Department of Health and Human Services: FY2020 Budget Request
Released: 2019-07-17T00:00:00

About the U.S. Department of Health and Human Services (HHS)

The mission of HHS is to "enhance the health and well-being of Americans by providing for effective health and human services and by fostering sound, sustained advances in the sciences underlying medicine, public health, and social services."

HHS is currently organized into 11 main agencies, called "operating divisions" (listed below), which are responsible for administering a wide variety of health and human services programs, and conducting related research. In addition, HHS has a number of "staff divisions" within the Office of the Secretary (OS). These staff divisions fulfill a broad array of management, research, oversight, and emergency preparedness functions in support of the entire department.

HHS Operating Divisions

Eight of the HHS operating divisions are part of the U.S. Public Health Service (PHS). PHS agencies have diverse missions in support of public health, including the provision of health care services and supports (e.g., IHS, HRSA, SAMHSA); the advancement of health care quality and medical research (e.g., AHRQ, NIH); the prevention and control of disease, injury, and environmental health hazards (e.g., CDC, ATSDR); and the regulation of food and drugs (e.g., FDA).

The three remaining HHS operating divisionsâACF, ACL, and CMSâare not PHS agencies. ACF and ACL largely administer human services programs focused on the well-being of vulnerable children, families, older Americans, and individuals with disabilities. CMSâwhich accounts for the largest share of the HHS budget by farâis responsible for administering Medicare, Medicaid, and the State Children's Health Insurance Program (CHIP), in addition to some aspects of the private health insuranceÂ market.

(For a summary of each operating division's mission and links to agency resources related to the FY2020 budget request, see the Appendix .)

Context for the FY2020 President's Budget Request

The initial President's budget request for FY2020 was submitted to Congress on March 11, 2019, about five weeks after the statutory deadline. (Additional components of the FY2020 request were released in subsequent weeks.) The delay in the budget submission was attributable, in part, to protracted negotiations over seven of the FY2019 annual appropriations acts, which resulted in a five-week partial government shutdown. (Five of the 12 annual appropriations acts had already received full-year appropriations for FY2019 when the shutdown commenced.)

At HHS, the FY2019 shutdown primarily affected FDA, IHS, and ATSDR. The remaining HHS operating and staff divisions generally had already received full-year FY2019 funding prior to the start of the fiscal year (Division B of P.L. 115-245 ). Full-year appropriations for FDA, IHS, and ATSDR were ultimately enacted on February 15, 2019, almost five months after the start of the fiscal year ( P.L. 116-6 ).

In light of this delay, the source of the FY2019 numbers contained in the FY2020 President's budget materials varies by HHS agency. In the case of FDA, IHS, and ATSDR, amounts shown for FY2019 were estimated based on annualized funding levels under the FY2019 continuing resolution (Division C of P.L. 115-245 , as amended), not final full-year enacted levels. By contrast, amounts shown for the remaining HHS agencies generally reflect enacted full-year appropriations provided in Division B of P.L. 115-245 .

Overview of the FY2020 HHS Budget Request

Under the President's budget request, HHS would spend an estimated $1.286 trillion in outlays in FY2020 (see Table 1 ). This is $56 billion (+5%) more than estimated HHS spending in FY2019 and about $166 billion (+15%) more than actual HHS spending in FY2018.

Historical estimates by the Office of Management and Budget (OMB) indicate that HHS has accounted for at least 20% of all federal outlays in each year since FY1995. Most recently, OMB estimated that HHS accounted for 27% of all federal outlays in FY2018.

Figure 1 displays proposed FY2020 HHS outlays by major program or spending category in the President's request. As this figure shows, mandatory spending typically accounts for the vast majority of the HHS budget. In fact, two programsâMedicare and Medicaidâare expected to account for 86% of all estimated HHS spending in FY2020. Medicare and Medicaid are "entitlement" programs, meaning the federal government is required to make mandatory payments to individuals, states, or other entities based on criteria established in authorizing law.

This figure also shows that discretionary spending accounts for about 8% of estimated FY2020 HHS outlays in the President's request. Although discretionary spending represents a relatively small share of total HHS spending, the department nevertheless receives more discretionary money than most federal departments. According to OMB data, HHS accounted for 7% of all discretionary budget authority across the government in FY2018, the same as the Department of Homeland Security. The Department of Defense was the only federal agency to account for a larger share of all discretionary budget authority in that year (47%).

Budgetary Resources Versus Appropriations

Readers should be aware that the HHS budget includes a broader set of budgetary resources than the amounts provided to HHS through the annual appropriations process. As a result, certain amounts shown in FY2020 HHS budget materials (including amounts for prior years) will not match amounts provided to HHS by annual appropriations acts and displayed in accompanying congressional documents. There are several reasons for this:

M andatory spending makes up a large portion of the HHS budget, and much of that spending is provided directly by authorizing laws, not through appropriations acts. All discretionary spending is controlled and provided through the annual appropriations process. By contrast, all mandatory spending is controlled by the program's authorizing statute. In most cases, that authorizing statute also provides the funding for the program. However, the budget authority for some mandatory programs (including Medicaid), while controlled by criteria in the authorizing statute, must still be provided through the annual appropriations process; such programs are commonly referred to as "appropriated entitlements" or "appropriated mandatories." The HHS budget request takes into account the department as a whole, while the appropriations process divides HHS funding across three different appropriations bills. Most of the discretionary funding for the department is provided through the Departments of Labor, Health and Human Services, and Education, and Related Agencies (LHHS) Appropriations Act. However, funding for certain HHS agencies and activities is appropriated in two other billsâthe Departments of the Interior, Environment, and Related Agencies Appropriations Act (INT) and the Agriculture, Rural Development, Food and Drug Administration, and Related Agencies Appropriations Act (AG). Table 2 lists HHS agencies by appropriations bill.

The Administration may choose to follow different conventions than those of congressional scorekeepers for its estimates of HHS programs. For example, certain transfers of funding between HHS agencies (or from HHS to other federal agencies) that occurred in prior fiscal years, or are expected to occur in the current fiscal year, may be accounted for in the Administration's estimates but not necessarily in the congressional documents. HHS budget materials include two different estimates for mandatory spending programs in FY2019 when appropriate: proposed law and current law . Proposed law estimates take into account changes in mandatory spending proposed in the FY2020 HHS budget request. Such proposals would need to be enacted into law to affect the budgetary resources ultimately available to the mandatory spending program. HHS materials may also show a current law or current services estimate for mandatory spending programs. These estimates assume that no changes will be made to existing policies, and instead estimate mandatory spending for programs based on criteria established in current authorizing law. The HHS budget estimates in this report reflect the proposed law estimates for mandatory spending programs, but readers should be aware that other HHS, OMB, or congressional estimates might reflect current law instead. In some cases, agencies within HHS have the authority to expend user fees and other types of collections that effectively supplement their appropriations. In addition, agencies may receive transfers of budgetary resources from other sources, such as from the Public Health Service Evaluation Set-Aside (also referred to as the PHS Tap) or one of the mandatory funds established by the Patient Protection and Affordable Care Act (ACA; P.L. 111-148 , as amended). Budgetary totals that account for these sorts of resources in the Administration estimates are referred to as being at the "program level." HHS agencies that have historically had notable differences between the amounts in the appropriations bills and their program level include FDA (due to user fees) and AHRQ (due to transfers). The program level for each agency is listed in the table entitled "Composition of the HHS Budget Discretionary Programs" in the HHS FY2020 Budget in Brief.

HHS Budget by Operating Division

Figure 2 provides a breakdown of the FY2020 HHS budget request by operating division. When taking into account both mandatory and discretionary budget authority (i.e., total budget authority shown in Figure 2 ), CMS accounts for the largest share of the request (nearly $1.17 trillion). The majority of the CMS budget request would go toward mandatory spending programs, such as Medicare and Medicaid.

When looking exclusively at discretionary budget authority, funding for CMS is comparatively smaller, accounting for just $3.6 billion of the HHS discretionary request. The largest share of the discretionary request would go to the PHS agencies (roughly $59.4 billion in combined funding for FDA, HRSA, IHS, CDC, ATSDR, NIH, and SAMHSA; no funds would go to AHRQ under the request ). NIH would receive the largest amount ($33.5 billion) of discretionary budget authority of any HHS operating division, and ACF would receive the second-largest amount ($18.3 billion).

Table 3 puts the FY2020 request for each HHS operating division and the Office of the Secretary into context, displaying it along with estimates of funding provided over the three prior fiscal years (FY2017-FY2019). These totals are inclusive of both mandatory and discretionary funding.

The amounts in this table are shown in terms of budget authority (BA) and outlays. BA is the authority provided by federal law to enter into contracts or other financial obligations that will result in immediate or future expenditures involving federal government funds. Outlays occur when funds are actually expended from the Treasury; they could be the result of either new budget authority enacted in the current fiscal year or unexpended budget authority that was enacted in previous fiscal years. As a consequence, the BA and outlays in this table represent two different ways of accounting for the funding that is provided to each HHS agency through the federal budget process. For example, Table 3 shows $0 in FY2020 BA for AHRQ because the President's budget proposes to eliminate this agency; however, the table shows an estimated $299 million in FY2020 AHRQ outlays, reflecting the expected expenditure of funds previously provided to the agency.

Appendix. HHS Operating Divisions: Missions and FY2020 Budget Resources

This appendix provides for each operating division a brief summary of its mission, the applicable appropriations bill, the FY2020 budget request level, and links to additional resources related to that request.

Food and Drug Administration (FDA)

The FDA mission is focused on regulating the safety, efficacy, and security of human foods, dietary supplements, cosmetics, and animal foods; and the safety and effectiveness of human drugs, biological products (e.g., vaccines), medical devices, radiation-emitting products, and animal drugs. It also regulates the manufacture, marketing, and sale of tobacco products.

Relevant Appropriations Bill:

AG

FY2020 Request:

BA: $3.329 billion Outlays: $2.837 billion

Additional Resources Related to the FY2020 Request:

Congressional Justification (all-purpose table on p. 15), https://www.fda.gov/downloads/AboutFDA/ReportsManualsForms/Reports/BudgetReports/UCM633738.pdf . BIB chapter (p. 21), https://www.hhs.gov/sites/default/files/fy-2020-budget-in-brief.pdf#page=25 .

Health Resources and Services Administration (HRSA)

The HRSA mission is focused on "improving health care to people who are geographically isolated, economically or medically vulnerable." Among its many programs and activities, HRSA supports health care workforce training; the National Health Service Corps; and the federal health centers program, which provides grants to nonprofit entities that provide primary care services to people who experience financial, geographic, cultural, or other barriers to health care.

Relevant Appropriations Bill:

LHHS

FY2020 Request:

BA: $11.004 billion Outlays: $11.864 billion

Additional Resources Related to the FY2020 Request:

Congressional Justification (all-purpose table on p. 16), https://www.hrsa.gov/sites/default/files/hrsa/about/budget/budget-justification-fy2020.pdf . BIB chapter (p. 29), https://www.hhs.gov/sites/default/files/fy-2020-budget-in-brief.pdf#page=33 .

Indian Health Service (IHS)

The IHS mission is to provide "a comprehensive health service delivery system for American Indians and Alaska Natives" and "raise the physical, mental, social, and spiritual health of American Indians and Alaska Natives to the highest level." IHS provides health care for approximately 2.2 million eligible American Indians and Alaska Natives through a system of programs and facilities located on or near Indian reservations, and through contractors in certain urban areas.

Relevant Appropriations Bill:

INT

FY2020 Request:

BA: $6.104 billion Outlays: $5.970 billion

Additional Resources Related to the FY2020 Request:

Congressional Justification (all-purpose table on p. 7), https://www.ihs.gov/sites/budgetformulation/themes/responsive2017/display_objects/documents/FY2020CongressionalJustification.pdf BIB chapter (p. 36), https://www.hhs.gov/sites/default/files/fy-2020-budget-in-brief.pdf#page=40 .

Centers for Disease Control and Prevention (CDC) and Agency for Toxic Substances and Disease Registry (ATSDR)

The CDC mission is focused on "disease prevention and control, environmental health, and health promotion and health education." CDC is organized into a number of centers, institutes, and offices, some focused on specific public health challenges (e.g., injury prevention) and others focused on general public health capabilities (e.g., surveillance and laboratory services).

In addition, the Agency for Toxic Substances and Disease Registry (ATSDR) is headed by the CDC director. For that reason, the ATSDR budget is often shown within CDC. Following the conventions of the FY2020 HHS BIB, ATSDR's budget request is included in the CDC totals shown in this report. ATSDR's work is focused on preventing or mitigating adverse effects resulting from exposure to hazardous substances in the environment.

Relevant Appropriations Bills:

LHHS (CDC) INT (ATSDR)

FY2020 Request (CDC and ATSDR combined):

BA: $6.767 billion Outlays: $7.877 billion

Additional Resources Related to the FY2020 Request:

CDC Congressional Justification (all-purpose table on p. 23), https://www.cdc.gov/budget/documents/fy2020/fy-2020-cdc-congressional-justification.pdf . ATSDR Congressional Justification, https://www.cdc.gov/budget/documents/fy2020/fy-2020-atsdr.pdf . BIB chapter (p. 43), https://www.hhs.gov/sites/default/files/fy-2020-budget-in-brief.pdf#page=47 .

National Institutes of Health (NIH)

The NIH mission is focused on conducting and supporting research "in causes, diagnosis, prevention, and cure of human diseases" and "in directing programs for the collection, dissemination, and exchange of information in medicine and health." NIH is organized into 27 research institutes and centers, headed by the NIH Director. (The FY2020 President's budget assumes that AHRQ's functions will be consolidated within NIH, in the new National Institute for Research on Safety and Quality (NIRSQ). This assumption is reflected in the figures below. )

Relevant Appropriations Bill:

LHHS

FY2020 Request:

BA: $33.669 billion Outlays: $36.652 billion

Additional Resources Related to the FY2020 Request:

Congressional Justification (all-purpose table on p. 18), available at https://officeofbudget.od.nih.gov/pdfs/FY20/br/Overview-Volume-FY-2020-CJ.pdf . BIB chapter (p. 52), available at https://www.hhs.gov/sites/default/files/fy-2020-budget-in-brief.pdf#page=56 .

Substance Abuse and Mental Health Services Administration (SAMHSA)

The SAMHSA mission is focused on reducing the "impact of substance abuse and mental illness on America's communities." SAMHSA coordinates behavioral health surveillance to improve understanding of the impact of substance abuse and mental illness on children, individuals, and families, and the costs associated with treatment.

Relevant Appropriations Bill:

LHHS

FY2020 Request:

BA: $5.535 billion Outlays: $5.684 billion

Additional Resources Related to the FY2020 Request:

Congressional Justification (all-purpose table on p. 8), https://www.samhsa.gov/sites/default/files/samhsa-fy-2020-congressional-justification.pdf . BIB chapter (p. 60), https://www.hhs.gov/sites/default/files/fy-2020-budget-in-brief.pdf#page=64 .

Agency for Healthcare Research and Quality (AHRQ)

The AHRQ mission is focused on research to make health care "safer, higher quality, more accessible, equitable, and affordable." Specific AHRQ research efforts are aimed at reducing the costs of care, promoting patient safety, measuring the quality of health care, and improving health care services, organization, and financing. The FY2020 President's budget proposes eliminating AHRQ and consolidating certain key AHRQ functions within NIH, in the new National Institute for Research on Safety and Quality (NIRSQ).

Relevant Appropriations Bill:

LHHS

FY2020 Request:

BA: $0 Outlays: $0.299 billion

Additional Resources Related to the FY2020 Request:

Congressional Justification for the proposed National Institute for Research on Safety and Quality, https://www.ahrq.gov/sites/default/files/wysiwyg/cpi/about/mission/budget/2020/FY_2020_CJ_-NIRSQ.pdf . There is no FY2020 BIB chapter for AHRQ.

Centers for Medicare & Medicaid Services (CMS)

The CMS mission is focused on supporting "innovative approaches to improve quality, accessibility, and affordability" of Medicare, Medicaid, the State Children's Health Insurance Program (CHIP), and private insurance, and on supporting private insurance market reform programs. The President's budget estimates that in FY2020, "over 145 million Americans will rely on the programs CMS administers including Medicare, Medicaid, the Children's Health Insurance Program (CHIP), and the [Health Insurance] Exchanges."

Relevant Appropriations Bill:

LHHS

FY2020 Request:

BA: $1,169.091 billion Outlays: $1,156.333 billion

Additional Resources Related to the FY2020 Request:

Congressional Justification (all-purpose table on p. 9), https://www.cms.gov/About-CMS/Agency-Information/PerformanceBudget/FY2020-CJ-Final.pdf . BIB chapter (p. 65), https://www.hhs.gov/sites/default/files/fy-2020-budget-in-brief.pdf#page=69 .

Administration for Children and Families (ACF)

The ACF mission is focused on promoting the "economic and social well-being of children, youth, families, and communities." ACF administers a wide array of human services programs, including Temporary Assistance for Needy Families (TANF), Head Start, child care, the Social Services Block Grant (SSBG), and various child welfare programs.

Relevant Appropriations Bill:

LHHS

FY2020 Request:

BA: $52.121 billion Outlays: $53.208 billion

Additional Resources Related to the FY2020 Request:

Congressional Justification (all-purpose table on p. 6), https://www.acf.hhs.gov/sites/default/files/olab/acf_congressional_budget_justification_2020.pdf . BIB chapter (p. 122), https://www.hhs.gov/sites/default/files/fy-2020-budget-in-brief.pdf#page=126 .

Administration for Community Living (ACL)

The ACL mission is focused on maximizing the "independence, well-being, and health of older adults, people with disabilities across the lifespan, and their families and caregivers." ACL administers a number of programs targeted at older Americans and the disabled, including Home and Community-Based Supportive Services and State Councils on Developmental Disabilities.

Relevant Appropriations Bill:

LHHS

FY2020 Request:

BA: $1.997 billion Outlays: $2.238 billion

Additional Resources Related to the FY2020 Request:

Congressional Justification (all-purpose table on p. 13), https://acl.gov/sites/default/files/about-acl/2019-04/FY2020%20ACL%20CJ%20508.pdf . BIB chapter (p. 136), https://www.hhs.gov/sites/default/files/fy-2020-budget-in-brief.pdf#page=140 .