International Family Planning Programs: Issues for Congress

Luisa Blanchfield
Specialist in International Relations

Since 1965, the U.S. government has supported international family planning activities based on principles of voluntarism and informed choice that gives participants access to services and information on a broad range of family planning methods. U.S. family planning policy and abortion restrictions have generated contentious debate for over three decades, resulting in frequent clarification and modification of U.S. international family planning programs. Given the divisive nature of this debate, U.S. funding of these programs will likely remain a point of contention during the 112th Congress.

In 1984, controversy arose over U.S. family planning assistance when the Ronald Reagan Administration introduced restrictions that became known as the “Mexico City policy.” The Mexico City policy required foreign non-governmental organizations (NGOs) to certify that they would not perform or actively promote abortion as a method of family planning—even if the activities were undertaken with non-U.S. funds. Presidents Reagan and George H. W. Bush also suspended grants to the U.N. Population Fund (UNFPA) due to evidence of coercive family planning practices in China, citing violations of the “Kemp-Kasten” amendment, which bans U.S. assistance to organizations that, as determined by the President, support or participate in the management of coercive family planning programs.

President Bill Clinton resumed UNFPA funding and rescinded the Mexico City policy in 1993. In 2001, however, President George W. Bush reapplied the Mexico City policy restrictions. The Bush Administration also suspended U.S. contributions to UNFPA from FY2002 to FY2008 following a State Department investigation of family planning programs in China. In January 2009, President Barack Obama issued a memorandum rescinding the Mexico City policy. The President also stated that the United States would resume U.S. contributions to UNFPA.

Recent international family planning-related appropriations and Obama Administration requests are outlined below.

• FY2012—On December 23, 2011, President Obama signed the Consolidated Appropriations Act, 2012 (P.L. 112-74), which directs that not less than $575 million should be made available for family planning and reproductive health activities. It also states that $35 million shall be made available for UNFPA. 
• FY2011—FY2011 appropriations for international family planning and reproductive health are included in the Department of Defense and Full-Year Continuing Appropriations Act, 2011 (P.L. 112-10), which directs that not less that $575 million should be made available for international family planning and reproductive health activities. It also allocated $40 million for UNFPA. 
• FY2010—In December 2009, the President signed the Consolidated Appropriations Act, 2010 (P.L. 111-117), which directs that not less than $648.457 million should be made available for international family planning and reproductive health activities. Of this amount, $55 million shall be made available for UNFPA. 

For further discussion of abortion and family planning-related restrictions in U.S. legislation and policy, see CRS Report R41360, Abortion and Family Planning-Related Provisions in U.S. Foreign Assistance Law and Policy, by Luisa Blanchfield, and CRS Report RL33467, Abortion: Judicial History and Legislative Response, by Jon O. Shimabukuro.


Date of Report: February 2, 2012
Number of Pages: 19
Order Number: RL33250
Price: $29.95

Follow us on TWITTER at http://www.twitter.com/alertsPHP or #CRSreports

Document available via e-mail as a pdf file or in paper form.
To order, e-mail Penny Hill Press or call us at 301-253-0881. Provide a Visa, MasterCard, American Express, or Discover card number, expiration date, and name on the card. Indicate whether you want e-mail or postal delivery. Phone orders are preferred and receive priority processing.

Medicaid: A Primer

Elicia J. Herz
Specialist in Health Care Financing

In existence for 47 years, Medicaid is a means-tested entitlement program that financed the delivery of primary and acute medical services as well as long-term care to more than 69 million people in FY2011. The estimated annual cost to the federal and state governments was roughly $404 billion in FY2010. In comparison, the Medicare program provided health care benefits to nearly 48 million seniors and certain persons with disabilities, and cost roughly $523 billion in FY2010.

In its report The Budget and Economic Outlook: An Update, August 2011, the Congressional Budget Office (CBO) projects that Medicaid outlays will rise an average annual rate of 9.0% during the 2013-2021 period due to both demographic changes and an increase in enrollment beginning in 2014 as a result of significant program changes under the recent Patient Protection and Affordable Care Act (ACA). That enrollment increase is estimated to be roughly 17 million individuals by 2021. This legislation also increased the federal share of Medicaid program costs for selected groups of beneficiaries and particular services in future years. Because Medicaid represents a large component of federal mandatory spending, Congress is likely to continue its oversight of Medicaid’s eligibility, benefits, and costs.

Understanding the complex statutory and regulatory rules that govern Medicaid is further complicated by the fact that each state designs and administers its own version of the program under broad federal rules. State variability is the rule rather than the exception in terms of eligibility levels, covered services, and how those services are reimbursed and delivered. The ACA makes both mandatory and optional changes to Medicaid along some of these dimensions.

This report describes the basic elements of Medicaid, focusing on the federal rules governing who is eligible, what services are covered, how the program is financed, and how beneficiaries share in the cost of care, how providers are paid, and the role of special waivers in expanding eligibility and modifying benefits. Examples of both mandatory and optional eligibility groups and benefits as defined in the federal statute are described. Basic program statistics are also provided. Finally, selected legislative changes at the federal level via the ACA that affect Medicaid in significant ways are also described.


Date of Report: February 6, 2012
Number of Pages: 18
Order Number: RL33202
Price: $29.95

Follow us on TWITTER at http://www.twitter.com/alertsPHP or #CRSreports

Document available via e-mail as a pdf file or in paper form.
To order, e-mail Penny Hill Press or call us at 301-253-0881. Provide a Visa, MasterCard, American Express, or Discover card number, expiration date, and name on the card. Indicate whether you want e-mail or postal delivery. Phone orders are preferred and receive priority processing.

Medicaid: The Federal Medical Assistance Percentage (FMAP)

Alison Mitchell
Analyst in Health Care Financing

Evelyne P. Baumrucker
Analyst in Health Care Financing

Medicaid is a means-tested entitlement program that finances the delivery of primary and acute medical services as well as long-term care. Medicaid is jointly funded by the federal government and the states. The federal government’s share of a state’s expenditures is called the federal medical assistance percentage (FMAP) rate. The remainder is referred to as the nonfederal share, or state share.

Generally determined annually, the FMAP formula is designed so that the federal government pays a larger portion of Medicaid costs in states with lower per capita incomes relative to the national average (and vice versa for states with higher per capita incomes). For FY2013, regular FMAP rates range from 50.00% to 74.43%. The FMAP rate is used to reimburse states for the federal share of most Medicaid expenditures, but exceptions to the regular FMAP rate have been made for certain states, situations, populations, providers, and services.

Some recent issues related to FMAP include state fiscal conditions, the disaster-related FMAP adjustment, and the exclusion of certain employer contributions from the FMAP calculation. While the fiscal environment for states is improving, states continue to face fiscal challenges, which makes it difficult for states to finance the state share of Medicaid expenditures. The Patient Protection and Affordable Care Act (ACA, P.L. 111-148 as amended) included a provision providing a disaster-recovery FMAP adjustment for states that have experienced a major, statewide disaster. The Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA, P.L. 111-3) included a provision allowing a state’s FMAP rate to be adjusted if the state had significantly disproportionate employer pension and insurance fund contributions in any calendar year since 2003.

Legislation was enacted during the 111th Congress that impacts the FMAP rate. First, the American Recovery and Reinvestment Act of 2009 (ARRA, P.L. 111-5) provided assistance to states through a temporary FMAP rate increase that was later extended by P.L. 111-226. Also, ACA contains a number of provisions affecting FMAP rates. Most notably, ACA provides initial FMAP rates of up to 100% for certain “newly eligible” individuals.

During the 112th Congress, there has been a focus on reducing the federal deficit; controlling federal Medicaid spending is often discussed as a means to reduce federal expenditures. For this reason, the FY2012 House budget resolution proposed restructuring Medicaid from an entitlement program to a block grant, and most federal deficit reduction proposals include Medicaid provisions.

This report describes the FMAP calculation used to reimburse states for most Medicaid expenditures, and it lists the statutory exceptions to the regular FMAP rate. In addition, this report discusses other FMAP-related issues, including state fiscal conditions, the temporary FMAP rate increase, the exclusion of certain employer contributions, FMAP changes in ACA, the Medicaid proposal included in the House budget resolution, and other federal deficit reduction proposals.


Date of Report: January 27, 2012
Number of Pages: 40
Order Number: RL32950
Price: $29.95

Follow us on TWITTER at http://www.twitter.com/alertsPHP or #CRSreports

Document available via e-mail as a pdf file or in paper form.
To order, e-mail Penny Hill Press or call us at 301-253-0881. Provide a Visa, MasterCard, American Express, or Discover card number, expiration date, and name on the card. Indicate whether you want e-mail or postal delivery. Phone orders are preferred and receive priority processing.

Older Americans Act: Funding Formulas

Kirsten J. Colello
Specialist in Health and Aging Policy

The Older Americans Act (OAA) is the major vehicle for the delivery of social and nutrition services for older persons. The act’s statutory funding formulas determine allotments to states and other entities under the following OAA Titles: 

•         Title III, Grants for State and Community Programs; 

•         Title V, the Community Service Senior Opportunities Act; 

•         Title VI, Grants for Older Native Americans; and 

•         Title VII, Vulnerable Elder Rights Protection Activities. 

These formula grants fund programs that assist older Americans with supportive services; congregate nutrition services (meals served at group sites such as senior centers, community centers, schools, churches, or senior housing complexes); home-delivered nutrition services; family caregiver support; community service employment; the long-term care ombudsman program; and services to prevent the abuse, neglect, and exploitation of older persons.

The OAA Amendments of 2006 (P.L. 109-365) reauthorized all programs under the act through FY2011. Among other things, P.L. 109-365 changed the formula allocation for most Title III programs. No changes were made to Title V, VI, or VII formulas. While the authorization of appropriations under the OAA expired at the end of FY2011, Congress has continued to appropriate funding for OAA-authorized activities for FY2012. The 112th Congress may consider reauthorization of the OAA and as a result may modify existing authorities.

This report describes the debate surrounding changes to the Title III funding formula during the OAA reauthorizations of 2000 and 2006. It then summarizes the OAA statutory provisions that allocate funds to states and other entities under current law.


Date of Report: January 30, 2012
Number of Pages: 12
Order Number: RS22549
Price: $29.95

Follow us on TWITTER at http://www.twitter.com/alertsPHP or #CRSreports

Document available via e-mail as a pdf file or in paper form.
To order, e-mail Penny Hill Press or call us at 301-253-0881. Provide a Visa, MasterCard, American Express, or Discover card number, expiration date, and name on the card. Indicate whether you want e-mail or postal delivery. Phone orders are preferred and receive priority processing.

Drivers of Premium Increases and Review of Health Insurance Rates

Bernadette Fernandez
Specialist in Health Care Financing

In general, the premiums charged by health insurance companies represent actuarial estimates of the amount that would be required to cover three main components: (1) the expected cost of the health benefits covered under the plan, (2) the business administrative costs of operating the plan, and (3) a profit. The final premium calculation often is adjusted upward or downward to reflect several factors, such as making up for a previous financial loss, that are often referred to as the “underwriting cycle.”

Health insurance premiums have been trending up, while the value of coverage generally has been trending down. Specifically, the year-over-year percentage increase by month in private health insurance premiums has averaged around 4.4% between 2004 and 2010, but has accelerated some since 2009, ranging from 4.8% to 5.5%. At the same time, cost-sharing requirements have generally increased. For example, a typical family of four with private employer-sponsored health benefits has seen its out-of-pocket cost sharing increase between 5.4% and 10.5% annually between 2006 and 2010.

Of the main components that constitute the premium amount, health benefits expenses represented about 85% of that amount in 2010. Publicly available data indicate that medical costs have steadily risen over the past several years, but the rate of growth in these expenses slowed between 2008 and 2010. The data also suggest that the rise in medical costs is primarily attributable to the price of services, not increased utilization.

The rise in the cost of health insurance has received considerable attention by Congress and resulted in calls for more regulation. The regulation of private health insurance has traditionally been under the jurisdiction of the states. Most states have used their regulatory authority over the business of insurance to require the filing of health insurance documents containing rate information for one or more insurance market segments or plan types.

Under the Patient Protection and Affordable Care Act (P.L. 111-148, ACA, as amended), the federal government will assume a role in private health insurance rate reviews by providing grants to states and requiring health insurance companies to provide justifications for proposed rate increases determined to be unreasonable. However, ACA does not authorize the federal government to decline or bar implementation of proposed rate increases; such authority still is retained by the states. On May 23, 2011, Health and Human Services (HHS) issued the final rule implementing the rate review provisions in ACA. The rule clarified which proposed rate increases would be subject to review (i.e., defining “unreasonable” rate increase), established a process for rate review to be conducted either by the state or HHS, and specified notice requirements to inform the public about the process and outcome of the rate reviews.

This report provides an overview of the concepts, regulation, and available public data regarding private health insurance premiums. Specifically, this report analyzes the four broad components of health insurance premiums: medical claims, administrative costs, profit, and the underwriting cycle. Finally, the report discusses state requirements to review health insurance rates, and rate review provisions under federal health reform.


Date of Report: January 20, 2012
Number of Pages: 31
Order Number: R41588
Price: $29.95

Follow us on TWITTER at http://www.twitter.com/alertsPHP or #CRSreports

Document available via e-mail as a pdf file or in paper form.
To order, e-mail Penny Hill Press or call us at 301-253-0881. Provide a Visa, MasterCard, American Express, or Discover card number, expiration date, and name on the card. Indicate whether you want e-mail or postal delivery. Phone orders are preferred and receive priority processing.