown of the ACA

 

                                 programs and activities receiving funds

 

                                 appropriated to implement the law, including

 

                                 the number of full-time equivalents (FTEs),

 

                                 for FY2014 and for each of the past four

 

                                 fiscal years (i.e., FY2010-FY2013).

 

 

                               o Required the HHS Secretary to include in the

 

                                 FY2015 budget justification a detailed

 

                                 breakdown of all funds used to date by CMS for

 

                                 the exchanges, including the proposed use of

 

                                 such funds in FY2015.

 

 

                               o Required the HHS Secretary to include in the

 

                                 FY2016 budget justification an analysis of how

 

                                 the ACA requirement that health plans cover

 

                                 recommended immunizations and other preventive

 

                                 services without any cost-sharing will impact

 

                                 eligibility for HHS discretionary programs.

 

 

                          Note: The explanatory statement to accompany P.L.

 

                          113-76, submitted by the House Appropriations

 

                          Committee Chairman and published in the January 15,

 

                          2014, Congressional Record, instructed HHS to include

 

                          in the FY2015 budget justification the amount of

 

                          expired unobligated balances available for transfer

 

                          to the Nonrecurring Expenses Fund (NEF), and the

 

                          amount of any such balances transferred to the NEF.

 

                          [Note: Section 4 of P.L. 113-76 stated that the

 

                          explanatory statement was to be treated as if it were

 

                          a joint explanatory statement of the conference

 

                          committee.]

 

 

                          Division E of P.L. 113-76 -- the FY2014 Financial

 

                          Services Appropriations Act -- included the following

 

                          ACA-related provision:

 

 

                               o Required the IRS Commissioner to allocate $92

 

                                 million in general program funds among the

 

                                 agency's appropriations accounts for various

 

                                 specified activities (e.g., improve delivery

 

                                 of services to taxpayers), but prohibited the

 

                                 use of such funds for ACA implementation.

 

 

 P.L. 113-46            Continuing Appropriations Act, 2014.

 

 Oct. 17, 2013                 P.L. 113-46 provided continuing appropriations

 

                               for the federal government through January 15,

 

                               2014, generally at FY2013 post-sequestration

 

                               funding levels. It included the following ACA-

 

                               related provisions:

 

 

                               o Required the HHS Secretary to certify in a

 

                                 report to Congress, due by January 1, 2014,

 

                                 that the health exchanges are verifying the

 

                                 eligibility of individuals applying for

 

                                 premium tax credits and cost-sharing subsidies

 

                                 consistent with the requirements of the ACA.

 

 

                               o Required the HHS Inspector General to report

 

                                 to Congress not later than July 1, 2014, on

 

                                 the effectiveness of procedures and safeguards

 

                                 provided under the ACA for preventing exchange

 

                                 applicants from submitting inaccurate or

 

                                 fraudulent information.

 

 ______________________________________________________________________________

 

 

 Legislative activity prior to enactment of P.L. 113-46. On September

 

 20, 2013, in the absence of any enacted appropriations bills for FY2014, the

 

 House approved a continuing resolution (CR; H.J.Res. 59) to provide temporary

 

 funding for the federal government through December 15. H.J.Res. 59, as passed

 

 by the House, incorporated language that would have prohibited the use of any

 

 federal funds -- mandatory or discretionary -- to carry out the ACA. The

 

 Senate amendment to H.J.Res. 59 did not incorporate the House ACA defunding

 

 language. On September 29, the House amended the Senate amendment with

 

 language that would have (1) repealed the ACA's medical device tax, and (2)

 

 delayed the law's implementation by one year, but the Senate tabled both of

 

 these amendments. On September 30, the House further amended the Senate

 

 amendment by adding language to (1) delay the ACA's individual insurance

 

 mandate by one year; and (2) expand the ACA's requirement for Members of

 

 Congress and their staff to obtain health coverage through the exchanges by

 

 including the President, Vice President, and political appointees, and

 

 prohibit any premium contribution by the government.

 

 Once again, the Senate tabled the House amendments. With the House and Senate

 

 unable to agree on the CR, the Administration on October 1, 2013, commenced a

 

 partial shutdown of the federal government. The government resumed full

 

 operations on October 17, 2013, after House and Senate lawmakers reached an

 

 agreement on a temporary funding measure, and the Continuing Appropriations

 

 Act, 2014, was signed into law (see above).

 

 

 Earlier in the summer of 2013, the House and Senate Appropriations Committees

 

 took the following actions on FY2014 appropriations. The Senate Appropriations

 

 Committee reported its FY2014 Labor-HHS-ED appropriations bill (S. 1284) on

 

 July 11, 2013. For the fourth year in a row, the Senate's L-HHS-ED

 

 appropriations bill would have instructed the HHS Secretary to allocate the

 

 PPHF funds to the accounts specified, in the amounts specified, and for the

 

 activities specified in a table included in the accompanying committee report

 

 (S.Rept. 113-71). S. 1284 also would have prohibited the Secretary from making

 

 any further transfers of PPHF funds. In addition, the bill would have required

 

 the HHS Secretary to establish a website with detailed information on the

 

 allocation and use of PPHF funds. S. 1284 would have provided CMS with its

 

 requested $1.4 billion increase in discretionary funds for ACA implementation

 

 in FY2014.

 

 

 The Senate Appropriations Committee reported its FY2014 Financial Services

 

 appropriations bill (S. 1371, S.Rept. 113-80) on July 25, 2013. S. 1371 would

 

 have provided some but not all of the requested $440 million increase in IRS

 

 funding for ACA implementation.

 

 

 The House Appropriations Committee reported its version of the FY2014

 

 Financial Services appropriations bill (H.R. 2786, H.Rept. 113-172) on July

 

 23, 2013. The measure did not provide any of the new IRS funds requested in

 

 the President's FY2014 budget for ACA implementation. H.R. 2786, as reported,

 

 would have prohibited the IRS from using any of the discretionary funds

 

 provided in the bill to implement the individual mandate, and would have

 

 prohibited transfers from HHS to the IRS to implement the ACA. The House

 

 Appropriations Subcommittee on Labor-HHS-ED did not introduce or report a

 

 FY2014 appropriations bill.

 

 ______________________________________________________________________________

 

 

                                FY2015

 

 ______________________________________________________________________________

 

 

 P.L. 113-235                    Consolidated and Further Continuing

 

 Dec. 16, 2014                   Appropriations Act, 2015.

 

                                 Division G of P.L. 113-235 -- the FY2015 L-

 

                                 HHS-ED Appropriations Act -- includes the

 

                                 following ACA-related provisions:

 

 

                               o Rescinded $10 million of IPAB's FY2015

 

                                 appropriation. [Note: A similar rescission was

 

                                 included in the FY2012, FY2013, and FY2014

 

                                 appropriations acts; see above.]

 

 

                               o Required the HHS Secretary to transfer the

 

                                 FY2015 PPHF funds to the accounts specified,

 

                                 in the amounts specified, and for the

 

                                 activities specified in a table included in

 

                                 the explanatory statement to accompany P.L.

 

                                 113-235 (Congressional Record, December 11,

 

                                 2014, p. H9839). Prohibited the Secretary from

 

                                 making further transfers. [Note: The

 

                                 requirement to transfer PPHF funds in

 

                                 accordance with the allocations specified by

 

                                 the committee has been included in each L-HHS-

 

                                 ED appropriations bill reported by the Senate

 

                                 Appropriations Committee since FY2011;

 

                                 however, the provision did not get included in

 

                                 the final enacted appropriations legislation

 

                                 until FY2014.]

 

 

                               o Required the HHS Secretary to establish a

 

                                 website with detailed information on the

 

                                 allocation and use of PPHF funds, organized by

 

                                 program or by state. [Note: The same provision

 

                                 was included in the FY2014 appropriations act;

 

                                 see above.]

 

 

                               o Prohibited the use of PPHF funds for lobbying,

 

                                 publicity, or propaganda purposes. [Note: The

 

                                 same provision was included in the FY2014

 

                                 appropriations act; see above.]

 

 

                               o Authorized the HHS Secretary to transfer up to

 

                                 $305 million from the Medicare trust funds to

 

                                 the CMS Program Management account for

 

                                 Medicare operations, but prohibited the use of

 

                                 such transferred funds for ACA implementation.

 

                                 [Note: The same provision was included in the

 

                                 FY2014 appropriations act; see above.]

 

 

                               o Required the HHS Secretary to include in the

 

                                 FY2016 budget justification and on the HHS

 

                                 website a detailed breakdown of the ACA

 

                                 programs and activities receiving funds

 

                                 appropriated to implement the law, including

 

                                 the number of full-time equivalents (FTEs),

 

                                 for FY2015 and for each of the past four

 

                                 fiscal years (i.e., FY2011-FY2014). [Note: The

 

                                 same provision was included in the FY2014

 

                                 appropriations act; see above.]

 

 

                               o Required the HHS Secretary to include in the

 

                                 FY2016 budget justification a detailed

 

                                 breakdown of all funds used to date by CMS for

 

                                 the exchanges, including the proposed use of

 

                                 such funds in FY2016. Funding details must be

 

                                 provided for all the activities specified

 

                                 under the heading "Health Insurance

 

                                 Marketplace Transparency" in the explanatory

 

                                 statement to accompany P.L. 113-235

 

                                 (Congressional Record, December 11, 2014, p.

 

                                 H9837). [Note: A less specific provision was

 

                                 included in the FY2014 appropriations act; see

 

                                 above.]

 

 

                               o Prohibited risk corridor payments (authorized

 

                                 by ACA Section 1342) from the CMS Program

 

                                 Management appropriations account.

 

 

                               Note: The explanatory statement to accompany

 

                               P.L. 113-235, submitted by the House

 

                               Appropriations Committee Chairman and published

 

                               in the December 11, 2014, Congressional Record,

 

                               instructed HHS to include in the FY2016 budget

 

                               justification the amount of expired unobligated

 

                               balances available for transfer to the non-

 

                               recurring expenses fund (NEF), and the amount of

 

                               any such balances transferred to the NEF. In

 

                               addition, the explanatory statement instructed

 

                               the HHS Office of the Inspector General to (1)

 

                               submit to Congress, within 60 days of enactment,

 

                               a plan of how it will conduct health reform

 

                               oversight activities; and (2) report to Congress

 

                               (jointly with the Treasury Inspector General),

 

                               no later than June 1, 2015, on the IRS's

 

                               procedures for reconciling premium tax credits

 

                               and reducing fraud and overpayments. [Note:

 

                               Section 4 of P.L. 113-235 stated that the

 

                               explanatory statement is to be treated as if it

 

                               were a joint explanatory statement of the

 

                               conference committee.]

 

 

                               Division E of P.L. 113-235 -- the FY2015

 

                               Financial Services Appropriations Act -- did not

 

                               include any ACA-related provisions. However, the

 

                               explanatory statement to accompany P.L. 113-235

 

                               (discussed above) instructed the IRS to submit

 

                               quarterly reports to Congress during FY2015 on

 

                               actions taken to reconcile advance premium tax

 

                               credit payments received in 2014 when 2014 tax

 

                               returns are filed in 2015, and required the

 

                               Treasury Secretary to provide Congress an

 

                               accounting each month of the number of

 

                               individuals who had not paid the full amount of

 

                               any premium owed for the preceding month for

 

                               health coverage obtained through an exchange.

 

 

                               Division M of P.L. 113-235 -- the Expatriate

 

                               Health Coverage Clarification Act of 2014 --

 

                               exempts expatriate health plans offered to

 

                               individuals working outside the United States

 

                               from certain ACA requirements. Prior to

 

                               enactment of this law, U.S. insurance companies

 

                               offering these plans had to fully comply with

 

                               the ACA, whereas foreign insurance companies did

 

                               not. [Note: The House passed a similar bill,

 

                               H.R. 4414, on April 29, 2014.]

 

 ______________________________________________________________________________

 

 

 Legislative activity prior to enactment of P.L. 113-235. The House

 

 passed the FY2015 Financial Services appropriations bill (H.R. 5016, H.Rept.

 

 113-508) on July 16, 2014. The measure did not include the $436 million

 

 increase in funding requested by the IRS for ACA implementation. Moreover, it

 

 would have (1) prohibited the IRS from using any of the discretionary funds

 

 provided in the bill to implement the individual mandate; (2) prohibited any

 

 transfers from HHS to the IRS for ACA implementation; and (3) required the

 

 Treasury Secretary to provide Congress an accounting each month of the number

 

 of individuals who had not paid the full amount of any premium owed for the

 

 preceding month for health coverage obtained through an exchange. Language in

 

 H.Rept. 113-508 would have directed the IRS to submit monthly status reports

 

 to Congress during FY2015 on actions taken to reconcile advance premium tax

 

 credit payments received in 2014 when 2014 tax returns are filed in 2015.

 

 

 The House Appropriations Subcommittee on Labor-HHS-ED did not introduce or

 

 report a FY2015 appropriations bill.

 

 

 The Senate Appropriations Subcommittee on Labor-HHS-ED approved a draft bill

 

 for FY2015 on June 10, 2014, and released an accompanying draft committee

 

 report, but no further action was taken. The Senate Appropriations

 

 Subcommittee on Financial Services approved a draft bill for FY2015 on June

 

 24, 2014, but no further action was taken.

 

 ______________________________________________________________________________

 

 

 Public Law and Date of Enactment Summary of Provisions FY2016 Legislative

 

 activity to date. The House Appropriations Committee approved its FY2016

 

 Financial Services appropriations bill on June 17, 2015. The measure would

 

 reduce the IRS's discretionary funding by about 8% compared to the FY2015

 

 level. It also would (1) prohibit the IRS from using any of the discretionary

 

 funds provided in the bill to implement the individual mandate, and (2)

 

 prohibit any transfers from HHS to the IRS for ACA implementation.

 

 

 The House Appropriations Committee approved its FY2016 Labor-HHS-ED

 

 appropriations bill on June 24, 2015. The bill would reduce funding for the

 

 CMS Program Management account by about 9% compared to the FY2015 level. It

 

 would continue all but one of the ACA provisions in the enacted FY2015 Labor-

 

 HHS-ED appropriations act (see above) -- the provision authorizing the

 

 transfer of Medicare trust funds to the CMS Program Management Account is not

 

 included. The House committee bill would prohibit the use of any of the

 

 discretionary funds provided in the bill to support (1) patient-centered

 

 outcomes research; (2) exchange navigators; (3) CCIIO; or (4) implementation

 

 of any provision of the ACA. It also would prohibit CMS from collecting and

 

 using exchange user fees. Besides rescinding $15 million of IPAB's FY2016

 

 appropriation (up from the $10 million in FY2015), the bill would rescind (1)

 

 $18 million of the remaining CO-OP funds; (2) $100 million of PCORTF's FY2016

 

 funding; and (3) all unobligated HIRIF funds.

 

 Moreover, the bill would terminate the NEF and rescind all its unobligated

 

 funds. In addition, it would require the HHS Secretary to include in the

 

 FY2017 budget justification an analysis of how the ACA requirement that health

 

 plans cover recommended immunizations and other preventive services without

 

 any cost-sharing will impact eligibility for HHS discretionary programs.

 

 Finally, the House committee bill incorporates the Health Care Conscience

 

 Rights Act (H.R. 940). Among other things, H.R. 940 would amend the ACA so

 

 that individuals/employers would not have to purchase/sponsor coverage of

 

 abortion or other items or services to which they have a moral or religious

 

 objection.

 

 

 The Senate Appropriations Committee reported its FY2016 Labor-HHS-ED

 

 appropriations bill (S. 1695, S.Rept. 114-74) on June 25, 2015. The bill would

 

 reduce funding for the CMS Program Management account by about 17% compared to

 

 the FY2015 level. Like the bill approved by the House Appropriations

 

 Committee, the Senate version would continue all of the ACA provisions in the

 

 enacted FY2015 Labor-HHS-ED appropriations act with the exception of the

 

 provision authorizing the transfer of Medicare trust funds to the CMS Program

 

 Management Account. In addition, the Senate committee bill would (1) rescind

 

 $18 million of the remaining CO-OP funds; (2) prohibit the use of any of CMS's

 

 Program Management funds to support exchange operations; and (3) require the

 

 Secretary to provide the Appropriations Committees with monthly exchange

 

 enrollment figures at least two days before making them publicly available.

 

Author Contact Information

 

 

C. Stephen Redhead

 

Specialist in Health Policy

 

credhead@crs.loc.gov, 7-2261

 

 

Ada S. Cornell

 

Information Research Specialist

 

acornell@crs.loc.gov, 7-3742

 

FOOTNOTES

 

 

1 The ACA was signed into law on March 23, 2010 (P.L. 111-148, 124 Stat. 119). A week later, on March 30, 2010, the President signed the Health Care and Education Reconciliation Act (HCERA; P.L. 111-152, 124 Stat. 1029). HCERA included several new health reform provisions and amended numerous provisions in the ACA. Several subsequently enacted bills made additional changes to selected ACA provisions. All references to the ACA in this report refer collectively to the law and to the changes made by HCERA and subsequent legislation.

2 Numerous CRS products that provide more in-depth information on the many new programs and activities authorized and funded by the ACA are available at http://www.crs.gov/pages/subissue.aspx?cliid=3746&parentid=13&preview=False.

3King v. Burwell, No. 14-114 slip op. (June 25, 2015), http://www.supremecourt.gov/opinions/14pdf/14-114_qol1.pdf.

4NFIB v. Sebelius, No. 11 -393, slip op. (June 28, 2012), http://www.supremecourt.gov/opinions/11pdf/11-393c3a2.pdf. For more information, see CRS Report R42367, Medicaid and Federal Grant Conditions After NFIB v. Sebelius: Constitutional Issues and Analysis, by Kenneth R. Thomas.

5 Authorizing legislation generally refers to substantive legislation, reported by a committee (or committees) of jurisdiction other than the House or Senate Appropriations Committees, that establishes or continues the operation of a federal program or agency either indefinitely or for a specific period.

6 For further information on direct spending, see CRS Report RS20129, Entitlements and Appropriated Entitlements in the Federal Budget Process, by Bill Heniff Jr.

7 For further information on discretionary spending, see CRS Report R42388, The Congressional Appropriations Process: An Introduction, by Jessica Tollestrup.

8 U.S. Congressional Budget Office, letter to the Honorable Nancy Pelosi, Speaker, U.S. House of Representatives, providing an estimate of the direct spending and revenue effects of ACA, as amended by HCERA (March 20, 2010), http://www.cbo.gov/sites/default/files/cbofiles/ftpdocs/113xx/doc11379/amendreconprop.pdf.

9 For a summary of all the ACA's mandatory appropriations, and the status of obligation of those funds, see CRS Report R41301, Appropriations and Fund Transfers in the Affordable Care Act (ACA), by C. Stephen Redhead.

10 The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA; P.L. 114-10, 129 Stat. 87) extended CHCF funding for the health centers program and the NHSC for two years by appropriating a total of $3.910 billion to the fund for each of FY2016 and FY2017. Of that amount, $3.6 billion is for the health centers program and the remaining $310 million is for the NHSC.

11 The ACA also reauthorized funding for many existing discretionary grant programs authorized under the Public Health Service Act; notably, the federal health workforce programs administered by the Health Resources and Services Administration (HRSA). The authorizations of appropriations for many of these programs expired prior to the ACA's enactment, though most of them were still receiving annual appropriations. The ACA also permanently reauthorized appropriations for the federal health centers program and for programs and services provided by the Indian Health Service (IHS). Congressional appropriators have in general continued to provide discretionary funding for these long-standing programs, though typically at funding levels below the amounts authorized by the ACA. For more details on all the authorizations (and reauthorizations) of discretionary funding in ACA, including the FY2011-FY2015 funding levels for programs that received an appropriation, see CRS Report R41390, Discretionary Spending Under the Affordable Care Act (ACA), coordinated by C. Stephen Redhead.

12 The Nonrecurring Expenses Fund is an account within the Department of the Treasury. The HHS Secretary is authorized to transfer to the NEF unobligated balances of expired discretionary funds. NEF funds are available until expended for use by the HHS Secretary for capital acquisitions including facility and information technology infrastructure.

13 For more discussion on the budget requests for, and sources of, funding to cover the administrative costs of implementing the ACA, see CRS Report R41390, Discretionary Spending Under the Affordable Care Act (ACA), coordinated by C. Stephen Redhead.

14 For more discussion and analysis of limitation provisions, including the relevant House and Senate rules and the procedural issues that arise during floor consideration of general appropriations measures that include such provisions, see CRS Report R41634, Limitations in Appropriations Measures: An Overview of Procedural Issues, by Jessica Tollestrup.

15 CRS Report R41634 (see footnote 2) discusses the differences between limitations and legislative provisions in appropriations measures, and how to distinguish between the two.

16 P.L. 113-46, 127 Stat. 558. For more analysis of the various legal and procedural considerations arising from the use of the appropriations process to delay or defund the ACA, see CRS Report R43246, Affordable Care Act (ACA) and the Appropriations Process: FAQs Regarding Potential Legislative Changes and Effects of a Government Shutdown,coordinated by C. Stephen Redhead.

17 P.L. 113-76, 128 Stat. 5.

18 Carl Hulse and Jeremy W. Peters, "Boehner Uses New Mandate to Muffle Talk of a Shutdown," New York Times, November 30, 2014; Paul Kane, "McConnell's Promise of No Shutdowns Will Be Tested by Senate's Staunch Conservatives," Washington Post, November 15, 2014.

 

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