- TXT
-
PDF
(PDF provides a complete and accurate display of this text.)
Tip
?
113th Congress Report
HOUSE OF REPRESENTATIVES
1st Session 113-45
======================================================================
HELPING SICK AMERICANS NOW ACT
_______
April 19, 2013.--Committed to the Committee of the Whole House on the
State of the Union and ordered to be printed
_______
Mr. Upton, from the Committee on Energy and Commerce, submitted the
following
R E P O R T
together with
DISSENTING VIEWS
[To accompany H.R. 1549]
[Including cost estimate of the Congressional Budget Office]
The Committee on Energy and Commerce, to whom was referred
the bill (H.R. 1549) to amend Public Law 111-148 to transfer
fiscal year 2013 through fiscal year 2016 funds from the
Prevention and Public Health Fund to carry out the temporary
high risk health insurance pool program for individuals with
preexisting conditions, and to extend access to such program to
such individuals who have had creditable coverage during the 6
months prior to application for coverage through such program,
having considered the same, report favorably thereon with an
amendment and recommend that the bill as amended do pass.
CONTENTS
Page
Purpose and Summary.............................................. 2
Background and Need for Legislation.............................. 3
Hearings......................................................... 3
Committee Consideration.......................................... 4
Committee Votes.................................................. 4
Committee Oversight Findings..................................... 7
Statement of General Performance Goals and Objectives............ 7
New Budget Authority, Entitlement Authority, and Tax Expenditures 7
Earmark, Limited Tax Benefits, and Limited Tariff Benefits....... 7
Committee Cost Estimate.......................................... 7
Congressional Budget Office Estimate............................. 7
Federal Mandates Statement....................................... 13
Duplication of Federal Programs.................................. 13
Disclosure of Directed Rule Makings.............................. 13
Advisory Committee Statement..................................... 13
Applicability to Legislative Branch.............................. 13
Section-by-Section Analysis of the Legislation................... 13
Changes in Existing Law Made by the Bill, as Reported............ 14
Dissenting Views................................................. 16
The amendment is as follows:
Strike all after the enacting clause and insert the
following:
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Helping Sick Americans Now Act''.
SEC. 2. PRIORITIZING FUNDING FOR SICK AMERICANS.
Section 4002(c) of Public Law 111-148 (42 U.S.C. 300u-11(c)) is
amended by adding at the end the following: ``Notwithstanding any other
provision of this section, the Secretary shall transfer amounts that
are in the Fund that are attributable to fiscal year 2013 that are not
otherwise obligated as of the date of the enactment of this sentence
and funds that would otherwise be made available to the Fund for fiscal
year 2014, fiscal year 2015, and fiscal year 2016 to the account within
the Department of Health and Human Services that provides for funding
to carry out the temporary high risk health insurance pool program
under section 1101 and such funds shall become available for obligation
under such section on such date of enactment and remain so available
through December 31, 2013.''.
SEC. 3. IMMEDIATE ACCESS TO HEALTH CARE FOR SICK AMERICANS.
(a) In General.--Section 1101(d) of Public Law 111-148 (42 U.S.C.
18001(d)) is amended--
(1) in paragraph (1), by adding at the end ``and'';
(2) by striking paragraph (2); and
(3) by redesignating paragraph (3) as paragraph (2).
(b) Effective Date.--The amendments made by subsection (a) shall
apply with respect to individuals applying for coverage through the
high risk insurance pool program on or after the date of the enactment
of this Act.
SEC. 4. ENSURING AN ORDERLY REOPENING OF THE PROGRAM FOR SICK
AMERICANS.
Section 1101(b) of Public Law 111-148 (42 U.S.C. 18001(b)) is amended
by adding at the end the following new paragraph:
``(4) Orderly reopening of program.--The Secretary shall
administer this section in accordance with the regulations
under part 152 of title 45, Code of Federal Regulations, as in
effect as of April 16, 2013, except as is necessary to reflect
the amendments made by the Helping Sick Americans Now Act.''.
Purpose and Summary
H.R. 1549, the Helping Sick Americans Now Act, was
introduced on April 15, 2013, by Rep. Joseph R. Pitts (R-PA)
and subsequently referred to the Committee on Energy and
Commerce.
The legislation would amend section 4002 of Public Law 111-
148 to transfer fiscal year 2013 through fiscal year 2016 funds
from the Prevention and Public Health Fund (``Fund'') to carry
out the temporary high risk health insurance pool program for
individuals with preexisting conditions, and to extend access
to such program to such individuals who have had creditable
coverage during the 6 months prior to application for coverage
through such program.
Background and Need for Legislation
Section 1101 of the Patient Protection and Affordable Care
Act (``PPACA'') established a $5 billion program to provide
health coverage for individuals with pre-existing conditions,
otherwise known as the Pre-Existing Condition Insurance Plan
(``PCIP''). Under PCIP, an individual is eligible to
participate in the program if that individual:
has been uninsured for at least six months;
has a pre-existing condition or have been
denied health coverage because of a health condition;
and,
is a United States citizen or legally
resides in the United States.
Shortly after passage of PPACA, the Chief Actuary for the
Centers for Medicare and Medicaid Services (``CMS'' or
``Agency'') estimated that the creation of PCIP would result in
roughly 375,000 people gaining coverage in 2010. However, only
107,139 individuals were enrolled in the program as of January
1, 2013.
On February 15, 2013, CMS announced to States that the
Agency was suspending enrollment in PCIP. This program was
intended to help individuals with pre-existing conditions
through December 31, 2013. Despite lower than expected
enrollment, CMS announced that it would no longer enroll new
individuals in the program and would bar States from accepting
new applications because of financial constraints.
H.R. 1549, the ``Helping Sick Americans Now Act,''
addresses the financial constraints of the PCIP program by
redirecting funds from the Fund toward helping sick patients.
The Secretary of Health and Human Services has broad discretion
on how to use the Fund. In past years, the Fund was spent on
various projects, including public health surveillance, health
workforce development, and prevention. Eliminating the Fund
does not cut any specific program because the Fund was never
directed at a specific program.
H.R. 1549 requires HHS to transfer approximately $4 billion
in fiscal year 2013 through fiscal year 2016 funding from the
Fund to PCIP. This would allow CMS to enroll sick and
chronically ill Americans who have been denied coverage due to
the Administration's suspension of PCIP.
H.R. 1549 also eliminates the statutory requirement for
individuals to remain uninsured for six months as a condition
of eligibility for the PCIP program.
Hearings
The Subcommittee on Health held a hearing on April 3, 2013,
entitled ``Protecting America's Sick and Chronically Ill.''
This hearing examined problems with the Patient Protection and
Affordable Care Act's Pre-Existing Condition Insurance Plan
(PCIP) and explored ways to help Americans with pre-existing
conditions obtain affordable health coverage.
Committee Consideration
On April 17, 2013, the full Committee met in open markup
session and approved H.R. 1549, as amended, by a recorded vote
of 27 yeas and 20 nays.
Committee Votes
Clause 3(b) of rule XIII of the Rules of the House of
Representatives requires the Committee to list the record votes
on the motion to report legislation and amendments thereto. Ms.
Capps offered an amendment to strike section 2, Prioritizing
Funding for Sick Americans. The amendment was not agreed to by
a roll call vote of 22 yeas and 27 nays. A motion by Mr. Upton
to order H.R. 1549 reported to the House, as amended, was
agreed to by a roll call vote of 27 yeas and 20 nays.
The following reflects the recorded votes taken during the
Committee consideration:
Committee Oversight Findings
Pursuant to clause 3(c)(1) of rule XIII of the Rules of the
House of Representatives, the Committee has not held oversight
or legislative hearings on this legislation.
Statement of General Performance Goals and Objectives
The goal of the legislation is to provide health insurance
coverage for those with pre-existing conditions.
New Budget Authority, Entitlement Authority, and
Tax Expenditures
In compliance with clause 3(c)(2) of rule XIII of the Rules
of the House of Representatives, the Committee finds that H.R.
1549, would result in no new or increased budget authority,
entitlement authority, or tax expenditures or revenues.
Earmark, Limited Tax Benefits, and Limited Tariff Benefits
In compliance with clause 9(e), 9(f), and 9(g) of rule XXI
of the Rules of the House of Representatives, the Committee
finds that H.R. 1549, Helping Sick Americans Now Act, contains
no earmarks, limited tax benefits, or limited tariff benefits.
Committee Cost Estimate
The Committee adopts as its own the cost estimate prepared
by the Director of the Congressional Budget Office pursuant to
section 402 of the Congressional Budget Act of 1974.
Congressional Budget Office Estimate
Pursuant to clause 3(c)(3) of rule XIII of the Rules of the
House of Representatives, the following is the cost estimate
provided by the Congressional Budget Office pursuant to section
402 of the Congressional Budget Act of 1974:
April 19, 2013.
Hon. Fred Upton,
Chairman, Committee on Energy and Commerce,
House of Representatives, Washington, DC.
Dear Mr. Chairman: The Congressional Budget Office has
prepared the enclosed cost estimate for H.R. 1549, the Helping
Sick Americans Now Act.
If you wish further details on this estimate, we will be
pleased to provide them. The CBO staff contact is Lisa Ramirez-
Branum.
Sincerely,
Douglas W. Elmendorf,
Director.
Enclosure.
H.R. 1549--Helping Sick Americans Now Act
Summary: H.R. 1549 would amend the Public Health Service
Act to direct the Secretary of the Department of Health and
Human Services (HHS) to transfer unobligated amounts from the
Prevention and Public Health Fund (PPHF) for fiscal years 2013
through 2016 to help carry out a program that provides
temporary health insurance for qualified individuals with pre-
existing health conditions.
Based on the historical spending patterns of both the PPHF
and the Pre-Existing Condition Insurance Plan (PCIP), CBO
estimates that enacting the legislation would result in a
decrease in net direct spending of $840 million over the 2013-
2023 period; therefore, pay-as-you-go procedures apply.
Enacting H.R. 1549 would not affect revenues.
H.R. 1549 contains no intergovernmental or private-sector
mandates as defined in the Unfunded Mandates Reform Act (UMRA).
Estimated cost to the Federal Government: The estimated
budgetary impact of H.R. 1549 is shown in the following table.
The costs of this legislation fall within budget function 550
(health).
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
By fiscal year, in Millions of Dollars--
-----------------------------------------------------------------------------------------------------------------------------------
2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2013-2018 2013-2023
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
CHANGES IN DIRECT SPENDING
Prevention and Public Health Funds:
Estimated Budget Authority.............................. -840 -930 -930 -930 0 0 0 0 0 0 0 -3,630 -3,630
Estimated Outlays....................................... -180 -430 -740 -900 -720 -470 -160 -10 0 0 0 -3,440 -3,610
Pre-Existing Insurance Program:
Estimated Budget Authority.............................. 3,630 0 0 0 0 0 0 0 0 0 0 3,630 3,630
Estimated Outlays....................................... 2,350 430 0 0 0 0 0 0 0 0 0 2,780 2,780
Net Impact:
Estimated Budget Authority.............................. 2,780 -930 -930 -930 0 0 0 0 0 0 0 0 0
Estimated Outlays....................................... 2,160 0 -740 -900 -720 -470 -160 -10 0 0 0 -670 -840
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Note: Components may not sum to total because of rounding.
Basis of estimate: Under current law, $1 billion per year
has been provided to the PPHF for fiscal years 2013 through
2017. (In later years, that amount increases gradually to $2
billion per year.) H.R. 1549 would direct the Secretary of HHS
to transfer any unobligated amounts from that fund for fiscal
years 2013 through 2016 to help carry out the PCIP program. CBO
estimates that about $3.7 billion of those funds would be
available after accounting for the effects of sequestration
under the Budget Control Act of 2011. (Following procedures
under that act, $51 million of the funds for the PPHF were
cancelled in 2013, and CBO estimates that an additional $210
million will be cancelled in fiscal years 2014 through 2016.)
In addition, assuming enactment of H.R. 1549 in the spring of
2013, an estimated $0.1 billion of 2013 funds will already be
obligated before such enactment.\1\ Thus, CBO estimates that
enacting the legislation would transfer a total of $3.6 billion
out of the fund, and thus decrease direct spending under the
PPHF by $3.6 billion over the 2013-2023 period.
---------------------------------------------------------------------------
\1\If H.R. 1549 were to be enacted later in fiscal year 2013, CBO
would expect that more of the balance of funds in the PPHF for 2013
would be obligated and thereby unavailable to transfer to the PCIP
program. In addition, enacting the bill later in the year would reduce
the number of months remaining between the enactment date and before
January 1, 2014, when the PCIP program is set to expire. As a result,
it would cost less to fund that program. Therefore, a later enactment
could result in lower estimated savings.
---------------------------------------------------------------------------
CBO estimates that the availability of an additional $3.6
billion for the PCIP program would result in an increase in
direct spending for that program of about $2.8 billion; that
amount is less than the amount of transferred funds in part
because the authority for PCIP terminates in early 2014.
Combining the decreased spending from the PPHF and the
increased spending in the PCIP program, CBO estimates that
enacting H.R. 1549 would, on net, reduce direct spending by
$840 million over the 2013-2023 period.
Prevention and Public Health Fund: As established, the PPHF
provides grant assistance to entities to carry out prevention,
wellness, and public health activities. Taking into account the
expected reductions in the PPHF due to the sequestration under
the Budget Control Act (about $260 million over the 2013-2016
period), CBO estimates that $3.7 billion would be available for
such grants over the 2013-2016 period. Historically, several
agencies within the Department of Health and Human Services
award those grants in the last quarter of each fiscal year. CBO
estimates that approximately $100 million will be obligated via
grant and contract agreements and thus will be unavailable to
transfer to the PCIP program by the time H.R. 1549 is assumed
to be enacted. As a result, CBO estimates that enacting H.R.
1549 would reduce direct spending under the PPHF by $3.6
billion over the 2013-2023 period.
Pre-Existing Condition Insurance Plan: The Patient
Protection and Affordable Care Act (ACA) appropriated $5
billion for the creation of the PCIP program to provide access
to health insurance to qualified individuals who were unable to
acquire coverage because of a pre-existing condition. The
temporary program is set to end on January 1, 2014, when
broader reforms enacted under the ACA go into effect. The ACA
also required the Secretary of HHS to make adjustments to the
PCIP program if in any fiscal year the estimated aggregate
spending would exceed the amount appropriated. To ensure that
aggregate spending would not exceed those amounts, the
Secretary announced in February that the PCIP program would
suspend enrollment.
H.R. 1549 would provide funding to re-open enrollment for
the PCIP program. In addition, the bill would remove a
provision of the ACA that requires qualified individuals to be
uninsured for six months prior to the date on which such
individuals apply for coverage through PCIP. Based on
enrollment trends and reported denial rates due to prior
insurance coverage, CBO estimates that H.R. 1549 would increase
direct spending under the PCIP program by $2.8 billion over the
2013-2023 period.
Pay-As-You-Go Considerations: The Statutory Pay-As-You-Go
Act of 2010 establishes budget-reporting and enforcement
procedures for legislation affecting direct spending or
revenues. The net changes in outlays that are subject to those
pay-as-you-go procedures are shown in the following table.
CBO ESTIMATE OF PAY-AS-YOU-GO EFFECTS FOR H.R. 1549, AS ORDERED REPORTED BY THE HOUSE COMMITTEE ON ENERGY AND COMMERCE ON APRIL 17, 2013
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
By fiscal year, in millions of dollars
--------------------------------------------------------------------------------------------------------------------------------------------------
2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2013-2018 2013-2023
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
NET INCREASE OR DECREASE (-) IN THE DEFICIT
Statutory Pay-As-You-Go Impact............... 2,160 0 -740 -900 -720 -470 -160 -10 0 0 0 -670 -840
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Intergovernmental and private-sector impact: H.R. 1549
contains no intergovernmental or private-sector mandates as
defined in UMRA. By transferring funds from PPHF to the PCIP
program, the bill would provide additional funds to the 27
states that chose to operate the PCIP program. Nonetheless, the
bill would decrease the amount of resources that state, local,
and tribal governments receive to conduct prevention, wellness,
and public health activities.
Estimate prepared by: Federal Costs: Lisa Ramirez-Branum;
Impact on State, Local, and Tribal Governments: Lisa Ramirez-
Branum; Impact on the Private Sector: Michael Levine.
Estimated approved by: Peter H. Fontaine, Assistant
Director for Budget Analysis.
Federal Mandates Statement
The Committee adopts as its own the estimate of Federal
mandates prepared by the Director of the Congressional Budget
Office pursuant to section 423 of the Unfunded Mandates Reform
Act.
Duplication of Federal Programs
No provision of H.R. 1549 establishes or reauthorizes a
program of the Federal Government known to be duplicative of
another Federal program, a program that was included in any
report from the Government Accountability Office to Congress
pursuant to section 21 of Public Law 111-139, or a program
related to a program identified in the most recent Catalog of
Federal Domestic Assistance.
Disclosure of Directed Rule Makings
The Committee estimates that enacting H.R. 1549 would not
direct specific rule making within the meaning of 5 U.S.C. 551.
Advisory Committee Statement
No advisory committees within the meaning of section 5(b)
of the Federal Advisory Committee Act were created by this
legislation.
Applicability to Legislative Branch
The Committee finds that the legislation does not relate to
the terms and conditions of employment or access to public
services or accommodations within the meaning of section
102(b)(3) of the Congressional Accountability Act.
Section-by-Section Analysis of the Legislation
Section 1. Short title
Section 1 provides the short title of the ``Helping Sick
Americans Now Act.''
Section 2. Prioritizing funding for sick Americans
Section 2 requires the Secretary to transfer fiscal years
2013, 2014, 2015, and 2016 funds from the Fund to support the
temporary high risk health insurance pool program to help
Americans with pre-existing conditions.
Section 3. Immediate access to health care for sick Americans
Section 3 eliminates the requirement for individuals to go
without coverage for six months in order to gain eligibility
for the program.
Changes in Existing Law Made by the Bill, as Reported
In compliance with clause 3(e) of rule XIII of the Rules of
the House of Representatives, changes in existing law made by
the bill, as reported, are shown as follows (existing law
proposed to be omitted is enclosed in black brackets, new
matter is printed in italic, existing law in which no change is
proposed is shown in roman):
PATIENT PROTECTION AND AFFORDABLE CARE ACT
(Public Law 111-148)
* * * * * * *
TITLE I--QUALITY, AFFORDABLE HEALTH CARE FOR ALL AMERICANS
* * * * * * *
Subtitle B--Immediate Actions to Preserve and Expand Coverage
SEC. 1101. IMMEDIATE ACCESS TO INSURANCE FOR UNINSURED INDIVIDUALS WITH
A PREEXISTING CONDITION.
(a) * * *
(b) Administration.--
(1) * * *
* * * * * * *
(4) Orderly reopening of program.--The Secretary
shall administer this section in accordance with the
regulations under part 152 of title 45, Code of Federal
Regulations, as in effect as of April 16, 2013, except
as is necessary to reflect the amendments made by the
Helping Sick Americans Now Act.
* * * * * * *
(d) Eligible individual.--An individual shall be deemed to be
an eligible individual for purposes of this section if such
individual--
(1) is a citizen or national of the United States or
is lawfully present in the United States (as determined
in accordance with section 1411); and
[(2) has not been covered under creditable coverage
(as defined in section 2701(c)(1) of the Public Health
Service Act as in effect on the date of enactment of
this Act) during the 6-month period prior to the date
on which such individual is applying for coverage
through the high risk pool; and]
[(3)] (2) has a pre-existing condition, as determined
in a manner consistent with guidance issued by the
Secretary.
* * * * * * *
TITLE IV--PREVENTION OF CHRONIC DISEASE AND IMPROVING PUBLIC HEALTH
Subtitle A--Modernizing Disease Prevention and Public Health Systems
* * * * * * *
SEC. 4002. PREVENTION AND PUBLIC HEALTH FUND.
(a) * * *
* * * * * * *
(c) Use of Fund.--The Secretary shall transfer amounts in the
Fund to accounts within the Department of Health and Human
Services to increase funding, over the fiscal year 2008 level,
for programs authorized by the Public Health Service Act, for
prevention, wellness, and public health activities including
prevention research, health screenings, and initiatives, such
as the Community Transformation grant program, the Education
and Outreach Campaign Regarding Preventive Benefits, and
immunization programs. Notwithstanding any other provision of
this section, the Secretary shall transfer amounts that are in
the Fund that are attributable to fiscal year 2013 that are not
otherwise obligated as of the date of the enactment of this
sentence and funds that would otherwise be made available to
the Fund for fiscal year 2014, fiscal year 2015, and fiscal
year 2016 to the account within the Department of Health and
Human Services that provides for funding to carry out the
temporary high risk health insurance pool program under section
1101 and such funds shall become available for obligation under
such section on such date of enactment and remain so available
through December 31, 2013.
* * * * * * *
DISSENTING VIEWS
We, the undersigned members of the Committee on Energy and
Commerce, oppose the passage of H.R. 1549, the Helping Sick
Americans Now Act, a bill to extend the Affordable Care Act
(ACA)'s temporary high-risk insurance pool program for
individuals with pre-existing conditions through the depletion
of funds from the ACA's Prevention and Public Health Fund.
Accordingly, we submit the following comments to express our
concerns about this legislation.
INTRODUCTION
Prior to the enactment of the ACA,\1\ insurers regularly
denied health care coverage to people with chronic or life-
threatening diseases such as diabetes, asthma, cancer, and HIV/
AIDS or offered them coverage at prices so high as to make it
effectively unavailable.\2\ As a result, many of the people
most in need of access to medical care found that they could
not obtain insurance to cover the cost of that care.
---------------------------------------------------------------------------
\1\The ACA is comprised of two public laws, Pub. L. No. 111-148
(2010) and Pub. L. No. 111-152 (2010).
\2\House Committee on Energy and Commerce, Coverage Denials for
Pre-Existing Conditions in the Individual Health Insurance Market,
111th Cong. (2010).
---------------------------------------------------------------------------
When the ACA is fully implemented in 2014, insurers will be
prohibited from discriminating against individuals with pre-
existing conditions, and those individuals will be able to
choose from a variety of health insurance coverage options. In
the immediate term, the ACA banned discrimination against
children with pre-existing conditions as of plan years
beginning on or after September 23, 2010. As a bridge to 2014
for adults with pre-existing conditions, the ACA created a
temporary high-risk pool known as the Pre-Existing Condition
Insurance Plan (PCIP) and provided $5 billion to cover the
program's costs.\3\
---------------------------------------------------------------------------
\3\ACA, Section 1101.
---------------------------------------------------------------------------
The PCIP program is authorized under the ACA as a
temporary, transitional program to provide health insurance
coverage to individuals who have been diagnosed with a pre-
existing condition and have been without health coverage for at
least six months.\4\ The ACA authorized to be appropriated and
appropriated $5 billion to pay beneficiary claims and cover
administrative costs that exceeded premiums collected from
enrollees in PCIP. The law also gave the Secretary of the
Department of Health and Human Services (HHS) authority to stop
accepting applications before the program's termination date of
December 31, 2013, and make other adjustments in order to
ensure that program costs did not exceed the $5 billion in
available funding.
---------------------------------------------------------------------------
\4\Id.
---------------------------------------------------------------------------
PCIP PROGRAM
Background
The ACA makes PCIP coverage available to U.S. citizens and
legal residents who have a pre-existing medical condition or
have been denied health insurance coverage because of their
health status and have been without health insurance for at
least six months. To extend coverage to those eligible, states
may either create their own programs or allow the federal
government to manage their programs. Twenty-seven states have
elected to run their own programs; the Center for Consumer
Information and Insurance Oversight (CCIIO) (within the Centers
for Medicare and Medicaid Services (CMS)) administers a single
insurance program covering eligible citizens and legal
residents of the remaining 23 states and the District of
Columbia (D.C.).\5\
---------------------------------------------------------------------------
\5\Center for Consumer Information and Insurance Oversight,
Covering People with Pre-Existing Conditions: Report on the
Implementation and Operation of the Pre-Existing Condition Insurance
Plan Program (Jan. 31, 2013) (online at http://cciio.cms.gov/resources/
files/pcip_annual_report_01312013.pdf).
---------------------------------------------------------------------------
The federally-administered PCIP program began accepting
applications for enrollment on July 1, 2010. The state-
administered programs began accepting applications between
August and October of 2010. Over the past three years, PCIP has
provided coverage to 135,000 previously-uninsured Americans
with severe and costly health care needs. CMS has closely
monitored PCIP enrollment and costs since the program's
inception and made adjustments to premiums and provider payment
rates to ensure that the program's costs did not exceed the $5
billion appropriation, while providing coverage that met the
affordability requirements outlined in the ACA.\6\
---------------------------------------------------------------------------
\6\Id.
---------------------------------------------------------------------------
Insuring a pool of policyholders with pre-existing
conditions is costly. By definition, this population has a
high-claims history, and the market rate for their coverage has
made it unaffordable where it is even available. The purpose of
PCIP is to offer coverage to these individuals at the same
market-based premiums available to individuals without pre-
existing conditions. As a result, the premiums PCIP enrollees
pay were never expected to cover the entire cost of insuring
them; the $5 billion in federal subsidies were designed to make
up the difference.\7\
---------------------------------------------------------------------------
\7\HealthCare.gov, State by State Enrollment in the Pre-Existing
Condition Insurance Plan (online at http://www.healthcare.gov/news/
factsheets/2012/11/pcip11162012a.html) (accessed Apr. 19, 2013).
---------------------------------------------------------------------------
The average cost per PCIP enrollee in 2012 was $32,108 per
year and varied widely by state, from a low of $4,276 per
enrollee to a high of $171,909 per enrollee. Not only do costs
vary by state, they also vary per enrollee. In one year, 4.4
percent of PCIP enrollees accounted for over 50% of claims
paid.\8\
---------------------------------------------------------------------------
\8\Supra, footnote 5.
---------------------------------------------------------------------------
CMS has implemented several changes to manage the program's
growth and its share of claims cost. In August 2012, CMS also
reduced the negotiated and out-of-network payment rates for
providers in the federally-administered PCIP, and negotiated
additional discounts on reimbursement rates for hospitals that
were treating a disproportionate number of PCIP enrollees. CMS
changed the coverage of specialty drugs, requiring that only
pharmacies and providers that are most cost effective be
allowed to dispense specialty drugs. To help control costs for
2013, the three benefit plan options were merged into one,
increasing the maximum out-of-pocket limit from $4,000 to
$6,250. CMS is conducting clinical and non-clinical assessments
to ensure that the 27 state-based and federally-administered
PCIPs are abiding by all the program's regulations.\9\
---------------------------------------------------------------------------
\9\Supra, footnote 5.
---------------------------------------------------------------------------
On February 15, 2013, CMS announced that the PCIP program
was temporarily suspending new enrollment in order to be
certain that there would be sufficient resources to provide
coverage for existing enrollees through the end of 2013. The
federally-run PCIP program operating in 23 states and D.C.
could accept and process all applications received on or before
February 15, 2013. State-based PCIPs could continue accepting
enrollment applications through March 2, 2013.\10\
---------------------------------------------------------------------------
\10\HealthCare.gov, PCIP--Enrollment Suspension (Feb. 15, 2013)
(online at www.pcip.gov/).
---------------------------------------------------------------------------
PCIP Program Not a Long-Term Solution
While it is a welcome development that Republicans are now
willing to join with Democrats to support the ACA's PCIP
program, it is important to note that high-risk pools are not a
long-term solution to reform the individual health insurance
market.
Starting in the 1970s, states opened their own high-risk
pools for individuals who were unable to get insurance or who
were charged unaffordable premiums in the individual market. By
2011, 35 states were operating pools, yet only 226,000 people
were covered nationwide. Enrollment, premiums, and deductibles
vary drastically across the country. Thirty state high-risk
pools have maximum lifetime benefit limits, five impose annual
benefit limits, and all have waiting periods for individuals
with pre-existing conditions. Many of these states have
struggled to make up the difference between premiums and claims
costs. Often costs are reduced by limiting enrollment;
enforcing waiting periods for individuals with pre-existing
conditions; and increasing premiums, deductibles, and co-
payments.\11\
---------------------------------------------------------------------------
\11\National Association of State Comprehensive Health Insurance
Plans (online at http://naschip.org/portal/
index.php?option=com_content&view;=article&id;=230) (accessed Mar. 30,
2013).
---------------------------------------------------------------------------
Republicans have long been supporters of high-risk
insurance pools like those created by PCIP and have advocated
expanding high-risk pools as part of their plan to ``repeal and
replace'' the ACA. Indeed, during consideration of the ACA,
House Republicans proposed $25 billion in funding to expand
state high-risk pools and reinsurance programs.\12\ Their
legislation attempted to place some limits on premiums in high-
risk pools and eliminate existing waiting lists but did not
provide for a sustainable funding mechanism or premium
assistance for enrollees. Furthermore, the legislation would
have allowed widespread discrimination on the basis of pre-
existing conditions to continue unabated in the private market
and would have had little impact on the number of uninsured
Americans.\13\
---------------------------------------------------------------------------
\12\H.R. 4038, 111th Cong. (2009).
\13\Republicans Eye Costs, Not the Uninsured, Politico (Jan. 24,
2011) (online at www.politico.com/news/stories/0111/48033.html).
---------------------------------------------------------------------------
The PCIP model was based on existing state high-risk pools
but included key additional enrollee protections such as limits
on out-of-pocket spending, protections against excessive
premium rating, a guarantee that at least 65% of claims cost
would be paid, immediate coverage for individuals with pre-
existing conditions, and a broad range of health benefits.
However, PCIP has experienced higher-than-expected claims cost
per enrollee because most PCIP enrollees have serious health
conditions and have gone untreated for a long period of time.
Similar to the state high-risk pools, there is also a large gap
between premiums and claims costs in PCIP. This difference
between premiums and claims costs is a persistent problem for
high-risk pools because they inherently lack a diverse group of
enrollees.\14\
---------------------------------------------------------------------------
\14\J. Hall and J. Moore, The Commonwealth Fund, Realizing Health
Reform's Potential (Sept. 2012) (online at www.commonwealthfund.org/ /
media/Files/Publications/Issue%20Brief/2012/Sep/
1627_Hall_PCIP_enrollment_costs_lessons_rb.pdf).
---------------------------------------------------------------------------
The ``Marketplaces'' (or Exchanges) that will be launched
in 2014, combined with the Medicaid expansion and comprehensive
ACA insurance market reforms, will offer a much more stable and
affordable health insurance market. This is especially true for
individuals with pre-existing conditions or serious health
needs, who will no longer be denied coverage when they seek it
on the open market. It is expected that within five years, 27
million people will gain coverage through Marketplaces, many of
whom will be eligible for significant assistance with their
premium costs.\15\ The broader risk pooling and premium
assistance made possible through the Marketplaces will allow
individuals with pre-existing conditions to access quality,
affordable coverage at a lower cost than is available in high-
risk pools. Spreading risk across the insurance market rather
than concentrating it in high-risk pools will also lead to a
far more efficient and sustainable use of resources than simply
expanding funding for high-risk pools.\16\
---------------------------------------------------------------------------
\15\Congressional Budget Office, CBO's February 2013 Estimate of
the Effects of the Affordable Care Act on Health Insurance Coverage
(online at http://www.cbo.gov/sites/default/files/cbofiles/attachments/
43900_ACAInsuranceCoverageEffects.pdf) (accessed Apr. 19, 2013).
\16\Testimony of Sara R. Collins, Ph.D., House Committee on Energy
and Commerce, Subcommittee on Health, Hearing on Protecting America's
Sick and Chronically Ill, 113th Cong. (Apr. 3, 2013).
---------------------------------------------------------------------------
PREVENTION AND PUBLIC HEALTH FUND
Background
The ACA is expected to expand affordable health insurance
coverage to over 27 million Americans and to improve health
benefits for millions more who are already insured.\17\
---------------------------------------------------------------------------
\17\Supra footnote 15.
---------------------------------------------------------------------------
But as valuable as it is, health insurance cannot do
everything necessary to render our nation healthy. Even if
other parts of the ACA make it possible for virtually everyone
to be insured, there will still be a major role for public
health. Moreover, there will be an ongoing need for funding for
these public health activities.
``Public health'' includes many different things:
It is working with groups and whole communities
to improve health, often more effectively than could be done
between an individual provider and patient. Fluoridation of
water for a town is, for instance, vastly better than simply
filling every citizen's cavities. Exercise programs to prevent
obesity are better than having to treat diabetes among people
who become morbidly overweight.
It is tailoring health insurance and health care
to prevent and diagnose disease early rather than simply
treating it in its later stages. Immunizations are always
better than outbreaks. Screening for hypertension is better
than simply waiting for strokes.
It is providing for safety-net services where the
insurance market alone fails to do so. Community health
centers, HIV-service providers, and breast and cervical cancer
screening programs provide care to people who might not
otherwise be able to find a provider. Health professions
education programs can add to the primary care workforce when
the market might produce only specialists. (Such programs will
be even more necessary once the insurance expansion provisions
of the ACA are fully implemented.)
And, least glamorous but crucial, it is the
infrastructure of daily disease control and health promotion.
Closing down unsanitary restaurants is better than treating
food poisoning. Compiling and studying epidemic trends can
prevent major waves of disease.
The case might be made clearer by analogy: No community
would be well-served if all its homeowners had fire insurance
but there were no fire departments, firefighters, fire
hydrants, smoke detectors, or indoor sprinklers. That very
well-insured town would still burn to the ground. Insurance is
necessary, but it is nowhere near sufficient.
The ACA addresses both approaches, with insurance and with
public health. This required going beyond the investments in
the law to provide health insurance to also include provisions
to make significant public health commitments.
It would be insufficient simply to authorize future
appropriations for these activities while providing mandatory
spending for coverage initiatives. While the Committees on
Appropriations of both the House and the Senate have shown
ongoing and great leadership in these public health programs,
the budget allocations for them have been too tight to allow
significant new initiatives of these sorts. Consequently, the
ACA provides as firm a funding and organizational base for
these services as possible--mandatory spending--because they
are essential in making insurance efficient and productive and
in making the nation healthier.
Among those programs designated for mandatory spending in
the ACA is the Prevention and Public Health Fund (the
Prevention Fund). Its purpose is ``to provide for expanded and
sustained national investment in prevention and public health
programs.''\18\ It is the first and only federal program with
dedicated, ongoing resources specifically designed to improve
the public's health, and in turn, to make the United States a
healthier nation.
---------------------------------------------------------------------------
\18\ACA, Section 4002.
---------------------------------------------------------------------------
The Prevention Fund is administered by the HHS Secretary
and may be used to support ``programs authorized by the Public
Health Service Act, for prevention, wellness, and public health
activities.''\19\ When the Prevention Fund was initially
created, it provided $5 billion in mandatory spending for these
activities over the period FY 2010 through FY 2014 and $2
billion in mandatory spending each fiscal year thereafter (for
a total of $15 billion for FY 2010 through FY 2019, and $18.75
billion for FY 2013 through FY 2022).
---------------------------------------------------------------------------
\19\Id.
---------------------------------------------------------------------------
Legislation enacted in 2012 reduced these authorized
funding levels by $6.25 billion for FY 2013 through FY
2022.\20\ More recently, the Prevention Fund lost dollars
through the implementation of the so-called ``sequester'' that
automatically chopped the Prevention Fund by some $51
million.\21\ These cutbacks make it even more imperative to
maintain both the Prevention Fund's mandatory spending
mechanism and its currently-authorized spending amounts. Such
resources are necessary to address the perpetual underfunding
of public health and prevention activities which, by some
estimates, account for only 3% of national health
expenditures.\22\ This view is supported by a recent Institute
of Medicine report that reaffirms the importance of building
upon existing streams of public health funding--including the
Prevention Fund--to ensure our nation has an adequate
infrastructure to improve health outcomes and to carry out
other critical public health purposes.\23\
---------------------------------------------------------------------------
\20\Middle Class Tax Relief and Job Creation Act of 2012, Pub. L.
No. 112-96.
\21\Office of Management and Budget, OMB Report to the Congress on
the Joint Committee Sequestration for Fiscal Year 2013 (online at
www.whitehouse.gov/sites/default/files/omb/assets/legislative_reports/
fy13ombjcsequestrationreport.pdf).
\22\Center for Medicare & Medicaid Services, National Health
Expenditure Data (online at www.cms.gov/Research-Statistics-Data-and-
Systems/Statistics-Trends-and-Reports/National HealthExpendData/
index.html?redirect=/NationalHealthExpendData/) (accessed Apr. 18,
2013).
\23\Institute of Medicine, For the Public's Health: Investing in a
Healthier Future (Apr. 10, 2012) (online at www.iom.edu/Reports/2012/
For-the-Publics-Health-Investing-in-a-Healthier-Future.aspx).
---------------------------------------------------------------------------
Support for prevention has long been on a bipartisan basis.
Members of this Committee from both sides of the aisle and
across the political spectrum have spoken strongly in favor of
this public health function.\24\
---------------------------------------------------------------------------
\24\See, e.g., comments made by Reps. Pallone, Eshoo, and Walden
during the Committee markup of H.R. 1549 (House Committee on Energy and
Commerce, Markup on H.R. 1549, the Helping Sick Americans Act et al.,
113th Cong. (Apr. 17, 2013) (transcript of the proceeding)):
Rep. Pallone: ``. . . the fund was enacted as part of the
ACA in response to overwhelming bipartisan support for prevention
efforts . . .'' (p. 17)
Rep. Eshoo: ``I don't think there is a member here or a
member in the Congress that doesn't understand how important prevention
is and the role of public health in that.'' (p. 24)
Rep. Walden: ``. . . we are being asked to choose about
prevention programs, which I am an advocate of . . .'' (p. 98)
---------------------------------------------------------------------------
Beyond the halls of Congress, this support is also
widespread. A November 2009 public opinion survey by Trust for
America's Health and the Robert Wood Johnson Foundation found
that 71% of Americans favored an increased investment in
disease prevention.\25\ And nearly 800 national, state, and
local organizations support the Prevention Fund as a primary
vehicle for making public health investments that would not
only help to improve the public's health, but also create jobs
and lower long-term health care costs.\26\
---------------------------------------------------------------------------
\25\See http://healthyamericans.org/newsroom/releases/
?releaseid=198 for a description of the poll's complete findings.
\26\Letter from Jeffrey Levi, Ph.D., Executive Director, Trust for
America's Health (on behalf of 760 health-related organizations) to
Chairman Fred Upton and Ranking Member Henry Waxman (Apr. 23, 2012)
(online at http://healthyamericans.org/health-issues/wp-content/
uploads/2012/04/Fund-Reconciliation-EC-April2012.pdf); Trust for
America's Health, State by State Groups Supporting ACA Prevention Fund
(Apr. 8, 2013) (online at http://healthyamericans.org/health-issues/wp-
content/uploads/2013/04/Groups-Supporting-Prevention-Fund-State-by-
State-List1.pdf) (accessed Apr. 18, 2013).
---------------------------------------------------------------------------
Prevention Fund Dollars at Work
The Prevention Fund is one of a number of ACA initiatives
that is already in place. Currently, all 50 states and the
District of Columbia are receiving Prevention Fund support.\27\
---------------------------------------------------------------------------
\27\For a description of these activities and state-by-state
information on the Prevention Fund, see HHS, The Affordable Care Act's
Prevention and Public Health Fund in Your State (online at www.hhs.gov/
aca/prevention/ppht-map.html) (accessed Apr. 18, 2013).
---------------------------------------------------------------------------
In general, the Prevention Fund is intended to provide
support for programs generated at the local or community-based
level. This is as it should be--communities know best what
public health challenges they face and what interventions are
most likely to work.
Currently, over 100 states and communities serving
approximately 130 million Americans receive funding to
implement evidence-based, community programs designed to reduce
tobacco use, promote healthy living, prevent and control high
blood pressure and high cholesterol, and address health
disparities.\28\ Twenty percent of funds go to support rural
and frontier populations.
---------------------------------------------------------------------------
\28\HHS, The Community Transformation Grants Program (online at
www.healthcare.gov/news/factsheets/2011/09/community09272011a.html)
(accessed Apr. 18, 2013).
---------------------------------------------------------------------------
The Prevention Fund has also been used to provide flu shots
and other immunizations; improve HIV/AIDS prevention through
testing and linkages to care; expand mental health and injury
prevention programs; train the public health workforce; and
strengthen the public health infrastructure necessary to track
and respond to disease outbreaks and disasters.\29\ Recently,
the Prevention Fund has supported the ``Tips From Former
Smokers'' campaign, the first federally-funded, nationwide
campaign focused on educating the public about the harms of
smoking. This initiative has been credited with increasing the
number of calls to state quitlines by 132% and generating a
428% increase in the number of unique visitors to an HHS
smoking cessation website.\30\
---------------------------------------------------------------------------
\29\Supra, footnote 27.
\30\Increases in Quitline Calls and Smoking Cessation Website
Visitors During a National Tobacco Education Campaign--March 19-June
10, 2012, Morbidity and Mortality Weekly Report (Aug. 31, 2012) (online
at www.cdc.gov/mmwr/preview/mmwrhtml/mm6134a2.htm).
---------------------------------------------------------------------------
Prevention Dollars Produce High-Value Outcomes
Preventable diseases cost the United States significant
resources--in terms of unnecessary deaths, lost productivity,
and enormous amounts of money. Indeed, seven out of every ten
deaths in this country are attributable to chronic diseases,
where modifiable risk factors--such as lack of physical
activity, poor nutrition, tobacco use, and excessive alcohol
use--are responsible for much of the resulting illness and
death.\31\ Chronic diseases consume an estimated 75% of the
nation's $2 trillion health care spending each year.\32\
Obesity and related chronic diseases alone cost employers up to
$93 billion each year in health insurance claims.\33\ A stable,
ongoing investment in prevention can help alleviate each of
these burdens.
---------------------------------------------------------------------------
\31\Centers for Disease Control and Prevention, Chronic Diseases
and Health Promotion (online at http://www.cdc.gov/chronicdisease/
overview/index.htm) (accessed Apr. 18, 2013).
\32\Centers for Disease Control and Prevention, Chronic Disease:
The Power to Prevent, the Call to Control: At-A-Glance (2009) (online
at www.cdc.gov/chronicdisease/resources/publications/aag/chronic.htm).
\33\Centers for Disease Control and Prevention, Worker Productivity
(online at www.cdc.gov/workplacehealthpromotion/businesscase/reasons/
productivity.html) (accessed Apr. 18, 2013).
---------------------------------------------------------------------------
It is true that some life-saving prevention interventions
actually involve expenditures. But so do most life-saving drugs
and devices. We provide mandatory funding for drugs and devices
through programs such as Medicare and Medicaid because steady
and secure funding for these programs ensures that more
Americans can live longer and healthier lives. Prevention
efforts can also reduce the number of deaths and promote the
health of Americans and should, therefore, also be supported
through the mandatory spending mechanism.
Some forms of prevention do, of course, save money--
immunizations, for example, are among our most cost-effective
public health investments. Community-based interventions can be
cost-effective as well. A 2009 Trust for America's Heath report
concluded that an investment of $10 per person per year in
proven community-based interventions to increase physical
activity, improve nutrition, and prevent smoking can save the
country more than $16 billion each year--a return of $5.60 for
every $1 invested.\34\ The Urban Institute estimates that
certain proven community-based diabetes prevention programs can
save as much as $191 billion over 10 years.\35\ A more recent
Trust for America's Health report concludes that a reduction of
body mass index rates (the measure for obesity) nationwide that
meets the HHS target of 5% would save over $158 billion in 10
years.\36\
---------------------------------------------------------------------------
\34\J. Levi et al., Trust for America's Health, Prevention for a
Healthier America: Investments in Disease Prevention Yield Significant
Savings, Stronger Communities (Feb. 2009) (online at: http://
healthyamericans.org/reports/prevention08/Prevention08.pdf).
\35\R. Berenson et al., Urban Institute and Robert Wood Johnson
Foundation, How We Can Pay for Health Reform (July 2009) (online at:
http://urban.org/uploadedpdf/411932_ howwecanpay.pdf).
\36\Trust for America's Health, Bending the Obesity Cost Curve:
Reducing Obesity Rates by Five Percent Could Lead to More Than $29
Billion in Health Care Savings in Five Years (Jan. 2012) (online at
http://healthyamericans.org/assets/files/
TFAH%202012ObesityBrief06.pdf).
---------------------------------------------------------------------------
Spending Authority
Despite the good and important work being done through the
Prevention Fund, the health care savings it may help to
produce, and the chronic underfunding of prevention activities
in the past, Republicans are determined to bring the Prevention
Fund to an end. They assert two principal arguments for their
opposition to it: (1) the Prevention Fund's funding mechanism--
mandatory spending; and (2) the Secretary's authority to
determine how the Prevention Fund's monies will be allocated.
The two arguments are interrelated; taken together, they
present a misleading analysis of how the Prevention Fund is
intended to operate.
ACA Section 4002(b) provides for mandatory funding for the
Prevention Fund. It authorizes to be appropriated and
appropriates specified funding levels for FY 2010 and beyond.
ACA Section 4002(d) addresses the role of the congressional
appropriations committees in specifying how the appropriated
funds are to be used. This section explicitly states that these
committees have the authority to allocate monies from the
Prevention Fund (in accordance with the Prevention Fund's
purpose to support prevention and other public health
activities). Senator Harkin (author of ACA Section 4002)
addressed this very issue in a 2011 letter to the Committee,
making it clear that it is the responsibility of congressional
appropriators to determine resource allocations.\37\
---------------------------------------------------------------------------
\37\Testimony of Senator Tom Harkin (submitted for the record),
House Committee on Energy and Commerce, Subcommittee on Health, Hearing
on Setting Fiscal Priorities in Health Care Funding, 112th Cong. (Mar.
9, 2011) (``Contrary to misperceptions that it evades the
appropriations process, the Fund was established . . . in such a way
that appropriators direct how monies from the Funds are spent'').
---------------------------------------------------------------------------
Contrary to Republican belief, the Prevention Fund is not
``a fund that the [HHS Secretary] can use at will.''\38\ It is
only when Congress fails to pass an HHS appropriations bill (or
does not allocate the Prevention Fund in an appropriations
bill) that the HHS Secretary has the authority to designate
which public health programs or activities would receive
Prevention Fund support. While it is true that the Secretary
has already exercised this authority, it is also true that she
has generally done so in a manner that is consistent with the
overall purpose of the Prevention Fund.\39\
---------------------------------------------------------------------------
\38\Section on Background and Need for Legislation, Majority Views
(Committee Report on H.R. 1549, the Helping Sick Americans Now Act).
\39\Republicans on the Committee support this view: ``In past
years, the [F]und was spent on various projects including public health
surveillance, health workforce development, and prevention.'' (Section
on Background and Need for Legislation, Majority Views (Committee
Report on H.R. 1549, the Helping Sick Americans Now Act)).
---------------------------------------------------------------------------
The Secretary's more recent actions to use the Prevention
Fund to assist with the implementation of the ACA is a direct
result of Republicans' relentless defiance to provide such
support through the appropriations process. In effect,
Republicans continue to try to end the ACA by depriving it of
the resources necessary to get it up and running, leaving the
Secretary little recourse but to cobble together a patchwork of
funding streams to help get the job done--and get it done on
time. It is our expectation that such action will no longer be
necessary if and when Congress adequately funds various
implementation-related ACA activities.
H.R. 1549: RIGHT GOAL; WRONG FIX
Republicans and Democrats alike agree on the goal of H.R.
1549: ``. . . to carry out the temporary high-risk insurance
pool program for individuals with pre-existing conditions, and
to extend access to such program to such individuals who have
had creditable coverage during the 6 months prior to
application for coverage through such program.''\40\ Where they
differ is with the means by which this goal can be achieved.
---------------------------------------------------------------------------
\40\H.R. 1549.
---------------------------------------------------------------------------
As has become their routine, Republicans have turned to the
Prevention Fund for the $2.8 billion the Congressional Budget
Office estimates will be required to carry out the purpose of
H.R. 1549. Section 2 of the bill would strip the Prevention
Fund of virtually all of its monies for the next four fiscal
years in order to continue the PCIP program for just another
eight months--until those eligible for the program will be able
to take full advantage of the insurance coverage provided under
the ACA. Because of the purpose and overall track record of the
Prevention Fund as described above, we believe this approach to
``pay for'' H.R. 1549's expanded coverage is both ill-conceived
and shortsighted.
But we also fully recognize the need to identify funding
sources to finance this $2.8 billion price tag. Democrats put
forth two proposals in an attempt to do just that.
The first, an amendment offered by Rep. Pallone, would pay
for the extension of the PCIP program with a small increase in
the tax on cigarettes (four cents per pack).\41\ This approach
not only would raise the funds necessary to extend the PCIP
program; it is also supported by evidence showing tobacco taxes
curb its use (especially among children)\42\ and, in turn,
reduce the number of diagnoses of cancer and heart disease--
some of the top pre-existing conditions covered through the
PCIP program. The Pallone Amendment was ruled out of order.
---------------------------------------------------------------------------
\41\See debate on the amendment offered by Rep. Frank Pallone
(House Committee on Energy and Commerce, Markup on H.R. 1549, the
Helping Sick Americans Act et al., 113th Cong., pp. 70-75 (Apr. 17,
2013) (transcript of the proceeding)).
\42\Campaign for Tobacco-Free Kids, Raising Cigarette Taxes Reduces
Smoking, Especially Among Kids (And the Cigarette Companies Know It)
(Oct. 11, 2012) (online at http://www.tobaccofreekids.org/research/
factsheets/pdf/0146.pdf); Congressional Budget Office, Raising the
Excise Tax on Cigarettes: Effects on Health and the Federal Budget
(June 2012) (online at www.cbo.gov/sites/default/files/cbofiles/
attachments/06-13-Smoking_Reduction.pdf).
---------------------------------------------------------------------------
The second, an amendment offered by Rep. Capps, would
remove the Prevention Fund as the funding source for H.R. 1549
to allow the Committee to identify a different option--a
bipartisan option--before the bill comes to the House
floor.\43\ Despite recognition that H.R. 1549 will not become
law because of its Prevention Fund pay for, Republicans
unanimously rejected the Capps Amendment; in effect, rejecting
the opportunity to put the goal of H.R. 1549 on a fast track to
success.\44\
---------------------------------------------------------------------------
\43\See debate on the amendment offered by Rep. Lois Capps. (House
Committee on Energy and Commerce, Markup on H.R. 1549, the Helping Sick
Americans Act et al., 113th Cong., pp. 75-111 (Apr. 17, 2013)
(transcript of the proceeding)).
\44\Id.
---------------------------------------------------------------------------
In light of both the Prevention Fund's purpose and track
record to date, it comes as a great disappointment that
Republicans continue to target this program for
elimination.\45\ Surely, this is not because of Republican
assertions about the merits of the various initiatives
supported by the Prevention Fund. And given traditional bi-
partisan support for prevention activities, Republican
opposition cannot be based on the substance of the program.
---------------------------------------------------------------------------
\45\During the 112th Congress, House Republicans passed the
following legislation designed to repeal or otherwise significantly
change the Public Health and Prevention Fund:
H.R. 1217, To Repeal the Prevention and Public Health
Fund (eliminated the Prevention Fund (Congressional Record, H2633-2647
(Apr. 13, 2011))).
H.R. 3630, Middle Class Tax Relieve and Job Creation Act
of 2012 (reduced authorized Fund amounts by $11 billion over 10 years--
more than 60% of its funding--as part of the original House payroll
extenders legislation (Congressional Record, H8762-8824 (Dec. 13,
2011))).
H.R. 4628, Interest Rate Reduction Act (eliminated the
Prevention Fund (Congressional Record, H2228-2252 (Apr. 27, 2012))).
H.R. 5652, Sequester Replacement Reconciliation Act of
2012 (eliminated the Prevention Fund (Congressional Record, H2583-2633
(May 10, 2012))).
---------------------------------------------------------------------------
Pure and simple, Section 2 of H.R. 1549 represents the
Republicans' unending attack to disrupt, dismantle, and
ultimately destroy the ACA--even programs that have been funded
and are up and running, including those that make good health
policy sense, in or out of the health reform law.\46\ And all
this despite the Supreme Court's ruling upholding the
constitutionality of the ACA.\47\ What they have not been able
to achieve whole cloth, Republicans continue to attempt to do
piece by piece.\48\ Section 2 puts the Prevention Fund in the
frontline of this ongoing assault yet again.
---------------------------------------------------------------------------
\46\During the 112th Congress, House Republicans voted over 30
times to repeal all or part of the ACA (House Has Voted 32 Times to
Repeal All or Part of Health-Care Reform Law, Washington Post (July 11,
2012) (online at www.washingtonpost.com/blogs/2chambers/post/house-has-
voted-32-to-repeal-all-or-part-of-health-care-reform-law-heres-the-
full-list/2012/07/10/gJQAzoqgbW_blog.html)).
\47\National Federation of Independent Business et al. v. Sebelius,
Secretary of Health and Human Services, et al. 567 U.S. __ (2012).
\48\See, e.g., comments by Rep. Phil Gingrey: ``A minority of our
conference feels that the only vote that should be taken against
ObamaCare is a repeal vote--all or nothing, to kill it dead . . . I've
always felt that . . . if we see areas we can chip away at, that are
the most egregious parts of the bill, we really should do that.'' (GOP
Seeks $4B for ObamaCare Program!, The Hill (Apr. 17, 2013) (online at
http://thehill.com/homenews/house/294673-gop-seeks-4b-obamacare-
increase)).
---------------------------------------------------------------------------
In our view, this is not where the Prevention Fund should
be. Rather, it should remain exactly where it is--at the
forefront of helping to realign the nation's approach to health
and health care, allowing Americans to become and remain
healthier and more productive.
CONCLUSION
We wholeheartedly agree with the goal of H.R. 1549 and
would very much welcome the opportunity to work with our
Republican colleagues to make it happen. But with a pay for
designed ``to rob Peter to pay Paul'' and to continue the
Republican war on the ACA, we regrettably cannot support the
legislation in its current form.
We stand ready to renew our efforts to find a pay-for
solution that all Members can support. Unless and until that
happens, we must oppose H.R. 1549.
Henry A. Waxman.
Doris O. Matsui.
Gene Green.
John P. Sarbanes.
Jan Schakowsky.
Bobby L. Rush.
Bruce Braley.
Edward J. Markey.
Eliot L. Engel.
Peter Welch.
G.K. Butterfield.
John D. Dingell.
Frank Pallone, Jr.
Anna Eshoo.
Diana DeGette.
Lois Capps.
Jim Matheson.
Kathy Castor.
Mike Doyle.
Ben Ray Lujan.
Paul D. Tonko.