29–006 

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 


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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. 


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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. 


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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: 


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pwalker on DSK7TPTVN1PROD with REPORTSInsert offset folio 8 here HR45.001

COMMITTEE ON ENERGY AND COMMERCE -- 113TH CONGRESS 

ROLL CALL VOTE # 5 

BILL: H.R. 1549, the Helping Sick Americans Now Act 

AMENDMENT: An amendment by Ms. Capps, No.2, to strike section 2, Prioritizing Funding for Sick 

Americans. 

DISPOSITION: NOT AGREED TO, by a roll call vote of22 yeas and 27 nays. 

REPRESENT A T1VE YEAS NAYS PRESENT REPRESENTATIVE YEAS NAYS PRESENT 

Mr. Upton X Mr. Waxman X 

Mr.Hali X Mr. Dingell X 

Mr. Barton X Mr. Markey 

Mr. Whitfield X Mr. Pallone X 

Mr. Shimkus Mr. Rush X 

Mr.Pitts X Ms. Eshoo X 

Mr. Walden X Mr. Engel X 

Mr. Terry X Mr. Green X 

Mr. Rogers Ms. DeGette X 

Mr. Murphy X Mrs. Capps X 

Mr. Burgess X Mr. Doyle X 

Mrs. Blackburn Ms. Schakowsky X 

Mr. Gingrey X Mr. Matheson X 

Mr. Scalise X Mr. Butterfield X 

Mr. Latta X Mr. Barrow X 

Mrs. McMorris Rodgers X Ms. Matsui X 

Mr. Harper X Ms. Christensen X 

Mr. Lance X Ms. Castor 

Mr. Cassidy X Mr. Sarbancs X 

Mr. Guthrie X Mr. McNerney X 

Mr. Olson X Mr. Braley X 

Mr. McKinley X Mr. Welch X 

Mr. Gardner X Mr. Lujan X 

Mr. Pompeo X Mr. Tonko X 

Mr. Kinzinger X 

Mr. Griffith X 

Mr. Bilirakis X 

Mr. Johnson X 

Mr. Long X 

Mrs. Ellmers X 

04117/2013 
6 


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COMMITTEE ON ENERGY AND COMMERCE -- 113TH CONGRESS 

ROLL CALL VOTE # 6 

BILL: H.R. 1549, the Helping Sick Americans Now Act 

AMENDMENT: A motion by Mr. Upton to order H.R. 1549 favorably reported to the House, as amended. 

(Final Passage) 

DISPOSITION: AGREED TO, by a roll call vote of27 yeas and 20 nays 

Mr. 

Mr. 

REPRESENTATIVE 

Hall 

Upton 

YEAS 

X 

X 

NAYS PRESENT 

Mr. 

Mr. 

REPRESENTATIVE 

Dingell 

Waxman 

I YEAS 

~ X 

Mr. Barton X Mr. Markey 

Mr. Whitfield X Mr. Pallone X 

Mr. Shimkus Mr. Rush 

Mr. Pitts X Ms. Eshoo X 

Mr. Walden X Mr. Engel 

Mr. Terry X Mr. Green X 

Mr. Rogers Ms. DeGette X 

Mr. Murphy X Mrs. Capps X 

Mr. Burgess X Mr. Doyle X 

Mrs. Blackburn Ms. Schakowsky X 

Mr. Gingrey X Mr. Matheson X 

Mr. Scalise X Mr. Buttertield X 

Mr.Latta X Mr. Barrow X 

Mrs. McMorris Rodgers X Ms. Matsui 

Mr. Harper X Ms. Christensen X 

Mr. Lance X Ms. Castor X 

idy X Mr. Sarbanes X 

Mr. Guthrie X Mr. McNerney X 

Mr. Olson X Mr. Braley X 

Mr. McKinley I X Mr. Welch X 

Mr. Gardner X Mr. Lujan X 

Mr. Pompeo X Mr. Tonka X 

Mr. Kinzinger X 

Mr. Griffith X 

Mr. Bilirakis X 

Mr. Johnson X 

Mr. Long X 

Mrs. Ellmers X 

04/17/2013 
7 

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. 


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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. 


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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. 

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. 

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 


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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. 


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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 


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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 RamirezBranum; 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. 


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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 

ø(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¿ 

ø(3)¿ (2) has a pre-existing condition, as determined in a 

manner consistent with guidance issued by the Secretary. 

* * * * * * * 


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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. 

* * * * * * * 


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1The 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). 3 ACA, Section 1101. 

4 Id. 

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. 

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

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. 


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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). 6 Id. 

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). 8Supra, footnote 5. 

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

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

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

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

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 pharVerDate Mar 15 2010 05:41 Apr 20, 2013 Jkt 029006 PO 00000 Frm 00017 Fmt 6604 Sfmt 6602 E:\HR\OC\HR045.XXX HR045

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9Supra, footnote 5. 10 HealthCare.gov, PCIP—Enrollment Suspension (Feb. 15, 2013) (online at www.pcip.gov/). 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). 12 H.R. 4038, 111th Cong. (2009). 13Republicans Eye Costs, Not the Uninsured, Politico (Jan. 24, 2011) (online at 

www.politico.com/news/stories/0111/48033.html). 

macies 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

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. Statebased PCIPs could continue accepting enrollment applications 

through March 2, 2013.10

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

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 preexisting conditions to continue unabated in the private market and 

would have had little impact on the number of uninsured Americans.13


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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). 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). 16Testimony 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). 17Supra footnote 15. 

The PCIP model was based on existing state high-risk pools but 

included key additional enrollee protections such as limits on outof-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

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

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

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 


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18 ACA, Section 4002. 

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. 

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 activiVerDate Mar 15 2010 05:41 Apr 20, 2013 Jkt 029006 PO 00000 Frm 00020 Fmt 6604 Sfmt 6602 E:\HR\OC\HR045.XXX HR045

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19 Id. 20Middle Class Tax Relief and Job Creation Act of 2012, Pub. L. No. 112–96. 21Office 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). 24See, 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) 25See http://healthyamericans.org/newsroom/releases/?releaseid=198 for a description of the 

poll’s complete findings. 26Letter 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 

Continued 

ties.’’ 19 When the Prevention Fund was initially created, it pro- vided $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). 

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

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

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


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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-StateList1.pdf) (accessed Apr. 18, 2013). 27For 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). 28 HHS, The Community Transformation Grants Program (online at www.healthcare.gov/ 

news/factsheets/2011/09/community09272011a.html) (accessed Apr. 18, 2013). 29Supra, 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). 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). 

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

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. 

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

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, 


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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). 36Trust 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). 

ongoing investment in prevention can help alleviate each of these 

burdens. 

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

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 ComVerDate Mar 15 2010 05:41 Apr 20, 2013 Jkt 029006 PO 00000 Frm 00023 Fmt 6604 Sfmt 6602 E:\HR\OC\HR045.XXX HR045

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37Testimony 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’’). 38Section 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)). 40 H.R. 1549. 

mittee, making it clear that it is the responsibility of congressional 

appropriators to determine resource allocations.37

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

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. 

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. 


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41See 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). 43See 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. 45During 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))). 46During 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-hasvoted-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. ll (2012). 

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. 

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

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. 

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 


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48See, 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)). 

continue to attempt to do piece by piece.48 Section 2 puts the Prevention Fund in the frontline of this ongoing assault yet again. 

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 LUJA ́ N. 

PAUL D. TONKO. 

Æ 


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