The Case of the Missing $115 billion

May 17, 2010

The printed version of the final health reform Act (PL 111-148) comes in at 907 pages (yes, lots of white space and pretty small pages – and yes, including an detour into student loans – but still, a very big Act any way you look at it). Many have noted the sweeping nature of the Act and how it touches everything related to health care – from public and private health coverage to how public health and medical care is delivered and financed.

The Act – in 10 titles and numerous sections – includes a broad array of initiatives and strategies to improve the quality, accessibility and cost of health care in the country. Indeed, just about every idea health care policy wonks have had over the years about how to improve health care in the US is included in the Act.

What is less well understood is that many of those ideas are still a glimmer in someone’s eye.

This past week, Doug Elmendorf, the director of the Congressional Budget Office, came out with an important (and completely under-reported) analysis about the cost of provisions in the Patient Protection and Affordable Care Act (PPACA) for which funds were authorized – but not appropriated. In a letter to House Appropriations Committee ranking member Jerry Lewis, Elmendorf said the price tag for those provisions exceeded $115 billion.

In the end, authorized but not appropriated items are advisory in nature: they represent things Congress would like to see done, but were not ready to set aside funding. A high proportion of those provisions are workforce-related proposals: everything from more education for primary care practitioners to training for geriatric providers. Many of the provisions with no funding attached also relate to some core public health elements in the Act: funding for the National Health Service Corps, operations of federally qualified health centers, and many of the prevention and wellness programs described in the Act, for example.

Of course, it’s easier to put something in a bill without funding than it is to actually appropriate funds*, but the choices Congress made in this regard – what to appropriate and what to essentially identify as “good idea” – provide an interesting insight into legislative process and thinking. Looking at the appropriations included in the Act, one can clearly see how heavily weighted they are to coverage issues and how light they are on care delivery and public health issues.

While there are some exceptions (such as maternal and infant home visitation programs and certain public health initiatives), the vast majority of funding in the Act goes for Medicaid expansion, subsidies for premiums and cost sharing for health insurance, transitional reinsurance, small employer tax credits, reinsurance for early retirees, and the Medicare coverage gap discount program.

On the theory that money talks louder than speeches, unpacking what’s real in the funding of PL 111-148 makes clear how much more this Act is about health insurance than health care delivery. Yet, the opportunity for health care reform to be about more than health insurance remains. As I have said before, the PPACA is a foundation upon which to build. It will be up to those who believe reform should be about more than just health insurance to understand how much more work needs to be done to put the house on that foundation.

* As a side note, this makes the issue I addressed in last week’s post – the Medicare method of adjusting physician payments – more notable for the fact that Congress couldn’t address that problem in health reform at all.