[House Report 113-45]
[From the U.S. Government Publishing Office]


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).


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                                                                                                           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.
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    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.
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                              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.

                                  
