House Appropriations Would Halt Most PPACA Implementation

The Appropriations Committee of the United States House of Representatives has released a bill that would withdraw funding for most implementation of the Patient Protection and Affordable Care Act (P.L. 111-148) and roll back other long-standing HHS programs. Section 529 contains the key provision:

None of the funds made available in this Act may be used to implement, administer, enforce, or further the provisions of [PPACA] and Title I and Subtitle B of Title II of the Health Care and Education Reconciliation Act (HCERA) (P.L. 111-152).

The section contains exceptions allowing HHS to implement and enforce the final rules for the Medicare rate-setting process for calendar year (CY) 2013 and fiscal year (FY) 2014 and changes to the limits on Medicaid payment and manufacturers’ rebates for prescription drugs for CY 2013. But the bill includes several less drastic fall-back provisions that would be unnecessary if section 529 or other broad provisions became law.

The committee’s bill would terminate the Agency for Healthcare Research and Quality (AHRQ) effective October 1, 2012.  No activity of the AHRQ could be taken over by another component of HHS unless it already has specific statutory authority for the activity. Certain specific areas of research could be assumed by the Office of the National Coordinator for Health Information Technology, the National Institutes of Health (NIH), the Centers for Disease Control or the Assistant Secretary for Health.

The bill also would allow no funding for:

  • the Center for Consumer Information and Insurance Oversight, at least to the extent of the funds available for program management;
  • additional grants for chronic disease self-management activities;
  • education and outreach on the benefits of preventive care pursuant to PPACA section 4004;
  • grants to promote evidence-based community health prevention programming under PPACA section 4201;
  • the Healthy Food Financing Initiative;
  • the Secretary’s discretionary fund for nonrecurring expenses created in 2009; and
  • Title X of the Public Health Service Act, which addresses population research and voluntary family planning (but a fall-back provision is discussed below).

The Secretary’s power to transfer up to 1 percent of the budget from one account to another would be limited. The transfer could not increase the funding for any line item by more than 3 percent and would be subject to the approval of the Appropriations Committees of both the House and the Senate. In contrast, the directors of the AIDS research programs must notify the committees but need not seek their approval.

The bill would bar certain uses of particular funds in the HHS budget. For example, the funds appropriated for program management could not be used to support the Center for Consumer Information and Insurance Oversight or for research, demonstration projects or evaluation. Similarly, discretionary funds could not be used for patient-centered outcomes research.

The Appropriations Committee bill pays special attention to issues of reproduction and sexual activity. In addition to, or as a fallback position from, the bar on implementation of PHSA Title X, the bill would require applicants for family planning grants to certify that they encourage family participation in adolescents’ decisions to access family planning services and that they provide counseling to minors on resisting coercion into sexual activity. Entities funded to provide abstinence education to adolescents would be required to agree not to provide any other information on sexual conduct unless they are required by law to provide health information or services. The other health information and services could not be provided in the same setting as the abstinence education.

The bill also would specifically prohibit the Planned Parenthood Federation of America (PPFA) and any of its clinics or affiliates from receiving any funds it makes available unless “the entities” certify that PPFA, its affiliates and clinics do not perform and will not provide funds to any other entity that performs abortions. An exception would apply to permit abortions when the pregnancy is the result of rape or incest or if the woman’s physician certifies that she suffers from a physical condition that places her “in danger of death” unless the abortion is performed. The life-threatening condition may be one arising from the pregnancy.

The Committee would withdraw all funding for the Medicare Advantage (MA) program if the Secretary denies participation to an otherwise eligible entity on the ground that it refuses to cover, pay or make referrals for abortion services. The MA organization would be required to tell its members where to find information about all services Medicare may cover.

The bill also would protect group and individual health plan issuers or sponsors who refuse to cover abortion “or other services” on religious or moral grounds. No federal funds could be used to enforce any requirement for coverage. If this provision is violated, Congress has granted an individual right to sue the government, including state government, for damages without exhausting any administrative remedies. A winning plaintiff would get attorneys fees, but a losing plaintiff would not have to pay the opponent’s fees.

The bill would continue to prohibit funding for the creation of human embryos for research purposes but continue funding of grants to help individuals obtain the administrative and health services needed for the adoption of embryos.

Finally, the bill would cut funding for several programs, including the Centers for Medicare and Medicaid Innovation, the Community Health Centers fund,Consumer Operated and Oriented Plans and the Independent Payment Advisory Board. It would slash $1 billion from the $1.25 billion previously appropriated for the Prevention and Public Health fund and $150 million from patient-centered outcomes research (the base amount that would have been increased incrementally).