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Friday, April 29, 2011

The Independent Payment Advisory Board


David Newman
Specialist in Health Care Financing

Christopher M. Davis
Analyst on Congress and the Legislative Process


In response, in part, to overall growth in Medicare program expenditures and growth in expenditures per Medicare beneficiary, the Patient Protection and Affordable Care Act (PPACA, P.L. 111-148, as amended) created the Independent Payment Advisory Board (IPAB, or the Board) and charged the Board with developing proposals to “reduce the per capita rate of growth in Medicare spending.” The Secretary of Health and Human Services (the Secretary) is directed to implement the Board’s proposals automatically unless Congress affirmatively acts to alter the Board’s proposals or to discontinue the automatic implementation of such proposals.

The annual IPAB sequence of events begins each year, starting April 30, 2013, with the Chief Actuary of the Centers for Medicare & Medicaid Services calculating a Medicare per capita growth rate and a Medicare per capita target growth rate. If the Chief Actuary determines that the Medicare per capita growth rate exceeds the Medicare per capita target growth rate, the Chief Actuary would establish an applicable savings target—the amount by which the Board must reduce future spending. This determination by the Chief Actuary also triggers a requirement that the Board prepare a proposal to reduce the growth in the Medicare per capita growth rate by the applicable savings target. The Board cannot ration care, raise premiums, increase cost sharing, or otherwise restrict benefits or modify eligibility. In generating its proposals, the Board is directed to consider, among other things, Medicare solvency, quality and access to care, the effects of changes in payments to providers, and those dually eligible for Medicare and Medicaid. If the Board fails to act, the Secretary is directed to prepare a proposal.

Board proposals must be submitted to the Secretary by September 1 of each year and to the President and Congress by January 15 of the following year. Board proposals are “fast-tracked” in Congress, and IPAB proposals go into force automatically unless Congress affirmatively acts to amend or block them within a stated period of time and under circumstances specified in the Act. Section 3403(d) of the Act establishes special “fast track” parliamentary procedures governing House and Senate committee consideration, and Senate floor consideration, of legislation implementing the Board or Secretary’s proposal. These procedures differ from the parliamentary mechanisms the chambers usually use to consider most legislation and are designed to ensure that Congress can act promptly on the implementing legislation should it choose to do so. PPACA also established a second “fast track” parliamentary mechanism for consideration of legislation discontinuing the automatic implementation process for the recommendations of the Board.

The Board’s charge is to develop proposals for the Secretary to implement that reduce the per capita growth in Medicare expenditures, not to reduce Medicare expenditures. Therefore, while the Congressional Budget Office projects that the cumulative impact of the Board’s recommendations from 2015 through 2019 will reduce total spending by $15.5 billion, during the same period, Medicare expenditures will total $3.9 trillion with average spending per beneficiary forecast to increase from $13,374 to $15,749. While the Board’s potential impact on total expenditures is likely to be relatively small compared to overall Medicare expenditures, its impact on particular Medicare providers or suppliers may be significant, particularly if the Board alters payment mechanisms. Finally, the Board’s impact may be larger if private insurers continue to track Medicare payment policies and adopt similar reductions in payments to their providers and suppliers.



Date of Report: April 18, 2011
Number of Pages: 39
Order Number: R41511
Price: $29.95

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Wednesday, April 27, 2011

Teenage Pregnancy Prevention: Statistics and Programs


Carmen Solomon-Fears
Specialist in Social Policy

In 2009, U.S. teen births accounted for 10.1% of all births and 21.4% of all nonmarital births. The birth rate for U.S. teenagers (ages 15 through 19) increased in 2006 and 2007 after a steady decline since 1991. However, in 2008 and 2009 the teen birth rate dropped below the 2007 teen birth rate, reversing the two-year upward trend. Although the birth rate for U.S. teens has dropped in 16 of the last 18 years, it remains higher than the teenage birth rate of most industrialized nations. In recognition of the negative, long-term consequences associated with teenage pregnancy and births, the prevention of teenage and out-of-wedlock childbearing is a major goal of this nation.

The Adolescent Family Life (AFL) program, created in 1981 (Title XX of the Public Health Services Act), was the first federal program to focus on adolescents. It was created to support demonstration projects that provide comprehensive and innovative health, education, and social services to pregnant and parenting adolescents, their infants, male partners, and their families. From 1998 to 2009, federal teen pregnancy prevention efforts in the AFL program and in general relied heavily on using abstinence-only education as their primary tool.

It appears that a consensus is now growing around the viewpoint that success in the teen pregnancy prevention arena does not necessarily have to be an “either-or” proposition in which abstinence-only education programs are pitted against comprehensive sex education programs. P.L. 111-117 (the Consolidated Appropriations for FY2010) included a new discretionary Teen Pregnancy Prevention (TPP) program, funded at $110 million for FY2010, which provides grants and contracts, on a competitive basis, to public and private entities to fund “medically accurate and age appropriate” programs that reduce teen pregnancy.

P.L. 111-148 (the health care reform law) established a new state formula grant program and appropriated $375 million at $75 million per year for five years (FY2010-FY2014) to enable states to operate a new Personal Responsibility Education Program (PREP), which is a comprehensive approach to teen pregnancy prevention that educates adolescents on both abstinence and contraception to prevent pregnancy and sexually transmitted diseases. PREP also provides youth with information on several adulthood preparation subjects (e.g., healthy relationships, adolescent development, financial literacy, parent-child communication, educational and career success, and healthy life skills).

The Title V Abstinence Education Block Grant to states was authorized under P.L. 104-193 (the 1996 welfare reform law). The Title V Abstinence Education program is formula grant program, specifically for abstinence-only education, funded by mandatory spending. The program’s funding expired on June 30, 2009, but P.L. 111-148 reauthorized the program and restored funding to it at the previous annual level of $50 million for each of FY2010-FY2014.

There are many other federal programs that can provide pregnancy prevention information and/or services to teens. They include Title X Family Planning, Medicaid family planning, the Maternal and Child Health block grant, the Title XX Social Services block grant, the TANF block grant, and several other Department of Health and Human Services (HHS) programs. This report briefly examines some of the data collected by the National Center for Health Statistics on teenage childbearing, offers potential reasons for high teen pregnancy and birth rates, and provides basic information on federal programs whose purpose, in whole or part, is to prevent teen pregnancy and reduce teen births.



Date of Report: April 22, 2011
Number of Pages: 20
Order Number: RS20301
Price: $29.95

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Dependent Care: Current Tax Benefits and Legislative Issues


Janemarie Mulvey
Specialist in Aging and Income Security

Christine Scott
Specialist in Social Policy


In the 2000 census, for more than 60% of the households with children under the age of six, all parents in the household worked. Some private surveys show that nearly 40% of those caring for aging parents and older individuals worked. For families, care for young children and older individuals who are physically or mentally unable to care for themselves is critical to maintaining participation in the workforce. To assist these families, current law provides two tax benefits related to dependent care: the dependent care credit and the exclusion from income for employerprovided dependent care assistance programs. Both provisions are for employment-related expenses for the care of dependents under the age of 13, or dependents (or a spouse) who are physically or mentally incapable of caring for themselves.

Some of the current tax provisions that were expanded in 2001 are set to expire December 31, 2012. These changes include increases for the 
  • maximum credit rate for the dependent care tax credit (DCTC) from 30% to 35%; 
  • income level at which the credit rate for the DCTC phases down from $10,000 to $15,000; and 
  • maximum amount of qualifying expenses from $2,400 to $3,000 for one child and from $4,800 to $6,000 for two or more children. 
In addition, the FY2012 Budget released by the Obama Administration in February 2011 proposes to increase the DCTC for families earning between $15,000 and $103,000 annually.

This report discusses current tax treatment of dependent care expenses under the DCTC and the dependent care assistance programs (DCAP), and issues for Congress in expanding tax benefits for working caregivers (including President Obama’s Budget proposal).



Date of Report: April 21, 2011
Number of Pages: 13
Order Number: RS21466
Price: $29.95

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Tuesday, April 26, 2011

Title X (Public Health Service Act) Family Planning Program

Angela Napili
Information Research Specialist

The federal government provides grants for voluntary family planning services through the Family Planning Program, Title X of the Public Health Service Act, codified at 42 U.S.C. § 300 to § 300a-6. The program, enacted in 1970, is the only domestic federal program devoted solely to family planning and related preventive health services. Title X is administered through the Office of Population Affairs (OPA) under the Office of the Assistant Secretary for Health in the Department of Health and Human Services (DHHS).

Although the authorization for Title X ended with FY1985, funding for the program has continued to be provided through appropriations bills for the Departments of Labor, Health and Human Services, and Education, and Related Agencies (Labor-HHS-Education). Within DHHS, Title X receives its funding through the Health Resources and Services Administration (HRSA) account.

P.L. 112-8, the Further Additional Continuing Appropriations Amendments, 2011, provides temporary FY2011 funding through April 15, 2011, at the FY2010 rate of operations and under the same conditions as in FY2010. These conditions include that Title X funds not be spent on abortions, that all pregnancy counseling be nondirective, and that funds not be spent on promoting or opposing any legislative proposal or candidate for public office. Grantees must also certify that they encourage “family participation” when minors decide to seek family planning services, and must certify that they counsel minors on how to resist attempted coercion into sexual activity. Appropriations law also clarifies that family planning providers are not exempt from state notification and reporting laws on child abuse, child molestation, sexual abuse, rape, or incest. H.R. 1473, the Department of Defense and Full-Year Continuing Appropriations Act, 2011, would provide $299.4 million for Title X in FY2011, a 6% decrease from the FY2010 funding level of $317.491 million.

The law (42 U.S.C. § 300a-6) prohibits the use of Title X funds in programs where abortion is a method of family planning. According to OPA, family planning projects that receive Title X funds are closely monitored to ensure that federal funds are used appropriately and that funds are not used for prohibited activities such as abortion. The prohibition on abortion does not apply to all the activities of a Title X grantee, but only to activities that are part of the Title X project. A grantee’s abortion activities must be “separate and distinct” from the Title X project activities.

In addition to H.R. 1473 mentioned above, several bills addressing Title X have been introduced in the 112
thCongress. H.R. 217, the Title X Abortion Provider Prohibition Act, and S. 96, the Title X Family Planning Act, would prohibit Title X grants to abortion-performing entities. H.R. 408 and S. 178, both called the Spending Reduction Act of 2011, would eliminate the Title X program. H.Con.Res. 36 would prohibit funds under H.R. 1473 from being made available “for any purpose” to the Planned Parenthood Federation of America (PPFA) or its affiliates. H.R. 1, as passed in the House, would eliminate funding for Title X for the remainder of FY2011 and would prohibit the bill’s funds from being made to PPFA or to any of 102 PPFA affiliates and offices listed in the bill. H.R. 1099, the Taxpayers’ Freedom of Conscience Act, would prohibit federal officials from expending federal funds for “any population control or population planning program or any family planning activity.” H.R. 1135/H.R. 1167, the Welfare Reform Act of 2011, would define “means-tested welfare” programs to include family planning and would require an overall spending limit on means-tested welfare programs.


Date of Report: April 13, 2011
Number of Pages: 24
Order Number: RL33644
Price: $29.95

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Monday, April 25, 2011

The Ryan White HIV/AIDS Program


Judith A. Johnson
Specialist in Biomedical Policy

The Ryan White HIV/AIDS Program makes federal funds available to metropolitan areas and states to assist in health care costs and support services for individuals and families affected by the human immunodeficiency virus (HIV) or acquired immune deficiency syndrome (AIDS). The Ryan White program currently serves more than half a million low-income people with HIV/AIDS in the United States; 33% of those served are uninsured, and an additional 56% are underinsured. The program is administered by the Health Resources and Services Administration (HRSA) of the Department of Health and Human Services (HHS). Its statutory authority is Title XXVI of the Public Health Service (PHS) Act, originally enacted in 1990.

The Ryan White program is composed of four major parts and several other components. Part A provides grants to urban areas and mid-sized cities. Part B provides grants to states and territories; it also provides funds for the AIDS Drug Assistance Program (ADAP). Part C provides early intervention grants to public and private nonprofit entities. Part D provides grants to public and private nonprofit entities for family-centered care for women, infants, children, and youth with HIV/AIDS. The other components, sometimes referred to as Part F, include the AIDS Dental Reimbursement (ADR) Program, the Community-Based Dental Partnership Program, the AIDS Education and Training Centers (AETCs), the Special Projects of National Significance (SPNS) Program, and the Minority AIDS Initiative (MAI).

In October 2009, the 111
th Congress passed and President Obama signed the Ryan White HIV/AIDS Treatment Extension Act of 2009 (P.L. 111-87), which reauthorized the Ryan White program through September 30, 2013. P.L. 111-87 maintains the hold-harmless provision for Part A and Part B and provides a continuation of the transition period for states that do not have a fully mature name-based HIV reporting system. The law requires that the Secretary establish a national HIV/AIDS testing goal of 5 million tests annually through programs administered by HRSA and the Centers for Disease Control and Prevention (CDC). It requires the Part A Planning Councils to develop a strategy for identifying individuals with HIV/AIDS who do not know their HIV status, making them aware of their status and connecting them with health care and support services. It also requires the Part B grant application to provide a comprehensive plan for the identification of such individuals and enable their access to medical treatment.

The Patient Protection and Affordable Care Act (PPACA, P.L. 111-148) contains general provisions to increase access to health insurance and which, therefore, will increase coverage for people living with HIV/AIDS. PPACA includes prohibitions on the cancellation of coverage by an insurer due to a preexisting condition, elimination of lifetime caps on insurance benefits and annual limits on coverage, and eligibility for tax subsidies to assist low- and middle-income individuals in the purchase of coverage from state health insurance exchanges. In addition, Medicaid eligibility will be broadened to include single adults, and PPACA phases out the Medicare Part D doughnut hole for HIV/AIDS individuals who are Medicare eligible.

The Ryan White program is currently operating under an interim FY2011 continuing resolution. The Continuing Appropriations Act, 2011 (P.L. 111-242), as amended, provides temporary FY2011 funding through April 8, 2011, at the FY2010 rate of operations. On February 19, 2011, the House passed H.R. 1, the Full-Year Continuing Appropriations Act, 2011. An amendment to H.R. 1 provides an additional $42 million for AIDS Drug Assistance Program (ADAP).

For FY2012, the Obama Administration has requested a total of $2.376 billion for the Ryan White program, an increase of $88 million compared with FY2010; most of the increase ($82 million) would go to the ADAP program.



Date of Report: April 5, 2011
Number of Pages: 21
Order Number: RL33279
Price: $29.95

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