{ "id": "IN10185", "type": "CRS Insight", "typeId": "INSIGHTS", "number": "IN10185", "active": true, "source": "EveryCRSReport.com, University of North Texas Libraries Government Documents Department", "versions": [ { "source": "EveryCRSReport.com", "id": 617447, "date": "2020-02-10", "retrieved": "2020-02-19T23:08:38.494037", "title": "Congress May Consider Options to Extend Expiring Funds for Primary Care", "summary": "The Affordable Care Act (ACA), enacted in March 2010, appropriated mandatory funds to support three programs focused on expanding access to primary care services for populations that are typically underserved. These three programs are the Health Centers program, the National Health Service Corps (NHSC), and payments to support medical residents training at teaching health centers\u2014outpatient health facilities that primarily provide care to underserved populations.\nThe mandatory ACA funds for these programs were initially provided for five years. Funding for each of these three programs had been subsequently extended through the end of FY2019.The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA, P.L. 114-10) provided the funding extensions for FY2016 and FY2017. The Bipartisan Budget Act of 2018 (BBA 2018, P.L. 115-123) provided the funding extensions for FY2018 and FY2019. BBA 2018 also included a number of changes to each program\u2019s authorizations and increased funding for health centers and for teaching health centers. \nPartial FY2020 funding has been provided in P.L. 116-94 through May 22, 2020. A longer funding extension has not been enacted, but a number of bills to provide longer extensions have been introduced, as discussed below. \nCommunity Health Center Fund\nThe ACA established the Community Health Center Fund (CHCF) to help support the Health Centers and NHSC programs. CHCF funding was initially intended to supplement the annual discretionary funds that the two programs typically received through the regular appropriations process. However, CHCF funds have replaced a significant portion of the Health Center program\u2019s annual discretionary appropriations (see Table 1). Since F2015, CHCF funding has represented more than 70% of the Health Center program\u2019s funding. In the case of the NHSC program, no annual discretionary appropriations were provided from FY2012 through FY2017, but subsequent discretionary appropriations provided funds for loan repayment for NHSC opioid treatment providers in FY2018-FY2020. Discretionary appropriations for FY2019 and FY2020 also included an additional $15 million for loan repayment to NHSC providers placed at Indian Health Service facilities. For FY2020, partial-year CHCF funding represents approximately 60% of each programs\u2019 funding. \nTable 1. Health Centers and NHSC Funding\n(Millions of Dollars, by Fiscal Year)\n\n2010\n2011\n2012\n2013\n2014\n2015\n2016\n2017\n2018\n2019\n2020\n\nHealth Centers\n\n\n\n\n\n\n\n\n\n\n\n\nDiscretionary\n2,141\n1,481\n1,472\n1,391a\n1,397\n1,392\n1,392\n1,387\n1,507\n1,506\n1,506\n\nCHCF\nNA\n1,000\n1,200\n1,465a\n2,145a\n3,509a\n3,600\n3,511a\n3,800\n4,000\n2,575b\n\n% CHCF\n0%\n40%\n45%\n51%\n59%\n72%\n72%\n72%\n72%\n73%\n63%b\n\nNHSC\n\n\n\n\n\n\n\n\n\n\n\n\nDiscretionary\n141\n25\n0\n0\n0\n0\n0\n0\n105c\n120c\n120c\n\nCHCF\nNA\n290\n295\n285a\n283a\n287a\n310\n289a\n310\n310\n200b\n\n% CHCF\n0%\n92.1%\n100%\n100%\n100%\n100%\n100%\n100%\n75%\n72%\n62%b\n\nSource: Prepared by CRS based on HHS budget documents and P.L. 116-94.\nAmounts were reduced by sequestration. FY2013 reflects sequestration of discretionary and CHCF funds; FY2014, FY2015, and FY2017 reflect sequestration of the CHCF.\nFY2020 CHCF amounts are partial-year funding for October 1, 2019 -May 22, 2020. As such, these amounts are not strictly comparable to those shown in other columns.\nNHSC discretionary amounts for FY2018-FY2020 were appropriated to expand the program to opioid treatment providers. FY2019 and FY2020 NHSC discretionary appropriations also included $15 million to place additional NHSC providers at Indian Health Service facilities.\nTeaching Health Centers\nThe teaching health center (THC) program was created in the ACA, which appropriated $230 million to be spent over a five-year period from FY2011 to FY2015. MACRA then provided $60 million for each of FY2016 and FY2017. BBA 2018 subsequently expanded funding for the program to permit additional programs to be developed and added additional reporting requirements. It provided $126.5 million annually for FY2018 and FY2019. This program has never received discretionary funding. The THC program has trained approximately 880 primary care residents primarily in underserved communities. Nearly two-thirds of recent program graduates are practicing primary care, and nearly 60% are doing so in a medically underserved area. \nThe Primary Care \u201cCliff\u201d\nThe expiration of these funds has been referred to as the primary care \u201ccliff,\u201d because it would (in the absence of new funding) result in a significant drop in funding for primary care programs that deliver services, place primary care providers in underserved areas, and train future providers.\nThe Health Centers and NHSC programs are cornerstones of the federal government\u2019s efforts to expand access to primary care. The Health Centers program helps support more than 1,400 community-based health centers operating over 12,000 delivery sites across the country. Health centers provide care to medically underserved populations regardless of their ability to pay. They provide care for more than 28 million people annually, or an average of 1 in 12 Americans. The NHSC program awards scholarships and loan repayment to certain health professionals\u2014more than 10,000 in FY2017\u2014who agree to practice in shortage areas, often at health centers. Funding for teaching health centers has also been included in discussions of this \u201ccliff\u201d because the program aims to increase the primary care workforce in underserved areas. \nVarious Options for FY2020 and Future Year Funding\nLegislation has been introduced in the 116th Congress that would extend the CHCF and the teaching health center program for five years (H.R. 1943, H.R. 1983, H.R. 2328, S. 106, S. 192, and S. 962). This differs from prior two-year extensions. A longer extension may provide these programs with funding stability. The bills under consideration include different amounts of funding for these programs. Separate legislation (H.R. 2815, S. 304, and S. 1191) has also been introduced to extend and increase funding for teaching health centers (but not the CHCF). In addition to these bills, a five-year funding extension for the health center program (with a funding increase) is included in a larger health care package under consideration related to prescription drug prices (H.R. 3). This bill does not include the extension of the NHSC or of teaching health centers. Five-year funding extensions of all three programs are also included in legislation that aims to address surprise medical billing. This bill would maintain program funding at FY2019 levels.", "type": "CRS Insight", "typeId": "INSIGHTS", "active": true, "formats": [ { "format": "HTML", "encoding": "utf-8", "url": "https://www.crs.gov/Reports/IN10185", "sha1": "9aacc60ac254ac9cd2dea2a2e9c4086ddc25c44f", "filename": "files/20200210_IN10185_9aacc60ac254ac9cd2dea2a2e9c4086ddc25c44f.html", "images": {} }, { "format": "PDF", "encoding": null, "url": "https://www.crs.gov/Reports/pdf/IN10185", "sha1": "4438d36f1a9672cb41fce2c2eb8cff4eb2173797", "filename": "files/20200210_IN10185_4438d36f1a9672cb41fce2c2eb8cff4eb2173797.pdf", "images": {} } ], "topics": [] }, { "source": "EveryCRSReport.com", "id": 461906, "date": "2017-06-13", "retrieved": "2017-08-22T14:21:52.165897", "title": "Congress Faces Calls to Address Expiring Funds for Primary Care", "summary": "The Affordable Care Act (ACA), enacted in March 2010, appropriated billions of dollars of mandatory funds to support grant programs and other activities. Specifically, it provided support for three programs focused on expanding access to primary care services for populations that are typically underserved. These three programs are the Health Centers program, the National Health Service Corps (NHSC), and payments to support medical residents training at teaching health centers\u2014outpatient health facilities that primarily provide care to underserved populations.\nThe ACA funds were initially for five years, but funding for these three programs was subsequently extended for two years (i.e., for FY2016 and FY2017) in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA; P.L. 114-10). The President\u2019s FY2018 budget proposes extending funding for these programs for two more years. \nCommunity Health Center Fund\nThe ACA established the Community Health Center Fund (CHCF) to help support the Health Centers and NHSC programs, and gave it a total of $11 billion in annual appropriations over the five-year period FY2011-FY2015. MACRA subsequently provided $7.2 billion for health centers and $580 million for the NHSC for an additional two years. CHCF funding was initially intended to supplement the annual discretionary funds that the two programs receive through the regular appropriations process. However, CHCF funds have replaced a significant portion of the Health Center program\u2019s annual discretionary appropriations, which Congress has reduced since FY2010 (see Table 1). In FY2016, CHCF funding represented about 71% of the Health Center program\u2019s funding. In the case of the NHSC program, Congress eliminated its annual discretionary appropriation entirely. Since FY2012, the program has relied solely on CHCF funding (see Table 1).\n\nTable 1. Health Centers and NHSC Funding \n(Millions of Dollars, by Fiscal Year) \n\n2010\n2011\n2012\n2013\n2014\n2015\n2016\n2017\n2018 (Request)\n\nHealth Centers\n\n\n\n\n\n\n\n\n\n\nDiscretionary\n2,141\n1,481\n1,472\n1,391\n1,400\n1,392\n1,492\n1,492\n1,489\n\nCHCF\nNA\n1,000\n1,200\n1,465\n2,145\n3,510\n3,600\n3,516\n3,600a\n\n% CHCF\n0%\n40.3%\n48.3%\n51.3%\n60.5%\n71.6%\n70.7%\n70.2%\n70.7%\n\nNHSC\n\n\n\n\n\n\n\n\n\n\nDiscretionary\n141\n25\n0\n0\n0\n0\n0\n0\n0\n\nCHCF\nNA\n290\n295\n285\n283\n287\n310\n289\n310a\n\n% CHCF\n0%\n92.1%\n100%\n100%\n100%\n100%\n100%\n100%\n100%\n\nSource: Prepared by CRS based on HHS budget documents.\nNotes: FY2013 reflects sequestrations of discretionary and CHCF funds; FY2014, FY2015, and FY2017 reflect sequestration of the CHCF. \nProposed mandatory funding.\n\nThe teaching health center (THC) program was created by the ACA, which appropriated $230 million for five years. MACRA subsequently provided $60 million for each of FY2016 and FY2017. This program has never received discretionary funding. The THC program has trained 600 primary care residents primarily in underserved communities. More than three-quarters of the program\u2019s recent graduates are practicing primary care and nearly a third are doing so in a medically underserved areas.\nThe Primary Care \u201cCliff\u201d\nIn FY2015, when the original ACA funding was set to expire, advocates for the nation\u2019s primary care system referred to this as a \u201cprimary care cliff\u201d that would have resulted in a significant drop in funding for primary care programs that deliver services, place primary care providers in underserved areas, and train future providers.\nThe Health Centers and NHSC programs are cornerstones of the federal government\u2019s efforts to expand access to primary care. The Health Centers program helps support more than 1,400 community-based health centers operating over 10,500 delivery sites across the country. Health centers provide care to medically underserved populations regardless of their ability to pay. They provide care for more than 24 million people annually, or an average of one in 13 Americans. The NHSC program awards scholarships and loan repayment to certain health professionals\u2014nearly 8,500 in recent years\u2014who agree to practice in shortage areas, often at health centers. \nNo Funding for FY2018\nAdvocates of these programs see the loss of mandatory funds at the end of FY2017 as compounded by the reduction\u2014in the case of the NHSC, the elimination\u2014of annual discretionary funding for these programs. If the MACRA funding is not extended beyond the current fiscal year, congressional appropriations would face a need for more than $4 billion in new discretionary funds in FY2018 in order to maintain the current level of support for these programs. That could prove a tall order under the discretionary spending limits currently in place. \nThe President\u2019s FY2018 budget proposes new mandatory funding\u2014$3.6 billion for health centers and $310 million for the NHSC\u2014for each of FY2018 and FY2019 (see Table 1).", "type": "CRS Insight", "typeId": "INSIGHTS", "active": true, "formats": [ { "format": "HTML", "encoding": "utf-8", "url": "http://www.crs.gov/Reports/IN10185", "sha1": "823607adfd51f5d8fe3c4bd286b39c6850fed2c6", "filename": "files/20170613_IN10185_823607adfd51f5d8fe3c4bd286b39c6850fed2c6.html", "images": {} } ], "topics": [] }, { "source": "University of North Texas Libraries Government Documents Department", "sourceLink": "https://digital.library.unt.edu/ark:/67531/metadc491500/", "id": "IN10185_2014Nov25", "date": "2014-11-25", "retrieved": "2015-01-27T19:40:46", "title": "Congress Faces Calls to Address Expiring ACA Appropriations", "summary": "This report discusses the Affordable Care Act (ACA), enacted in March 2010, which appropriated billions of dollars of mandatory funds to support grant programs and other activities authorized by the law.", "type": "CRS Report", "typeId": "REPORT", "active": false, "formats": [ { "format": "PDF", "filename": "files/20141125_IN10185_112d5f39b5a5bf1eb2d408234d0c0c02cdfbded7.pdf" }, { "format": "HTML", "filename": "files/20141125_IN10185_112d5f39b5a5bf1eb2d408234d0c0c02cdfbded7.html" } ], "topics": [ { "source": "LIV", "id": "Appropriations", "name": "Appropriations" }, { "source": "LIV", "id": "Health policy", "name": "Health policy" }, { "source": "LIV", "id": "Comprehensive health care", "name": "Comprehensive health care" } ] } ], "topics": [ "Appropriations", "CRS Insights" ] }