House Energy & Commerce Committee Issues Report on Community Health, Medical Professionals Improve Our Nation Act

WASHINGTON, Oct. 22 -- The House Energy and Commerce Committee issued a report (H.Rpt. 115-359) on legislation (H.R. 3922) to extend funding for certain public health programs. The report was advanced by Rep. Greg Walden, R-Ore., on Oct. 19.

Excerpts of the report follow:

Purpose and Summary

H.R. 3922 was introduced on October 3, 2017, by Representative Greg Walden (R-OR). The bill extends federal funding for important public health priorities, including Community Health Centers, the Special Diabetes Programs, the National Health Service Corps, the Teaching Health Center Graduate Medical Education Program, Family-to-Family Health Information Centers, the Youth Empowerment Program, and the Personal Responsibility Education Program.

Background and Need for Legislation

On September 30, 2017, the funding for several important programs authorized under the Public Health Service Act expired. These critical programs, such as the Community Health Centers program and the Special Diabetes Program, have helped to reduce costs, improve health outcomes, and deliver cost- effective care. Programs like the National Health Service Corps and the Teaching Health Center Graduate Medical Education Program play a critical role in training and placing primary care providers in underserved areas.

Committee Action

The Committee on Energy and Commerce has not held hearings on the legislation.

On October 4, 2017, the full Committee on Energy and Commerce met in open markup session and ordered H.R. 3922, as amended, favorably reported to the House by a recorded vote of 28 yeas and 23 nays.

Committee Votes

Clause 3(b) of rule XIII requires the Committee to list the record votes on the motion to report legislation and amendments thereto. The following reflects the record votes taken during the Committee consideration:

Oversight Findings and Recommendations

Pursuant to clause 2(b)(1) of rule X and clause 3(c)(1) of rule XIII, the Committee has not held hearings on this legislation.

New Budget Authority, Entitlement Authority, and Tax Expenditures

Pursuant to clause 3(c)(2) of rule XIII, the Committee finds that H.R. 3922 would result in no new or increased budget authority, entitlement authority, or tax expenditures or revenues.

Congressional Budget Office Estimate

Pursuant to clause 3(c)(3) of rule XIII, the following is the cost estimate provided by the Congressional Budget Office pursuant to section 402 of the Congressional Budget Act of 1974.

U.S. Congress,

Congressional Budget Office,

Washington, DC, October 19, 2017.

Hon. Greg Walden,

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. 3922, the CHAMPION Act of 2017.

If you wish further details on this estimate, we will be pleased to provide them. The CBO staff contact is Emily King.

Sincerely,

Keith Hall,

Director.

Enclosure.

H.R. 3922--CHAMPION Act of 2017

Summary: H.R. 3922 would extend funding for Community Health Centers and several other public health programs for two years, through 2019. It also would shorten the grace period during which premiums can be paid and reduce funding available for the Prevention and Public Health Fund. On net, CBO estimates that implementing the legislation would reduce the deficit by $1.4 billion over the 2018-2027 period.

Enacting H.R. 3922 would affect direct spending and revenues; therefore, pay-as-you-go procedures apply.

CBO estimates that enacting H.R. 3922 would not increase net direct spending or on-budget deficits in one or more of the four consecutive 10-year periods beginning in 2028.

H.R. 3922 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 effect of H.R. 3922 is shown in the following table. The costs of this legislation fall within budget functions 550 (health) and 500 (education, training, employment, and social services).

(TABLE OMITTED)

Basis of estimate: For this estimate, CBO assumes that H.R. 3922 will be enacted near the start of calendar year 2018. Estimated outlays are based on historical spending patterns for the affected programs.

Extension of expiring provisions

H.R. 3922 would extend several public health provisions that would otherwise expire under current law. In total, CBO estimates that enacting those extensions would increase federal spending by about $8.9 billion over the 2018-2027 period. The budget authority for those extensions include:

$3.6 billion per year in 2018 and 2019 for the Community Health Center Fund, which provides grants to health centers that can be used for infrastructure, management, training, and other expenses related to providing health care services;

$310 million per year in 2018 and 2019 for the National Health Service Corps, which funds scholarships for primary care providers that serve in underserved communities;

$263 million in 2018 and $300 million in 2019 for the Special Diabetes Program, which funds research on the prevention and cure of type 1 diabetes at the National Institutes of Health and funds diabetes treatment and prevention programs for American Indians through Indian Health Service, Tribal, and Urban Indian health providers;

$111.5 million in 2018 and $126.5 million in 2019 for the Teaching Health Center Graduate Medical Education program, which supports training for medical and dental residents in primary care settings;

$75 million per year for 2018 and 2019 for the Youth Empowerment Program (known as the Abstinence Education program under current law), which funds education on avoiding sexual risk;

$75 million per year for 2018 and 2019 for the Personal Responsibility Education Program, which funds youth education about abstinence, contraception, and topics to prepare youth for adulthood; and

$6 million per year for 2018 and 2019 to fund the Family-to-Family Health Information Centers, which support families of children with special health care needs.

Qualified health plan grace period requirements

Under current law, people who enroll in subsidized health insurance purchased through a marketplace established under the Affordable Care Act (ACA) and pay the premium for at least their first month of coverage are granted a grace period of three months if they miss a subsequent payment. If they pay their premiums in full during that grace period, their coverage continues normally. If, at the end of three months, they have not made their premium payments, their coverage is terminated retroactively to the end of the first month of their grace period.

H.R. 3922 would shorten the grace period to one month unless a state sets a different one. CBO and the staff of the Joint Committee on Taxation (JCT) estimate that many people who, under current law, would have paid their delinquent premiums during the second or third month of their grace period would instead have their coverage terminated under this bill. CBO and JCT estimate that the subsidies those people would have received for coverage during the remainder of the calendar year would no longer be paid, resulting in a reduction in the federal deficit. In addition, some of those people who became uninsured would pay a penalty for not maintaining health insurance coverage under provisions known as the individual mandate, which would increase revenues. Based on information from states, insurers, surveys, and the Department of Health and Human Services, CBO and JCT estimate that fewer than 500,000 people would have their coverage terminated at some point each year. As a result, CBO and JCT estimate that this provision would reduce the deficit by about $4.9 billion over the 2018-2027 period; that estimated savings includes about $4.2 billion in reduced outlays and about $700 million in increased revenues.

Prevention and Public Health Fund

The legislation would reduce funding available to the Prevention and Public Health Fund. The Department of Health and Human Services awards grants through that fund to public and private entities to carry out prevention, wellness, and other public health activities. Under current law, annual funding available for these purposes totals $900 million in 2018, and rises to $2.0 billion in 2027 and each year thereafter. Over the 2019-2026 period, the legislation would reduce that funding by $6.3 billion. CBO estimates that enacting the provision would reduce direct spending by $5.5 billion over the 2018-2027 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 and revenues 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. 3922, AS ORDERED REPORTED BY THE HOUSE COMMITTEE ON ENERGY AND COMMERCE ON OCTOBER 4, 2017

(TABLE OMITTED)

Increase in long-term direct spending and deficits: CBO estimates that enacting the legislation would not increase net direct spending or on-budget deficits in any of the four consecutive 10-year periods beginning in 2028.

Intergovernmental and private-sector impact: H.R. 3922 contains no intergovernmental or private-sector mandates as defined in UMRA.

Estimate prepared by: Federal costs: Kate Fritzsche, Jennifer Gray, Emily King, Lisa Ramirez-Branum, Robert Stewart, and Ellen Werble and the staff of the Joint Committee on Taxation; intergovernmental and private-sector impact: Amy Petz.

Estimate approved by: Holly Harvey, Deputy 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.

Statement of General Performance Goals and Objectives

Pursuant to clause 3(c)(4) of rule XIII, the general performance goal or objective of this legislation is to extend funding for certain public health programs.

Duplication of Federal Programs

Pursuant to clause 3(c)(5) of rule XIII, no provision of H.R. 3922 is known to be duplicative of another Federal program, including any program that was included in a report to Congress pursuant to section 21 of Public Law 111-139 or the most recent Catalog of Federal Domestic Assistance.

Committee Cost Estimate

Pursuant to clause 3(d)(1) of rule XIII, 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.

Earmark, Limited Tax Benefits, and Limited Tariff Benefits

Pursuant to clause 9(e), 9(f), and 9(g) of rule XXI, the Committee finds that H.R. 3922 contains no earmarks, limited tax benefits, or limited tariff benefits.

Disclosure of Directed Rule Makings

Pursuant to section 3(i) of H. Res. 5, the Committee finds that H.R. 3922 contains no directed rule makings.

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 that the Act may be cited as the "Community Health And Medical Professionals Improve Our Nation Act of 2017" or the "CHAMPION Act".

Section 2. Table of contents

Section 2 lists the table of contents.

Section 101. Extension for community health centers and the National Health Service Corps

Section 101 extends the funding for Community Health Centers and the National Health Service Corps (NHSC) for two years, at $3.6 billion a year for Community Health Centers, and $310 million a year for the NHSC.

In addition, section 101 includes technical and programmatic changes that improve the health centers ability to function in the modern health care landscape. Specifically, this section provides the Health Resources and Services Administration (HRSA) with explicit authority to make supplemental awards to Health Centers focused on quality improvement, and to make grants for New Access Points and Expanded Services. It clarifies the focus on unmet need and extends the current rural to urban statutory ratio guardrails for New Access Points and Expanded Services.

This section adds homeless veterans and veterans at risk of homelessness to the list of focus populations for grants focused on care to the homeless. It provides $25 million for health centers to participate in the All of Us Research Program, an effort to accelerate health research and medical breakthroughs by creating the most diverse biomedical data resource in history. It requires health centers to consult and collaborate with existing local providers, programs and agencies with respect to the services and programs offered by a new site, and it requires health centers to have written policies and procedures around appropriate use of federal funds to ensure that the center is operated in compliance with applicable federal laws and regulations.

Finally, this section provides the legal authority for HRSA to require direct employment of health center CEOs and Executive Directors.

Section 102. Extension for special diabetes programs

Section 102 extends the funding for two years for the Special Diabetes Program for Type 1 Diabetes and the Special Diabetes Program for Indians at $150 million a year each.

Section 103. Reauthorization of program of payments to teaching health centers that operate graduate medical education programs

Section 103 extends the funding for the Teaching Health Center Graduate Medical Education Program for two years, at $126.5 million a year.

Section 104. Extension for family-to-family health information centers

Section 104 extends the Family-to-Family Health Information Center program for two years at $6 million a year. This section also establishes Family-to-Family Health Information Centers in all of the territories and for the Indian tribes.

Section 105. Youth empowerment program; personal responsibility education

Section 105 extends the Personal Responsibility Education Program for two years at $75 million a year. This section also renames the Abstinence Education Program as the Youth Empowerment Program (PREP) and extends its funding for two years at $75 million a year. In addition, section 105 includes technical and programmatic changes to the Youth Empowerment Program, that better reflects the intent of the program to empower youth to make healthy decisions, resist sexual risk, and set goals for the future.

Similar to PREP, if a State does not apply for grant funding, the Secretary shall allot to one or more entities in the State, through a competitive grant process, the amount that would have been allocated to the State had it applied for the funding. A State or entity that receives funding must collect information on the programs and activities funded through its allotment and submit a report to the Secretary on the data from such programs and activities. In consultation with relevant stakeholders, the Secretary must also establish and conduct one or more national evaluations of the education funded through the Youth Empowerment Program and submit a report to Congress on the collected information.

Section 201. Providing for qualified health plan grace period requirements for issuer receipt of advance payments of cost- sharing reductions and premium tax credits that are more consistent with State law grace period requirements

Under current law, subsidized patients with exchange plans have a three-month grace period when they do not pay their health insurance premiums. During these three months, their plan cannot discontinue coverage for nonpayment of premiums. This means that patients receiving the advance premium tax credits (APTCs) and cost sharing reductions (CSRs) can pay for only nine months of health insurance, but receive a full year's coverage. According to one McKinsey report, one-in-five exchange enrollees stopped payment in 2015 with nearly 90 percent of these individuals repurchasing a plan the following year. Of this group, half enrolled in the same plan they stopped payment for in 2015. Section 201 allows States to define their grace period, or move to a default of one month.

Section 202. Prevention and Public Health Fund

The Prevention and Public Health Fund (PPHF) was created in the Affordable Care Act to fund "programs authorized by the Public Health Service Act for prevention, wellness, and public health activities." Section 202 allocates $6.35 billion from the PPHF to support the public health programs in the CHAMPION Act.

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, and existing law in which no change is proposed is shown in roman):

PATIENT PROTECTION AND AFFORDABLE CARE ACT

MINORITY VIEWS

Committee Democrats unanimously oppose H.R. 3922, the "Community Health and Medical Professionals Improve Our Nation Act of 2017," or the CHAMPION Act. While we support the reauthorization of the critical public health programs included in the CHAMPION Act, we cannot support doing so using the partisan offsets the Republicans have proposed in this bill. Rather than working together to identify offsets that we all could support, the Committee Republicans chose to continue their efforts to repeal and undermine the Affordable Care Act (ACA) through this legislation.

THE MINORITY MEMBERS OPPOSE PAYING FOR CRITICAL PUBLIC HEALTH PROGRAMS WITH CUTS TO THE AFFORDABLE CARE ACT

The CHAMPION Act would cut $6.35 billion or nearly half of the funding from the Prevention and Public Health Fund (Prevention Fund) over the next decade, which will harm efforts to improve America's health and to prepare and respond to public health crises. The Prevention Fund was created by the ACA and is the federal government's only dedicated mandatory investment in improving our nation's public health system. As a result of the Republican proposed cuts to the Prevention Fund, funding would not be available to invest in critical preventive and public health programs such as efforts to reduce tobacco use, increase physical activity, expand mental health and injury prevention, and improve our ability to detect and respond to infectious disease and other public health threats. Therefore this legislation is forcing Congress to make a false choice between cutting funding for important public health programs in order to provide funding to maintain others. We reject this harmful action.

Cutting nearly half of the funding from Prevention Fund could cripple our public health prevention, preparedness, and response capabilities. The Centers for Disease Control and Prevention (CDC) plays a critical role in saving the lives and protecting the health of Americans. Currently, the Prevention Fund provides 12 percent of the annual budget of CDC. The proposed $400 million cut to the Prevention Fund next year included in the CHAMPION Act would require CDC to roll back their public health programs as well as cut the funding it provides to states, communities, and tribal and community organizations.

Such a cut could not come at a worse time as we are in the midst of a near endless series of public health crises. From the lead crisis in Flint, to the international Zika and Ebola outbreaks, to the opioid epidemic, and now to our response to the trio of hurricanes that have devastated Texas, Florida, Puerto Rico, and the Virgin Islands, we have relied on CDC to be on the front lines to help protect the health of all Americans. Cutting funding to CDC as proposed by this legislation could mean that CDC and its state and local partners will not have the resources necessary to prepare and mount a timely response to such events.

In addition to helping us prepare and respond to emerging public health crises, CDC is leading efforts to prevent and control chronic disease. Today in America, chronic disease, such as heart disease, diabetes, and cancer, are among the nation's most common, costly, and preventable health problems. Unsurprisingly, spending on chronic disease alone accounts for roughly 86 percent of all health care expenditures in the United States.1 Chronic diseases also take a toll on American lives. In fact, chronic diseases account for 7 out of 10 deaths in the United States. Yet, despite the harms caused by chronic diseases, only a small percentage of government health expenditures are directed at preventing these diseases before they happen.

1Centers for Disease Control and Prevention (CDC), Chronic Disease Prevention and Health Promotion (Nov. 2016) (https:// www.cdc.gov/chronicdisease/index.htm).

Using funding from the Prevention Fund, CDC supports public health programs like the highly successful Tips from Former Smokers national campaign. A recent study published in the Lancet found that the first three months of the national ad campaign led an estimated 1.6 million smokers to attempt to quit smoking and helped more than 100,000 Americans quit smoking permanently.2 Another study published in the American Journal of Preventive Medicine found that the campaign prevented more than 17,000 premature deaths in the United States.3 Slashing nearly half of the funding to the Prevention Fund over the next decade could prevent CDC from implementing other successful public health interventions like Tips from Former Smokers.

2Tim McAfee, et al., Effect of the First Federally Funded US Antismoking National Media Campaign, The Lancet (Sept. 9, 2013).

3Xin Xu, et al., A Cost-Effectiveness Analysis of the First Federally Funded Antismoking Campaign, American Journal of Preventive Medicine (Dec. 9, 2014).

Compounding the harmful cuts to the Prevention Fund is that the Republican proposed cuts would further strain the safety net health care system. Cutting nearly half the funding from the Prevention Fund could mean that more people would need health services from community health centers and other safety net programs. However, this legislation provides level funding needed to meet the current demand for services provided by community health centers--not increased funding to take on the additional burden that would result from cuts to the Prevention Fund. Therefore we reject this proposal that would require us to cut important investments in certain public health programs to fund needed investments in others.

Additionally, the minority members oppose paying for these important public health priorities by cutting funding for financial assistance for low and middle-income Americans who purchase subsidized coverage in the Marketplaces. Under the ACA, individuals have up to 90 days in order to pay premiums before insurers can terminate their coverage. These grace periods are important to ensure that low and middle-income families facing temporary difficulties paying premiums are not unfairly excluded from coverage. Shortening grace periods to 30 days could result in harsh consequences for these families, who would lose coverage and would be barred from reenrolling until the next open enrollment season.

The minority members oppose the majority's continued attempts to repeal and undermine the ACA. We urge Committee Republicans to turn to the important task of stabilizing the Marketplaces and ending the widespread uncertainty due to the Trump Administration's continual threats to unilaterally end the payment of cost-sharing reductions. Failure to provide this certainty is resulting in significantly higher premiums and fewer choices for consumers.4

4Congressional Budget Office, Federal Subsidies for Health Insurance Coverage for People Under Age 65: 2017 to 2027 (Sept. 2017); Kaiser Family Foundation, An Early Look at 2018 Premium Changes and Insurer Participation on ACA Exchanges (Aug. 10, 2017).

Frank Pallone, Jr.,

Ranking Member.

Gene Green,

Ranking Member, Subcommittee on Health.

The full text of the report is found at: https://www.congress.gov/congressional-report/115th-congress/house-report/359/1?r=1

TARGETED NEWS SERVICE: Myron Struck, editor; 703/304-1897; [email protected]; http://www.targetednews.com