www.cbo.gov | @uscbo

Congressional Budget Office

Nonpartisan Analysis for the U.S. Congress

February 2020

The Congress uses CBO’s cost estimates to help it implement rules and procedures related to 

budget enforcement. CBO’s cost estimates provide information about how a bill would affect major 

components of the federal budget and details about CBO’s analysis—the reasoning, analytical 

methods, and sources of data used to develop the estimate, as well as any sources of uncertainty.

See also CBO’s Cost Estimates Explained, www.cbo.gov/publication/54437; 

How CBO Prepares Cost Estimates, www.cbo.gov/publication/53519; and Glossary, www.cbo.gov/publication/42904.

Congressional Budget Office

Cost Estimate

September 18, 2019

At a Glance

H.R. 2328, Reauthorizing and Extending America’s Community Health Act

As ordered reported by the House Committee on Energy and Commerce on July 17, 2019

By Fiscal Year, Millions of Dollars 2019 2019-2024 2019-2029

Direct Spending (Outlays) 0 40,394 41,027

Revenues 0 6,631 20,938

Increase or Decrease (-) 

in the Deficit 0 33,764 20,090

Spending Subject to 

Appropriation (Outlays) 0 67 not estimated

Statutory pay-as-you-go 

procedures apply? Yes Mandate Effects

Increases on-budget deficits in any 

of the four consecutive 10-year 

periods beginning in 2030?

No

Contains intergovernmental mandate? Yes, Over 

Threshold

Contains private-sector mandate? Yes, Over 

Threshold

The bill would

 Extend funding for public health programs including those that support health centers and health education

 Extend funding for several programs financed through the Medicare trust funds, change some other aspects 

of Medicare, and change supplemental coverage for some military retirees

 Reduce scheduled funding cuts to state allotments to hospitals that treat a disproportionate share of 

uninsured and Medicaid patients 

 Protect patients from surprise medical billing and reduce payments to some health care providers working in 

facilities where surprise bills are likely

 Increase funding for Medicaid in the U.S. territories

 Impose intergovernmental and private-sector mandates by prohibiting surprise medical billing 

Estimated budgetary effects would primarily stem from 

 Increased funding for public health programs 

 Changes to Medicare coverage and payment rules

 Increased Medicaid spending on payments to hospitals and to the U.S. territories

 Reduced federal subsidies for health care and health insurance

Areas of significant uncertainty include

 Estimating coverage choices for military retirees and trends in prostate cancer testing and treatment 

 Accurately projecting how states would respond to scheduled reductions in funding for hospital payments

 Accurately anticipating the nature and effects of provider and insurer responses to the bill’s provisions that 

address surprise bills

 Estimating what the U.S. territories would spend on Medicaid 

Detailed estimate begins on the next page.

Procedural Information. 

The following questions are 

answered: 

• Do procedures specified 

under the Statutory PayAs-You-Go (PAYGO) Act 

of 2010 apply?

• Will the bill increase 

long-term on-budget 

deficits?

• Does the bill contain any 

mandates as defined in 

the Unfunded Mandates 

Reform Act (UMRA)? 

At a 

Glance

The first page 

summarizes 

CBO’s estimate 

of the bill’s 

effects on major 

components 

of the federal 

budget.

Highlights. Key points 

are noted, including the 

ways that the bill would 

affect the federal budget 

and any uncertainties 

that might result in 

outcomes that are higher 

or lower than CBO’s 

estimates.

General Information. The bill number, title, and legislative status are shown. Most estimates are for 

bills that have been ordered reported by a full committee. The same bill number may appear on 

different estimates when a bill is considered by more than one committee or when CBO provides an 

estimate for legislation that has been passed by one chamber and is awaiting action in the other. The 

date in the upper right corner shows when CBO published the estimate. 

Budgetary 

Information. 

Components of 

the federal budget 

(explained more 

fully on the next 

page) include 

direct spending, 

revenues, the 

deficit, and 

spending subject 

to appropriation. 

Totals for the 

bill’s estimated 

effects on each 

component are 

provided for the 

current year and 

subsequent years 

in the budget 

window.

COST 

ESTIMATES

EXPLAINED
CBO’s Cost Estimates Explained February 2020

2 www.cbo.gov | @uscbo

CBO Cost Estimate H.R. 2328, as ordered reported by the House Committee on Energy

 and Commerce

Page 2

Bill Summary

H.R. 2328 would extend funding for several federal public health programs, change portions 

of Medicare, and reduce scheduled cuts to allotments for Medicaid disproportionate share

hospitals (DSH) that defray the costs of treating uninsured and Medicaid patients. In 

addition, H.R. 2328 would protect patients from surprise medical bills, and it would reduce 

payments to health care providers who work in facilities where surprise bills are likely, 

particularly providers of emergency care and ancillary services such as anesthesia. The bill 

also would increase federal funding for Medicaid in the U.S. territories. 

Estimated Federal Cost

The estimated budgetary effect of H.R. 2328 is shown in Table 1. The costs of the legislation 

fall within budget functions 500 (education, training, employment, and social services), 

550 (health), and 570 (Medicare).

Basis of Estimate

For this estimate, CBO assumes that the bill will be enacted near the end of 2019 and that the 

specified and estimated authorization of appropriations will be provided each year. Outlay 

estimates are based mainly on historical spending patterns for affected programs.

Direct Spending and Revenues

CBO and the staff of the Joint Committee on Taxation (JCT) estimate that enacting 

H.R. 2328 would increase direct spending by about $41.0 billion and increase revenues by 

$20.9 billion over the 2019-2029 period, for a net increase in the deficit of $20.1 billion.

Title I, Public Health Extenders. Title I would extend funding for several federal health 

care programs. CBO estimates that over the 2019-2029 period, title I would increase direct 

spending by $19.5 billion.

Section 101, Extension for Community Health Centers, the National Health Service Corps, 

and Teaching Health Centers That Operate Graduate Medical Education Programs. For 

each fiscal year from 2020 through 2023, section 101 would appropriate $4.0 billion for 

community health centers, $310 million for the National Health Service Corps, and 

$126.5 million for Teaching Health Centers that operate graduate medical education 

programs. CBO estimates that enacting section 101 would increase direct spending by 

$17.7 billion over the 2019-2029 period.

CBO Cost Estimate H.R. 2328, as ordered reported by the House Committee on Energy

 and Commerce

Page 3

Table 1. 

Estimated Budgetary Effects of H.R. 2328

By Fiscal Year, Millions of Dollars

2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029

2019-

2024

2019-

2029

Increases or Decreases (-) in Direct Spending

Title I, Public Health

Extenders

Budget Authority 0 4,887 4,887 4,887 4,887 0 0 0 0 0 0 19,546 19,546

Estimated Outlays 0 1,892 3,887 4,833 4,868 2,981 985 40 6 0 0 18,461 19,491

Title II, Medicare Extenders

Estimated Budget Authority 0 1,005 1,402 1,476 240 -6 -14 -7 9 11 21 4,117 4,137

Estimated Outlays 0 1,004 1,402 1,476 241 -6 -14 -7 9 11 21 4,117 4,137

Title III, Medicaid Provisions

Estimated Budget Authority 0 1,385 3,201 1,790 0 0 0 0 0 0 0 6,375 6,375

Estimated Outlays 0 1,385 3,201 1,790 0 0 0 0 0 0 0 6,375 6,375

Title IV, No Surprises Act

Estimated Budget Authority 0 1 -45 -91 -103 -106 -114 -122 -126 -131 -137 -345 -976

Estimated Outlays 0 1 -45 -91 -103 -106 -114 -122 -126 -131 -137 -345 -976

Title V, Territories Health 

Care Improvement Act

Estimated Budget Authority 0 2,759 2,829 2,896 2,981 321 214 0 0 0 0 11,786 12,000

Estimated Outlays 0 2,759 2,829 2,896 2,981 321 214 0 0 0 0 11,786 12,000

Total Changes in Direct 

Spending

Estimated Budget Authority 0 10,036 12,273 10,958 8,004 209 86 -129 -117 -120 -116 41,480 41,082

Estimated Outlays 0 7,040 11,274 10,904 7,986 3,190 1,071 -89 -112 -120 -116 40,394 41,027

Increases or Decreases (-) in Revenues

Title IV, No Surprises Act

Estimated Change in 

Revenues 0 -2 849 1,675 1,972 2,137 2,300 2,651 2,903 3,110 3,342 6,631 20,938

On-budget revenues 0 -1 603 1,189 1,399 1,521 1,639 1,942 2,146 2,303 2,477 4,711 15,218

Off-budget revenues 0 -1 246 486 572 616 661 709 757 807 865 1,920 5,719

Net Increase or Decrease (-) in the Deficit from Changes in Direct Spending and Revenues

Total Effect on the Deficit 0 7,042 10,425 9,230 6,015 1,052 -1,230 -2,741 -3,015 -3,230 -3,459 33,764 20,090

On-budget deficits 0 7,042 10,671 9,716 6,587 1,668 -569 -2,031 -2,258 -2,423 -2,594 35,683 25,809

Off-budget deficits 0 1 -246 -486 -572 -616 -661 -709 -757 -807 -865 -1,920 -5,719

Increases in Spending Subject to Appropriation

Estimated Authorization 0 58 8 2 1 1 n.e. n.e. n.e. n.e. n.e. 70 n.e.

Estimated Outlays 0 14 28 20 4 1 n.e. n.e. n.e. n.e. n.e. 67 n.e.

For section-by-section estimates, see Supplemental Table 1.

Components may not sum to totals because of rounding; n.e. = not estimated.

Estimated Federal Cost

This section notes which of the 20 broad budget 

functions (such as national defense, agriculture, health, 

and income security) would be affected by the bill. 

A table summarizes the bill’s estimated effects on major 

components of the federal budget.

Totals. The totals 

are for estimated 

budgetary effects 

over periods that 

are relevant for 

Congressional 

budget enforcement 

procedures. 

Estimates of 

changes in direct 

spending and 

revenues generally 

cover the current 

year and the 

subsequent 10 

years; estimates 

of changes 

in authorized 

spending subject 

to appropriation 

often cover only 

the subsequent 

5 years, as specified 

in the Congressional 

Budget Act of 1974.

Revenues. Estimated 

increases or decreases 

in revenues are shown. 

The staff of the Joint 

Committee on Taxation 

provides estimates for 

proposed changes to 

the Internal Revenue 

Code, and CBO 

estimates the changes 

in other governmental 

receipts. Positive 

numbers indicate 

increases in revenues; 

negative numbers 

represent losses.

Direct Spending. 

CBO’s estimates are 

shown for increases or 

decreases in budget 

authority (authority 

for agencies to incur 

financial obligations) 

and outlays that would 

occur if the legislation 

was enacted. The 

benchmark is CBO’s 

10-year baseline, 

which generally 

reflects current law. 

Positive numbers 

represent costs; 

negative numbers 

indicate savings. 

Spending Subject to Appropriation. The estimates 

reflect potential changes in discretionary spending 

that would result if the legislation was enacted and 

if future appropriations were provided consistent 

with the legislation’s provisions. The benchmark is 

based on current authorization law (under which many 

programs are not authorized beyond the current year) 

and thus differs from CBO’s 10-year baseline. 

The Deficit. The 

estimated effects on 

deficits reflect the 

net total of estimated 

changes to direct 

spending and revenues. 

Positive numbers 

represent deficit 

increases; negative 

numbers indicate deficit 

reductions.
February 2020 CBO’s Cost Estimates Explained

www.cbo.gov | @uscbo 3

CBO Cost Estimate H.R. 2328, as ordered reported by the House Committee on Energy

 and Commerce

Page 2

Bill Summary

H.R. 2328 would extend funding for several federal public health programs, change portions 

of Medicare, and reduce scheduled cuts to allotments for Medicaid disproportionate share

hospitals (DSH) that defray the costs of treating uninsured and Medicaid patients. In 

addition, H.R. 2328 would protect patients from surprise medical bills, and it would reduce 

payments to health care providers who work in facilities where surprise bills are likely, 

particularly providers of emergency care and ancillary services such as anesthesia. The bill 

also would increase federal funding for Medicaid in the U.S. territories. 

Estimated Federal Cost

The estimated budgetary effect of H.R. 2328 is shown in Table 1. The costs of the legislation 

fall within budget functions 500 (education, training, employment, and social services), 

550 (health), and 570 (Medicare).

Basis of Estimate

For this estimate, CBO assumes that the bill will be enacted near the end of 2019 and that the 

specified and estimated authorization of appropriations will be provided each year. Outlay 

estimates are based mainly on historical spending patterns for affected programs.

Direct Spending and Revenues

CBO and the staff of the Joint Committee on Taxation (JCT) estimate that enacting 

H.R. 2328 would increase direct spending by about $41.0 billion and increase revenues by 

$20.9 billion over the 2019-2029 period, for a net increase in the deficit of $20.1 billion.

Title I, Public Health Extenders. Title I would extend funding for several federal health 

care programs. CBO estimates that over the 2019-2029 period, title I would increase direct 

spending by $19.5 billion.

Section 101, Extension for Community Health Centers, the National Health Service Corps, 

and Teaching Health Centers That Operate Graduate Medical Education Programs. For 

each fiscal year from 2020 through 2023, section 101 would appropriate $4.0 billion for 

community health centers, $310 million for the National Health Service Corps, and 

$126.5 million for Teaching Health Centers that operate graduate medical education 

programs. CBO estimates that enacting section 101 would increase direct spending by 

$17.7 billion over the 2019-2029 period.

CBO Cost Estimate H.R. 2328, as ordered reported by the House Committee on Energy

 and Commerce

Page 16

Pay-As-You-Go Considerations

The Statutory Pay-As-You-Go Act of 2010 establishes budget-reporting and enforcement 

procedures for legislation affecting on-budget direct spending or revenues. The net changes 

in outlays and revenues that are subject to those pay-as-you-go procedures are shown in 

Table 3. 

Table 3. 

CBO’s Estimate of Pay-As-You-Go Effects of H.R. 2328

By Fiscal Year, Millions of Dollars

2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029

2019-

2024

2019-

2029

Net Increase or Decrease (-) in the On-Budget Deficit

Statutory Pay-As-You-Go

Effect 0 7,042 10,671 9,716 6,587 1,668 -569 -2,031 -2,258 -2,423 -2,594 35,683 25,809

Memorandum:

Changes in Outlays 0 7,040 11,274 10,904 7,986 3,190 1,071 -89 -112 -120 -116 40,394 41,027

Changes in Revenues 0 -1 603 1,189 1,399 1,521 1,639 1,942 2,146 2,303 2,477 4,711 15,218

Increase in Long-Term Deficits

CBO estimates that enacting H.R. 2328 would not increase on-budget deficits by more than 

$5 billion in any of the four consecutive 10-year periods beginning in 2030. 

Mandates

H.R. 2328 would impose intergovernmental and private-sector mandates as defined in 

the Unfunded Mandates Reform Act (UMRA). 

CBO estimates that the cost of the bill’s intergovernmental mandates would average about 

$90 million annually and that, in at least two of the first five years the mandates are in effect, 

those costs would exceed the intergovernmental threshold established in UMRA ($82 million 

in 2019, adjusted annually for inflation).

CBO estimates that the cost of the bill’s private-sector mandates would average $7.2 billion 

annually and that, in each of the first five years the mandates are in effect, those costs would 

Basis of Estimate

This section describes CBO’s assumption about the timing of the bill’s enactment and provides the 

following details about the basis of the agency’s estimates:

• Provisions that would have 

budgetary effects, 

• Sources of data and information 

that CBO considered,

• The reasoning and analytical methods that the 

agency used to develop its estimates, and 

• Significant sources of uncertainty 

surrounding the estimates.

The section typically mirrors the organization of the table summarizing the estimated budgetary 

effects (shown on the previous page) and includes subsections on direct spending, revenues, 

spending subject to appropriation, and uncertainty. For complicated legislation, additional tables 

may provide more details on the estimated effects of particular provisions.

Pay-As-You-Go 

Considerations

The PAYGO Act 

established budgetreporting and 

enforcement procedures 

for legislation that affects 

direct spending or 

revenues. That act can 

trigger across-the-board 

cuts (or sequestration) 

in mandatory budget 

authority. Because the act 

excludes certain changes 

in direct spending and 

revenues from budget 

enforcement procedures, 

the amounts shown in this 

section can differ from the 

estimated net changes in 

deficits presented in the 

summary table.

Increase in 

Long-Term 

Deficits 

To help the House 

and Senate Budget 

Committees 

determine whether 

certain budgetary 

procedures apply 

to the legislation, 

this section states 

whether the bill 

is estimated to 

increase on-budget 

deficits in any of 

the four decades 

after the period 

covered by the 

cost estimate that 

exceed a specified 

threshold.
CBO’s Cost Estimates Explained February 2020

4 www.cbo.gov | @uscbo

y ygpg 

procedures for legislation affecting on-budget direct spending or revenues. The net changes 

in outlays and revenues that are subject to those pay-as-you-go procedures are shown in 

Table 3. 

Table 3. 

CBO’s Estimate of Pay-As-You-Go Effects of H.R. 2328

By Fiscal Year, Millions of Dollars

2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029

2019-

2024

2019-

2029

Net Increase or Decrease (-) in the On-Budget Deficit

Statutory Pay-As-You-Go

Effect 0 7,042 10,671 9,716 6,587 1,668 -569 -2,031 -2,258 -2,423 -2,594 35,683 25,809

Memorandum:

Changes in Outlays 0 7,040 11,274 10,904 7,986 3,190 1,071 -89 -112 -120 -116 40,394 41,027

Changes in Revenues 0 -1 603 1,189 1,399 1,521 1,639 1,942 2,146 2,303 2,477 4,711 15,218

Increase in Long-Term Deficits

CBO estimates that enacting H.R. 2328 would not increase on-budget deficits by more than 

$5 billion in any of the four consecutive 10-year periods beginning in 2030. 

Mandates

H.R. 2328 would impose intergovernmental and private-sector mandates as defined in 

the Unfunded Mandates Reform Act (UMRA). 

CBO estimates that the cost of the bill’s intergovernmental mandates would average about 

$90 million annually and that, in at least two of the first five years the mandates are in effect, 

those costs would exceed the intergovernmental threshold established in UMRA ($82 million 

in 2019, adjusted annually for inflation).

CBO estimates that the cost of the bill’s private-sector mandates would average $7.2 billion 

annually and that, in each of the first five years the mandates are in effect, those costs would 

far exceed the private sector-threshold established in UMRA ($164 million in 2019, adjusted 

annually for inflation).

Title IV, No Surprises Act 

Title IV would impose intergovernmental and private-sector mandates by prohibiting 

surprise billing, requiring insurers to treat certain out-of-network services as in-network 

services when calculating cost sharing for enrollees, and requiring providers to accept 

median in-network rates for those services. 

CBO Cost Estimate H.R. 2328, as ordered reported by the House Committee on Energy

 and Commerce

Page 18

to those services. Some air ambulances are operated by public entities, most commonly by 

state, county, or large city police and fire departments. CBO estimates that the mandate 

would impose small administrative costs related to compiling, aggregating, and reporting the 

required information.

JCT has determined that the tax provisions of H.R. 2328 would impose a private-sector 

mandate by extending fees on health insurance policies to fund transfers to the PCOR trust 

fund. The revenue from those fees are part of the CBO baseline because current law requires

CBO to assume that excise taxes dedicated to a trust fund, if expiring, are extended. For 

private entities, however, paying the fees would extend an expiring duty, which is a mandate 

as defined in UMRA. Based on information from JCT, CBO estimates that the cost of the 

mandate would average $500 million annually in the three years authorized under the bill.

Other Effects

Title V would increase the amount of Medicaid funds available to the U.S. territories and 

increase the FMAP they receive under the program. The title also would require the 

territories to implement several program integrity measures with respect to their Medicaid 

programs. For large entitlement programs, including Medicaid, UMRA defines an increase in 

the stringency of conditions on states or territories as an intergovernmental mandate only if 

the affected governments lack authority to offset those costs while continuing to provide 

required services. Because the territories possess significant flexibility to alter their 

responsibilities within Medicaid, the duty to operate these programs would not be a mandate 

as defined in UMRA.

Previous CBO Estimates

S. 1895, the Lower Health Care Costs Act. On July 16, 2019, CBO transmitted a cost 

estimate for S. 1895 as ordered reported by the Senate Committee on Health, Education, 

Labor, and Pensions on June 26, 2019. 

 Section 101 of H.R. 2328 is similar to section 411 of S. 1895: Both bills would extend 

funding for community health centers, the National Health Service Corps, and 

Teaching Health Centers that operate graduate medical education programs. The 

Senate bill would appropriate an additional year of funding for each program; the 

House bill would not. 

 Section 102 of H.R. 2328 is similar to section 412 of S. 1895. Both bills would extend 

funding for the special diabetes programs. The Senate bill would appropriate an 

additional year of funding for each program; the House bill would not.

 Title IV of H.R. 2328 is similar to title I of S. 1895: Each aims to address surprise 

medical billing and includes the same protections for patients. Both would set the outof-network payment rate to equal the median in-network payment rate. CBO Cost Estimate H.R. 2328, as ordered reported by the House Committee on Energy

 and Commerce

Page 20

Estimate Prepared By 

Federal Costs: Alice Burns, Jennifer Gray, Philippa Haven, Lori Housman,

Bayard Meiser, Daria Pelech, Lisa Ramirez-Branum, Lara Robillard, Sarah 

Sajewski, Matthew Schmit, Robert Stewart, Rebecca Yip, Katherine Young, and the 

Staff of the Joint Committee on Taxation

Mandates: Andrew Laughlin

Editing and Production: Kate Kelly and Darren Young 

Estimate Reviewed By 

Tom Bradley

Chief, Health Systems and Medicare Cost Estimates Unit

Chad Chirico

Chief, Low-Income Health Programs and Prescription Drugs Cost Estimates Unit

Susan Willie

Chief, Public and Private Mandates Unit 

Leo Lex 

Deputy Assistant Director for Budget Analysis 

Theresa Gullo 

Assistant Director for Budget Analysis 

Contributors. The 

CBO analysts who 

prepared the cost 

estimate are listed, 

and if the staff of the 

Joint Committee on 

Taxation contributed 

to the estimate, 

that is indicated. 

The managers 

who reviewed the 

estimate also are 

named.

This document was prepared by Megan Carroll, Kathleen FitzGerald, and Leo Lex and reviewed by Theresa Gullo and Robert Sunshine. The editors were 

Kate Kelly and Bo Peery, and the graphics editor was Jorge Salazar. This document is available at www.cbo.gov/publication/56166.

Mandates

Any mandates (as defined in the Unfunded Mandates Reform 

Act) that the legislation would impose on state, local, or tribal 

governments or on private entities are noted, as is the basis of 

CBO’s estimate of whether the aggregate cost of complying with 

mandates in the bill would exceed the thresholds specified in UMRA 

(which are adjusted annually for inflation).

Cost estimates are published on CBO’s 

website at www.cbo.gov/cost-estimates, 

where they are searchable by several 

variables. Estimates vary in length and 

may not include all the sections shown in 

this example, but they contain the same 

basic information.

See these related publications:

• How CBO Prepares Cost Estimates, 

www.cbo.gov/publication/53519;

• “Frequently Asked Questions About 

CBO Cost Estimates,” www.cbo.gov/

about/products/ce-faq; and 

• Glossary, www.cbo.gov/

publication/42904.

Previous 

CBO 

Estimates

CBO compares its 

current estimate 

with any earlier cost 

estimates that it 

prepared for similar 

legislation during the 

same Congress.