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December 22, 2014

Posts in "Budget/Appropriations"

December 12, 2014

Health Care Agency Funding Bill Races Toward Finish Line

Week in Review

The Senate today is the last stop before final passage of an omnibus year-end spending bill. The House on Thursday — in contentious voting — approved the package, along with a stopgap spending resolution keeping federal agencies open over the next few days as senators deliberate on the larger spending bill.

The measure has been in negotiations for several weeks, but added spending is limited due to previously established budgetary caps, which left lawmakers little room to add money for discretionary health programs. Overall, funding for the agencies within the Department of Health and Human Services remain largely at last year’s levels or receive modest increases. However, separate mandatory spending for the Medicare and Medicaid programs jumps by more than $60 billion compared to 2014 levels, spurred by a huge increase in Medicaid funding to the states due to the Affordable Care Act.

Additional funding to respond to the Ebola crisis, particularly focused on assistance to West African countries and FDA and NIH drug and vaccine development, reduced any wiggle room for new spending. The original $6.2 billion White House Ebola response request was reduced in the spending package to $5.4 billion and is spread out between HHS agencies, the State Department and the Defense Department. Also, Republicans claimed no new health care overhaul law funding but omitted any major health law program cuts, except for a continued hold on money for a dormant health law provider payment advisory board. Separately, the measure continued a long-standing federal abortion ban and calls for administration action to clarify health plan abortion coverage requirements.

Congress this week completed action on a bill reauthorizing newborn screening programs (HR 1281), offering education, information tools and research on inheritable disorders in newborns and children. Also, the House passed bills updating veterans’ suicide prevention efforts (HR 5059) and renewing breast health education programs (HR 5185). The Senate could quickly complete action on the two measures today or this weekend prior to ending the term of the 113th Congress. The House has already retired for the year.

Planning on Reading the Spending Bill? Try the Explanatory Report First

The Senate today is racing toward completing votes on a spending bill package  that includes money for health care programs through the end of fiscal 2015.  The 1600+ page bill details spending levels for most federal agencies, except for temporary stopgap funding provided for the Department of Homeland Security. However, the main bill text itself offers very dense reading material. A separate accompanying explanatory statement on the bulk of the bill’s health care agencies provides useful background and commentary on many health care issues that have recently attracted lawmaker attention. At 110 pages, the document — complete with copy-editor notations — describes congressional views and suggestions for health programs and regulatory activities.

CQ HealthBeat’s (@CQHealthTweet) KerryYoung reported (subscription) on several elements included in the explanatory statement. The Centers for Disease Control and Prevention is ordered to direct funding for fighting prescription drug overdoses to states hit hardest by the drug abuse (see explanatory statement page 30). The report also urges the Centers for Medicare and Medicaid Services to reconsider a decision on Medicare coverage for a high-tech heart pump, with an eye toward expanding eligibility for the device (see bottom of page 75).

Items noted in the explanatory statement may not be included in the actual bill text. Often a provision is too contentious for the bill, but a compromise can land some commentary in the accompanying report. Such a compromise in this year’s bill led to explanatory instructions clarifying coverage requirements for health plans purchased through health insurance exchanges, with an eye toward a dispute over plan coverage of abortion services. The report instructs HHS to take heed of a recent federal audit of health plan abortion coverage and orders quick responses to complaints on violations of “conscience protection” provisions on abortion services coverage (view health plan transparency and provider complaint comments beginning on page 81).


December 5, 2014

Congress Presses Toward a Spending Bill; Agencies Try To Tackle Circumcision & Blood Donation Guidance

Weekly Review

Congressional appropriators toil today to craft a year-end spending package. The objective is to assemble the full-year spending bills for most federal agencies, including contentious health care agency funding and policy riders, plus a stopgap temporary funding resolution for more controversial immigration provisions.

Meanwhile, the Senate is preparing for votes next week on a Pentagon re-authorization bill, which includes a hike in prescription co-payments for service members and blocks a ban on military sales of tobacco products. Senators are also seeking to avoid any amendments on a tax extension bill due to worries that someone will seek an amendment repealing a medical device excise tax.

Earlier this week, the House completed legislative action on bills calling for improved reporting on sudden infant deaths and adds Ebola drugs to an existing FDA rapid drug development program. Also, the House overwhelmingly approved a bill creating a tax-exempt accounts for persons with disabilities. The measure is largely funded through Medicare payment ban on vacuum systems to treat erectile dysfunction and other Medicare provider payment adjustments.

Meanwhile, the Centers for Disease Control staked out guidance on awkward health care provider conversations with patients on the benefits of male circumcision but a FDA panel avoided offering guidance on overturning a controversial ban on blood donations from gay men.

December 4, 2014

DeLauro Hopes Third Chair’s the Charm for Labor-HHS

Rosa DeLauro of Connecticut, a fiery liberal Democrat with a clear passion for medical issues, is hoping that her new partner on the House Labor-Health and Human Services-Education Appropriations subcommittee will get the once influential panel back on track. Tom Cole, R-Okla., will take the Labor-HHS gavel in the 114th session.

This subcommittee oversees the spending and operations of some of the most highly regarded federal agencies, including the National Institutes of Health and Centers for Disease Control and Prevention. Yet, the Labor-HHS panel has not advanced an annual spending bill as far as a full committee markup, let alone the House floor, since Republicans took control of the chamber in 2011. During that time,  DeLauro has served as ranking Democrat to two GOP subcommittee chairmen, Denny Rehberg of Montana and Jack Kingston of Georgia. Both ended their House careers to make failed Senate bids, Rehberg’s in 2012 and Kingston’s in 2014.

“I hope that 2015 will be the year we finally manage to debate a Labor-HHS appropriations bill,” DeLauro told CQ Roll Call.

DeLauro also said that she is looking forward to working with Cole, with whom she has collaborated in the past on legislation regarding the needs of children in foster care who have behavioral needs and disabilities.

While Rehberg and Kingston had to commit time to their Senate races, Cole appears to have no immediate ambition beyond the House. His choice to lead the Labor-HHS panel could auger well for the neglected panel. Cole is a member of the House GOP whip team and an ally of Speaker John A. Boehner. Cole has said that he is looking forward to the chance to “craft legislation,” despite the challenges of “complex and at times even controversial” matters covered by the Labor-HHS bill.

Cole’s soon-to-be counterpart on the House Energy and Commerce Committee also indicated that he expects the Labor-HHS panel to be busy in the 114th session. The House Energy and Commerce Committee is planning to introduce broad legislation affecting the regulation of medical products in the next session. Joe Pitts, the Pennsylvania Republican who leads Energy and Commerce’s health panel, has congratulated Cole on his selection to lead the “critical” Labor-HHS panel.

“I am looking forward to working with him closely on health issues in the coming Congress,” Pitts said. “There’s a lot of work that will require close cooperation between the authorizing and appropriating committees.”

November 24, 2014

CBO Offers Some Uncomfortable Deficit Reduction Options

Congressional anxiety over the federal debt level and consistent annual budget deficits has recently taken a back seat to other battles. Also, deficit worries were put on hold by last year’s bipartisan budget agreement that set 2014 and 2015 spending levels. However, the budget battle will resume again next year and will be spurred by required action on raising the ceiling on the federal debt limit. Republican control over both chambers, plus the development of the annual congressional budget plan, will likely shift the focus back onto efforts to reduce deficit spending.

Health care program spending figures prominently in any debate on budgetary and deficit matters. The Congressional Budget Office last week compiled a summary of policy choices available to manage deficit and debt levels. Many of the items have been debated in Congress in the past and are highly contentious. The budgetary advisory agency estimated 10-year savings from several policy options including:

  • Limiting funding for the National Institutes of Health (savings: $11.5 – $34.7 billion)
  • Increasing the excise tax on cigarettes (added revenue $34.7 billion)
  • Limiting medical malpractice awards (savings: $60.4 billion)
  • Change Medicare cost-sharing rules and restricting Medigap policies (savings: $111 billion)
  • Increasing premiums for Medicare Parts B and D (savings $ 314 billion)
  • Requiring drug manufacturers to pay minimum rebates on Medicare Part D drugs (savings $103 billion)
  • Requiring minimum out-of-pocket fees for military retirees (savings: $27 billion)
  • Raising military retiree health plan enrollment fees and restrict coverage options (savings: $19 – $73 billion)




November 17, 2014

Examining the Impact Stopgap Spending and a Federal Shutdown

Congress will have to pass some form of a spending bill by Dec. 11, which is when congressional authority for temporary continuing spending expires. Appropriators are keen on a complete omnibus bill, which will fund the federal government, including health agencies and programs, through the end of fiscal year 2015. However, an omnibus bill is vexed by the complexities of agreeing on all the spending program details and funding levels, plus anxiety over looming administration action on immigration policy.

A likely alternative is a new stopgap spending bill, or continuing resolution, which would fund the government at largely current levels into the first few months of 2015. The short-term spending bill could include added funding elements for Ebola response efforts.

Budget chiefs at federal agencies likely wince at the idea of another continuing resolution (CR) because it greatly complicates federal budgeting and spending. A 2012 Congressional Research Service report explained that a CR not only adds to paperwork but agencies could also delay hiring, issuing grant awards and cut back on travel expenses. However, the alternative to a CR is a federal government shutdown, which poses much more severe headaches and federal employee furloughs. A Government Accountability Office report issued last week examined the impact of last year’s federal shutdown on HHS agencies.



November 14, 2014

Weekly Roundup: Emergency Ebola Funding Seeks a Spending Bill Home

Congress this week returned from the longest election recess break since 1960 and immediately began posturing on an upcoming spending bill and other possible available options for the lame duck session. A temporary extension of fiscal 2015 spending expires on Dec. 11. Congressional appropriators spent the week urging passage of a complete full-year spending package, which would include funding for health agencies and programs. Alternatively, some Republicans suggest a further spending bill extension, which would shift spending decisions into January.

The U.S. had no Ebola patients for only a few days this week. Following the release of a NY physician on Tuesday, a new patient from Sierra Leone arrives in Nebraska on Saturday. The administration’s emergency funding request for Ebola response activities, both in West Africa and domestic preparedness was examined on Wednesday in a Senate hearing (view Roll Call video). Separately, a House committee hearing on Thursday largely supported emergency funding to help the State Department respond to the Ebola outbreak in West Africa.

The biggest threat to the Ebola funding request appears to be if Congress resorts to a further extension of stopgap spending instead of a complete omnibus measure due to political pressures. In that case, a portion of the extra Ebola funding would likely be tacked onto a stopgap continuing resolution. However, the entire spending bill package is also threatened by possible Republican reaction to any White House action on immigration policies.

Meanwhile, a Senate committee this week set up a pathway for action on a measure (S 2917) adding Ebola drug research to an existing FDA drug development program. Action over the next few weeks is also possible on a bill (HR 5059) seeking to reduce veterans’ suicide rates. Also, the House on Thursday completed voting — and sent to the President — a bill renewing traumatic brain injury research programs (S 2539) and a measure urging the FDA to expedite the approval of sunscreen ingredients (S 2141).


November 10, 2014

Week Ahead: Committees Examine New Ebola Response Funding; Allows Exchange Plan Viewing Today

House and Senate committees this week return to examination of the U.S response to the Ebola virus outbreak in West Africa and a review of domestic public health preparedness plans. Senate appropriators on Wednesday afternoon seek details from Health and Human Services Secretary Sylvia Mathews Burwell and the HHS Ebola response duo of FDA Director Thomas Frieden and Anthony Fauci the director of National Institute of Allergy and Infectious Diseases, plus State and Homeland Security department officials. On Thursday the House Foreign Affairs Committee also examines international Ebola response efforts in West Africa.

The White House last week requested $6.18 billion in additional funding. The formal request includes $2.4 billion for Department of Health and Human Services agencies, with the bulk of funding directing toward Centers for Disease Control and Prevention efforts to respond to the outbreak and other infectious disease threats. The White House also seeks $2.1 billion for the U.S. Agency for International Development for humanitarian assistance; $157 million for the Biomedical Advanced Research and Development Agency to manufacture vaccines for clinical trials; and $112 million for the Defense Advanced Research Projects Agency research on the virus. Other funding will be held in a contingency fund pending further developments of the epidemic (view White House fact sheet). The funding is in addition to $88 million in CDC and drug development funds approved by Congress earlier this year and $750 million in reprogrammed Pentagon spending for a West African relief mission.

Also this week, the House Veterans Affairs Committee honors Veterans’ Day sentiments in a hearing on recently enacted legislation expanding veterans’ health care treatment options.

Separately, a new enrollment period for health insurance exchanges begins on Nov. 15 but you can see plan data online starting today. The Centers for Medicare and Medicaid Services says that early look at plan details will assist consumers prior to beginning the formal enrollment process.


November 7, 2014

Weekly Review: Election Shock and New Health Law Battles; Additional Ebola Response Funding Requested

The 2014 congressional mid-term elections this week vaulted Republicans into control of the Senate and bolstered GOP majorities in the House. The new Congress, which convenes in January, will press the White House on changes – including a possible an outright repeal — of the Affordable Care Act.

CQ Roll Call followed the election as results came in on Tuesday evening (view Roll Call election maps) and wrapped up the election in an election impact conference on Thursday (view C-SPAN video of election commentary and reporter roundtable discussion).

The newly reconfigured Congress will likely also pressure the administration on federal agency and health program spending priorities and policies. Additionally, a new Congress requires a restructuring of committees that can address health care issues. Separately, election results for state governorships signaled a likely delay in any further action on expanding the Medicaid program.

However, the old Congress returns starting next week to wrap-up remaining topics, primarily an extension of federal spending beyond the scheduled Dec. 11 expiration of funding for federal agencies. The White House requested that the spending bill, which likely will extend fiscal 2015 funding into the new year, include new emergency funding to bolster the U.S. response to the Ebola outbreak in West Africa and precautionary efforts to support domestic preparedness programs.

Meanwhile, the Supreme Court this week passed up on an opportunity to accept a legal challenge to health insurance subsidies offered to policies purchased on the federally operated insurance exchanges. Justices meet again today in a private conference and have another opportunity to consider accepting pending cases. Official notice of the decision – or no decision – will be officially posted on Monday morning. [Update: CQ Roll Call's Todd Ruger reports (subscription) that the court on Friday agreed to hear the health law subsidy challenge case. The White House said it is confident the court will agree that the intent of the law was to include subsidies in all states].


October 23, 2014

Health Programs Factor in Upcoming House Committee Leadership Changes

The focus on upcoming November congressional elections understandably centers on possible election results and which party will control the Senate. However, the election of a new Congress, which convenes in January, also starts the process for reconfiguring the leadership of pivotal House committees. Roll Call’s Emma Dumain and Matt Fuller today examine possible GOP leadership changes in 11 different committees.

Health care program funding authority, particularly for the Medicare program, falls under the jurisdiction of the House Ways and Means Committee. The committee’s current chairman, Michigan Republican Rep. Dave Camp is retiring and Wisconsin Republican Rep. Paul D. Ryan has the inside track — but has some competition — to take over the gavel of the powerful tax committee.

Ryan has led a long-running campaign to overhaul the Medicare program as the chief of the House Budget Committee. His annual budget proposals (view the 2015 budget plan) have suggested ideas on overhauling the Medicare program allowing Medicare beneficiaries to choose between competing private coverage programs with the federal government offering premium support payments. In 2011, a liberal advocacy group attacked an earlier Ryan Medicare proposal with a video featuring a Ryan look-alike actor pushing an elderly woman in a wheelchair off a cliff.  At the helm of the Ways and Means Committee, Ryan would have the opportunity to craft a Medicare overhaul measure instead of offering budgetary suggestions.

If Ryan departs from the budget panel, the heir apparent is the committee’s current Vice Chairman, Rep. Tom Price, a conservative physician from Georgia. Price is a staunch opponent of the 2010 health care overhaul law and has authored his own proposal on overhauling health insurance coverage options. Price’s plan relies on offering tax breaks to give people the means to buy health insurance instead of the current health insurance exchange plan subsidies.

October 22, 2014

Annual Spending Waste Report Mocks State Medicaid Provider Taxes and Assorted NIH Grants

Oklahoma Republican Sen. Tom Coburn today unveiled an annual report listing examples of possibly dubious spending on various government programs. The report always offers interesting and sometimes humorous reading and illustrates the often-unusual nature of federal program and grant spending. Sen. Coburn usually highlights examples of unusual health program spending.

This year’s report mocks National Institutes of Health research on human interaction with dogs, the impact of meditating through reading Buddhist texts, and funding for a smart-phone application that helps parents manage the eating habits of fussy children. The eccentric nature of  some NIH grants is a regular target for the annual report. Last year’s waste report blasted a study on marital conflict between husbands and wives.

The 2014 report includes a critique of state Medicaid provider taxes, particularly on nursing homes, which inflates federal Medicaid payments to the state. States collect both the additional tax and the additional Medicaid funding.  In July, Healthopolis highlighted a report that indicates states are increasing relying on Medicaid provider taxes to fund the program.

Other items in this year’s report blast the weighting of sleep apnea as grounds for veterans’ disability benefits and the random assignment of Medicare Part D prescription drug plans to beneficiaries who do not indicate a preference. Roll Call’s Niels Lesniewski reports that this year’s report is presumably the last of the senator’s annual compilation of unusual federal spending. Sen. Coburn is retiring from the Senate at the end of the year.



October 17, 2014

This Week: Congress Focuses on a Travel Ban and Ebola Response Funding

Lawmakers this week escalated calls for a travel ban for people coming from Ebola-ravaged West African countries. The pleas for travel restrictions culminated at a special recess House subcommittee hearing on Thursday (view C-SPAN video), where lawmakers grilled federal health and border control officials about their recent actions and missteps in managing the response to the first U.S. Ebola case. Republican members are leading the charge for a travel ban – or imposing restrictions on visas –but some Democrats have also endorsed the idea.

However, Centers for Disease Control and Prevention Director Thomas Frieden continued to insist this week that restrictions would only encourage people to avoid regular travel channels and limit governments’ ability to track those who have been exposed to the virus. The Economist, in an opinion that coincided with its cover article on Ebola published today, echoed the same reasoning for avoiding travel restrictions. President Obama told reporters at the White House on Thursday that he does not have a “philosophical objection” to a travel ban but is relying on advice from infectious disease experts, who say the current screening process is the best approach to managing potentially infected travelers.

Meanwhile, a separate congressional battle is brewing over added Ebola response funding for the CDC and the National Institutes of Health. Roll Call’s David Eldridge reported that Democrats are pressing for a separate hearing on Ebola response funding prior to the end of the recess break and claim the CDC cannot do its job adequately without more congressional appropriations. Roll Call’s Emma Dumain wrote that Republicans countered by noting that the CDC has not yet asked for additional funding. Also, CQ HealthBeat’s John Reichard reported (subscription) that hospital executives are scrambling for grant funding for technical assistance in managing Ebola cases, and CQ Roll Call’s Melanie Zanona noted (subscription) that health provider groups have ramped up calls for a boost in funding for a federal hospital preparedness program.

Other related Healthopolis reports on Ebola this week:

October 9, 2014

CBO: Annual Deficit is Lower But Health Program Spending Is Up

The federal government ended the 2014 fiscal year with an estimated $486 billion annual deficit, which is the lowest deficit level since 2008. The Congressional Budget Office monthly budget report pegs the lower deficit estimate largely on increased receipts from taxpayers.

However, overall federal spending — measured as outlays — increased and Medicaid and health insurance subsidy payments increased by 19 percent over 2013 levels. The CBO identifies the 2014 start of subsidized insurance plans and expanded state Medicaid coverage as a main reason for overall spending increase. Federal outlays on Medicaid and insurance premium subsidies increased in 2014 by $49 billion.

In September, the final month of the fiscal year, defense spending and reduced unemployment benefit outlays were down by $2 billion but spending for Medicaid increased 10 percent and Medicare increased 5 percent.





October 1, 2014

GAO Opinion Bolsters GOP Case on Insurer Risk Payments

A group of Republican lawmakers on Tuesday obtained a legal opinion on legislative instructions for funding a key factor enticing health insurance participation in the state and federal exchanges. Exchange health plans can be obtained without restrictions due to preexisting health conditions and eliminating insurance limitations on preexisting conditions is a primary objective of the Affordable Care Act.

However, to avoid a catastrophic insurance market breakdown, the law instituted an individual coverage mandate, which broadens the coverage pool.  Also, the law added a temporary premium stabilization program for insurers to re-balance the coverage risk. The federal government subsidizes plans that have losses above a set amount and recovers money from plans that have gains.

CQ Health Beat’s (@CQHealthTweet) Rebecca Adams reported that the Centers for Medicare and Medicaid Services, in insurance exchange rules issued in May, tweaked the amounts this year given to insurers to cover losses and offset the cost of caring for high-cost patients. CMS expects the insurer subsidies and recouped payments to offset each other, but the final rule text notes:

In the unlikely event of a shortfall for the 2015 program year, HHS recognizes that the Affordable Care Act requires the Secretary to make full payments to issuers. In that event, HHS will use other sources of funding for the risk corridors payments, subject to the availability of appropriations.

On Tuesday, the Government Accountability Office provided Alabama Sen. Jeff Sessions and Michigan Rep. Fred Upton with an opinion noting that legislation covering fiscal year 2015 spending, which begins today and is funded through a stopgap spending resolution through Dec. 11, should also include special funding instructions for risk payments.


September 29, 2014

Ebola Patient Arrives at NIH; Congress Slowly Releases Ebola Response Funds

On Sunday afternoon, the National Institutes of Health received its first Ebola patient. An American physician who was volunteering services in an Ebola treatment unit in Sierra Leone and was exposed to the virus was admitted to the NIH Clinical Center’s high-level isolation unit.

Meanwhile, congressional appropriators are slowly releasing the requested transfer of funding for the U.S. Ebola response effort in West Africa. Roll Call’s Humberto Sanchez and Niels Lesniewski reported on Friday that the approval of the transfer of the entire $1 billion request is held up pending further details on Pentagon plans to keep soldiers from contracting the illness.

Appropriations and defense committee leaders have released only portions of the request. The partial release of funding, which would have expired at the end of the last week, allows the Pentagon to spend $100 million of the funds while lawmakers await details of how the funds will be used.





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