	Introduction

Implementation of the Affordable Care Act (ACA) is having a substantial impact on federal mandatory spending. Most of the mandatory spending under the law is for expanding health insurance coverage. In addition, the ACA authorized new Medicare spending and appropriated billions of dollars in mandatory funds to support numerous other activities and programs. For example, it provided a permanent appropriation—available for 10-year periods—for a Center for Medicare & Medicaid Innovation to test and implement innovative health care payment and service delivery models. The two agencies primarily responsible for the ACA's implementation are the Centers for Medicare & Medicaid Services (CMS), within the Department of Health and Human Services (HHS), and the Internal Revenue Service (IRS), within the Department of the Treasury. ACA Authorizations of Appropriations

The ACA authorized numerous new discretionary grant programs and provided for each an authorization of appropriations, typically through FY2014 or FY2015. The ACA also was a convenient legislative vehicle to reauthorize funding—in most instances through FY2014 or FY2015—for many existing discretionary grant programs, primarily ones authorized under the Public Health Service Act (PHSA). They include most, but not all, of the health workforce education and training programs administered by the Health Resources and Services Administration (HRSA). The authorizations of appropriations for many of these established programs had expired prior to the ACA, though most of them were continuing to receive annual funding. Importantly, the ACA permanently reauthorized appropriations for the federal health centers program, the National Health Service Corp (NHSC), and many programs and services provided by the Indian Health Service (IHS). Amendatory provisions either add a new program to the statute or modify an existing one. Annual Appropriation Amounts to Date

The Congressional Budget Office (CBO) estimated that fully funding the discretionary grant programs authorized (or reauthorized) by the ACA, based on the amounts specified in the authorizations of appropriations, would result in appropriations of almost $100 billion over the period FY2012-FY2021. An examination of the tables in this report, however, shows that the total amount of discretionary funding provided to date falls well below CBO's estimate. The first reason is that few of the new grant programs authorized by the ACA have received any discretionary appropriations, though a handful have received mandatory funds from the ACA's Prevention and Public Health Fund (PPHF). The second reason is that programs that were reauthorized by the ACA generally have received discretionary appropriations at levels well below the amounts authorized in the law. Both agencies have requested an increase in their annual appropriations in each of the past five years (i.e., FY2013-FY2017) to help cover those costs. But Congress has repeatedly denied their requests for additional discretionary funding for ACA implementation. CMS has instead relied on funding from a variety of sources to support the development and operation of the federally facilitated exchange (FFE).
The Affordable Care Act (ACA) authorized many new discretionary grant programs and provided each one with an authorization of appropriations—typically through FY2014 or FY2015—to carry them out. The ACA also reauthorized funding for numerous existing programs with expired authorizations of appropriations, most of which were still receiving annual funding.
The Congressional Budget Office (CBO) estimated that fully funding the discretionary grant programs authorized (or reauthorized) by the ACA, based on the amounts specified in the authorizations of appropriations, would result in appropriations of almost $100 billion over the period FY2012-FY2021. However, the total amount of discretionary funding provided to date falls well below CBO's estimate for two reasons. First, few of the new grant programs authorized by the ACA have received any discretionary appropriations. Second, programs that were reauthorized by the ACA generally have received discretionary appropriations at levels well below the amounts authorized in the law.
The ACA included provisions intended to strengthen the health care safety net and improve access to care. For example, it permanently reauthorized the federal health center program and the National Health Service Corps (NHSC). The NHSC provides scholarships and student loan repayments to individuals who agree to a period of service as a primary care provider in a federally designated Health Professional Shortage Area. In addition, the ACA addressed concerns about the current size, specialty mix, and geographic distribution of the health care workforce. It reauthorized and expanded existing health workforce education and training programs under Titles VII and VIII of the Public Health Service Act (PHSA). Title VII supports the education and training of physicians, dentists, physician assistants, and public health workers through grants, scholarships, and loan repayment. The ACA created several new programs to increase training experiences in primary care, in rural areas, and in community-based settings, and provided training opportunities to increase the supply of pediatric subspecialists and geriatricians. It also expanded the nursing workforce development programs authorized under PHSA Title VIII.
As part of a comprehensive framework for federal community-based public health activities, including a national strategy and a national education and outreach campaign, the ACA authorized several new grant programs with a focus on preventable or modifiable risk factors for disease (e.g., sedentary lifestyle, tobacco use). The new law also leveraged a number of mechanisms to improve health care quality, including new requirements for quality measure development, collection, analysis, and public reporting; programs to develop and disseminate innovative strategies for improving the quality of health care delivery; and support for care coordination programs such as medical homes and the co-location of primary health care and mental health services. Additionally, the ACA authorized funding for programs to prevent elder abuse, neglect, and exploitation; grants to expand trauma care services and improve regional coordination of emergency services; and demonstration projects to implement alternatives to current tort litigation for resolving medical malpractice claims, among other provisions.
The two agencies primarily responsible for implementing the ACA's expansion of insurance coverage and its revenue provisions—the Centers for Medicare & Medicaid Services (CMS) and the Internal Revenue Service (IRS)—have requested an increase in their annual appropriations in each of the past five years (i.e., FY2013-FY2017) to help cover these costs. But Congress has not provided the agencies with any additional discretionary funding for ACA implementation. CMS, in particular, has relied on funding from a variety of other sources to support these activities.