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Wednesday, December 29, 2010

The New York State Disaster Relief Medicaid Program Established After the Terrorist Attacks of September 11, 2001

TO: The Honorable Carolyn Maloney  
Attention: Benjamin Chevat


From:
Evelyne Baumrucker, Analyst in Health Care Financing   
Sarah A. Lister, Specialist in Public Health and Epidemiology  
Domestic Social Policy Division


This memorandum responds to your request for information about the New York State Disaster Relief Medicaid (DRM) program established after the terrorist attacks of September 11, 2001, and how it differs from the World Trade Center Medical Monitoring and Treatment Program (MMTP) administered by the Centers for Disease Control and Prevention (CDC), National Institute for Occupational Safety and Health (NIOSH). As you requested, this memorandum also provides an update of the status of the DRM program, including the resolution of New York State’s appeal to the Federal Emergency Management Agency (FEMA) for reimbursement of the state’s share of Medicaid costs, as described in CRS Report RL33083, Hurricane Katrina: Medicaid Issues, by Evelyne P. Baumrucker et al. (p. 17).


Date of Report: August 25, 2010
Number of Pages: 8
Order Number: M-082510
Price: $19.95

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Comparison of Selected Senate Energy and Climate Change Proposals


Brent Yacobucci, Coordinator
Specialist in Energy and Environmental Policy

This memorandum provides a short summary and comparison of four legislative proposals that may receive attention in the Senate.  This memorandum will not be updated.


Date of Report: June 24, 2010
Number of Pages: 17
Order Number: M-062410
Price: $29.95

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Tuesday, December 28, 2010

Appropriations and Fund Transfers in the Patient Protection and Affordable Care Act(PPACA)


C. Stephen Redhead
Specialist in Health Policy

On March 23, 2010, President Obama signed into law a comprehensive health care reform bill, the Patient Protection and Affordable Care Act (PPACA; P.L. 111-148). The following week, on March 30, 2010, the President signed the Health Care and Education Reconciliation Act of 2010 (HCERA; P.L. 111-152), which amended various health care and revenue provisions in PPACA.

Among its many provisions, PPACA, as amended, restructures the private health insurance market, sets minimum standards for health coverage, creates a mandate for most U.S. residents to obtain health insurance, and provides for the establishment by 2014 of insurance exchanges through which certain individuals and families will be able to receive federal subsidies to reduce the cost of purchasing that coverage. The new law expands eligibility for Medicaid; amends the Medicare program in ways that are intended to reduce the growth in Medicare spending that had been projected under preexisting law; imposes an excise tax on insurance plans found to have high premiums; and makes other changes to the tax code, Medicare, Medicaid, and numerous other federal programs.

In some instances, PPACA mandates appropriations or requires the Secretary of Health and Human Services to transfer from the Medicare Part A and Part B trust funds billions of dollars to support new or existing grant programs and other activities. This report summarizes those mandated appropriations and fund transfers. They include funding for a temporary insurance program for individuals who have been uninsured for several months and have a preexisting condition, as well as funding for states to plan and establish exchanges. PPACA also provides funding for various Medicare and Medicaid demonstration programs, for the creation of a Center for Medicare and Medicaid Innovation to test and implement innovative payment and service delivery models, and for an independent board to provide Congress with proposals for reducing Medicare cost growth and improving quality of care for Medicare beneficiaries.

Among other provisions, the new health reform law appropriates funding for health workforce and maternal and child health programs, and establishes three multi-billion dollar funds. The first fund will provide a total of $11 billion over five years in supplementary funding for community health centers and the National Health Service Corps. (A separate appropriation provides $1.5 billion for health center construction and renovation.) The second fund will support comparative effectiveness research through FY2019 with a mixture of appropriations and fund transfers. The third fund, which is funded in perpetuity, is to support prevention, wellness, and other public health-related programs and activities authorized under the Public Health Service Act (PHSA).

This report will be updated periodically with information on recent PPACA funding announcements. In addition to the mandated appropriations and fund transfers discussed herein, PPACA authorizes new funding for numerous existing discretionary grant and other programs and activities, primarily ones authorized under the PHSA. The law also creates a number of new discretionary grant programs and activities and provides for each an authorization of appropriations. Funding for all of these discretionary programs and activities is subject to action by congressional appropriators. A companion product, CRS Report R41390, Discretionary Funding in the Patient Protection and Affordable Care Act (PPACA), coordinated by C. Stephen Redhead, summarizes all the provisions in PPACA for which appropriations are authorized.



Date of Report: December 10, 2010
Number of Pages: 18
Order Number: R41301
Price: $29.95

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Comparison of the Current World Trade Center Medical Monitoring and Treatment Program and the World Trade Center Health Program Proposed by Title I of H.R. 847


Scott Szymendera
Analyst in Disability Policy

Sarah A. Lister
Specialist in Public Health and Epidemiology


In the wake of the September 11, 2001, terrorist attack on New York City, Congress passed appropriations to provide limited health screening and treatment services to persons involved in rescue, recovery, and cleanup operations around the former site of the World Trade Center. This program, now known as the World Trade Center (WTC) Medical Monitoring and Treatment Program (MMTP), is not authorized in statute but rather relies on discretionary appropriations to provide services to eligible individuals. Since its inception in FY2002, the MMTP has received approximately $475 million in federal funds, and over 57,000 responders and community members have met initial eligibility requirements for the program.

Title I of H.R. 847, as amended and passed by the House of Representatives, would eliminate the current MMTP and replace it with a program authorized in statute and financed through mandatory federal spending, partially matched by New York City. This program, proposed to be called the World Trade Center Health Program (WTCHP), would provide full medical screening and treatment benefits to eligible WTC responders and community members. In addition, Title I of H.R. 847 would establish formal eligibility requirements based on a person’s activities after September 11, 2001, and his or her current health conditions. Health benefits would be provided by a national network of providers, and the program would be administered by the Department of Health and Human Services (HHS).

The proposed WTCHP would sunset at the end of FY2020, or in FY2019 if a federal spending cap is met. Total federal spending on the program would be capped at $3.348 billion over the life of the program. New York City would contribute 10% of the program’s costs until FY2019, after which its contribution would become equal to one-ninth of federal spending in the remaining fiscal years. In addition to persons already receiving services under the MMTP, the WTCHP would serve up to 25,000 new responders and 25,000 new community members.

The House of Representatives passed an amendment in the nature of a substitute to H.R. 847 on September 29, 2010.

The Senate version of the bill, S. 1334, was referred to the Senate Committee on Health, Education, Labor, and Pensions, where it was the subject of a hearing on June 29, 2010. The Senate bill has not otherwise advanced. However, on December 9, 2010, cloture on the motion to proceed to H.R. 847 was voted on but not invoked in the Senate.



Date of Report: December 14, 2010
Number of Pages: 14
Order Number: R41292
Price: $29.95

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Monday, December 27, 2010

Requiring Individuals to Obtain Health Insurance: A Constitutional Analysis

Jennifer Staman
Legislative Attorney

Cynthia Brougher
Legislative Attorney

Edward C. Liu
Legislative Attorney

Erika K. Lunder
Legislative Attorney

Kenneth R. Thomas
Legislative Attorney


As part of the Patient Protection and Affordable Care Act, P.L. 111-148, as amended, Congress enacted an “minimum essential coverage requirement,” a provision compelling certain individuals to have a minimum level of health insurance (i.e., an “individual mandate”). Individuals who fail to do so are subject to a monetary penalty, administered through the tax code. Although the federal government provides health coverage for many individuals through federal programs such as Medicare, it had never before required individuals to purchase health insurance.

This report analyzes certain constitutional issues raised by compelling individuals to purchase health insurance. It addresses the authority of Congress to pass a law of this nature under its taxing power or its power to regulate interstate commerce. With regard to the taxing power, the requirement to purchase health insurance might be construed as a tax and upheld so long as it was found to comply with the constitutional restrictions imposed on direct and indirect taxes. On the other hand, opponents of the minimum essential coverage requirement may argue that since it is imposed conditionally and may be avoided by compliance with regulations set out in the statute, that the requirement may be more accurately described as a penalty. If so, the taxing power alone might not provide Congress the constitutional authority to support this provision.

In evaluating under the minimum essential coverage requirement under the Commerce Clause, a court may rely on Supreme Court precedent and look to several factors to determine whether the minimum essential coverage requirement passes constitutional muster. Among other things, a court may evaluate whether the requirement is a regulation of economic activity. One could argue that the requirement to purchase health insurance is economic in nature because it regulates how an individual participates in the health care market, through insurance or otherwise. On the other hand, it may be argued that the minimum essential coverage requirement goes beyond the bounds of the clause, because while regulation of the health insurance industry or the health care system is economic activity, regulating a choice to purchase health insurance is not.

It has been questioned whether the requirement to have health insurance might violate certain protections found under the U.S. Constitution. This report discusses how a court might evaluate a challenge to the minimum essential coverage requirement on Fifth Amendment due process, takings clause, or equal protection grounds, as well as under the Tenth Amendment. This report also addresses whether the exceptions to the minimum essential coverage requirement to purchase health insurance satisfy First Amendment freedom of religion protections.

Several lawsuits have been filed that challenge the minimum essential coverage requirement on constitutional grounds. For example, in Florida v. HHS, attorneys general and governors in 20 states as well as others brought an action against the Secretaries of Health and Human Services, Treasury, and Labor, seeking declaratory and injunctive relief from certain provisions of PPACA. On October 14, 2010, the district court held that the claims against the minimum essential coverage requirement could proceed to the next stage of litigation. In Virginia ex rel. Cuccinelli v. Sebelius, the Virginia attorney general filed a separate lawsuit challenging the federal requirement to purchase health insurance. On December 13, 2010, the judge in the Virginia case found that the minimum essential coverage requirement is unconstitutional. In contrast, two federal district courts have upheld the minimum essential coverage requirement as a constitutional exercise of the Commerce Clause. Many expect that one or more of these cases will reach the Supreme Court.



Date of Report: December 16, 2010
Number of Pages: 31
Order Number: R40725
Price: $29.95

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