The Global Challenge of HIV/AIDS, Tuberculosis, and Malaria

Alexandra E. Kendall
Analyst in Global Health

The spread of human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS), tuberculosis (TB), and malaria across the world poses a major global health challenge. The international community has progressively recognized the humanitarian impact of these diseases, along with the threat they represent to economic development and international security. The United States has historically been a leader in the fight against HIV/AIDS, TB, and malaria; it is currently the largest single donor for global HIV/AIDS and has been central to the global response to TB and malaria. In its second session, the 112th Congress will likely consider HIV/AIDS, TB, and malaria programs during debate on and review of U.S.-supported global programs, U.S. foreign assistance spending levels, and foreign relations authorization bills.

Over the past decade, Congress has demonstrated bipartisan support for addressing HIV/AIDS, TB, and malaria worldwide, authorizing more than $52.5 billion for U.S. global efforts to combat the diseases from FY2001 through FY2012. During this time, Congress supported initiatives proposed by President George W. Bush, including the President’s Emergency Plan for AIDS Relief (PEPFAR) and the President’s Malaria Initiative (PMI), both of which have demonstrated robust U.S. engagement in global health. Through the Global Health Initiative (GHI), President Barack Obama has led efforts to coordinate U.S. global HIV/AIDS, TB, and malaria programs and create an efficient, long-term, and sustainable approach to combating these diseases.

In 2011, there were several significant scientific advancements in global health, including, most notably, evidence that early HIV treatment not only saves lives but can reduce the risk of transmission by 96%. Despite this scientific landmark, and ongoing progress in fighting HIV/AIDS, TB, and malaria, these diseases remain leading global causes of morbidity and mortality. Many health experts urge Congress to capitalize on recent gains and bolster U.S. leadership and funding to combat these diseases. In contrast, some Members of Congress have proposed cuts to these programs as part of deficit reduction efforts.

This report reviews the U.S. response to HIV/AIDS, TB, and malaria and discusses several issues Congress may consider as it debates spending levels and priority areas for related programs. The report includes analysis of: 

·         Funding Trends: Combined funding for the three diseases has increased significantly over the past decade, from approximately $832 million in FY2001 to $7.1 billion in FY2012. The bulk of the increase over time has been targeted toward HIV/AIDS, although in recent years funding for global HIV/AIDS has begun to level off. When compared to FY2011, funding in FY2012 included decreases for global HIV/AIDS, and slight increases for global TB and malaria programs. Some health experts applaud what they see as a shift toward less expensive efforts that maximize health impact. Others experts warn that divestment from HIV/AIDS could significant endanger lives of those reliant on U.S. assistance and could reverse fragile gains made against the epidemic and other diseases. 

·         Disease-Specific Issues: HIV/AIDS, TB, and malaria each present unique challenges. Rising numbers of people in need of life-long HIV/AIDS treatment, as well as new evidence about the preventive benefits of early treatment, has heightened concern over the sustainability of treatment programs and incited debate over the appropriate balance of funding between antiretroviral treatment (ART) and other HIV/AIDS interventions. Growing rates of HIV/TB co-infection and drug-resistant TB strains have increased calls for escalating TB control efforts. Finally, growing resistance to anti-malaria drugs and insecticides threatens malaria control efforts, leading to calls for more attention to reducing resistance and developing new anti-malaria commodities. 

·         Cross-Cutting Issues: Several cross-cutting issues are currently being debated, particularly in relation to increased efficiency and sustainability of HIV/AIDS, TB, and malaria programs under the GHI. These include 

o   Health Systems Strengthening; 

o   Country Ownership in Recipient Countries; 

o   Research and Development; 

o   Monitoring and Evaluation; and 

o   Engagement with Multilateral Organizations. 

For details on particular characteristics of the HIV/AIDS, TB, and malaria epidemics and the U.S. response, see the following CRS reports, by Alexandra E. Kendall. 

·         CRS Report R41645, U.S. Response to the Global Threat of HIV/AIDS: Basic Facts 

·         CRS Report R41643, U.S. Response to the Global Threat of Tuberculosis: Basic Facts 

·         CRS Report R41644, U.S. Response to the Global Threat of Malaria: Basic Facts

Date of Report: February 23, 2012
Number of Pages: 56
Order Number: R41802
Price: $29.95

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Individual Mandate and Related Information Requirements under ACA

Janemarie Mulvey
Specialist in Health Care Financing

This report describes the individual mandate under Section 1501 and Section 10106 of the Patient Protection and Affordable Care Act (ACA, P.L. 111-148), as amended by Section 1002 of the Health Care and Education Reconciliation Act of 2010 (P.L. 111-152). Hereinafter, “ACA” will refer to ACA as amended by the reconciliation act and other laws. In addition, ACA includes several reporting requirements designed, in part, to assist individuals in providing evidence of having met the mandate, as well as other related information about their health insurance. These requirements are also described in this report.

Beginning in 2014, ACA requires individuals to maintain health insurance, with some exceptions. Most individuals will be required to maintain minimum essential coverage, which includes eligible employer coverage, individual coverage, grandfathered plans, and federal programs such as Medicare and Medicaid, among others. Those who do not maintain minimum essential coverage, and who are not exempt from the mandate, will be required to pay a penalty for noncompliance.


Date of Report: February 21, 2012
Number of Pages: 16
Order Number: R41331
Price: $29.95

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Medicare Physician Payment Updates and the Sustainable Growth Rate (SGR) System

Jim Hahn
Specialist in Health Care Financing

Janemarie Mulvey
Specialist in Health Care Financing

The Sustainable Growth Rate (SGR) is the statutory method for determining the annual updates to the Medicare physician fee schedule. The SGR system was established because of the concern that the Medicare fee schedule itself would not adequately constrain overall increases in spending for physicians’ services. While the fee schedule limits the amount that Medicare will pay for each service, there are no limits on the volume or mix of services. Under the SGR formula, if expenditures over a period are less than the cumulative spending target for the period, the annual update is increased. However, if spending exceeds the cumulative spending target over a certain period, future updates are reduced to bring spending back in line with the target.

In the first few years of the SGR system, the actual expenditures did not exceed the targets and the updates to the physician fee schedule were close to the Medicare economic index (MEI, a price index of inputs required to produce physician services). For the next two years, in 2000 and 2001, the actual physician fee schedule update was more than twice the MEI for those years. Beginning in 2002, the actual expenditure exceeded allowed targets, and the discrepancy has grown with each year. However, with the exception of 2002, when a 4.8% decrease was applied, Congress has enacted a series of laws to override the reductions.

There is a growing consensus among observers that the SGR system is fundamentally flawed and is creating instability in the Medicare program for providers and beneficiaries. The SGR system treats all services and physicians equally in the calculation of the annual payment update, which is applied uniformly with no distinction across specialties. In addition, there has been an increased concern that continued declines in physician payment rates, especially among primary care specialties, may potentially jeopardize access to services. Finally, legislative overrides since 2002 have only provided temporary reprieve from projected reductions in payments under the SGR calculation, requiring even steeper reductions in payment rates in the future.

Unless Congress enacts legislation to override projected SGR changes, physician fees would be reduced by 27.4% in calendar year 2012. A one-year freeze to physician payments would cost an estimated $11 billion in FY2012 and $21 billion over 10 years (2012 to 2021), according to the Congressional Budget Office (CBO); a long-term fix such as a repeal of SGR combined with a freeze in physician pay rates over the next 10 years would cost about $290 billion.

On October 14, 2011, the Medicare Payment Advisory Commission (MedPAC) sent its recommendations for addressing the SGR and Medicare physician payments to Congress. The commission recommends that Congress repeal the SGR system and replace it with a 10-year schedule of specified updates for the physician fee schedule. Specifically, primary care practitioners would have a 0% update over the next 10 years, while non-primary care practitioners would experience a 5.9% decline in payment rates the first three years and 0% thereafter. MedPAC estimates this would cost about $200 billion over 10 years and provided some options to offset this cost, spread across other providers and Medicare beneficiaries.

On December 13, 2011, the House passed H.R. 3630, which included a 1% increase in physician fee schedule reimbursements each year for 2012 and for 2013. On December 17, 2011, the Senate passed an amended version of H.R. 3630 that included a two-month override through February 2012, freezing reimbursement rates at 2011 levels. On December 23, 2011, H.R. 3765, which contained a two-month override through February 2012, was passed by both the House and the Senate by unanimous consent and was signed into law. On February 16, 2012, House and Senate conferees came to an agreement on a conference report for H.R. 3630 that extends the override through December 31, 2012, maintaining physician fee schedule payments at the current level.


Date of Report: February 17, 2012
Number of Pages: 24
Order Number: R40907
Price: $29.95

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Community Living Assistance Services and Supports (CLASS) Provisions in the Patient Protection and Affordable Care Act (ACA)

Janemarie Mulvey
Specialist in Health Care Financing

Kirsten J. Colello
Specialist in Health and Aging Policy

Under current law, the majority of paid long-term services and supports (LTSS) are funded by public programs, such as Medicaid and Medicare. However, these programs are limited in scope and continue to face increased financial pressures. Although private long-term care (LTC) insurance is available to provide some financial protection against an individual’s risk of the potentially high cost of LTSS, fewer than 10% of individuals aged 50 and older own such a policy. Thus, for the majority of older Americans, the out-of-pocket cost of obtaining paid help for these services may far exceed their financial resources. The Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended) establishes a federally administered voluntary LTC insurance program entitled the Community Living Assistance Services and Supports (CLASS) program. The stated purpose of the CLASS program, among other things, is to provide a financing mechanism for long-term care services that supports personal choice and independence to live in the community. However, a number of concerns have been raised about the long-run sustainability of the program.

Once the CLASS program is established, employed individuals aged 18 and older can voluntarily enroll in the CLASS program. This is a voluntary program and employers would have the option of participating. The ACA specifies two processes for enrollment into the CLASS program. The first is an automatic enrollment process. Within the automatic enrollment process, employers who choose to participate would be responsible for withholding CLASS premiums through payroll deductions. Employees would then have the opportunity to “opt-out” if they do not want to participate. These enrollment procedures for employers in the CLASS program are intended to be similar to those currently established for 401(k) and other similar retirement plans by the Internal Revenue Service. An alternative enrollment process would also be developed for self-employed individuals, those with more than one employer, and those who have an employer that does not elect to participate in the automatic enrollment process.

Premiums for the CLASS program are to be determined by the Secretary based on 75-year actuarial estimates of expected future use and expenditures. Premiums would vary by age at enrollment. The ACA also includes premium subsidies for workers with incomes below the federal poverty level and full-time students aged 18 to 21 who currently are working. To be eligible to receive benefits an individual must be an active enrollee who meets the five-year vesting and minimum earnings requirements. In addition, an eligible individual must have a functional limitation, as certified by a licensed health care practitioner, that is expected to last for 90 days. Benefits to eligible recipients include a cash benefit of at least an average of $50 a day. Other benefits include advocacy services, and advice and assistance counseling on accessing and coordinating LTSS.

On October 14, 2011, the Department of Health and Human Services (HHS) sent a letter to Congress stating that after careful examination of how the Administration might implement a long-term financially stable CLASS program, HHS does not see a viable path forward for implementation at this time. On February 1, 2012, the House passed H.R. 1173 (as amended), which would repeal the CLASS program. The bill has now been sent to the Senate for consideration. This CRS report first discusses the cost and financing for LTSS and the current market for private LTC insurance. It then details the various CLASS program requirements. Finally, it provides a discussion of the long-run sustainability concerns, the status of implementation, and recent legislative activity.


Date of Report: February 15, 2012
Number of Pages: 20
Order Number: R40842
Price: $29.95

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