DEPARTMENT OF HEALTH AND HUMAN SERVICES 200 INDEPENDENCE AVENUE S.W., WASHINGTON, D.C. 20201 THIS DOCUMENT IS ALSO AVAILABLE AT HTTP://WWW.HHS.GOV/BUDGET TABLE OF CONTENTS Overview................................................................................................................................................................1 Food and Drug Administration ........................................................................................................................... 14 Health Resources and Services Administration.................................................................................................. 19 Indian Health Service .......................................................................................................................................... 25 Centers for Disease Control and Prevention ...................................................................................................... 28 National Institutes of Health .............................................................................................................................. 36 Substance Abuse and Mental Health Services Administration .......................................................................... 44 Centers for Medicare & Medicaid Services ........................................................................................................ 49 Medicare ...................................................................................................................................................... 51 Program Integrity ......................................................................................................................................... 57 Medicaid ....................................................................................................................................................... 59 Children's Health Insurance Program .......................................................................................................... 64 State Grants and Demonstrations................................................................................................................ 68 Program Management ................................................................................................................................. 70 Administration for Children and Families........................................................................................................... 74 Discretionary Programs ................................................................................................................................ 75 Mandatory Programs ................................................................................................................................... 79 Administration for Community Living ................................................................................................................ 85 Office of the Secretary........................................................................................................................................ 89 General Departmental Management ........................................................................................................... 89 Office of Medicare Hearings and Appeals.................................................................................................... 91 Office of the National Coordinator for Health Information Technology ..................................................... 93 Office for Civil Rights .................................................................................................................................... 95 Office of Inspector General ................................................................................................................................ 97 Public Health and Social Services Emergency Fund ........................................................................................... 99 Abbreviations and Acronyms ........................................................................................................................... 104 PUTTING AMERICA’S HEALTH FIRST FY 2018 President’s Budget for HHS 2016 dollars in millions Budget Authority Total Outlays Full-time Equivalents (FTE) 2017 /1 2018 1,119,166 1,103,145 1,126,789 1,130,835 1,112,883 1,131,256 77,499 79,505 80,027 1/ A full-year 2017 appropriation was not enacted at the time the budget was prepared; therefore, the budget assumes operations under the Further Continuing Appropriations Act, 2017 (P.L. 114–254). The amounts included for 2017 reflect the annualized level provided by the Continuing Resolution. $1,131 Billion in Outlays Children's Entitlement Programs 3% Discretionary Programs 7% Medicare 52% TANF 1% Other Mandatory Programs 1.5% Medicaid 36% General Notes Detail in this document may not add to the totals due to rounding. Budget data in this book are presented “comparably” to the FY 2018 Budget, since the location of programs may have changed in prior years or be proposed for change in FY 2018. This approach allows increases and decreases in this book to reflect true funding changes. The FY 2017 and FY 2018 mandatory figures reflect current law and mandatory proposals reflected in the Budget. Putting America’s Health First 1 PUTTING AMERICA’S HEALTH FIRST The Department of Health and Human Services (HHS) is enhancing the health and well-being of the American people by providing effective health and human services and by fostering sound, sustained advances in the sciences underlying medicine, public health, and social services. The President’s Fiscal Year (FY) 2018 Budget supports the Department’s mission by making strategic investments to protect the health and well-being of Americans; delivering hope and healing to the American people; promoting patient-centered care; strengthen services to tribes; investing in the health of America’s future; and ensuring responsible stewardship of taxpayer dollars for long-term sustainability. Achieving these goals will require HHS to make strategic investments and carry out our mission in the most effective manner possible. Failing to tackle unsustainable deficit spending means passing growing debt on to our children and grandchildren and creating serious economic damage. The Federal Government’s deficit spending has created a growing debt that cannot be sustained, because it is consuming an increasing portion of national income and limiting resources for private investment and public programs. Over the next ten years, interest payments on our national debt are projected to consume trillions of dollars and surpass annual spending on national defense, Medicaid, or science. The President’s Budget request for HHS proposes $69 billion in discretionary budget authority and $1,046 billion in mandatory funding to help HHS deliver on the promises the Administration has made to the American people. The Budget focuses resources on direct services and proven investments while streamlining or eliminating programs that are duplicative or have limited impact. The Department’s approach to budgeting this fiscal year puts the American people first by supporting fiscal discipline within the Federal Government and saving taxpayers a net estimated $665 billion over 10 years. Without action, future generations of Americans will be burdened with unsustainable debt. To restore the people’s trust, we must take a fiscally sustainable approach. The Budget begins the process of expanding choices for individuals and families; enabling market forces and competition to encourage innovation and restrain costs; encouraging self-sufficiency; and promoting federalism, allowing States and localities the flexibility they need to serve their populations. With responsibility for the major drivers of mandatory spending in the Budget, HHS is in a unique position to help lead the Administration’s efforts to rebuild fiscal solvency and to secure the trust of current and future generations of Americans. A COMMITMENT TO FISCAL RESPONSIBILITY— RESTORING TRUST TO GENERATIONS OF AMERICANS REFORMING THE AMERICAN HEALTH CARE SYSTEM The FY 2018 President’s Budget brings Federal spending under control and returns the Federal budget to balance within ten years. Of its total net estimated ten-year savings over this period, the HHS Budget contributes $665 billion in mandatory savings primarily from giving States new flexibilities to operate their Medicaid programs under per capita caps or block grants beginning in Fiscal Year 2020. The President has embraced these bold reforms that save, strengthen, and secure the promises of the Federal Government’s major benefits programs. The Budget ensures that Medicaid and other programs focus on the most vulnerable Americans that they were intended to serve—the elderly, people with disabilities, children, and pregnant women. Providing Relief from Obamacare The Budget includes $250 billion in net deficit savings over 10 years associated with health care reform as part of the Administration’s commitment to expand choices, increase access, and lower premiums. The Administration continues to support a repeal and replace approach that improves Medicaid's sustainability and targets resources to those most in need, eliminates Obamacare’s onerous taxes and mandates, provides funding for States to stabilize markets and ensure a smooth transition away from Obamacare, and helps Americans purchase the coverage they want through the use of tax credits and expanded Health Savings Accounts. The Administration urges the Congress to continue its work to repeal and 2 Putting America’s Health First replace Obamacare. The $250 billion in combined savings accrue to both Treasury and HHS. practice of defensive medicine. These medical liability reforms will benefit all Americans by cutting unnecessary health care spending. The Administration will continue to work with Congress to provide for a stable transition from the burdensome requirements of Obamacare to a health care system that provides Americans with access to care that meets their needs and increases options for patients and providers. The Administration also supports State flexibility to create a free and open health care market and will empower States to make decisions that work best for their markets. In light of these goals, the Budget promotes efficient operations and funds critical activities to continue to operate the law’s health insurance Exchanges. In addition to reducing health care costs, these reforms will help physicians focus on patients and on evidencebased medicine rather than on frivolous lawsuits. By providing a safe harbor based on clinical guidelines, physicians can focus on delivering effective care, and - if an inherently risky medical procedure does not work out as intended - physicians will be able to express sympathy to a grieving family without fear of giving rise to a lawsuit. Specifically, the Budget proposes the following medical liability reforms: • Capping awards for noneconomic damages at $250,000 indexed to inflation; • Providing safe harbors for providers based on clinical standards; • Authorizing the Secretary to provide guidance to States to create expert panels and administrative health care tribunals; • Allowing evidence of a claimants’ income from other sources such as workers compensation and auto insurance to be introduced at trial; • Providing for a three-year statute of limitations; • Allowing courts to modify attorney's fee arrangements; • Establishing a fair‐share rule to replace the current rule of joint and several liability; • Excluding provider expressions of regret or apology from evidence; and • Requiring courts to honor a request by either party to pay damages in periodic payments for any award equaling or exceeding $50,000. Reforming Medicaid The Budget fulfills the President’s pledge to give States the resources and flexibility they need to care for the most vulnerable in their communities through Medicaid. To this end, the Budget reforms Medicaid funding to States starting in FY 2020 through either a per capita cap or a block grant. The Budget also provides other flexibilities to States and encourages them to innovate and test new ideas that will improve access to care and health outcomes. These proposals will save $610 billion through FY 2027 and will allow States to prioritize Federal resources for the most vulnerable populations. The Budget extends the Children’s Health Insurance Program for two years (through FY 2019) and makes modest reforms that taken together save a net $5.8 billion over the Budget window. The reforms to the Children’s Health Insurance Program ensure the program’s focus on serving the most vulnerable low-income families. Enhancing Direct-to-Patient Relationships HHS is committed to reducing regulatory burdens facing medical professionals, especially those serving in rural areas. To achieve this goal, HHS continues to look for ways to improve or eliminate regulations that impede the ability of medical professionals to provide the best possible care to their patients. HHS also believes that health care providers are a valuable resource whose input and ideas are essential to a positive health care reform effort. HHS also is committed to an open and transparent process for developing new voluntary payment models that providers can participate in. Finally, HHS has established various avenues of technical assistance to Modernizing the Medical Liability System The current medical liability system disproportionately benefits a relatively small group of plaintiffs and trial lawyers at the expense of adding significantly to the cost of health care for every American and imposing a significant burden on health care providers. The current medical liability system does not work for patients or providers, nor does it promote high-quality, evidence-based care. The Budget proposes medical liability reforms that will save HHS programs $31.8 billion over 10 years and $55 billion to the Federal Government overall. A significant portion of these savings are attributable to the estimated reduction in unnecessary services and curbing the Putting America’s Health First 3 help clinicians be successful in providing efficient, high-quality care to their patients. stockpiles of vaccines as well as sustaining domestic vaccine manufacturing infrastructure. Achieving the President’s goals to reform Medicaid will require providing States with more flexibility to improve healthcare delivery to meet the needs of their unique populations. Direct Primary Care practices, in which physicians offer primary care services to patients at a set price, generally without payer or insurer involvement, are a mechanism to improve physician-patient relationships. Some State Medicaid programs are already testing this innovative care delivery model. HHS will explore opportunities for States and providers to further expand Direct Primary Care, which will support improved health outcomes for Medicaid populations. Human infections with a new avian influenza (H7N9) virus were first reported internationally in China in March 2013. The World Health Organization has reported 566 human infections with the H7N9 virus during the fifth epidemic, making it the largest to date. This count brings the cumulative number of H7N9 cases reported by the World Health Organization to 1,364. The FY 2018 Budget includes a $207 million investment to respond to the needs of the American people in the event of an influenza pandemic. Research and Development of Medical Countermeasures The Budget invests $1.02 billion into the research and development of medical countermeasures needed during disasters. Using these funds, the Department partners with industry leaders to develop an effective response capability to protect Americans from radiological, nuclear, chemical, and biological threats. The Department supports a broad portfolio of countermeasures to bridge the gap from early discovery to advanced development and procurement. These investments meet a unique Federal role to partner with industry in developing drugs and other countermeasures for which a sufficient market is lacking. PROTECTING THE HEALTH AND WELL-BEING OF AMERICANS Supporting Life-Saving Preparedness and Response Activities The Department fills a unique Federal role in emergency preparedness and response. HHS is the Federal Government’s lead agency in responding to public health emergencies. The Department coordinates the prevention of, preparation for, and response to public health emergencies and disasters. It supports numerous critical activities to enhance the Federal, State, and local capacity to respond to public health disasters—from outbreaks of infectious disease to chemical, biological, radiological, nuclear, and cyber threats. Preparedness Grants The Budget restructures HHS preparedness grants to direct resources to States with the greatest need and innovative approaches. The Budget will introduce competition, risk, and link awards to performance across ASPR’s Hospital Preparedness Program and CDC’s Public Health and Emergency Preparedness Program. The grants will support entities that are most innovative in their approach to health care delivery system readiness and public health preparedness. The Budget provides $2.9 billion to ensure that the Department is equipped to support life-saving preparedness and response activities aimed at addressing public health disasters and threats. This includes maintaining key investments in biodefense capabilities. Emergency preparedness initiatives to address pandemic influenza, as well as the research and development of medical countermeasures, are described in greater detail below. DELIVERING HOPE AND HEALING TO AMERICA The opioid epidemic is the deadliest drug epidemic in American history. Deaths from opioid overdose have risen steadily over the past two decades and have become the leading cause of death from injury in the United States, claiming 91 lives every day. We are losing more Americans to overdoses every year than we did during the entire Vietnam War. Pandemic Influenza The Budget supports activities within the Public Health and Social Services Emergency fund to respond to and protect the American people from pandemic influenza threats, such as the H7N9 virus circulating in China. These activities include maintenance of the current 4 Putting America’s Health First Advancing Better Practices for Pain Management While actions to address prescription opioid abuse must focus on both prescribers and high-risk patients, prescribers are the first line of defense for preventing inappropriate access. The FY 2018 CDC Budget includes $75.4 million to improve the way opioids are prescribed through clinical practice guidelines and support State programs, which help health care providers offer safer, more effective treatments while reducing opioid-related abuse and overdose. CDC aims to save lives and prevent prescription opioid overdoses by equipping providers with the knowledge, tools, and guidance they need. The Administration has made combating opioid abuse and fighting addiction an Administration-wide effort and priority, and the Budget reflects this commitment. It continues to invest in activities to fight opioid abuse, maintains funding for substance abuse treatment, and seeks to improve prescribing practices and the use of medication-assisted treatment. The Budget also invests in high-priority mental health initiatives by targeting resources for serious mental illness, suicide prevention, homelessness prevention, and children’s mental health. Improving Prescribing Practices and Expanding Use of Medication-Assisted Treatment To fight against opioid abuse, medication must be correctly prescribed and utilized. HHS is focused on providing support for cutting-edge research on pain addiction and strengthening our understanding of the epidemic through health surveillance. In addition, the Budget makes investments to improve access to treatment and recovery services, target the availability and distribution of overdose-reversing drugs, and advance better practices for pain management. In addition, the Centers for Medicare and Medicaid Services’ Budget continues to support the agency’s work to implement more effective, patient-centered strategies to reduce the risk of opioid use disorders, overdoses, inappropriate prescribing, and drug diversion. Improving Access to Mental Health Treatment In 2015, an estimated 10 million American adults battled serious mental illness, such as a psychotic or serious mood or anxiety disorder. The Budget includes high-priority mental health funding that addresses suicide prevention, homelessness prevention, and children’s mental health. It also includes funding to address the needs of adults with serious mental illness and children experiencing a mental health crisis. The Budget provides $119 million for the Children’s Mental Health Services program, which helps States, Tribes, and communities deliver evidence-based services and support for children and youth with serious mental health concerns. These funds facilitate effective collaboration between child and youth-serving systems such as juvenile justice, child welfare, and education. The Budget also proposes that up to 10 percent of the funds will be available for a new demonstration project focused on earlier interventions. This new set-aside reflects recent research by the National Institute on Mental Health indicating that earlier psychosocial interventions with those who are high-risk may prevent the further development of serious emotional disturbances and ultimately serious mental illness. Improving Access to Treatment and Recovery Services Medication-assisted treatment is a proven effective intervention for individuals suffering from addiction. The Budget includes $500 million for the Substance Abuse and Mental Health Administration’s State Targeted Response to the Opioid Crisis Grants authorized in the 21st Century Cures Act to expand access to life-saving, transformative treatments, including Medication-Assisted Treatment. The Budget also continues the $1.9 billion Substance Abuse Block Grant, which States can use to provide life-saving treatments, and $25 million in SAMHSA for other targeted efforts focused specifically on expanding access to critical interventions. Targeting Availability and Distribution of OverdoseReversing Drugs First responders to an overdose in progress have precious little time to save a life by reversing the effects of an overdose. The FY 2018 Budget for SAMHSA includes $24 million to equip first responders with overdose reversing drugs and to train them on their use, supporting the implementation of key provisions of the Comprehensive Addiction and Recovery Act. Putting America’s Health First The Budget maintains $60 million in critical funding for grants to States, colleges, and the suicide prevention resource center to raise suicide awareness and disseminate best practices for prevention. The Budget also continues to provide funding for the National Suicide Prevention Lifeline, which coordinates a 5 national network of crisis centers by providing suicide prevention and crisis intervention services. Those seeking help can reach the Lifeline at 1-800-273-TALK at any time, day or night. nearly 20 percent of school-aged children are obese. Children with obesity are at higher risk for having other chronic health conditions and diseases that impact physical health, such as asthma, sleep apnea, bone and joint problems, type 2 diabetes, and risk factors for heart disease. Providing Patient-Centered Care HHS is committed to addressing the challenges many Americans continue to confront under a health care system that is failing to meet their needs. The Department is supporting a patient-centered health care reform effort that is aimed at empowering patients, families, and doctors when it comes to making health care decisions. HHS is making progress toward this priority by taking administrative and regulatory actions that will provide the American people relief from the current law, build a partnership with states to improve health care choices for patients, reform the medical liability system, and enhance the doctor-patient relationship. In FY 2018, the Department will invest nearly $400 million in services, training for medical professionals, and approaches that respond to the diverse health care needs across America. The Budget represents a commitment to uplifting the health of the next generation by investing in services that promote healthy eating and physical activity. To accomplish this priority, the Budget invests in a new CDC block grant to address childhood obesity and other state priorities, and enhances Children’s Health Insurance Program flexibility. CDC Childhood Obesity and America’s Health Block Grant The FY 2018 Budget will support investments in the most effective childhood obesity prevention and intervention strategies within CDC and promote better nutrition, increased physical activity, and prevention of future chronic illness. CDC will continue to provide funding to States to implement programs intended to reduce the risk factors associated with childhood obesity, manage chronic conditions in schools, and promote the well-being and healthy development of all children and youth. Strengthening Services to Tribes HHS is committed to providing quality health care to over 2.2 million American Indian and Alaska Native people by effectively leveraging resources and implementing new and innovative ways to improve access to and the delivery of quality health care. As part of the unique government-to-government relationship between the Federal Government and Tribal Governments, the Indian Health Service provides health care to members of more than 567 Federally-recognized tribes. The FY 2018 IHS Budget prioritizes funding for direct health care services, including behavioral health services. The Budget includes a new CDC $500 million America’s Health Block Grant to increase State flexibility and focus on leading public health challenges. The newly-established block grant will provide flexibility in FY 2018 for each State to implement specific interventions that address its population’s unique public health issues, including interventions to spur improvements in physical activity and the nutrition of children and adolescents. Prioritizing Direct Health Services in Indian Country The Budget reflects HHS’s high-priority commitment to Indian Country and protects direct health care investments. In FY 2018, the Budget maintains funding for clinical services at $3.3 billion, which includes inpatient and outpatient care in hospitals and clinics, behavioral health services, and dental health services. In FY 2018, IHS estimates that they will serve 2.2 million American Indians and Alaska Natives. RESPONSIBLE STEWARDSHIP OF TAXPAYER DOLLARS AND REDEFINING THE FEDERAL ROLE The Budget allows HHS to continue to support priority activities at an overall lower level while restoring fiscal discipline and promoting long-term fiscal stability across the Federal Government. In order to make targeted, strategic investments and carry out the Department’s mission in the most efficient manner possible, the Budget proposes reorganizations and specific HHS efficiencies, proposals to revisit key partnerships within the private sector, and proposals to strengthen the integrity of the Medicare and Medicaid programs. INVESTING IN THE HEALTH OF AMERICA’S FUTURE The percentage of children with obesity in the United States has more than tripled since the 1970s. Today, 6 Putting America’s Health First and Centers. This change will enable NIH to focus on higher priority activities. Reorganizations and HHS-Specific Efficiencies While large-scale reorganization, workforce restructuring, and efficiency proposals are under development within the Department, the Budget offers select HHS restructuring and efficiency proposals. The Budget consolidates the Agency for Healthcare Research and Quality into NIH and maintains $272 million in discretionary funding for these activities. As part of this consolidation, NIH will conduct a review of health services research across NIH and develop a strategy to ensure that the highest priority health services research is conducted and made available across the Federal Government. The consolidation proposal preserves key activities, such as patient safety research, that improve the quality and safety of American health care. The Budget reduces or eliminates lower-priority programs that overlap with activities administered by other components of HHS. Medicare Appeals HHS remains committed to working with Congress on comprehensive and common sense reforms to the Medicare appeals process. The Budget includes investing $1.3 billion over ten years to address the pending backlog and HHS is pursuing reforms to revamp the process to address appeals as early as possible and prevent escalation to subsequent levels. These changes will make the appeals system easier to navigate, increase adjudicatory capacity to address incoming annual receipts, and reduce backlogged appeals pending at the Office of Medicare Hearings and Appeals and the Departmental Appeals Board. The Department is committed to work with Congress to address the Medicare appeals backlog. Revisiting Key Partnerships with the Private Sector The Budget envisions a recalibration of how to pay for the Food and Drug Administration’s (FDA) premarket review activities. Industry fees are increased to fund 100 percent of costs for premarket review and approval activities in the animal drug, animal generic, prescription and generic drug, biosimilar, and medical device programs. In a constrained budget environment, industries that directly benefit from FDA’s administrative actions can and should pay to support FDA’s capacity. The fee-funded approach is consistent with the overarching goals of the Administration’s Budget, which are to reprioritize Federal spending to advance the safety and security of the American people. The Budget also includes reforms that balance the demand for scientific rigor and access to reliable, life-saving cures. In addition, the Budget will include regulatory relief to the industry and speed the development of safe and effective medical products. National Institutes of Health (NIH) Structural Changes NIH will continue to support core mission-critical activities in the Budget, while implementing policies to reduce burden on its grantees. On average, from FY 1994 to FY 2014, NIH spent approximately 30 percent of its research resources on indirect costs, leaving only 70 percent for direct research and other supporting research activities. Other entities, including private foundations and payers, spend a much higher portion of their grants on direct science. The current indirect rate setting process requires each grantee to provide hundreds of pages of documentation to negotiate their indirect rate with the Government. NIH will implement reforms to release grantees from the costly and time-consuming indirect rate setting process and reporting requirements. Applying a uniform indirect cost rate to all grants mitigates the risk for fraud and abuse because it can be simply and uniformly applied to grantees. The Budget allows FDA to remain an acknowledged leader among the world’s regulatory agencies in both the number of new drugs approved each year and in the timeliness of review. These proposals will allow FDA to continue carrying out its statutory responsibilities of protecting public health by promoting innovative, safe treatments that are responsive to the needs of the American people. The Budget includes this critical reform to reduce indirect costs and preserve more funding for direct science. Strengthening the Integrity of Medicare and Medicaid The Budget strengthens the integrity and sustainability of Medicare and Medicaid by investing an additional $70 million in new Health Care Fraud and Abuse Control Program funding in FY 2018, targeting activities The Budget also proposes the elimination of the Fogarty International Center, but retains all Federal staff and maintains key activities in other NIH Institutes Putting America’s Health First 7 that prevent fraud, waste, and abuse and promote quality, patient-centered health care. The increase in funding reflects the Administration’s commitment to fighting fraud and the belief that this investment will pay off in significant returns to the Medicare Trust Fund and the Treasury. For example, recent reports to Congress show Medicare program integrity efforts yielding approximately a $12 to $1 return and law enforcement and litigation efforts yielding a $5 to $1 return. 8 Putting America’s Health First HHS BUDGET BY OPERATING DIVISION /1 2016 2017 2018 2,725 2,566 2,741 2,698 1,891 2,080 10,777 10,263 10,654 10,372 10,205 10,828 Indian Health Service Budget Authority Outlays 4,916 4,682 4,953 5,191 4,898 4,939 Centers for Disease Control and Prevention Budget Authority Outlays 8,698 7,504 7,696 7,920 6,374 7,275 31,718 29,280 31,829 32,117 26,049 30,195 3,642 3,443 4,156 3,672 3,771 3,688 Agency for Healthcare Research and Quality Budget Authority Program Level Outlays 334 428 269 333 426 300 0 0 288 Centers for Medicare & Medicaid Services /2 Budget Authority Outlays 999,037 990,120 1,006,775 1,006,929 1,009,626 1,019,633 Administration for Children and Families /3 Budget Authority Outlays 53,068 50,905 54,116 54,479 46,535 48,289 1,936 1,972 1,937 1,956 1,851 1,935 60 85 60 128 38 43 dollars in millions Food and Drug Administration Budget Authority Outlays Health Resources and Services Administration Budget Authority Outlays National Institutes of Health Budget Authority Outlays Substance Abuse and Mental Health Services Administration Budget Authority Outlays Administration for Community Living Budget Authority Outlays Office of the National Coordinator Budget Authority Outlays Putting America’s Health First 9 HHS BUDGET BY OPERATING DIVISION 2016 2017 2018 107 107 107 107 242 242 38 16 38 41 33 33 478 889 578 1,956 270 576 1,948 1,516 1,530 2,792 1,663 1,736 77 82 77 107 68 84 707 546 707 1,568 737 760 Offsetting Collections Budget Authority Outlays -975 -975 -1,373 -1,373 -1,243 -1,243 Other Collections Budget Authority Outlays -125 -125 -125 -125 -125 -125 1,119,166 1,103,145 1,126,789 1,130,835 1,112,883 1,113,256 77,499 79,505 80,027 dollars in millions Medicare Hearings and Appeals Budget Authority Outlays Office for Civil Rights Budget Authority Outlays Departmental Management /4 Budget Authority Outlays Public Health and Social Services Emergency Fund Budget Authority Outlays Office of Inspector General Budget Authority Outlays Program Support Center (Retirement Pay, Medical Benefits, Misc. Trust Funds) Budget Authority Outlays Total, Health and Human Services Budget Authority Outlays Full-time Equivalents 1/ The Budget Authority levels presented here are based on the Appendix, and potentially differ from the levels displayed in the individual Operating or Staff Division Chapters. 2/ Budget Authority includes Non-CMS Budget Authority for Hospital Insurance and Supplementary Medical Insurance for the Social Security Administration and MEDPAC. 3/ The amounts listed for FY 2018 Budget Authority and Outlays do not take into account updated scoring of legislative proposals in Temporary Assistance for Needy Families that are displayed in ACF budget documents. 4/ Includes the Pregnancy Assistance Fund, Transfer from the Patient-Centered Outcomes Research Trust Fund, Health Insurance Reform Implementation Fund, Payment to the State Response to the Opioid Abuse Crisis Account and the Nonrecurring Expenses Fund. 10 Putting America’s Health First COMPOSITION OF THE HHS BUDGET DISCRETIONARY PROGRAMS 2016 2017 2018 2018 +/-2017 2,728 4,745 2,743 4,660 1,888 5,116 -855 +456 6,147 10,543 6,150 10,401 5,548 9,941 -602 -460 4,808 6,160 4,798 6,148 4,739 6,091 -59 -57 Centers for Disease Control and Prevention Program Level 6,345 12,028 6,368 12,096 5,054 11,059 -1,314 -1,037 National Institutes of Health Program Level 31,381 32,311 31,674 32,593 25,883 26,920 -5,791 -5,673 3,634 4,144 3,771 -373 3,781 4,291 3,892 -399 334 428 333 426 0 0 -333 -426 3,975 6,476 3,967 6,031 3,588 5,609 -379 -422 18,870 18,870 19,284 19,284 14,482 14,482 -4,802 -4,802 1,965 2,048 1,961 2,042 1,851 1,907 -110 -135 General Departmental Management Program Level 456 552 455 550 305 399 -150 -151 Office of Medicare Hearing and Appeals Program Level 107 107 107 107 117 242 +10 +135 dollars in millions Discretionary Programs (Budget Authority): Food and Drug Administration Program Level Health Resources and Services Administration Program Level Indian Health Service /1 Program Level Substance Abuse and Mental Health Services Administration Program Level Agency for Healthcare Research and Quality /2 Program Level Centers for Medicare & Medicaid Service Program Level Administration for Children and Families /3 Program Level Administration for Community Living Program Level Office of the Secretary: Putting America’s Health First 11 COMPOSITION OF THE HHS BUDGET DISCRETIONARY PROGRAMS 2016 2017 2018 60 60 60 60 38 2018 +/-2017 -22 -22 77 343 76 341 68 359 -8 -18 39 39 33 -6 1,533 1,533 1,530 1,530 1,663 1,663 +133 +133 681 681 751 +70 26 28 31 +3 Total, Discretionary Budget Authority 83,167 84,401 69,810 -14,591 NEF Cancellation /3 — -400 -560 -160 Less One-Time Rescissions -6,742 -6,806 -4,472 +2,334 Revised, Discretionary Budget Authority 76,425 77,195 64,778 -12,417 Discretionary Outlays 80,216 90,832 79,552 -11,280 dollars in millions Office of the National Coordinator Program Level Office of Inspector General Program Level Office for Civil Rights Public Health and Social Services Emergency Fund Program Level Discretionary HCFAC Accrual for Commissioned Corps Health Benefits 38 1/ The FY 2016 level includes a revised estimate of $718 million for Contract Support Costs and the FY 2017 level reflects an estimated actual cost of Contract Support Costs. 2/ The 2018 Budget includes $272 million within NIH to consolidate AHRQ's activities within NIH. 3/ The 2017 amount reflect the $300 million transfer to ACF and $100 million rescission included in the 2017 CR. 12 Putting America’s Health First COMPOSITION OF THE HHS BUDGET MANDATORY PROGRAMS Mandatory Programs (Outlays):1/ Medicare Medicaid Temporary Assistance for Needy Families /2 /3 Foster /are and Adoption Assistance /hildren's Health Insurance Program /4 /hild Support Enforcement /hild /are Entitlement Social Services Block Grant Other Mandatory Programs Offsetting /ollections Subtotal, Mandatory Outlays Total, HHS Outlays 2016 2017 2018 2018 +/-2017 588,309 368,280 16,196 7,700 14,358 4,079 2,788 1,780 20,414 -975 1,022,929 592,593 378,455 17,120 8,025 16,879 4,266 2,968 1,699 19,371 -1,373 1,040,003 586,579 403,713 15,436 8,457 13,417 4,302 2,946 362 17,735 -1,243 1,051,704 -6,014 +25,258 -1,684 +432 -3,462 +36 -22 -1,337 -1,636 +130 +11,701 1,103,145 1,130,835 1,131,256 +421 1/ Totals may not add due to rounding. 2/ Includes outlays for the TANF program and TANF /ontingency Fund. 3/ The amounts listed for FY 2018 Outlays do not take into account updated scoring of legislative proposals in Temporary Assistance for Needy Families that are displayed in A/F budget documents. 4/ Includes outlays for the /hild Enrollment /ontingency Fund. Putting America’s Health First 13 Food and Drug Administration dollars in millions FDA Programs /2 Foods Human Drugs Biologics Animal Drugs and Feeds Medical Devices National Center for Toxicological Research Tobacco Products Headquarters and Office of the Commissioner White Oak Consolidation GSA Rental Payment Other Rent and Rent Related Activities Subtotal, Salaries and Expenses Export Certification Fund Color Certification Fund Rare Pediatric Priority Review Vouchers Buildings and Facilities 21st Century Cures Act Total, Program Level Current Law User Fees /3 Prescription Drug /4 Medical Device /4 Animal Drug /4 Animal Generic Drug /4 Food Reinspection Food Recall Family Smoking Prevention and Tobacco Control Act Generic Drug /4 Biosimilars /4 Mammography Quality Standards Act Export Certification Fund Color Certification Fund Rare Pediatric Priority Review Vouchers Voluntary Qualified Importer Program Third Party Auditor Program Outsourcing Facility Subtotal, Current Law User Fees Proposed Law User Fees Export Certification /6 Subtotal, Proposed Law User Fees Less Total, User Fee FDA Totals Total, Discretionary Budget Authority 14 2016 2017 /1 2018 /5 2018 +/- 2017 1,010 1,391 355 189 450 63 564 300 52 224 120 4,716 5 9 8 9 -4,745 993 1,324 339 191 441 63 563 291 52 236 116 4,609 5 10 8 9 20 4,660 922 1,612 366 183 490 60 626 322 57 250 133 5,021 9 10 8 9 60 5,116 -71 +287 +27 -7 +49 -3 +63 +31 +5 +14 +17 +411 +4 +0 --+40 +456 851 138 23 10 6 1 599 318 22 20 5 9 8 5 1 1 2,017 755 126 24 11 6 1 598 323 22 21 5 10 8 5 1 1 1,917 1,262 439 70 18 6 1 672 616 87 21 5 10 8 5 1 1 3,223 +508 +313 +47 +7 --+74 +293 +65 --+0 ---+0 +1,306 --2,017 --1,917 4 4 3,228 +4 +4 1,311 2,728 2,743 1,888 -854 Food and Drug Administration Food and Drug Administration dollars in millions Full-time Equivalents 2016 2017 2018 /4 16,527 17,134 17,614 2018 +/- 2017 +480 st 1/ Reflects the annualized level of the Continuing Resolution that ended April 28, 2017, including the across the board reduction, the 21 Century Cures Act, and directed transfers. 2/ Reflects a transfer of $1.5 million to the HHS Office of Inspector General for FDA oversight activities as specified in the FY 2016 appropriation and continued by the FY 2017 Continuing Resolution less a rescission. 3/ Does not reflect priority review voucher user fee for Medical Countermeasures as FDA continues to develop an estimated fee level. 4/ The prescription and generic drug, biosimilar, and medical device user fee programs expire on October 1, 2017. The Budget includes legislative proposals to reauthorize these four user fee programs. The Budget also includes legislative proposals to increase fees for the animal drug and animal generic drug user fee programs in their fifth and final year of authorization. 5/ All figures are displayed comparable to the FY 2018 President’s Budget. The FY 2016, FY 2017, and FY 2018 columns have been updated to reflect reallocated funding across the programs addressing previous reorganizations that consolidated economists in Headquarters and established the Oncology Center of Excellence, as well as to better aligning the funding structure to services related to intergovernmental affairs. 6/ The FY 2018 President’s Budget proposes to increase the statutory user fee limit for export certification. The Food and Drug Administration is responsible for protecting the public health by assuring the safety, efficacy, and security of human and veterinary drugs, biological products, medical devices, the Nation’s food supply, cosmetics, and products that emit radiation. FDA also advances the public health by helping to speed innovations that make medicines more effective, safer, and affordable; and by helping the public get the accurate, science-based information they need to use medicines and foods to maintain and improve their health. Furthermore, FDA has responsibility for regulating the manufacturing, marketing, and distribution of tobacco products to protect the public health and to reduce tobacco use by minors. Finally, FDA plays a significant role in the Nation’s counterterrorism capability by ensuring the security of the food supply and by fostering development of medical products to respond to deliberate and naturally emerging public health threats. FDA PROGRAMS and approval of safe and effective medical products, supporting the continued transformation of the food safety system, supporting the Department’s preparedness enterprise, and conducting innovative research. The Food and Drug Administration (FDA) protects and advances public health through an array of programs and activities, ranging from minimizing occurrences of drug shortages to carrying out inspections of imported food products. FDA estimates that Americans currently pay approximately two cents per day to ensure that the products it regulates—which account for more than 20 percent of every consumer dollar spent on products in the United States—are safe and effective. The Fiscal Year (FY) 2018 Budget includes $5.1 billion in total resources for FDA—an increase of $456 million or 10 percent above the FY 2017 Continuing Resolution. At this total level, the Budget provides an increase of $1.3 billion in user fees, while reducing budget authority by $854 million. With the proposals in this budget, the burden on American taxpayers will be even lower—a little over one cent per American per day. ADVANCING ACCESS TO SAFE AND EFFECTIVE MEDICAL PRODUCTS FDA’s Center for Drug Evaluation and Research approved 22 novel drugs in calendar year 2016. Approvals included the first treatment for patients with spinal muscular atrophy, a new drug to treat patients with a rare chronic liver disease known as primary biliary cirrhosis, and two new treatments for patients with hepatitis C. Additionally, 2016 marked the highest number of generic drug approvals and tentative approvals—more than 800—in the history of FDA’s generic drug program. Many of these approvals were for first-time generic drugs, with the introduction of a generic counterpart for a brand-name product for which there was previously no generic. The Budget prioritizes resources across core public health activities including advancing the development Food and Drug Administration 15 PROGRAM HIGHLIGHT These examples reflect only a few of the many medical product responsibilities FDA carries out. FDA oversees the safety, effectiveness, availability, and quality of an extensive range of regulated products available to Americans, which encompass prescription and over-the-counter drugs; biologics including vaccines, blood products, and gene therapies; animal drugs; and, medical devices ranging from bandages to laser surgical equipment and radiation-emitting products. FDA also ensures that regulated products are marketed according to Federal standards and that products available to the public continue to be safe especially as new clinical information becomes available. Across the vast jurisdiction of FDA-regulated products and activities, FDA continues to incorporate cutting-edge regulatory science into its evaluations to support patient access to safe and effective medical products. Drug Shortages FDA not only makes available safe and effective medical products, but also takes great efforts—within its legal authority—to address and prevent drug shortages. Drug shortages can occur for many reasons, including manufacturing and quality problems, delays, and discontinuations. FDA works closely with manufacturers of drugs in short supply to communicate the issue and to help restore availability. FDA also works with other firms who manufacturer the same drug, asking them to increase production, if possible, in order to prevent or reduce the impact of a shortage. In 2016, FDA prevented 115 drug shortages. Budget increases user fee resources by over $1 billion to support all medical product review and approval activities across these programs. To support speeding patient access to safe and effective medical products, the Budget also includes a portfolio of administrative actions to achieve regulatory efficiencies through programs and process improvements. These actions include: • Encouraging the use of 21st Century Cures Act tools for drug evaluation, review, and approval; • Simplifying administrative requirements to reduce drug and device manufacturers' reporting burden; • Clarifying treatment of value-based purchasing arrangements; and • Improving predictability for payers and enhanced dissemination of evidence by fostering the exchange of scientifically sound information between manufacturers and payers pre-approval to reduce uncertainty and improve payer ability to more accurately set premiums. As a result of the 21st Century Cures Act (P.L. 114-255), FDA will continue to build on ongoing efforts to advance medical product innovation and ensure that patients get access to treatments as quickly as possible, with continued assurance from high quality evidence that they are safe and effective. Examples of the new activities carried out include: • Further incorporating the patient perspective in the drug review process; • Supporting the Oncology Center of Excellence; • Advancing the review of breakthrough devices; • Incorporating the latest in regulatory science evidence; and • Continuing work on regenerative advanced therapies. The FY 2018 Budget supports FDA’s critical role to ensure safe and effective medical products are advanced to market by recalibrating how to finance these activities. In a constrained budget environment, the Budget acknowledges medical product industries have sufficiently matured to assume a greater share of costs associated with FDA's administrative actions. User fees have been instrumental in allowing FDA to build capacity and improve the timeliness of the medical product review process without compromising the agency’s high standards. As part of this recalibration, accompanying the Budget will be four legislative proposals to reauthorize the prescription and generic drugs, biosimilar, and medical device user fee programs as well as additional proposals to revise the animal drugs and animal generics programs. The The Budget will advance FDA’s highest priority activities to ensure medical products available to the American public meet current requirements and standards for safety and efficacy. Medical product safety investments in the FY 2018 Budget total $3.2 billion at the program level, which is $505 million above the spending appropriated under the annualized level of the FY 2017 Continuing Resolution. This total includes $648 million in budget authority, and 16 Food and Drug Administration $2.5 billion in user fees. In FY 2018, FDA activities include—but are not limited to—review of new medical products, research to inform sound regulatory decisions about benefits and risks of products that increasingly involve new technologies, and monitoring of the quality of marketed medical products through surveillance, inspections, and compliance programs. availability of nutritional information to assist with decisions made by individuals and their families, ensuring that food additives and color additives standards set by FDA and guarding public health by ensuring information on food labels is based on the most current science. The Budget includes $1.3 billion for food safety across FDA programs, a decrease of $83 million below the funding appropriated by the FY 2017 Continuing Resolution. This total includes $1.2 billion in budget authority—a reduction of $109 million—and $42 million in user fees, an increase of $26 million. PROGRAM HIGHLIGHT Regulatory Reform The President is committed to fostering an environment that enables industry to advance innovative, safe, and effective treatments and cures to the patients who need them as quickly as possible. To achieve this goal in FY 2018, FDA will implement programs and process improvements to achieve greater regulatory efficiency and speed the availability of innovative, safe, and effective medical products in the market. In FY 2018, FDA will continue its most critical public health and safety activities, including outbreak response, implementation of Food Safety Modernization Act regulations, and ensuring that foods are safe and properly labeled. FDA will make targeted reductions to the Food Safety program, including reducing staff levels through attrition. FDA will continue support for food safety research, cosmetics safety, partnerships with academic institutes, and international capacity building at reduced levels. Outcomes of these efforts will include increasing engagement with manufacturers, including providing standardized and predictable pathways for early interactions to help reduce uncertainty in medical product development; reducing review times by streamlining processes and gaining efficiencies to the greatest extent possible; and reducing regulatory burden and leveraging FDA’s statutory mandates, including recent enhancements through the 21st Century Cures Act. Currently authorized fees support programs such as the voluntary qualified importer program, export certification, and the third party auditor program. FDA INFRASTRUCTURE AND FACILITIES FDA has issued all seven foundational final rules that established the framework for a strengthened and modernized food safety system, including preventive controls for manufactured food and feed where compliance dates for larger business began in fall 2016. In FY 2017, FDA will build on these regulations and guide the modernization of our food safety system by prioritizing prevention, supporting risk-based oversight, and expanding collaboration in the food safety community. These activities ultimately will improve public health by lowering the incidence of illness due to food hazards and will avoid interruptions to the food supply. FDA infrastructure and facilities, including 56 laboratories strategically located across the continental United States and Puerto Rico, directly support mission critical work and enable FDA to respond to food safety and medical product emergencies. These responsibilities have increased as a result of groundbreaking legislation passed over recent years, which also has resulted in additional staff. The FY 2018 Budget ensures that FDA laboratories and offices can continue to support staff in carrying out the Agency’s growing responsibilities for food and medical product safety. The Budget invests a total of $440 million - $36 million above the FY 2017 Continuing Resolution - in FDA infrastructure, including costs to keep up with the science and continue planned activities at both headquarters (including the White Oak Campus) and in the field. In FY 2018, the FDA food safety portfolio will continue to support other vital food and feed safety activities that are important to the public such as improving the The Budget also provides $9 million, the same as the FY 2017 Continuing Resolution, to fund repairs and improvements of FDA-owned facilities. CONTINUING THE TRANSFORMATION OF THE FOOD SAFETY SYSTEM Food and Drug Administration 17 ADVANCING MEDICAL COUNTERMEASURES REDUCING THE USE AND HARMS OF TOBACCO FDA actively supports the establishment and sustainment of an adequate supply of medical countermeasures to protect against chemical, biological, radiological, nuclear, and emerging infectious disease threats such as pandemic influenza, Ebola virus, and Zika virus. Since FY 2016, FDA mobilized more than 500 staff members to support the agency’s critical contributions to the U.S. Government’s response to the Zika virus outbreak in the Americas, and sustained response effort to the 2014 Ebola epidemic in West Africa, and the Middle East Respiratory Syndrome coronavirus outbreak, which was first noted in 2012. FDA has enabled the use of 30 diagnostic tests under its Emergency Use Authorizations authority and facilitated the development of therapeutics and vaccines to respond to those threats. FDA also issued an Emergency Use Authorizations to permit the emergency use of an atropine auto-injector to help strengthen the Nation’s public health protections against chemical threats. FDA approved the majority of medical countermeasure marketing applications under review in FY 2016 that met standards for safety, efficacy, and quality. The FY 2018 Budget includes $25 million to continue the Medical Countermeasures program which directly supports medical countermeasures efforts across FDA in support of the Department’s preparedness and response activities. These resources will help accelerate the development, evaluation, and approval of critical medical countermeasures. In addition, this funding will support the development and coordination of policies to advance emergency preparedness and response. FDA, through the Center for Tobacco Products, executes its regulatory and public health responsibilities in program areas that support the following objectives: preventing initiation; decreasing the harms of tobacco product use; and encouraging cessation. Tobacco use is the leading cause of preventable disease, disability, and death in the United States. The United States spends nearly $170 billion on medical care to treat smoking-related disease in adults each year. FDA also has contracts to conduct compliance check inspections at tobacco retail establishments with 55 States, Territories, and tribal jurisdictions. FDA publishes guidance to the tobacco industry to increase awareness of their new obligations and of FDA’s responsibilities. The FY 2018 Budget includes $672 million in user fees to support the FDA tobacco program. USER FEES The Budget assumes resources from reauthorizing the human and generic drug, medical device, and biosimilar user fee programs set to expire at the end of FY 2017, increasing total fees collected under the animal drugs program, increasing the allowable fee amount for the export certification fee, and additional increases in all currently authorized user fee programs. Resources from user fees are critical to enable FDA to carry out its mission and institute performance metrics that lead to greater efficiencies and increased speed at which products are available to the public. 18 Food and Drug Administration Health Resources and Services Administration dollars in millions 2016 /1 2017 /2 2018 2018 +/- 2017 4,992 1,392 3,600 100 0.1 5,092 4,900 1,389 3,511 100 0.1 5,000 4,989 1,389 3,600 100 0.1 5,089 +89 -+89 --+89 310 83 39 36 60 30 5 21 229 295 21 49 1,178 289 83 39 36 56 30 5 21 229 294 18 48 1,148 Primary Health Care Health Centers Discretionary Budget Authority [non-add] Mandatory Funding [non-add] Health Centers Tort Claims Free Clinics Medical Malpractice Subtotal, Primary Care Health Workforce National Health Service Corps [Mandatory] Training for Diversity Training in Primary Care Medicine Oral Health Training Teaching Health Centers Graduate Medical Education [Mandatory] Area Health Education Centers Health Care Workforce Assessment Public Health and Preventive Medicine Programs Nursing Workforce Development Children's Hospital Graduate Medical Education National Practitioner Data Bank User Fees Other Workforce Programs Subtotal, Health Workforce Health Resources and Services Administration 19 310 ---60 -5 -83 295 18 -771 +21 -83 -39 -36 +4 -30 --21 -146 +1 --48 -377 Health Resources and Services Administration 2018 +/- 2017 2016 /1 2017 /2 2018 Maternal and Child Health Block Grant Sickle Cell Demonstration Program Autism and Other Developmental Disorders Heritable Disorders Healthy Start Universal Newborn Hearing Screening Emergency Medical Services for Children Family-to-Family Health Information Centers [Mandatory] Home Visiting [Mandatory] Subtotal, Maternal and Child Health 638 4 47 14 104 18 20 5 400 1,250 637 4 47 14 118 18 20 5 372 1,236 667 ---128 --5 400 1,200 +30 -4 -47 -14 +10 -18 -20 Ryan White HIV/AIDS Program Emergency Relief - Part A Comprehensive Care - Part B AIDS Drug Assistance Program [non-add] Early Intervention - Part C Children, Youth, Women, and Families - Part D AIDS Education and Training Centers - Part F Dental Services - Part F Special Projects of National Significance (SPNS) Subtotal, Ryan White HIV/AIDS Healthcare Systems 656 1,315 900 205 75 34 13 25 2,323 655 1,313 899 205 75 34 13 25 2,318 655 1,313 899 205 75 -13 -2,260 ------34 --25 -59 Organ Transplantation Cord Blood Stem Cell Bank C.W. Bill Young Cell Transplantation Program Poison Control Centers 340B Drug Pricing Program Hansen's Disease Programs Subtotal, Healthcare Systems Rural Health 24 11 22 19 10 17 103 24 11 22 19 10 17 103 24 11 22 19 10 13 99 ------4 -4 Rural Outreach Grants Rural Hospital Flexibility Grants Telehealth Rural Health Policy Development State Offices of Rural Health Radiation Exposure Screening and Education Black Lung Clinics Subtotal, Rural Health 64 42 17 9 10 2 7 150 63 42 17 9 9 2 7 149 51 -10 5 -2 7 74 -13 -42 -7 -4 -9 ---75 dollars in millions Maternal and Child Health 20 -- +28 -35 Health Resources and Services Administration Health Resources and Services Administration dollars in millions Family Planning Program Management Vaccine Injury Compensation Program Direct Operations Subtotal, Other Activities HRSA Budget Totals—Less Funds from Other Sources Total, Program Level User Fees Current Law Mandatory Funding New Mandatory Proposals Total, Discretionary Budget Authority Full-time Equivalents 2016 /1 2017 /2 2018 286 154 8 448 286 154 7 448 286 152 9 448 2018 +/- 2017 --2 +2 -- 10,543 21 -4,375 -6,147 10,401 18 -4,232 -6,150 9,940 18 --4,375 5,548 -460 -+4,232 -4,375 -602 2,211 2,117 -94 1,996 1/ In addition, the FY 2016 Zika Response and Preparedness Act (P.L. 114-223) provided $387 million in supplemental resources to the Public Health and Social Services Emergency Fund for Zika response and preparedness activities, of which $66 million was allocated for HRSA. 2/ Reflects the annualized level of the Continuing Resolution that ended April 28, 2017, including the across the board reduction, the 21st Century Cures Act, and directed transfers. The Health Resources and Services Administration is the primary Federal agency for improving access to health care services for people who are uninsured, isolated, or medically vulnerable. The FY 2018 Budget provides a total of $9.9 billion in funding for HRSA, which is $460 million below the funding level provided by the FY 2017 Continuing Resolution, and prioritizes the provision of direct health care services. ENSURING ACCESS TO DIRECT HEALTH CARE SERVICES in Fiscal Years 2018 and 2019. At this funding level, health centers will serve nearly 26 million patients across the United States and its Territories in FY 2018. Within this funding, the FY 2018 Budget continues $50 million for grants from the prior year related to the treatment, prevention, and awareness of opioid abuse. The Fiscal Year (FY) 2018 President’s Budget prioritizes direct health care services within the Health Resources and Services Administration (HRSA), including Health Centers and Ryan White HIV/AIDS programs. These safety-net providers deliver critical health care services to low-income and vulnerable populations. Ryan White HIV/AIDS Programs For nearly three decades, the Ryan White HIV/AIDS Program has provided medical and support services to low-income individuals living with HIV/AIDS who do not have sufficient health care coverage or resources to access lifesaving care. As the largest Federal program focused exclusively on domestic HIV/AIDS care, the Ryan White HIV/AIDS Program reduces the use of more costly inpatient care, increases access to health services for underserved populations, improves survival, and reduces HIV transmission. Health Centers For over 50 years, health centers have provided high-quality preventive and primary health care to Americans across the country. More than 24 million people—1 in 13 nationwide—receive direct health care services at health centers. Health centers advance a model of coordinated, comprehensive, and patient-centered medical, dental, behavioral, and patient services. Today, nearly 1,400 health centers operate over 10,400 service delivery sites and provide affordable health care services to patients in every State, the District of Columbia, Puerto Rico, U.S. Virgin Islands, and the Pacific Basin. The FY 2018 Budget provides $5.1 billion for Health Centers, which includes an additional $3.6 billion in new mandatory resources Health Resources and Services Administration The FY 2018 Budget provides $2.3 billion—$59 million below the FY 2017 Continuing Resolution—for the Ryan White HIV/AIDS Program. The Ryan White HIV/AIDS Program provides a comprehensive system of primary medical care, treatment, and supportive services to 21 more than half of the people in the United States who have been diagnosed with HIV. The Budget proposes prioritizing funding for direct health care services to people living with HIV by discontinuing the Ryan White HIV/AIDS Part F AIDS Education and Training Programs and Special Projects of National Significance. communities facing a shortage of such specialists by providing scholarships and loan repayments and by requiring service commitment. National Health Service Corps Since its inception in 1972, the National Health Service Corps has been committed to providing services to underserved populations. The National Health Service Corps provides scholarships and loan repayment to health care professionals in return for service commitments in communities experiencing a shortage of health professionals. The Budget includes $310 million in new mandatory resources for the National Health Service Corps in both FY 2018 and FY 2019, which will support an approximate field strength of 8,600 providers in FY 2018. The program continues to be one of the Nation’s most effective programs in placing health care professionals in communities with the greatest need. DIRECT SERVICES PROGRAMS Ryan White HIV/AIDS Program Individuals receiving HIV care through Ryan White achieve higher viral suppression, in comparison to the national average of 54.7 percent. In 2015, 83.4 percent of clients served by the Ryan White HIV/AIDS Program achieved viral suppression. Within the requested funding level, the Budget provides $899 million, the same level as the FY 2017 Continuing Resolution for the AIDS Drug Assistance Program. This essential program provides grants to States to pay for HIV/AIDS medications and related services for uninsured, underinsured, and low-income patients who cannot afford them. Children’s Hospitals Graduate Medical Education The Budget provides $295 million in discretionary funding for the Children’s Hospital Graduate Medical Education Program, which advances children’s health by providing funding to eligible freestanding hospitals to support the training of pediatricians and other residents. This program enables residents to provide health care services dedicated to children’s unique health care needs. Adequate residency training in pediatric care is important for residents who pursue a variety of specialties. In FY 2015, Children’s Hospitals Graduate Medical Education grantees reported training a total of 6,877 resident full-time equivalents on- and off-site. The Budget request will maintain this resident FTE level in FY 2018. The Administration looks forward to working with Congress to reauthorize the Ryan White program to ensure that Federal funds are allocated to address the changing landscape of HIV across the United States. Reauthorization of the Ryan White program should include changes to the funding methodologies for Parts A and B to ensure that funds may be allocated to target populations experiencing high or increasing levels of HIV infections/diagnoses, such as minority populations, while continuing to support Americans that are already living with HIV across the nation. African Americans, for example, account for a higher proportion of new HIV diagnoses, those living with HIV, and those ever diagnosed with AIDS as compared to other races/ethnicities. The new Ryan White authorization should allow for resources to be focused on populations with disproportionately high rates of new infections/diagnoses. Teaching Health Center Graduate Medical Education The Budget maintains funding for the Teaching Health Center Graduate Medical Education Program and requests $60 million in new mandatory funding in both FY 2018 and FY 2019. This program increases health care access in underserved communities by supporting primary care resident training in community-based, patient care settings. Since the Teaching Health Center Graduate Medical Education program’s inception in 2010, the number of supported programs has grown from 11 residency programs in the first year of funding to 59 programs in Academic Year 2016-2017 located in 24 different States across the Nation. OPTIMIZING THE NATION’S HEALTH WORKFORCE The FY 2018 Budget provides $771 million in mandatory and discretionary resources for HRSA health workforce programs, which is $377 million below the FY 2017 Continuing Resolution. At this level, funding is maintained for activities that directly increase the number of health care professionals working in 22 Health Resources and Services Administration NURSE Corps Scholarship and Loan Repayment Program The NURSE Corps Scholarship and Loan Repayment Program provides scholarships and loan repayment for individuals who are enrolled in an accredited school of nursing or nurses with eligible nursing educational loans in exchange for health care services in areas with critical nursing shortages. The Budget provides $83 million—the same level as the FY 2017 Continuing Resolution—to support over 1,200 nurses and nursing students. Resolution. The Healthy Start Program connects individuals with services that can reduce infant mortality and improve perinatal outcomes while allowing grantees to tailor services according to community need. In prioritizing the Maternal and Child Health Block Grant and Healthy Start, the Budget achieves a savings of $103 million by discontinuing smaller maternal and child health programs. States may continue to support these activities with their Maternal and Child Health Block Grant awards. SECRETARY’S PRIORITIES Health Care Workforce Assessment The Health Care Workforce Assessment Program supports the collection and analysis of data and information necessary to evaluate the effectiveness of the health workforce nation-wide. The Budget provides $5 million for this program—the same level as the FY 2017 Continuing Resolution—to continue supporting high-quality information collection and up-to-date research on the impacts of health workforce activities. Response to Zika In FY 2017, HRSA received $66 million in emergency supplemental funds to provide access to comprehensive health care and support services for children and families affected by the Zika virus in the United States and its Territories. Additionally, this funding played a critical role in increased clinical expertise of pediatric clinicians to provide care, and provided training and technical assistance on family-to-family support and referral services for children exposed to or affected by Zika in United States and its Territories. Workforce Program Eliminations Priority is given to health workforce programs that support more targeted efforts to provide direct health care services to patients in primary care settings and in medically underserved communities. The Budget reduces funding for health workforce activities by $403 million by discontinuing diversity training programs, mental and behavioral health programs, oral health programs, and select nursing and physician training programs. The Budget also provides $400 million in new mandatory resources in Fiscal Years 2018 and 2019 for grants to States to provide home visiting services to at-risk pregnant women, mothers, and their families. These services build upon decades of scientific research that shows that home visits by a nurse, social worker, or early childhood educator during pregnancy and in the first years of life have the potential to improve the lives of children and families. Additionally, research shows that home visits provide a positive return on investment by reducing reliance upon emergency room visits and public benefits receipt, decreasing interaction with child protective services, and increasing parental earnings. KEEPING FAMILIES AND COMMUNITIES HEALTHY Maternal and Child Health The FY 2018 Budget prioritizes direct health care services and provides States and communities the flexibility to meet local needs. The request increases the funding that States receive through the Maternal and Child Health Block Grant to $667 million, which is an increase of $30 million above the FY 2017 Continuing Resolution. This funding supports services to more than half of the pregnant women and nearly one-third of all infants and children in the country. The additional funding will support greater State investment to improve the health of all mothers, children, and adolescents, particularly those in low-income families. The FY 2018 Budget also provides $128 million for the Healthy Start Program, which is a $10 million increase above the FY 2017 Continuing Health Resources and Services Administration Rural Health The Federal Office of Rural Health Policy provides technical assistance, conducts research, and makes grants to enhance health care delivery in rural communities. The President’s Budget provides $74 million—$75 million below the FY 2017 Continuing Resolution—to target funding for critical rural health activities such as Rural Health Outreach Network and Quality Improvement Grants, Rural Health Policy Development, Black Lung Clinics, and Telehealth. These investments will improve access to quality health care services in rural and underserved areas. Rural 23 Hospital Flexibility Grants and State Offices of Rural Health are discontinued to prioritize programs that provide direct services. to eligible health care organizations at reduced prices. This program helps safety-net health care providers to optimize scarce resources and expand access to care. The Budget provides $10 million for the 340B Drug Pricing Program, the same level as the FY 2017 Continuing Resolution. Additionally, the Budget proposes to update regulatory authority in the 340B Drug Pricing Program to increase transparency and improve program integrity. Family Planning The Budget provides $286 million—the same level as the FY 2017 Continuing Resolution—to support low-income individuals with comprehensive family planning and related preventive health services through the Title X Family Planning program. Historically, 90 percent of family planning clients have family incomes at or below 200 percent of the Federal poverty level. In FY 2017, approximately 90 percent of family planning funding will be used for clinical services, including the treatment and prevention of sexually transmitted diseases and cervical cancer. These services, along with community-based education and outreach, assist individuals and families with pregnancy leading to healthy birth outcomes and preventing unintended pregnancies. Program Management The Budget requests $152 million—which is $2 million below the FY 2017 Continuing Resolution—to support the infrastructure necessary to operate HRSA programs. Funding in FY 2018 will allow HRSA to maintain oversight of grant and contract recipients, support program integrity efforts and reduce improper payments, develop and maintain its information technology infrastructure, train and support skilled staff, improve processes and business operations, and eliminate duplication. ADDITIONAL HRSA PROGRAMS 340B Drug Pricing Program The 340B Drug Pricing Program requires drug manufacturers to provide outpatient prescription drugs 24 Health Resources and Services Administration Indian Health Service ` 2016 2017 /1 2018 2018 +/- 2017 3,237 914 156 718 8 45 48 72 4,284 3,231 912 155 717 8 45 48 72 4,276 3,253 914 157 718 5 45 43 72 4,292 +22 +2 +2 +1 -3 --5 -+16 Subtotal, Facilities Total, Budget Authority 105 99 223 74 23 523 4,808 105 99 222 73 23 522 4,798 100 75 192 60 20 447 4,739 -5 -24 -30 -13 -3 -75 -59 Total, Program Level 1,194 9 150 6,160 1,194 9 147 6,148 1,194 9 150 6,091 --+3 -56 15,059 15,096 15,096 -- dollars in millions Services Clinical Services: Purchased/Referred Care (non-add) Preventive Health Contract Support Costs Tribal Management/Self-Governance Urban Health Indian Health Professions Direct Operations Subtotal, Services Facilities Health Care Facilities Construction Sanitation Facilities Construction Facilities and Environmental Health Support Maintenance and Improvement Medical Equipment Funds From Other Sources Health Insurance Collections Rental of Staff Quarters Diabetes Grants Full-time Equivalents 1/ Reflects the annualized level of the Continuing Resolution that ended April 28, 2017, including the across the board reduction, the 21st Century Cures Act, and directed transfers. The mission of the Indian Health Service is to raise the physical, mental, social, and spiritual health of American Indians and Alaska Natives to the highest level. PRIORITIZING HEALTH CARE SERVICES As part of the unique Government-to-Government relationship between the Federal Government and Tribal Governments, the Indian Health Service (IHS) provides health care to members of more than 567 Federally-recognized Tribes. IHS provides comprehensive healthcare services through a network of over 679 hospitals, clinics, and health stations on or near Indian reservations. The Budget reflects the high priority commitment to Indian Country, protecting direct health care investments in the context of an 18 percent reduction to the overall HHS discretionary budget. The FY 2018 Budget provides $3.3 billion for clinical services, which is an increase of $22 million above the FY 2017 Continuing Resolution—restoring funding for direct health care services to FY 2016 levels. Direct health care services The Fiscal Year (FY) 2018 Budget requests $6.1 billion for IHS, which is $56 million below the FY 2017 Continuing Resolution. The FY 2018 Budget prioritizes funding the delivery of health care services to American Indians and Alaska Natives across Indian Country. Indian Health Service 25 include outpatient and inpatient care in hospitals and clinics, behavioral health services, and dental health services. In FY 2018, IHS estimates that they will serve approximately 2.2 million American Indians and Alaska Natives. $2 million above the FY 2017 Continuing Resolution. IHS, in partnership with Tribes, uses evidence-based practices at the local level to reduce the incidence of preventable disease, and increase the health of individuals, families, and communities across Indian Country. Programs such as public health nursing, health education, and community health representatives deliver culturally appropriate services to American Indian and Alaska Natives and serve as a link to accessing care for many who live in rural and isolated communities. Staffing for Newly Opened Facilities The Budget request includes funding to support the staffing of two newly opened facilities. In FY 2018, IHS will support staffing in two Joint Venture projects, the Choctaw Nation Regional Medical Center in Oklahoma and the Flandreau Health Center in South Dakota. Under Joint Venture agreements, IHS partners with Tribal entities to provide funds for staffing, equipping, and operating a facility while participating Tribes cover the design and construction costs associated with the new facility. These funds will allow the new facilities to expand the provision of health care in areas where the existing capacity is overextended, while balancing the need to maintain existing services across the country. Purchased/Referred Care The Purchased/Referred Care program is a high priority for American Indians and Alaska Natives because it provides, through contracts with hospitals and other health care providers, the critical health care services that IHS and tribally-managed facilities are otherwise unable to provide. The Budget provides $914 million for Purchased/Referred Costs—an increase of $2 million above the FY 2017 Continuing Resolution—to support medical care for catastrophic injuries, specialized care, and other critical care services. Special Diabetes Program for Indians The Budget requests $150 million in mandatory funding for the Special Diabetes Program for Indians, an increase of $3 million above the FY 2017 Continuing Resolution. Diabetes health outcomes have improved significantly in American Indian and Alaska Native communities since the inception of the Special Diabetes Program for Indians, which provides grants for evidence-based diabetes treatment and prevention services across Indian Country. One of the most important achievements has been an eight percent reduction in the average blood sugar level of American Indian and Alaska Natives with diagnosed diabetes between 1997 and 2015. Improved blood sugar control reduces complications from diabetes. Behavioral Health While Tribes battle several chronic health problems, high rates of alcohol and substance abuse, mental health disorders, suicide, and chronic diseases are particular scourges that have had a tragic impact on American Indian and Alaska Native communities. The FY 2018 Budget requests a total of $288 million for Mental Health and Alcohol and Substance Abuse to support ongoing efforts to meet these persistent behavioral health challenges in Indian Country. This represents an increase of $1 million above the FY 2017 Continuing Resolution. Health Insurance Reimbursements The FY 2018 Budget request for IHS estimates $1.2 billion in health insurance reimbursements from third party collections. The collection of health insurance reimbursements for the provision of care to people covered by Medicare, Medicaid, the Veterans Health Administration, as well as by private insurance, allows IHS and contracting or compacting Tribes to expand the provision of health care services, purchase Preventive Health Services In FY 2018, the Budget provides $157 million for preventive health services, which is an increase of 26 Indian Health Service new medical equipment, maintain and improve buildings, and meet accreditation standards. below the FY 2017 Continuing Resolution—to maintain IHS’s agreement to fund staffing in joint venture agreements and to ensure direct patient care services are funded. Other Programs To prioritize health services and staffing for new facilities, the Budget reduces funding for Self-Governance and Indian Health Professions and discontinues the Tribal Management Grant Program. Other Facilities Improvement and Construction Programs The FY 2018 Budget reduces funding for Maintenance and Improvement, Facilities, and Environmental Health Support and Equipment. The Budget requests $60 million for Maintenance and Improvement, which is $13 million below the FY 2017 Continuing Resolution. These funds are the primary source of funding to maintain, repair, and improve existing IHS and Tribal health care facilities. The Budget requests $192 million for the Facilities and Environmental Health Support program, which is $30 million below the FY 2017 Continuing Resolution. This program supports an extensive array of real property, as well as community and institutional environmental health, injury prevention, and sanitation facilities construction services. The Budget also includes $20 million for Equipment, which is $3 million below the FY 2017 Continuing Resolution. The Budget will allow IHS to maintain its responsibility and commitment to patient care services as well as joint venture agreements with Tribes. The FY 2018 Budget requests $5 million for Self-Governance, which is $1 million below the FY 2017 Continuing Resolution. The Indian Health Professions program funds efforts to recruit and retain health professionals to provide high-quality primary care and clinical preventive services to American Indian and Alaska Native communities. The Budget provides a total of $43 million for Indian Health Professions, which is $5 million below the FY 2017 Continuing Resolution. This funding level will maintain funding for current scholarship and loan payments. FACILITIES AND CONSTRUCTION The FY 2018 Budget request includes a reduction of $75 million below the FY 2017 Continuing Resolution in facilities improvements and construction costs, for a total of $447 million in FY 2018, to prioritize funding for direct health care services to American Indians and Alaska Natives as well as staffing costs for newly opened health care facilities. FURTHERING INDIAN SELF-DETERMINATION Under the Indian Self-Determination and Education Assistance Act of 1975, Tribes and Tribal organizations can take over the operation of Indian Health Service programs. IHS recognizes the importance of their partnerships with Tribes and also understands that Tribes and Tribal organizations are the most knowledgeable about the needs in their communities. More than 60 percent of the IHS budget is administered directly by Tribes. Health Care Facilities Construction In FY 2018, the Budget provides $100 million for Health Care Facilities Construction, which is $5 million below the FY 2017 Continuing Resolution. The Budget requests $100 million for the on-going construction of the following three facilities: the Alamo Health Center in New Mexico; the Rapid City Health Center in South Dakota; and the Dilkon Alternative Rural Health Center in Arizona. Contract Support Costs Contract support costs funding supports certain operational costs of Tribes and Tribal organizations administering health care service programs under self-determination contracts and self-governance compacts. The Budget fully funds contract support costs at an estimated $718 million, and continues the use of an indefinite appropriation. The indefinite appropriation allows IHS to guarantee full funding of contract support costs while protecting funding for direct service Tribes. Sanitation Facilities Construction The Sanitation Facilities Construction Program supports construction projects that ensure access to safe drinking water and waste disposal across Indian Country. The Sanitation Facilities Construction program has had much success in disease prevention by ensuring that Tribal communities have access to safe drinking water and waste disposal. The Budget requests $75 million for these activities—$24 million Indian Health Service 27 Centers for Disease Control and Prevention dollars in millions 2016 /1 2017 /2 2018 Immunization and Respiratory Disease Prevention and Public Health Fund (non-add) Balances from PHSSEF Pandemic Flu (non-add) Vaccines For Children HIV/AIDS, Viral Hepatitis, STIs and TB Prevention Emerging and Zoonotic Infectious Diseases Prevention and Public Health Fund (non-add) Chronic Disease Prevention and Health Promotion Prevention and Public Health Fund (non-add) Birth Defects, Developmental Disabilities, Disability and Health Environmental Health Prevention and Public Health Fund (non-add) Injury Prevention and Control Public Health Scientific Services PHS Evaluation Funds (non-add) Occupational Safety & Health World Trade Center Health Program /3 Energy Employee Occupational Illness Compensation Program Global Health Public Health Preparedness and Response Buildings and Facilities CDC-Wide Activities and Program Support Prevention and Public Health Fund (non-add) Agency for Toxic Substances and Disease Registry (ATSDR) CORD MACRA Mandatory Funds User Fees Subtotal, Program Level CDC Budget Totals—Less Funds from Other Sources Vaccines for Children Energy Employee Occupational Injury Compensation Program World Trade Center Health Program /3 PHS Evaluation Funds CORD MACRA Mandatory Funds Prevention and Public Health Fund User Fees Balances from PHSSEF Pandemic Flu Total, Discretionary Budget Authority Full-Time Equivalents 797 324 15 4,400 1,121 582 52 1,177 339 136 182 17 236 491 339 313 50 427 1,413 10 411 160 75 10 2 12,172 783 324 4,437 1,120 579 52 1,175 338 135 217 17 236 491 338 347 50 426 1,402 10 273 160 75 2 12,096 701 204 4,598 934 514 137 952 500 100 157 216 460 143 200 366 55 350 1,266 20 105 62 2 11,059 2018 +/- 2017 -82 -121 -+161 -186 -65 +85 -222 +162 -35 -60 -17 -19 -31 143 -138 +18 +5 -76 -136 +10 -168 -160 -13 ---1,038 4,400 50 313 10 892 2 15 6,489 11,806 4,437 50 347 891 2 6,368 11,948 4,598 55 366 143 841 2 5,054 11,948 +161 +5 +18 +143 --51 ---1,315 -- 1/ In addition, the FY 2016 Zika Response and Preparedness Act (P.L. 114-223) provided $397 million to CDC for Zika preparedness and response. 2/ Reflects the annualized level of the Continuing Resolution that ended April 28, 2017, including the across the board reduction, the 21st Century Cures Act, and directed transfers. 3/ Reflects Federal share obligations only; NYC share is not included. Obligations for FY 2016 reflect actual; FY 2017/FY 2018 reflect estimates. 28 Centers for Disease Control and Prevention The Centers for Disease Control and Prevention (CDC) works 24/7 to protect America from health, safety, and security threats, both foreign and in the United States. Whether diseases start at home or abroad, are chronic or acute, curable or preventable, human error or deliberate attack, CDC fights disease and supports communities and citizens to do the same. CDC increases the health security of our nation. As the nation’s health protection agency, CDC saves lives and protects people from health threats. To accomplish our mission, CDC conducts critical science and provides health information that protects our nation against expensive and dangerous health threats, and responds when these arise. At this funding level, CDC will continue to protect the nation and the world by: detecting, responding to, and stopping new and emerging health threats; preventing injuries, illness, and premature deaths; and discovering new ways to protect and improve the public’s health through science and advanced technology. The Budget prioritizes funding for key areas where CDC can have the greatest impact, including: continuing the fight against opioid abuse, misuse, and overdose; supporting efforts to combat childhood obesity; protecting the Nation’s national security through medical countermeasure stockpiling; and investing in CDC’s infrastructure to ensure the safety, security and productivity of CDC staff. The Centers for Disease Control and Prevention (CDC) is the Nation’s health protection agency, working 24/7 to conduct critical scientific research, provide information that protects our nation against dangerous health threats, and respond when such threats arise. CDC increases the health security of our nation. As the nation’s health protection agency, CDC is committed to maximizing the impact of every dollar entrusted to it and continuing critical work to increase public health capacity at local, State, national, and global levels. CDC keeps America secure by controlling disease outbreaks; making sure food and water are safe; helping people avoid leading causes of death such as heart disease, cancer, stroke, and diabetes; and working globally to reduce threats to the Nation’s health. Good public health decision-making depends on the right information. CDC monitors health-related issues, informs decision-makers, and provides the public with information so they can take responsibility for their own health. By connecting State and local health departments across the United States, CDC can discover patterns of disease and respond when needed. Local and State labs must be able to safely detect and respond to health threats in order to prevent premature death, injury, and disease. CDC trains and guides State and local public health lab partners. The Budget provides CDC with increased flexibility to allocate resources and implement policies that best support mission-critical activities based on current science and public health expertise. This programmatic flexibility will enable the CDC to focus on programs that have been proven effective, while reducing costs and improving the efficient use of resources. The Budget establishes the new America’s Health Block Grant, reforming the model of existing state-based chronic disease programs to increase flexibility, allowing States to focus on leading public health challenges specific to their State. IMMUNIZATION AND RESPIRATORY DISEASES CDC is the key source of information for health professionals around the world. Ranging from recommendations from the Advisory Committee on Immunization Practices to clinical guidance on emerging health threats like Zika virus and Ebola, health professionals count on CDC for accurate and timely guidance and situational updates. CDC protects Americans from infectious diseases by issuing recommendations and guidance for the prevention and control of vaccine-preventable diseases and respiratory diseases. Through programs such as the Vaccines for Children Program, CDC improves access to immunization services for uninsured and underinsured United States populations and supports the scientific base for vaccine policy and practices. CDC delivers critical epidemiology and laboratory capacity to detect, prevent, and respond to vaccine-preventable and respiratory infectious disease threats and conducts preparedness planning for pandemic influenza. The Fiscal Year (FY) 2018 Budget for CDC and the Agency for Toxic Substances and Disease Registry (ATSDR) is $11.1 billion, a decrease of $1.0 billion relative to FY 2017. This total includes $5.1 billion in budget authority, $841 million from the Prevention and Public Health Fund, and $143 million in Public Health Service (PHS) Evaluation Funds. Centers for Disease Control and Prevention The FY 2018 Budget includes $701 million for the discretionary programs supported within CDC’s National Center for Immunization and Respiratory 29 Diseases, $82 million below the funding level reflected in the FY 2017 Continuing Resolution. Within this funding level, the influenza prevention and control program is prioritized to ensure domestic and global capacity is supported to respond to annual seasonal influenza epidemics, detect and mitigate the next influenza pandemic, and respond to other influenza emergencies. Core influenza activities are a critical foundation in supporting any effective pandemic response, which is especially pertinent given the recent H7N9 influenza outbreak in China. continue to support: vaccination-based prevention strategies; new infections detection, investigation, and response efforts; and expansion of testing and linkage to medical care. EMERGING AND ZOONOTIC INFECTIOUS DISEASES CDC’s National Center for Emerging and Zoonotic Infectious Diseases is committed to protecting people from infectious diseases no matter where they occur. CDC targets infectious diseases ranging from the familiar, such as foodborne illnesses and healthcare-associated infections, to the less common but deadly, such as anthrax and Ebola. CDC manages a broad portfolio of science-based programs that combine laboratory, epidemiologic, analytic, and prevention technologies with public health tools. CDC collaborates with state and local health departments, other Federal government agencies, industry, and foreign ministries of health. The Budget includes $514 million to support CDC’s National Center for Emerging and Zoonotic Infectious Diseases, a decrease of $65 million below the spending level allowed by FY 2017 Continuing Resolution. HIV/AIDS, VIRAL HEPATITIS, SEXUALLY TRANSMITTED INFECTIONS AND TUBERCULOSIS PREVENTION CDC’s National Center for HIV/AIDS, Viral Hepatitis, Sexually Transmitted Infections, and Tuberculosis Prevention prioritizes cost-effective, scalable programs, policies, and research to achieve the greatest impact on reducing the incidence of HIV, viral hepatitis, sexually transmitted infections, and tuberculosis and preventing related illness and death. These infections result in high personal, societal, and economic costs, both in the United States and around the world. The Budget includes $934 million for domestic HIV/AIDS, viral hepatitis, sexually transmitted infections, and tuberculosis prevention, a decrease of $186 million below the spending level allowed by the FY 2017 Continuing Resolution. Diseases spread by mosquitos and ticks will continue to evolve and move into new areas, including the United States. Outbreaks like Zika will not be a onetime event. Capacity building at all levels, as well as innovation in diagnostics, is needed to prevent and control these outbreaks and understand more about the vectors. To continue supporting CDC’s efforts around Zika preparedness and other vector-borne diseases, the Budget includes an increase of $23 million above the spending level allowed by the FY 2017 Continuing Resolution for a total of $49 million. CDC leads the fight to prevent new HIV infections, to eliminate tuberculosis, and to control sexually transmitted infections. The Budget prioritizes the most effective, evidence-based activities and maintains funding levels for hepatitis. Today, an estimated 4.4 million Americans from all walks of life are living with chronic viral hepatitis infection and are at increased risk for liver disease, liver cancer, and death. In 2012, hepatitis C-related deaths surpassed deaths from all other reportable infectious diseases combined and continued to rise in 2013 and 2014, killing more Americans each year. At this funding level, CDC will Foodborne illness is a common, costly—yet preventable—public health problem. CDC estimates that one in six Americans get sick from contaminated foods or beverages and 3,000 die each year. The United States Department of Agriculture estimates that foodborne illnesses cost $15.6 billion dollars each year. PROGRAM HIGHLIGHT America’s Health Block Grant Program The Budget reforms the CDC through a new $500 million America’s Health Block Grant to increase State, tribal and territorial flexibility and focus on the leading chronic disease challenges specific to each State. The newly-established America’s Health Block Grant will provide flexibility in FY 2018 for each state to implement specific interventions that address leading causes of death and disability, including interventions to spur improvements in physical activity and the nutrition of children and adolescents, and other leading causes of death such as heart disease. 30 Centers for Disease Control and Prevention CDC’s National Center for Chronic Disease Prevention and Health Promotion works to prevent these behaviors and support healthy living from birth through old age. CDC research indicates chronic diseases are responsible for seven of 10 deaths each year, and treating people with chronic diseases accounts for 86 percent of our nation’s health care costs. CDC provides the vital link between illness in people and the food safety systems of government agencies and food producers. The Budget maintains support for CDC’s Food Safety activities at a total of $51 million. This funding will support: investigations of current outbreaks and evaluations of past outbreaks; State and local health agencies to enhance national surveillance, improving foodborne outbreak detection, response, and prevention; and data analysis to drive prevention efforts. PROGRAM HIGHLIGHT Childhood Obesity PUBLIC HEALTH SCIENTIFIC SERVICES Childhood obesity is a serious problem in the United States. Today, three times as many children are obese as compared to rates from the 1970s. Obesity during childhood can have a harmful effect on the body in a variety of ways. Not only is childhood obesity associated with negative health consequences in childhood, these risks continue into adulthood increasing the likelihood of type 2 diabetes, cardiovascular disease, and certain cancers. Despite recent declines among preschool-aged children, obesity amongst all children is still too high, affecting one in six children and adolescents. Research has shown that well-designed, well-implemented school programs can effectively promote physical activity and healthy eating. Healthy eating and regular physical activity play a powerful role in preventing chronic diseases, including heart disease, cancer, and stroke—the three leading causes of death among adults aged 18 years or older. CDC’s Office of Public Health Scientific Services leads CDC’s efforts to improve the collection, analysis, and availability of public health data and information to improve America’s health, safety, and security. CDC provides guidance and advice across HHS and advances data system modernization and interoperability, information innovation, and enhanced data analysis, synthesis, and translation. High-quality health statistics are necessary to make evidence-based decisions to improve health and healthcare in the United States. The National Center for Health Statistics serves as one of the nation’s principal statistical agencies, collecting, analyzing, and disseminating accurate, objective data to monitor long-term trends as well as detect short-term changes of public health importance. Leaders, health professionals, and an increasingly connected public look to CDC for relevant, credible, and objective health information. In the FY 2018 Budget, CDC will continue to support its School Health programs, which provide funding to States to implement efforts to reduce the risk factors associated with childhood obesity, manage chronic conditions in schools, and promote the well-being and healthy development of all children and youth. The FY 2018 Budget includes $460 million to support public health scientific services activities, a decrease of $31 million below the spending level allowed by the FY 2017 Continuing Resolution. CDC will continue to support the most effective public health workforce training and workforce development programs, and core health care statistics at the reduced level. In addition, the newly-established America’s Health Block Grant will provide flexibility for each state to implement specific interventions to address its population’s unique public health issues, which could include interventions to spur improvements in physical activity and nutrition of children and adolescents. CHRONIC DISEASE PREVENTION AND HEALTH PROMOTION The FY 2018 Budget includes $952 million for chronic disease prevention and health promotion activities, a decrease of $222 million below the spending level allowed by the FY 2017 Continuing Resolution. At this funding level, CDC will maximize its efficiency and public health impact by focusing on programs that implement evidence-based strategies and improve results across a variety of health outcomes. In alignment with this strategy, the Budget establishes a Chronic diseases are the main cause of sickness, disability, death, and health care costs. They are often preventable. Most chronic diseases are caused by a few risk behaviors: tobacco use, poor nutrition, lack of physical activity, and excessive alcohol consumption. Centers for Disease Control and Prevention 31 new America’s Health Block Grant to provide flexibility for each state to implement specific interventions to address its population’s unique public health issues. States could use this funding to support interventions such as: tobacco prevention and control; diabetes; heart disease and stroke; nutrition, physical activity, and obesity; and arthritis. health research provide a wealth of information used to identify causes of birth defects, find opportunities to prevent them, and improve the health of those living with birth defects. Developmental disabilities, such as attention deficit/hyperactivity disorder, autism, cerebral palsy, hearing loss, and vision impairment, are some of the most significant child health issues facing families and our nation today. About one in six children in the United States have developmental disabilities or other developmental delays. CDC works to understand how common developmental disabilities are, identifying factors that can put children at risk, exploring possible causes, and improving identification of developmental delays so children and families can get the services and support they need as early as possible. The Budget includes $337 million for cancer prevention and control, a decrease of $18 million below the spending level allowed by the FY 2017 Continuing Resolution. This new approach will allow CDC to address the highest priorities and foster a more efficient cancer program overall, allowing cross-cutting activities to provide support to multiple types of cancer. BIRTH DEFECTS AND DEVELOPMENTAL DISABILITIES The FY 2018 Budget includes $100 million to support birth defects and developmental disabilities, a decrease of $35 million below the spending level allowed by the FY 2017 Continuing Resolution. At this funding level, CDC will focus its birth defects and developmental disabilities portfolio on core public health activities that align with CDC’s mission and have proven interventions to make an impact on America’s health. CDC’s National Center on Birth Defects and Developmental Disabilities prevents birth defects and developmental disorders where possible and enhances the health and quality of life for people who live with them. The early years of life (birth to five years of age) are critical to a child’s cognitive, social, and emotional development. CDC works with partners to develop public health tools and interventions that give all children the opportunity to reach their full potential. ENVIRONMENTAL HEALTH Every four and a half minutes, a baby is born with a birth defect in the United States, resulting in nearly 120,000 babies affected by birth defects each year. CDC’s state-based birth defects tracking and public CDC protects America’s health from environmental hazards that can be present in the air we breathe, the water we drink, and the world that sustains us. The National Center for Environmental Health investigates Childhood Lead Poisoning Prevention PROGRAM HIGHLIGHT Nearly 24 million homes in the U.S. have deteriorated lead-based paint and lead-contaminated house dust. In children, lead exposure can result in serious effects on cognitive and physiological development. Lead can reduce kidney function and increase risk of hypertension and essential tremor among adults. The lead contamination crisis in Flint, Michigan, affecting approximately 99,000 residents, has renewed the nation’s focus on this major problem. In response to this crisis, CDC received $35 million in additional funding in FY 2017, available through FY 2018, to: implement a lead exposure registry; establish an advisory committee; and provide increased support to CDC’s Childhood Lead Poisoning Prevention Program. CDC has assisted Flint with monitoring blood lead levels in more than 50 percent of the community’s children under six years of age and connected more than 90 percent of children with elevated blood lead levels to case management. Lead poisoning is 100 percent preventable, and the effects of elevated blood lead levels can be mitigated through timely provision of educational, medical, and behavioral interventions and social services. The FY 2018 Budget continues to support CDC’s Childhood Lead Poisoning Prevention program, which provides national expertise and works with States to monitor childhood blood lead levels to prevent lead poisoning and help those who have elevated blood lead levels by assuring appropriate follow up and access to services. This program also supports State and local efforts to collect vital lead data that enables them to target and implement primary prevention and response activities. 32 Centers for Disease Control and Prevention the relationship between environmental factors and health, develops guidance, and builds partnerships to support healthy decision-making. These investments contribute to CDC’s overall goal of keeping Americans safe from environmental hazards. quality and surveillance to monitor and respond to the epidemic; supporting States in their efforts to implement effective solutions and interventions; and equipping healthcare providers with the data and tools needed to improve the safety of their patients. The FY 2018 Budget includes $75 million in funding to support these efforts, maintaining the spending level allowed by the FY 2017 Continuing Resolution funding level. The FY 2018 Budget includes $157 million to support environmental health—$60 million below the spending level allowed by the FY 2017 Continuing Resolution— which includes $35 million for lead prevention and safe water activities, available through FY 2018. CDC programs will monitor environmentally related diseases, respond to urgent public health threats, provide training and guidance for the nation’s environmental health workforce, and assist in emergency preparedness and response efforts. PROGRAM HIGHLIGHT Preventing Opioids Abuse and Overdose Opioids, such as prescription opioids and heroin, killed more than 33,000 people in 2015, more than any year on record. Since 1999, the number of overdose deaths involving opioids quadrupled. From 2000 to 2015 more than half a million people died from drug overdoses. Ninety-one Americans die every day from an opioid overdose. The Budget includes $17 million in funding for the Childhood Lead Prevention Program, which is flat with the program’s base spending allowed by the FY 2017 Continuing Resolution. In FY 2018, this program will continue to build upon CDC’s past success in reducing children’s blood lead levels in the United States. CDC’s latest national analyses indicate that the increase in opioid overdose death rates is driven in large part by illicit opioids, like heroin and illicitly-manufactured fentanyl, a synthetic opioid. Historical data have also indicated that increased prescribing and sales of opioids—quadrupling since 1999— helped create and fuel this epidemic. INJURY PREVENTION AND CONTROL Injuries and violence affect everyone, regardless of age, race, or economic status. In the first half of life, more Americans die from violence and injuries—such as motor vehicle crashes, falls, or homicides—than from any other cause, including cancer, HIV/AIDS, or the flu. CDC is committed to an approach that protects the public's health and prevents opioid overdose deaths. The FY 2018 Budget includes $75 million to continue supporting this mission, specifically by: • Improving data quality and timeliness to better track trends, identify communities at risk, and evaluate prevention strategies; • Improving patient safety by equipping health care providers with the data and tools needed to improve opioid prescribing; and • Strengthening State efforts by scaling up effective interventions. As the nation’s leading authority on violence and injury prevention, CDC’s National Center for Injury Prevention and Control is committed to saving lives, protecting people, and lowering the social and economic costs of violence and injuries. CDC collects data to identify problems and monitor progress, uses research to understand what works, and promotes evidence-based strategies to inform real-world solutions. CDC’s goal is to offer individuals, communities, and states timely, accurate information and useful resources to keep people safe where they live, work, play, and learn. The Budget prioritizes domestic violence prevention programs, such as the Rape Prevention Program, which provides funding to grantees to implement statewide sexual violence prevention plans, implement and evaluate prevention programs, and address local sexual violence prevention needs. The FY 2018 Budget includes $216 million in budget authority for injury prevention and control activities, a decrease of $19 million below the spending level allowed by the FY 2017 Continuing Resolution. OCCUPATIONAL SAFETY AND HEALTH CDC’s National Institute for Occupational Safety and Health is the only Federal entity responsible for conducting research and making recommendations for the prevention of work-related injury and illness. One of CDC’s top priorities in the FY 2018 Budget is to sustain support to activities preventing opioid abuse and overdose. CDC applies its scientific expertise to help curb the epidemic in three ways: improving data Centers for Disease Control and Prevention 33 NIOSH works closely with the Occupational Safety and Health Administration and the Mine Safety and Health Administration in the United States Department of Labor to protect American workers and miners. NIOSH also administers the World Trade Center Health Program, which provides medical monitoring and treatment for eligible 9/11 responders and survivors and funds research into health conditions associated with the September 11, 2001, terrorist attacks. health emergencies. The program will implement reforms to improve the efficiency of the program; these reforms are complementary to the programmatic changes in the Hospital Preparedness Program within the Assistant Secretary for Preparedness and Response. The Budget restructures HHS preparedness grants to reduce overlap and administrative costs and directs resources to States with the greatest need. The Budget will introduce competition, risk, and link awards to performance. These grants will support entities that are most innovative in their approach to health care delivery system readiness and public health preparedness. These reforms will provide resources to localities with the greatest need, and encourage innovation by introducing competition to the grant program. Additionally, the program will focus funding decisions on performance by providing awards to recipients who are demonstrating critical emergency preparedness outcomes. The FY 2018 Budget includes $200 million to support occupational health and safety, a decrease of $138 million below the spending level allowed by the FY 2017 Continuing Resolution. NIOSH will conduct research to reduce worker illness and injury, and to advance worker well-being, but will not continue to fund State and academic partners for conducting, translating, or evaluating research. In addition, the Budget includes $366 million in mandatory funding supported by the World Trade Center Health Program, and $55 million in mandatory funding for the Energy Employees Occupational Illness Compensation Program Act. The Budget includes $575 million for the Strategic National Stockpile—$1 million above the spending level allowed by the FY 2017 Continuing Resolution—to maintain a repository of medical countermeasures that can be rapidly deployed to support State, territorial, and local response to public health threats. CDC’s Strategic National Stockpile is the largest Federallyowned supply of lifesaving pharmaceuticals and medical equipment available for emergency use. At this funding level, CDC will be able to maintain inventory levels for the majority of stockpiled products and continue training responders nationwide to receive and use medical countermeasures when deployed. PUBLIC HEALTH PREPAREDNESS AND RESPONSE CDC’s Office of Public Health Preparedness and Response works to strengthen and support the Nation’s health security to save lives and protect against public health threats. CDC protects the safety, security, and health of the United States by providing lifesaving response to chemical, biological, radiological, and nuclear threats, as well as other disasters, outbreaks, and epidemics. The Budget provides $1.3 billion for public health emergency preparedness activities within CDC, which is $136 million below the spending level allowed by the FY 2017 Continuing Resolution. The Budget provides reduced funding for operations for CDC’s Emergency Operation Center, which conducts real-time research monitoring of public health events, outbreaks, and hazardous agents and the Select Agents Program, which keeps communities safe by overseeing laboratories that work with deadly pathogens and toxins. A critical component of CDC’s preparedness and response activities are the Public Health and Emergency Preparedness cooperative agreements, which directly support State and local health departments. The Budget provides $551 million to the cooperative agreements to enable public health agencies to build resilient communities that have strong public health emergency management and response systems, all resulting in improving the overall safety of American communities. State and local health departments use this funding to advance, sustain, and develop the necessary tools to ensure local communities can effectively management public GLOBAL HEALTH By ensuring that countries have the capacity to prevent, detect, and respond to threats within their borders, CDC’s Center for Global Health helps prevent regional and global health crises that affect health, security, and economic stability abroad and at home. These activities provide a global safety net by monitoring for disease outbreaks 24/7 around the world. CDC uses scientific data to track diseases and other health threats and target services to those who 34 Centers for Disease Control and Prevention need them most across a variety of programs, including global immunization, HIV/AIDS, tuberculosis, parasitic diseases and malaria, and disease detection and response, as well as health systems and laboratories. CDC’s infrastructure are essential to ensure that CDC can respond to the public health needs in the next decade. AGENCY FOR TOXIC SUBSTANCES AND DISEASE REGISTRY (ATSDR) The FY 2018 Budget includes $350 million for global health activities, a decrease of $76 million below the spending level allowed by the FY 2017 Continuing Resolution. This funding will support key global health activities including polio eradication, global tuberculosis, measles and other vaccine-preventable diseases, parasitic diseases and malaria, and ongoing global health protection. The Agency for Toxic Substances and Disease Registry (ATSDR) is a nonregulatory environmental health agency that provides public health expertise to keep Americans safe from hazards in the environment. Environmental factors contribute to more than 25 percent of diseases worldwide, including cancer, asthma, and heart disease. This funding level also includes support of ongoing efforts in polio eradication. CDC’s leadership and guidance in accountability, environmental surveillance, and scientific and programmatic implementation has contributed substantially to the more than 99.9 percent decline in global and United States polio cases. In FY 2018, CDC will focus its polio eradication efforts on core public health activities that align with CDC’s mission and use proven interventions to move towards global eradication to ensure Americans are not at risk from this deadly disease anymore. ATSDR experts provide a 24/7 response to toxic chemical exposure, hazardous leaks and spills, environmentally related poisonings, natural disasters, and terrorist acts. ATSDR works in communities to assess human exposures to potentially harmful contaminants; advises Federal and State regulatory agencies and community members on actions needed to protect health; answers questions about environmental exposures; and provides guidance to health care providers. BUILDINGS AND FACILITIES The FY 2018 Budget includes $62 million for ATSDR, a decrease of $13 million below the spending level allowed by the FY 2017 Continuing Resolution. At this funding level, ATSDR will support the highest priority community requests for public health assessments and consultations. The FY 2018 Budget includes $20 million for CDC’s facility repair and improvements, an increase of $10 million above the spending level allowed by the FY 2017 Continuing Resolution. This additional funding will support infrastructure repairs and improvements to ensure CDC’s critical public health work can continue in buildings and facilities that support a safe, world-class research environment. Investments in Centers for Disease Control and Prevention 35 National Institutes of Health 2016 /1 /2 dollars in millions Institutes/Centers National Cancer Institute National Heart, Lung and Blood Institute National Institute of Dental and Craniofacial Research National Inst. of Diabetes & Digestive & Kidney Diseases National Institute of Neurological Disorders and Stroke National Institute of Allergy and Infectious Diseases National Institute of General Medical Sciences Eunice K. Shriver Natl. Inst. of Child Health & Human Development National Eye Institute National Institute of Environmental Health Sciences: Labor/HHS Appropriation National Institute of Environmental Health Sciences: Interior Appropriation National Institute on Aging Natl. Inst. of Arthritis & Musculoskeletal & Skin Diseases Natl. Inst. on Deafness and Communication Disorders National Institute of Mental Health National Institute on Drug Abuse National Institute on Alcohol Abuse and Alcoholism National Institute of Nursing Research National Human Genome Research Institute Natl. Institute of Biomedical Imaging and Bioengineering Natl. Institute on Minority Health and Health Disparities Natl. Center for Complementary and Integrative Health National Center for Advancing Translational Sciences Fogarty International Center National Library of Medicine Office of the Director Buildings and Facilities National Institute for Research on Safety and Quality /5 Total, Program Level 36 2018 2017 /3 2018 /5 5,206 3,109 413 1,964 1,693 4,797 2,509 1,338 707 693 5,505 3,110 415 1,955 1,693 4,621 2,509 1,337 715 692 4,474 2,535 321 1,600 1,356 3,783 2,186 1,032 550 534 -1,031 -575 -94 -355 -337 -838 -323 -305 -165 -159 77 77 60 -18 1,596 541 422 1,517 1,049 467 146 513 343 280 130 684 70 395 1,571 129 1,597 541 422 1,545 1,075 467 146 518 346 279 131 684 70 394 1,620 129 32,358 32,593 1,304 418 326 1,245 865 361 114 400 283 215 102 557 -373 1,452 99 379 26,920 -294 -123 -96 -301 -210 -105 -33 -118 -64 -64 -29 -127 -70 -21 -168 -30 +379 -5,674 +/‐ 2017 National Institutes of Health 2016 /1 /2 dollars in millions 2017 /3 2018 /5 2018 +/2017 Less Funds from Other Sources PHS Evaluation Funds (NLM) ‐780 ‐780 ‐780 — Type 1 Diabetes Research (NIDDK) /4 ‐150 ‐140 ‐150 -10 -107 ‐5,791 Patient-Centered Outcomes Research Trust Fund /5 Total, Discretionary Budget Authority 31,428 31,674 -107 25,883 Appropriations Labor/HHS Appropriation Interior Appropriation 31,351 77 31,597 77 25,823 60 ‐5,917 -18 Full‐Time Equivalents /6 17,723 18,105 18,352 +247 1/ In addition, the FY 2016 Zika Response and Preparedness Act (P.L. 114-223) provided $152 million in supplemental resources to NIH for Zika response and preparedness activities. 2/ Reflects the annualized level of the Continuing Resolution that ended April 28, 2017, including the across the board reduction, the 21st Century Cures Act, and directed transfers. 3/ These mandatory funds were appropriated in P.L. 114-10, the Medicare Access and CHIP Reauthorization Act of 2015. 4/ The FY 2018 Budget consolidates Agency for Healthcare Research and Quality (AHRQ) within NIH as the National Institute for Research on Safety and Quality. AHRQ previously received mandatory funds transferred from the Patient‐Centered Outcomes Research Trust Fund to implement section 937 of the Public Health Service Act. This institute is proposed to receive the mandatory resources from the Patient-Centered Outcomes Research Trust Fund in FY 2018 ($107 million). 5/ Full time equivalent levels exclude AHRQ in FY 2016 and FY 2017, and include FTE consolidated from AHRQ in FY 2018. The mission of the National Institutes of Health (NIH) is to seek fundamental knowledge about the nature and behavior of living systems and the application of that knowledge to enhance health, lengthen life, and reduce illness and disability. NIH builds its research portfolio by evaluating current scientific opportunities and public health needs while maintaining strong support for investigator-initiated research. NIH strategic planning and priority setting processes provide an established framework within which priorities are identified, reviewed, and justified. The National Institutes of Health is the largest public funder of biomedical research in the world. NIH expands the biomedical knowledge base by funding cutting-edge research, improves health by seeking new treatment and prevention options, supports the training of the current and future biomedical workforce, and drives economic growth and productivity. The Fiscal Year (FY) 2018 Budget provides $26.9 billion for NIH, which is $5.7 billion below the FY 2017 Continuing Resolution level. The FY 2018 Budget eliminates the Fogarty International Center while retaining a total of $25 million in mission-critical international research and research related activities within NIH Office of Director. The FY 2018 Budget also includes $272 million in budget authority within NIH to preserve key research activities previously carried out by the Agency for Healthcare Research and Quality (AHRQ), including critical survey activities, support for the U.S. Preventive Services Task Force, evidence-based practice centers, patient safety, investigator-initiated grants, and researcher training grants. Remaining funds will be directed towards evidence-based practice centers, addressing the opioid epidemic, and the Healthcare Cost and Utilization Project. This reorganization within National Institutes of Health 37 NIH would structure AHRQ as an institute and preserve links between many of the closely-related continuing activities, simplify administrative responsibilities for consolidating and continuing the programs, and maintain an entity that can serve as a center of excellence for improving the quality and safety of health care services. improve the detection and treatment of diseases and conditions. Basic research represents more than half of NIH’s research budget and will continue to be a very high priority. Treatments and Cures Designing effective treatments and cures depends upon innovative researchers translating fundamental knowledge about cells, systems, and organisms, into potential targets for therapeutic development. Cell or tissue samples, animal models, and computer simulations often are used to design and test candidate approaches for diagnostics, devices, treatments, and cures. The most promising are then moved into human clinical trials, where they are tested first for safety and then efficacy. NIH supports research all along this pipeline to facilitate discovery of novel treatments for myriad diseases and conditions. More than 80 percent of NIH's budget supports the extramural research community through nearly 50,000 competitive grants. These grants support work by more than 300,000 researchers at more than 2,500 universities, medical schools, and other research institutions in every State and around the world. About 10 percent of the NIH budget supports projects conducted by nearly 6,000 scientists in its own laboratories, most of which are on the NIH campus in Bethesda, Maryland. Within the FY 2018 Budget, NIH will also support planning, policy-making, administration, management, and communication of NIH research. One groundbreaking treatment supported by NIH resources is cancer immunotherapy. This powerful technique harnesses a patient’s own immune system to attack cancer cells. Patients with a variety of cancers have benefitted from immunotherapy, and ongoing and future NIH-supported research aims to understand what enables immunotherapy to work in some patients, but not in others, as well as to expand the use of immunotherapy to other types of cancer. Studies also will test the efficacy of cancer immunotherapies earlier in disease progression as well as in combination with other standard cancer treatments such as chemotherapy and/or radiation. RESEARCH PRIORITIES IN FY 2018 Fundamental Science Enhanced by Technological Advances NIH invests in the essential building blocks of research, including basic science (knowledge of the mechanisms of biology and behavior), data science, and the development of new technologies. This research can be applied across NIH’s disease portfolio and forms the foundation for translational and clinical studies. For example, researchers are developing cryo-electron microscopy techniques to determine the atomic structures of proteins more rapidly than current methods allow. These advances will identify more accurate protein structures and aid the development of more targeted and effective drugs. Another example of potentially pivotal basic research is NIH’s investment in single cell analysis. Though individual cells within a cluster may seem to be of the same type, such as a neuron or a nephron, in fact they can differ dramatically, with important consequences for the function of the entire organism. By analyzing the dynamic states of single cells it may be possible to predict which cells in a group are more likely to become infected with a virus, or are more prone to cancer, or even to becoming drug resistant. NIH-funded investigators have revealed a huge diversity of neuronal subtypes in the human brain. Single cell analysis has the potential to uncover fundamental biological principles and ultimately Health Promotion and Disease Prevention NIH supports research to promote health, prevent disease, and develop strategies to address the progression of disease before symptoms appear. Advances in these research areas require a deep understanding of the many factors that affect health, and include identification and assessment of genetic and environmental risk factors, screening of at-risk individuals for diseases, development of risk-reduction strategies, as well as translation, dissemination, and implementation of strategies to prevent diseases and conditions. One important preventive strategy is vaccination, which is the safest, most cost-effective, and efficient way to reduce the burden of infectious diseases. NIH is engaged in research to develop vaccines for many diseases, including a universal influenza vaccine to protect against seasonal infection that can sometimes lead to very serious health complications. Such a vaccine would induce a strong, 38 National Institutes of Health long-lasting immune response to the part of the virus that does not change much from year to year, and several NIH-funded researchers have made progress towards this goal. PROGRAM HIGHLIGHT Childhood Obesity Obesity is a critical public health crisis in the United States, and the percentage of obese children has tripled since the 1970s. The most recent National Health and Nutrition Examination Surveys (2011-2014) indicate that about 17 percent of children ages 2-19 years are obese. An additional 16 percent are considered overweight. Childhood obesity can increase risk for other chronic health conditions, including asthma, sleep apnea, bone and joint problems, type 2 diabetes, and heart disease. NIH conducts and supports research on a broad range of areas related to excess weight gain in children, including the causes, effects, prevention and treatment of obesity and related conditions. Because environment and genetics play important roles in childhood obesity, NIH works to increase understanding of the metabolic and behavioral factors involved in determining body weight regulation and body composition during childhood. Prevention is an important focus of NIH efforts. Developed by NIH, We Can! (Ways to Enhance Children’s Activity & Nutrition) is a national movement designed to provide parents, caregivers, and communities with resources to encourage improved nutritional choices, increased physical activity, and reduced screen time in youth ages 8–13. Research shows that parents and caregivers are the primary influence on this age group, and We Can! focuses on programs and activities for parents and families to promote healthy, active lifestyles. We Can! also outlines ways that school systems, parks and recreation departments, health care systems, and community based organizations can help youth in their community lead healthier lives. Enhancing Stewardship As stewards of Federal investments in biomedical research, NIH strives to earn and maintain the public’s trust. The role of the United States as a leader in biomedical research depends not only on innovation in the laboratory and the clinic, but also innovation in how science is funded, performed, and managed. NIH is engaged in many efforts to encourage good stewardship practices across all levels of the biomedical research enterprise. These include ways to streamline administrative processes for investigators, efforts to support new and early stage investigators, and a focus on cultivating a world-class biomedical research workforce. A key way in which NIH is strengthening stewardship is through new policies designed to enhance reproducibility of scientific research through increased rigor and transparency in reporting. NIH has released principles and guidelines for reporting preclinical research and created training materials for graduate students and fellows in best practices in experimental design. Planned future activities include extending NIH’s previously established Rigor and Reproducibility Policy to additional types of grants, collaborating with scientific journal editors and other stakeholders to improve rigor and reproducibility in publications, and working to improve data sharing and accessibility. In FY 2017, Congress enacted the 21st Century Cures Act, authorizing $4.8 billion over ten years in support of high priority NIH initiatives and research areas: the Precision Medicine Initiative; the Brain Research through Advancing Innovative Neurotechnologies (BRAIN) Initiative; the Beau Biden Cancer Moonshot; and Regenerative Medicine. The NIH FY 2018 Budget includes $496 million authorized for these initiatives. 21st Century Cures Act Precision Medicine Initiative: This initiative was launched in 2015 to accelerate our understanding of individual variability and its effect on disease onset, progression, prevention, and treatment. Toward this goal, NIH is establishing a group of one million or more volunteer participants that reflect the diversity of the United States to contribute health information over many years, known collectively as the All of Us Research Program. This national resource of clinical, environmental, lifestyle and genetic data will help uncover new information that can be used to find new National Institutes of Health 39 strategies for preventing and treating diseases that account for individual variability. trans-NIH efforts at planning and assessment and in consultation with HHS leadership, NIH continually seeks innovative ways to streamline its processes and structure to ensure efficient and effective scientific management. BRAIN: Informed by a report (BRAIN 2025: A Scientific Vision) of a working group of the Advisory Committee to the NIH Director, the BRAIN Initiative seeks to accelerate the development and application of innovative technologies to produce a new, dynamic picture of the brain that shows how individual cells and the neural circuits they form interact in time and space. This information will fill current knowledge gaps and provide opportunities to explore how the brain records, stores, processes, and uses information. This understanding will provide important new insights on the connection between brain function and behavior and could transform our ability to diagnose and treat neurological and mental disorders. Restructuring Global Health Research at NIH The Budget for NIH eliminates the Fogarty International Center. Approximately $25 million within the Office of the Director will be dedicated to coordinating global health research across the NIH, including issues regarding workforce development and engagement with NIH’s international biomedical research partners. Beau Biden Cancer Moonshot: By capitalizing on emerging scientific discoveries, the Beau Biden Cancer Moonshot aims to accelerate progress in cancer research, improve prevention and early diagnosis, and ensure access to cancer treatment and clinical trials for all patients. A Blue Ribbon Panel of experts established ten scientific priorities for the initiative, including enhanced data sharing, developing new cancer technologies, expanded use of prevention and early detection strategies, cancer immunotherapy, and pediatric cancer. NIH released funding opportunity announcements related to these priorities in FY 2017, and more are planned for the future. Opioids PROGRAM HIGHLIGHT In 2015, a record number of Americans—more than 33,000—died from an overdose of opioids. Addressing the opioid epidemic continues to be a high priority for NIH and all of HHS, and as outlined in the HHS National Pain Strategy, released in March 2016. NIH supports research efforts focused on: preventing opioid misuse and addiction; developing new and improved treatments for opioid addiction; improving the deployment of evidence based strategies for combatting overdose and preventing and treating addiction; and developing more effective treatments for pain with reduced potential for addiction and misuse. By building on findings such as the recent development of Probuphine, an implantable formulation of buprenorphine (an opioid used to treat opioid addiction) that delivers a constant dose for six months, NIH continues to seek better treatment for those addicted to opiates. And to prevent addiction, NIH is aggressively addressing better pain management approaches. For example, NIH is currently exploring potential partnerships with other federal and private stakeholders to capitalize on the emergence of numerous potential targets for non-addictive pain medications and preliminary research findings that could lead to the development and validation of biomarkers for pain which would result in better targeting of pain treatment. Efforts also are underway to identify new opioid pain medicines with reduced misuse, tolerance, and dependence risk, as well as alternative delivery systems and formulations for existing drugs that minimize diversion and misuse (e.g., by preventing tampering) and reduce the risk of overdose deaths. Regenerative Medicine: Regenerative medicine seeks to develop functional tissues and organs to repair or replace biological function that has been lost due to congenital abnormalities, injury, disease, or aging. The state-of-the-art in regenerative medicine integrates tissue engineering (based on advanced biomaterials development) and cell-based therapy, springing from advances in stem cell research and developmental biology. Funding from the 21st Century Cures Act will be awarded in coordination with the Food and Drug Administration to support clinical research using adult stem cells, which could open doors for possible new treatments. MAXIMIZING EFFICIENCY AND EFFECTIVENESS The institutes, centers, and offices that make up NIH work together to coordinate and collaborate on research priorities, leveraging resources and expertise toward the common goal of improving health. Through 40 National Institutes of Health Consolidation of Healthcare Research and Quality To help focus resources on the highest priority research and reorganize federal activities in a more effective manner, the Budget consolidates the Agency for Healthcare Research and Quality (AHRQ) into NIH. The Budget consolidates select research activities within a new National Institute for Research on Safety and Quality (NIRSQ) to improve efficiency, minimize potential overlap, and increase coordination of health services research. The creation of NIRSQ will simplify administrative responsibilities for consolidating and continuing former AHRQ programs, and maintain an entity that can serve as a center of excellence for improving the quality and safety of health care services. comprehensive annual data on the use of medical care in the U.S., the survey provides an important data source for research efforts aimed at improving health services. PROGRAM HIGHLIGHT Tissue Chip Technology The tissue-on-a-chip research initiative funded by the National Institutes of Health and several partners, both private and public, is aimed at developing 3-D human tissue chips that accurately model the structure and function of human organs, allowing for better, more human-oriented safety and efficacy testing for medications. Research teams have begun to develop 3-D cellular microsystems that recreate approximately 10 different human organ systems, including the heart, lung, and nervous system. Researchers also are beginning to integrate their individual microsystems onto miniaturized platforms that combine 2-4 systems together. Recently, a team of scientists built EVATAR™, a miniaturized 3-D representation of five organs of the female reproductive system, along with the liver, on an integrated tissue chip platform. The system successfully mimicked the processes in a woman’s body, including the 28-day reproductive cycle. The team plans to use EVATAR™ to better understand the basic hormonal and cellular functioning of the reproductive tract. At present, the effects of hormonal changes in women in drug metabolism are largely understudied and have led to gender-specific adverse drug reactions. When coupled with other tissue chips, EVATAR™ will be an invaluable tool in optimizing drugs and therapies for women. The Budget includes $272 million in budget authority for the NIRSQ. As part of the consolidation, the institute will invest $5 million in a comprehensive review of health services and translational research across NIH to identify gaps and develop a strategy for investing in the highest priority research and ensuring that the research is adopted by other Federal agencies and stakeholders. The Budget also preserves key activities that were previously funded in AHRQ to improve the quality and safety of American health care, while reducing or eliminating lower priority programs that may potentially overlap with activities administered by other components of HHS. The Budget continues funding for select former AHRQ activities that have a demonstrated record of effectiveness and make unique contributions to quality improvement and patient safety through supporting the data generation, analysis, and evaluation necessary to improve quality of care and enhance patient safety. The Budget includes support for research to enhance patient safety at AHRQ’s FY 2017 Continuing Resolution level to continue driving progress on reducing healthcare-associated infections, and developing and disseminating evidence on the frequency and prevention of safety incidents. NIRSQ will continue to provide administrative support for the United States Preventive Services Task Force at $7 million, a reduction of $4 million below AHRQ’s FY 2017 Continuing Resolution level. Within Health Services Research, Data, and Dissemination, the Budget includes funding of $46 million for investigator-initiated research grants and research training, $10 million for the Healthcare Cost and Utilization Project, $1 million for Evidence-Based Practice Centers, and $3 million for opioid treatment research grants. These investments will provide researchers the support needed to conduct studies that focus on quality, effectiveness, and efficiency of health care services, and provide a means for the dissemination of research results with the greatest potential to improve care. Many public and private healthcare organizations across the country rely on this evidence base to provide the strategies and tools needed to minimize risks and harms to patients. Funding for the Medical Expenditure Panel Survey will continue at $70 million— $4 million above the FY 2017 Continuing Resolution level—to maintain the integrity of the national and State sample sizes and the quality of the core data products. As the only national source for National Institutes of Health The Budget reduces or eliminates potentially overlapping or lower priority programs. For instance, no funding is included for the research and 41 training researchers to conduct high quality studies in this area and research designed to help patients and providers make better informed health care decisions. dissemination activities of the Health Information Technology portfolio, which could potentially be funded by other continuing programs. Many contract-funded activities in Health Services Research, Data, and Dissemination, such as development of quality measures are discontinued due to potential overlap with other HHS programs. Indirect Costs Increasing efficiencies within the NIH remains a priority of the Administration. The FY 2018 Budget changes reimbursement of indirect costs for NIH grants, which will be capped as a percentage of total research, in order to better target available funding toward high priority research. In addition, Federal research requirements for grantees will be streamlined to reduce grantee burden through targeted approaches as proposed by NIH. In addition, NIRSQ is projected to receive $107 million in mandatory resources from the Patient-Centered Outcomes Research Trust Fund to continue translating and targeted dissemination of comparative clinical effectiveness research study results and workforce development efforts. These funds will also support 42 National Institutes of Health Overview by Mechanism 2016 /2 2017 /3 2018 Mechanism Research Project Grants (dollars) [ # of Non‐Competing Grants] 17,837 [23,528] 17,927 [24,595] 14,189 [24,499] -3,739 [-96] [ # of New/Competing Grants] [10,364] [8,974] [7,326] [-1,648] [1,689] [1,780] [1,578] [-202] [35,580] [35,349] [33,403] [1,946] 2,575 2,020 804 2,915 3,685 1,653 599 [676] 144.863 77 -32,311 2,496 2,151 843 2,912 3,673 1,718 650 [674] 144.618 77 -32,593 2,080 1,732 738 2,489 3,064 1,577 777 [454] 109 60 107 26,920 -417 -420 -106 -423 -609 -142 127 [-220] -36 -18 +107 -5,674 ‐780 ‐150 31,381 ‐780 ‐140 31,673 -780 -257 25,883 --117 -5,790 31,304 77 31,596 77 25,824 60 ‐1,067 -17 dollars in millions [ # of Small Business Grants] [ Total # of Grants ] Research Centers Other Research Research Training Research and Development Contracts Intramural Research Research Management and Support Office of the Director /4 NIH Common Fund (non‐add) Buildings and Facilities /5 NIEHS Interior Appropriation (Superfund) Patient Centered Outcomes Research Total, Program Level Less Funds Allocated from Other Sources PHS Evaluation Funds (NLM) /6 Type 1 Diabetes Research (NIDDK) and PCORTF /7 Total, Budget Authority Labor/HHS Appropriation Interior Appropriation 2018 +/2017 1/ Subtotals and Totals may not add due to rounding. 2/ In addition, the FY 2016 Zika Response and Preparedness Act (P.L. 114-223) provided $152 million in supplemental resources to NIH for Zika response and preparedness activities. 3/ Reflects the annualized level of the Continuing Resolution that ended April 28, 2017, including the across the board reduction, the 21st Century Cures Act, and directed transfers. 4/ Number of grants and dollars for the Common Fund and ORIP components of OD are distributed by mechanism and are noted here as a non-add. The Office of the Director - Appropriations also is noted as a non-add because the remaining funds are accounted for under OD - Other. 5/ Includes B&F appropriation and funds for facilities repairs and improvements at the NCI Federally Funded Research and Development Center in Frederick, Maryland. 6/ Number of grants and dollars for Program Evaluation Financing are distributed by mechanism above; therefore, the amount is deducted to provide subtotals only for the Labor/HHS Budget Authority. 7/ Number of grants and dollars for mandatory Type I Diabetes are distributed by mechanism above; therefore, Type I Diabetes amount is deducted to provide subtotals only for the Labor/ HHS Budget Authority. National Institutes of Health 43 Substance Abuse and Mental Health Services Administration 2016 dollars in millions 2017 /1 2018 +/-2017 2018 Mental Health Community Mental Health Services Block Grant 533 532 416 -116 Programs of Regional and National Significance 415 414 277 -136 60 60 60 -- 119 119 119 -- Projects for Assistance in Transition from Homelessness 65 65 65 -- Protection and Advocacy for Individuals with Mental Illness Subtotal, Mental Health 36 36 36 -- 1,167 1,165 912 -252 211 223 150 -73 211 223 150 -73 1,858 1,855 1,855 -- -- 500 500 -- 337 342 342 -- 2,195 2,696 2,696 -- Program Support 80 79 73 -6 Health Surveillance 47 47 34 -13 Performance and Quality Information Systems 13 13 13 -- Public Awareness and Support 16 16 12 -4 2 2 2 -- 51 51 1 -50 50 50 -- -50 208 207 134 -74 3,781 4,291 3,892 -399 -12 -12 -- +12 -134 -133 -120 +13 -2 -2 -2 -- 3,634 4,144 3,771 -374 620 615 610 -5 Suicide Prevention Programs (non-add) Children's Mental Health Services Substance Abuse Prevention Programs of Regional and National Significance Subtotal, Substance Abuse Prevention Substance Abuse Treatment Substance Abuse Prevention and Treatment Block Grant State Targeted Response to the Opioid Crisis Grants Programs of Regional and National Significance Subtotal, Substance Abuse Treatment Health Surveillance and Program Support Data Request and Publications User Fees Agency-Wide Initiatives Behavioral Health Workforce Education & Training (non-add) Subtotal, Health Surveillance and Program Support SAMHSA Budget Totals, Program Level Total, Program Level Less Funds from Other Sources: Prevention and Public Health Fund PHS Evaluation Funds User Fees for Data Request and Publications TOTAL, Discretionary Budget Authority Full-Time Equivalents 1/ Reflects the annualized level of the Continuing Resolution that ended April 28, 2017, including the across the board reduction, the 21st Century Cures Act, and directed transfers. 44 Substance Abuse and Mental Health Services Administration The Substance Abuse and Mental Health Services Administration reduces the impact of substance abuse and mental illness on America’s communities. The Fiscal Year (FY) 2018 President's Budget provides $3.9 billion for the Substance Abuse and Mental Health Services Administration (SAMHSA), a reduction of $399 million below the FY 2017 Continuing Resolution. The Budget focuses on addressing the Nation’s opioid crisis, expanding suicide prevention efforts, and addressing serious mental illness. More broadly, SAMHSA will support its core mission and carefully consider the organization’s unique Federal role. decades, and have become the leading cause of death from injury in the United States. From 2000 to 2015, more than half a million people died from drug overdoses, and 91 Americans die every day from an opioid overdose. The Budget provides $2.7 billion—the same amount as in the FY 2017 Continuing Resolution—for substance abuse treatment activities. HHS is committed to fighting the opioid epidemic. In 2015, the National Survey on Drug Use and Health estimated that 3.8 million people misused prescription pain relievers such as opioids in a given month. A greater number of people, 12.5 million, reported misusing prescription pain relievers such as opioids at some point in the past year. Individuals who misuse pain relievers obtain them from a variety of sources, as described in the following chart. SUBSTANCE ABUSE An estimated 21 million Americans needed treatment for a serious substance abuse problem in 2015. Substance abuse is associated with significant health impacts and increased costs for health care, but also vast financial and social consequences extending beyond the health care system. Deaths from drug overdose have risen steadily over the past two Source: SAMHSA. Prescription drug use and misuse in the United States: Results from the 2015 National Survey on Drug Use and Health. Hughes, A., Williams, M. R., Lipari, R. N., Bose, J., Copello, E. A. P., & Kroutil, L. A. NSDUH Data Review, September, 2016. Substance Abuse and Mental Health Services Administration 45 Fighting the Opioid Epidemic The opioid epidemic is the deadliest drug epidemic in American history. The Budget includes $589 million in SAMHSA targeted to fighting the opioid epidemic. This includes $500 million authorized in the 21st Century Cures Act in each of FY 2017 and FY 2018 for States to increase access to treatment and to reduce unmet need and overdose related deaths. First year grants were awarded to States in April 2017 to provide opioid abuse prevention, treatment, and recovery support services. workforce, and provide technical assistance and training to States, Tribes, and communities. The Budget reduces funding for the Strategic Prevention Framework to $58 million—$61 million below the FY 2017 Continuing Resolution—to prioritize other high-need programs. The Budget also reduces funding for the Minority AIDS programs, as States can use the Substance Abuse Prevention and Treatment Block Grant for activities to prevent the onset of substance abuse and the transmission of HIV/AIDS. MENTAL HEALTH The Budget also includes $17 million—the same amount as in the FY 2017 Continuing Resolution—for programs newly authorized under the Comprehensive Addiction and Recovery Act of 2016. The programs will expand efforts to train first responders on the use of the opioid overdose reversing drugs and to equip them with the needed drugs, provide additional recovery support services to help those in recovery succeed, and provide additional support for pregnant women and families struggling with addiction. The Budget also maintains $56 million for other efforts in SAMHSA to ensure the most effective evidence-based treatment for opioid abuse—known as medication-assisted treatment—is widely available and to ensure Opioid Treatment Programs are operating safely and effectively. In 2015, an estimated 43 million American adults— 18 percent—met the medical standard for having a mental, behavioral, or emotional disorder that substantially interfered with or limited major life activities. Of these, 10 million people—or four percent of all American adults—had a serious mental illness. A 2011 study estimated that societal costs of mental disorders exceeded the costs of diabetes, respiratory disorders, and cancer combined. Including estimated expenditures for mental health treatment with projections of lost earnings and public disability insurance payments associated with mental illness, the financial cost of mental disorders was at least $467 billion in the United States in 2012. The Budget provides $912 million—$252 million below the FY 2017 Continuing Resolution—for mental health activities. Substance Abuse Prevention and Treatment Block Grant The Budget provides $1.9 billion for the Substance Abuse Prevention and Treatment Block Grant, which is the same amount as in the FY 2017 Continuing Resolution. This grant is provided by formula to States to assist in the treatment of approximately 2 million individuals. This funding is a cornerstone of States' substance abuse financing, and it accounts for over a third of public funds expended for prevention and treatment of substance abuse. Community Mental Health Services Block Grant The Budget includes $416 million for the Community Mental Health Services Block Grant, which is a reduction of $116 million below the FY 2017 Continuing Resolution. The block grant is a flexible source of funding that allows States to target resources to local needs. The funding will continue its focus exclusively on addressing the needs of adults living with serious mental illness and children experiencing serious emotional disturbances, and will continue to direct States to spend at least 10 percent of the funds on early interventions to assist those experiencing a first episode of psychosis. This funding represents just one percent of total public spending on mental health. Historically, the provision of mental health services has largely rested with States. Promoting Effective Prevention of Substance Abuse The Budget includes $150 million for substance abuse prevention efforts, which is $73 million below the FY 2017 Continuing Resolution. This total includes $62 million—the same level as in the FY 2017 Continuing Resolution—for programs that support Federal drug-free workplace efforts, fight underage drinking, and support grants to expand the provision of opioid overdose reversing drugs. Also within this group of programs are those that expand tribal behavioral health, training for the minority behavioral health Children’s Mental Health Services The Budget continues the Children’s Mental Health Services program at $119 million, which is the same amount as the FY 2017 Continuing Resolution. This 46 Substance Abuse and Mental Health Services Administration program helps States, Tribes, and communities deliver evidence-based services and supports for children and youth with serious emotional disturbances. These funds ensure effective collaboration between child- and youth-serving systems such as juvenile justice, child welfare, and education. The Budget also proposes that up to 10 percent of the funds will be available for a new demonstration to translate recent research by the National Institute of Mental Health indicating that earlier psychosocial intervention with those at high risk may prevent the further development of serious emotional disturbances and ultimately serious mental illness. end discontinues funding for both Project Advancing Wellness and Resiliency in Education (AWARE) and the Healthy Transitions program. Primary and Behavioral Healthcare Integration The Budget does not include funding for the Primary and Behavioral Healthcare Integration program, which is a reduction of $52 million below the FY 2017 Continuing Resolution. Under the Budget, States can choose to dedicate Federal resources received through the block grant or other sources of funding to integrate primary and behavioral health care. For example, eight States will participate in a Medicaid demonstration in FY 2018 to operate Certified Community Behavioral Health Centers. Suicide Prevention The Budget continues support for Suicide Prevention programs, providing $60 million—the same amount as in the FY 2017 Continuing Resolution—to reduce the overall suicide rate and number of suicides in the United States. This program supports State efforts to raise suicide awareness and improve emergency room referral processes and clinical care practice standards. States will also be supported to develop and implement youth suicide prevention and early intervention strategies involving public-private collaboration among youth-serving institutions. The funding also supports American Indian/Alaska Native Suicide Prevention through specialized technical assistance and support. PERFORMANCE HIGHLIGHT National Suicide Prevention Lifeline The Budget supports the National Suicide Prevention Lifeline (Lifeline), 1-800-273-TALK, which coordinates a network of 164 crisis centers across the United States by providing suicide prevention and crisis intervention services for individuals seeking help at any time, day or night. The Lifeline averaged nearly 124,000 calls per month in FY 2016, with over 90 percent of callers reporting that calling the crisis hotline helped stop them from killing themselves. More than 40,000 callers per month identified themselves as veterans and were seamlessly connected to a specialized veterans’ suicide prevention hotline developed in collaboration with the Department of Veterans Affairs. Increasing the Focus on Serious Mental Illness To ensure that the Budget targets those who need help most, the Budget includes $5 million in new funding for Assertive Community Treatment in SAMHSA. This is a new program authorized by the 21st Century Cures Act. The program will help communities establish, maintain, or expand evidence-based efforts to avoid the dangerous and unsettling cycling of patients with mental illness through emergency and inpatient settings. This practice is proven to reduce hospitalization of those with serious mental illness at the same cost with higher patient satisfaction. HEALTH SURVEILLANCE AND PROGRAM SUPPORT The Budget includes $107 million for staff and related program management expenses necessary to effectively monitor a wide array of Federal programs, as well as for Health Surveillance, which in total is a reduction of $20 million below the FY 2017 Continuing Resolution. This funding level prioritizes activities for which there is a unique Federal role, such as certain public health surveillance associated with the National Survey on Drug Use and Health and the National Registry of Evidence-Based Programs and Practices. Youth Violence Prevention The Budget continues support for the Youth Violence Prevention Program at $23 million—the same amount as in the FY 2017 Continuing Resolution—to implement an enhanced, coordinated, and comprehensive plan of activities, programs, and services that promote healthy childhood development, prevent violence, and prevent alcohol and drug use. The Budget seeks to eliminate duplication of the school-based programs and to that Substance Abuse and Mental Health Services Administration Behavioral Health Workforce Education and Training No funding is provided for the Behavioral Health Workforce Education and Training program—a reduction of $50 million below the FY 2017 Continuing Resolution—to prioritize targeted efforts to provide 47 direct health care services. For example, the National Health Service Corps administered by the Health Resources and Services Administration directly hires behavioral health professionals serving in communities with shortages, directly responding to public health needs. inform public health efforts to advance the behavioral health of the nation through programmatic data collection and monitoring. Savings are achieved through reductions in the scope of other communications and public affairs activities and through the natural conclusion of the Science of Changing Social Norms program, which has successfully met its objectives. Public Awareness and Support The Budget includes $12 million for Public Awareness and Support—a reduction of $4 million below the FY 2017 Continuing Resolution—to raise the public’s awareness of mental and substance use disorders and 48 Substance Abuse and Mental Health Services Administration Centers for Medicare & Medicaid Services: Overview dollars in millions Current Law /1 Medicare /2 Medicaid CHIP State Grants and Demonstrations Other Health Insurance Programs Center for Medicare and Medicaid Innovation Total Net Outlays, Current Law /3 Proposed Law Medicare—Benefits /2 Medicare - Administration Medicaid CHIP Medical Liability Reform Impacts (non-add) Discretionary Program Management Total Proposed Law Total Net Outlays, Proposed Law /4 Savings from Program Integrity Investments /5 Total Net Outlays, Proposed Policy 2016 2017 2018 2018 +/− 2017 594,483 368,280 14,358 553 11,561 1,156 990,391 599,678 378,455 16,879 537 9,637 1,294 1,006,480 593,154 407,570 12,017 534 7,225 1,408 1,021,908 -6,524 +29,115 -4,862 -3 -2,412 +114 +15,428 - - 990,391 990,391 1,006,480 1,006,480 39 2 -3,857 1,400 -149 26 -2,390 1,019,559 -102 1,019,416 +39 +2 -3,857 +1,400 -149 +26 -2,390 +13,059 -102 +12,936 1/ Reflects the annualized level of the Continuing Resolution that ended April 28, 2017, including the across the board reduction, the 21st Century Cures Act, and directed transfers. 2/ Current law Medicare outlays net of offsetting receipts. 3/ Totals may not add due to rounding. 4/ Total net proposed law outlays equal current law outlays plus the impact of proposed legislation and offsetting receipts. 5/ Includes non-PAYGO scorecard savings from discretionary Health Care Fraud and Abuse Control Program (HCFAC) above savings already assumed in current law. The Centers for Medicare & Medicaid Services ensures availability of effective, up-to-date health care coverage and promotes quality care for beneficiaries. The Fiscal Year (FY) 2018 Budget estimate for the Centers for Medicare & Medicaid Services (CMS) is $1 trillion in mandatory and discretionary outlays, a net increase of $13 billion from the FY 2017 level. This request finances Medicare, Medicaid, the Children’s Health Insurance Program (CHIP), other health Centers for Medicare & Medicaid Services insurance programs, program integrity efforts, and operating costs. CMS’s legislative package promotes fiscal responsibility, State flexibility, and curbs the practice of defensive medicine. In total, the Budget proposes targeted savings of $636 billion to CMS Federal health benefit programs over the next decade. 49 BUDGETARY REQUEST focused on increasing choices for patients and providers and promoting state flexibility and control. CMS is dedicated to moving toward a health care system that will drive down costs, give Americans more choices, and put patients and doctors in control of their health care. To achieve this, CMS will empower patients and doctors to make decisions about their health care while reducing burdensome regulations and building a patient-centered system of care that increases competition, quality, and access. CMS will usher in a new era of state flexibility and local leadership. Because the States are in the best position to assess the unique needs of their populations and drive reforms, this shift will result in better health care outcomes. Medical Liability Reform The Budget proposes nationwide medical liability reforms that will reduce medical malpractice costs and the practice of defensive medicine, saving HHS programs a combined $31.8 billion over ten years; decreasing provider burdens; and reducing costs for patients, States, and insurers. Program Integrity The Budget includes a new $70 million investment in the Health Care Fraud and Abuse Control Program within HHS and the Department of Justice to enhance efforts to identify and prevent fraud and abuse before it happens and restore taxpayer dollars to the Medicare Trust Funds. Medicare The Budget does not include any direct Medicare cuts. The Budget proposes to repeal the Independent Payment Advisory Board and also provides resources and signals a commitment to reform the Medicare appeals process. Discretionary Program Management The Budget for Program Management enables CMS to continue to effectively administer Medicare, Medicaid, and CHIP. The Budget also includes one new discretionary user fee. Medicaid and CHIP The Budget includes legislative proposals in Medicaid and CHIP, which have a net savings of $616 billion on Federal spending over 10 years.1 The Budget makes fundamental reforms to Medicaid’s fiscal structure and gives States greater flexibility to implement solutions reflective of the needs of their unique populations. The Budget includes an initiative that helps to rebuild the patient-physician relationship. Finally, the Budget extends CHIP for two years through FY 2019, along with reforms to return the focus of the program to the most vulnerable low-income families and children that the program was intended to serve. Repeal and Replace The Budget includes $250 billion in net deficit savings over 10 years related to repealing and replacing Obamacare, and implementing reforms that provide the American people with access to the kind of high-quality, affordable care that works best for them. The Budget promotes efficient operations and funds necessary activities to continue to operate the Exchanges in 2018. This will provide for a stable transition from the burdensome requirements of Obamacare to a patient-centered health care system 1 This includes $3 billion in savings to Exchange subsidies and related impacts, reflected in the Department of Treasury programs and accounts. 50 Centers for Medicare & Medicaid Services Medicare dollars in millions Current Law Outlays and Offsetting Receipts Benefits Spending (gross) /1 Less: Premiums Paid Directly to Part D Plans /2 Subtotal, Benefits Net of Direct Part D Premium Payments Related-Benefit Expenses /3 Administration /4 Total Outlays, Current Law Premiums and Offsetting Receipts Current Law Outlays, Net of Offsetting Receipts Proposed Law and Savings from Program Integrity Investments Medicare Proposals, Net of Offsetting Receipts Medicare Trust Fund Administration /5 Savings from Program Integrity Investments /6 Total Net Outlays, Adjusted Baseline, Savings from Program Integrity Investments and Proposed Law Mandatory Total Net Outlays, Proposed Policy /7 2016 2017 2018 2018 +/- 2017 682,994 -9,115 673,879 16,239 8,492 698,610 -104,127 594,483 696,219 -10,050 686,169 14,079 10,260 710,508 -110,830 599,678 704,588 -10,868 693,720 14,883 9,474 718,077 -124,923 593,154 +8,369 -818 +7,551 +804 -786 +7,569 -14,093 -6,524 0 0 0 0 0 0 39 2 -102 +39 +2 -102 594,483 588,309 599,678 592,593 593,093 586,579 -6,585 -6,014 1/ Represents all spending on Medicare benefits by either the Federal Government or other beneficiary premiums. Includes Medicare Health Information Technology Incentives. 2/ In Part D only, some beneficiary premiums are paid directly to plans and are netted out here because those payments are not paid out of the Trust Funds. 3/ Includes savings from investments in Social Security disability reviews and related benefit payments, including refundable payments made to providers and plans, transfers to Medicaid, and premiums to Medicare Advantage plans paid out of the Trust Funds from beneficiary Social Security withholdings. 4/ Includes CMS Program Management, Health Care Fraud and Abuse Control Program (HCFAC), Quality Improvement Organizations, and other administration. 5/ Includes the following proposed administration in FY 2018: $18 million in outlays for supporting the continuation of four Administration for Community Living programs, and -$16 million in reduced outlays from eliminating the Independent Payment Advisory Board. 6/ Includes non-PAYGO scorecard savings from discretionary HCFAC above savings already assumed in current law. 7/ Removes total Medicare discretionary amount: FY 2016 -$6,174 million; FY 2017 -$7,085 million; and FY 2018 -$6,514 million. In Fiscal Year (FY) 2018, the Office of the Actuary has estimated that gross current law spending on Medicare benefits will total $704.6 billion. Medicare will provide health insurance to 60 million individuals who are age 65 or older, disabled, or have end-stage renal disease. beneficiary coinsurance. In 2017, beneficiaries pay a $1,316 deductible for a hospital stay of 1–60 days, and $164.50 daily coinsurance for days 21–100 in a skilled nursing facility. Part A ($202.8 billion gross fee-for-service spending in 2018) Medicare Part A pays for inpatient hospital, skilled nursing facility, home health related to a hospital stay, and hospice care. Part A financing comes primarily from a 2.9 percent payroll tax paid by both employees and employers. Part B ($201.9 billion gross fee-for-service spending in 2018) Medicare Part B pays for physician, outpatient hospital, end-stage renal disease, laboratory, durable medical equipment, certain home health, and other medical services. Part B coverage is voluntary, and about 91 percent of all Medicare beneficiaries are enrolled in Part B. Approximately 25 percent of Part B costs are financed by beneficiary premiums, with the remaining 75 percent covered by general revenues. Generally, individuals with 40 quarters of Medicare-covered employment are entitled to Part A without paying a premium, but most services require The standard monthly Part B premium is $134 in 2017, an increase of $12.20 over the 2016 standard premium amount. However, approximately 70 percent of Part B THE FOUR PARTS OF MEDICARE Centers for Medicare & Medicaid Services 51 enrollees are held harmless from the full increase in the Part B premium and will pay a premium of $109 per month, on average. Some beneficiaries pay a higher Part B premium based on their income: those with annual incomes above $85,000 (single) or $170,000 (married) will pay from $187.50 to $428.60 per month in 2017. The Part B deductible in 2017 is $183 for all beneficiaries. Medicare and Medicaid Services (CMS) data confirm that 99 percent of Medicare beneficiaries will have access to at least one Medicare Advantage plan in 2018. Additionally, while premiums have remained stable, Medicare Advantage supplemental benefits have increased, and enrollment is growing faster than in traditional Medicare. Part D ($96.8 billion gross spending in 2018) Medicare Part D offers a standard Medicare Benefits by Service, 2018 Current Law Estimate: $704.6 billion prescription drug benefit with a 2017 deductible of $400 and an average Physician Other 10% 12% estimated monthly premium of $35. Enhanced and alternative benefits are also Outpatient Hospital 7% available with varying deductibles and premiums. Beneficiaries who choose to Home Health participate are responsible for covering a Drug Benefit 3% 15% portion of the cost of their prescription drugs. This portion may vary depending on whether the medication is generic or a brand name and how much the beneficiary has already Inpatient Hospital 20% spent on medications that year. Low-income beneficiaries are responsible for varying degrees of cost-sharing, with co-payments ranging from $0 to $8.25 in 2017 and low or Managed Care 29% no monthly premiums. For 2018, the number Skilled Nursing Facility 1% of beneficiaries enrolled in Medicare Part D is Hospice 3% expected to increase by about 3.5 percent to 45.7 million, including about 12.9 million beneficiaries Part C ($203.0 billion gross spending in 2018) who receive the low-income subsidy. In 2017, Medicare Part C, the Medicare Advantage Program, approximately 57 percent of those with Part D pays plans a capitated monthly payment to provide all coverage are enrolled in a stand-alone Part D Part A and B services, and Part D services if offered by Prescription Drug Plan, 39 percent are enrolled in a the plan. Plans can offer additional benefits or Medicare Advantage Prescription Drug Plan, and the alternative cost-sharing arrangements that are at least remaining beneficiaries are enrolled in an employer as generous as the standard Parts A and B benefits plan or the Limited Income Newly Eligible Transition under traditional Medicare. In addition to the regular plan. Overall, approximately 76 percent of all Medicare Part B premium, beneficiaries who choose to beneficiaries receive prescription drug coverage participate in Part C may pay monthly plan premiums through Medicare Part D or employer-sponsored which vary based on the services offered by the plan retiree health plans, and approximately another 10 and the efficiency of the plan. percent though other creditable coverage. In 2018, Medicare Advantage enrollment will total approximately 20.8 million, or approximately 38 percent of all Medicare beneficiaries. Centers for Medicare Enrollment (person-years in millions) Aged 65 and Over Disabled Total 2016 47.5 9.0 56.5 2017 49.2 9.0 58.2 2018 51.0 9.0 60.0 2018 +/- 2017 +1.8 +0.0 +1.8 Source: CMS Office of the Actuary estimates. 52 Centers for Medicare & Medicaid Services The Medicare Part D coverage gap, or “donut hole,” is being closed through a combination of manufacturer discounts and gradually increasing Federal subsidies. Beneficiaries fall into the coverage gap once their total drug spending exceeds an initial coverage limit ($3,700 in 2017), until they reach the threshold for qualified out-of-pocket spending ($4,950 in 2017), at which point they are generally responsible for five percent of their drug costs. Previously beneficiaries were responsible for 100 percent of their drug costs in the coverage gap. In 2018, non-low income subsidy beneficiaries who reach the coverage gap will pay 35 percent of the cost of covered Part D brand drugs and biologics and 44 percent of the costs for all generic drugs in the coverage gap. Cost-sharing in the coverage gap will continue to decrease each year until beneficiaries are required to pay only 25 percent of the costs of covered Part D drugs in 2020 and beyond. PROGRAM UPDATE Medicare Access and CHIP Reauthorization Act: Progress Implementing the Quality Payment Program The Medicare Access and CHIP Reauthorization Act (MACRA) repealed the Sustainable Growth Rate for physician fee schedule payments and created clinician payment provisions that collectively comprise the Quality Payment Program. The Quality Payment Program includes two tracks: the Meritbased Incentive Payment System and incentive payments for participation in Advanced Alternative Payment Models. The goal of the program is to provide the resources and tools clinicians need to provide the best possible care to their patients. While the program officially began on January 1, 2017, clinicians have the flexibility to start their participation anytime between January 1 and October 2, 2017. HHS envisions the first year as being a trial run for clinicians in order for them to get experience participating in the program and being assessed on their performance. Clinicians ready to fully participate are encouraged to do so and may be eligible for additional bonus payments. HHS will carefully monitor how the first year progresses and, as HHS develops policies for future years, will work to reduce provider burden while providing incentives for providing high-quality care. In 2016, more than 4.9 million beneficiaries reached the coverage gap and saved more than $5.6 billion on their medications due to the prescription drug discount program. These savings averaged about $1,149 per person. MEDICARE HIGHLIGHTS - 21ST CENTURY CURES PERFORMANCE HIGHLIGHT Hospital Harm Reduction On December 7, 2016, Congress passed the 21st Century Cures Act, which includes a number of key changes to the Medicare program. The Agency for Healthcare Research and Quality National Scorecard data released in December 2015 reveals great success in hospital harm reduction, such as reduced infections. The data demonstrate a reduction in harm to patients of 21 percent over 5 years. Calendar Year 2010—Baseline 2011 2012 2013 2014 2015 These include clarifying that certain hospital outpatient departments should be exempt from site-neutral payment policies and by allowing rural and critical access hospitals to operate under requirements that reflect the realities of their environments and support patients’ access to care. The 21st Century Cures Act extends the Rural Community Hospital Demonstration by five years. The Act also provides relief for long-term care hospitals, including through an exception to the current moratorium on new beds, a one-year pause in enforcement of the 25-percent threshold policy, and an exemption for certain clinical services from site-neutral payments. # Harms per 1,000 Discharges 145 142 132 121 121 115 Medicare hospital value-based purchasing payment incentives, Quality Improvement Organizations, and the Partnership for Patients program have all contributed to this outcome. Centers for Medicare & Medicaid Services The 21st Century Cures Act will also increase choice for Medicare beneficiaries by allowing people with EndStage Renal Disease to enroll in Medicare Advantage starting in 2021 and by allowing beneficiaries to switch between Medicare Advantage and traditional Medicare one time, during the first three months of the year, starting in 2019. 53 MEDICARE QUALITY IMPROVEMENT ORGANIZATIONS include direct Medicare cuts. The Budget repeals the Independent Payment Advisory Board, commits to improving the Medicare appeals process, and supports efforts to limit defensive medicine as a part of a larger medical liability reform effort. The mission of the Quality Improvement Organization Program is to improve the effectiveness, efficiency, economy, and quality of services delivered to Medicare beneficiaries. The Organizations are experts in the field working to drive local change, which can translate into national quality improvement. The current five-year contract cycle, or 11th Statement of Work, began on August 1, 2014, and provides approximately $802 million in FY 2018 and $4.4 billion over five years. The 12th Scope of Work will begin in FY 2019. Reforming the Medicare Appeals Process The Budget includes the following proposals to reform the Medicare appeals process. Provide Additional Resources for Medicare Appeals: This proposal would provide the Department mandatory funding to implement system reforms and invest in addressing the backlog of pending appeals. The Secretary would be authorized to transfer funding across all levels of the appeals system. [$1.3 billion in costs over 10 years] In the 11th Statement of Work, there are 14 Quality Innovation Network contracts and five Beneficiary and Family Centered Care contracts. Quality Innovation Network contractors have been working to reduce patient harms such as central-line bloodstream infections, hospital readmissions, and adverse drug events. Beneficiary and Family Centered Care is the program’s statutory case review work, and includes beneficiary complaints, concerns related to early discharge from health care settings, and patient and family engagement. Since 2016, Quality Innovation Network contractors have provided clinicians with technical assistance related to MACRA’s Quality Payment Program, with a focus on those with the greatest need. Remand Appeals to the Redetermination Level with the Introduction of New Evidence: This proposal would remand an appeal to the first level of appeal when new documentary evidence is submitted into the administrative record at the second level of appeal or above. Exceptions may be made if evidence was provided to the lower level adjudicator but erroneously omitted from the record, or an adjudicator denies an appeal on a new and different basis than earlier determinations. This proposal incentivizes appellants to include all evidence early in PROGRAM HIGHLIGHT the appeals process and ensures the same record is reviewed Estimated Quality Improvement Organization Funding 11th Statement of and considered at subsequent Work (2014-2018) levels of appeal. [No budget (dollars in millions) impact] Increase Minimum Amount in Controversy for Administrative Law Judge Adjudication of $433 Claims to Equal Amount $2,060 Required for Judicial Review: This proposal increases the $1,070 minimum amount in controversy required for $4,368 adjudication by an Administrative Law Judge to the Federal District Court amount in controversy requirement ($1,560 in calendar year 2017 and updated annually). This will allow the amount at issue to better align with the amount spent to adjudicate the claim. Appeals not reaching the minimum amount in controversy will be adjudicated by a Medicare magistrate. The minimum Clinical Quality Improvement $805 Beneficiary and Family Centered Care Infrastructure, Support, and Special Initiatives Other Support Contracts and Staff Subtotal Funding 2018 LEGISLATIVE PROPOSALS The FY 2018 Budget reflects the President’s commitment to preserve Medicare and does not 54 Centers for Medicare & Medicaid Services amount in controversy will increase consistency with the amount in controversy set for Federal court. [No budget impact] an appellant due to binding limits on authority. [No budget impact] HHS is committed to working with Congress on a comprehensive and common sense reform package to improve the Medicare appeals process and address the pending backlog. Establish Magistrate Adjudication for Claims with Amount in Controversy Below New Administrative Law Judge Amount in Controversy Threshold: This proposal allows the Office of Medicare Hearings and Appeals to use Medicare magistrates for appealed claims below the Federal District Court amount in controversy threshold ($1,560 in calendar year 2017 and updated annually), reserving Administrative Law Judges for more complex and higher amount in controversy appeals. [No budget impact] Other Proposals Repeal the Independent Payment Advisory Board: The Budget proposes to repeal the Independent Payment Advisory Board, created by Section 3403 of the Affordable Care Act, and all amendments thereto. All remaining unobligated administrative funds would be rescinded. [$7.6 billion in costs over 10 years] Expedite Procedures for Claims with No Material Fact in Dispute: This proposal allows the Office of Medicare Hearings and Appeals to issue decisions without holding a hearing if there is no material fact in dispute. These cases include appeals, for example, in which Medicare does not cover the cost of a particular drug or the Administrative Law Judge cannot find in favor of Centers for Medicare & Medicaid Services Medical Liability Reform: The Budget includes a set of proposals for medical liability reform. This initiative will reduce Federal spending on healthcare, including by curbing the provision of unnecessary services in Medicare. See the Budget in Brief Overview for proposal descriptions. [$31.4 billion in Medicare savings over 10 years] 55 Medicare FY 2018 Medicare Legislative Proposals (Negative numbers reflect savings and positive numbers reflect costs) dollars in millions Medicare Appeals Proposals Provide Additional Resources for Medicare Appeals Remand Appeals to the Redetermination Level with the Introduction of New Evidence Increase Minimum Amount in Controversy for Administrative Law Judge Adjudication of Claims to Equal Amount Required for Judicial Review Establish Magistrate Adjudication for Claims with Amount in Controversy Below New Administrative Law Judge Amount in Controversy Threshold Expedite Procedures for Claims with No Material Fact in Dispute Other Medicare Benefits Proposals Repeal the Independent Payment Advisory Board Medicare Interactions Medical Liability Reform (Medicare Impact) Total /1 2018 2018 -2022 2018 -2027 127 635 1,270 — — — — — — — — — — — — — — 7,621 -88 39 -6,422 -5,787 -31,449 -22,557 1/ Total may not add due to rounding. 56 Centers for Medicare & Medicaid Services Program Integrity dollars in millions 2016 2017 2018 Health Care Fraud and Abuse Control Discretionary /1 Health Care Fraud and Abuse Control Mandatory /2 /3 Total, Budget Authority 681 1,279 1,960 681 1,270 1,951 751 1,352 2,103 2018 +/-2017 +70 +82 +152 1/ Reflects the annualized level of the Continuing Resolution that ended April 28, 2017, including the across the board reduction, the 21st Century Cures Act, and directed transfers. 2/ The FY 2016 and FY 2017 mandatory base includes sequester reductions. 3/ Does not include Deficit Reduction Act funding for the Medicaid Integrity Program, which is discussed in this chapter but is in the State Grants and Demonstrations account. Discretionary Health Care Fraud and Abuse Control Account The Budget requests $751 million in discretionary Health Care Fraud and Abuse Control funding, $70 million above the FY 2016 enacted level. The Budget requests base discretionary funds ($317 million) plus a discretionary cap adjustment ($434 million), which is consistent with the Budget Control Act of 2011. The discretionary funding is allocated to CMS program integrity activities ($610.4 million), the Department of Justice ($66.4 million), and the HHS Office of Inspector General ($74.2 million). The Fiscal Year (FY) 2018 Budget strengthens the integrity and sustainability of Medicare and Medicaid by investing in activities that prevent fraud, waste, and abuse and promote quality and efficient health care. For FY 2018, the Budget assumes $2.1 billion in total mandatory and discretionary investments in the Health Care Fraud and Abuse Control program. HEALTH CARE FRAUD AND ABUSE CONTROL PROGRAM The FY 2018 Budget proposes to build on recent progress by increasing support for the Health Care Fraud and Abuse Control program through both mandatory and discretionary funding streams. The FY 2018 Health Care Fraud and Abuse Control program level is $2.1 billion. Of the total FY 2018 program level, $1.4 billion is mandatory funding and $751 million is discretionary funding. Recent investments in Health Care Fraud and Abuse Control have allowed for the expansion of fraud and abuse prevention efforts and led to a shift away from the “pay-and-chase” model toward preventing fraud, waste, and abuse on the front end. The Health Care Fraud and Abuse Control investment also supports efforts to reduce the Medicare and Medicaid improper Health Care Fraud and Abuse Control Multi-Year Investment and Savings (in millions) 2018 2019 2020 2021 2022 2018 -2022 2018 -2027 Mandatory Funding 1,352 1,382 1,414 1,436 1,469 7,054 14,924 Discretionary Funding Total Program Level /1 751 2,103 778 2,161 805 2,219 833 2,269 857 2,326 4,024 11,078 8,718 23,642 Savings from Discretionary Investment /2 -923 -980 -1,040 -1,102 -1,158 -5,203 -11,677 1/ Total Program Levels may not add due to rounding. 2/ Reflects savings already assumed in current law, as well as savings attributable to the new discretionary investment request above current law. Savings are not scoreable under PAYGO. Centers for Medicare & Medicaid Services 57 Return on Investment Program integrity returns on investment are measured by program area and separately reported by activity type. There are three key ways in which returns from program integrity activities are described. First, programs supported by Health Care Fraud and Abuse Control Program mandatory funds have a proven record of returning more money to the Medicare Trust Funds than the dollars spent. The most recent estimate of the Medicare Integrity Program return on investment is $12 to $1, and the Medicare Integrity Program has recently yielded a consistent return of over $10 billion in savings annually. payment rates, while implementing new processes to reduce provider burden. Mandatory Health Care Fraud and Abuse Control Account The $1.4 billion in mandatory base funds for FY 2018 are financed from the Medicare Part A Trust Fund. The funding is allocated to: the Medicare Integrity Program; the Health Care Fraud and Abuse Control Account, which is divided annually among the HHS Office of Inspector General; other HHS agencies; Department of Justice; and the Federal Bureau of Investigation. These dollars fund comprehensive efforts to combat health care fraud, waste, and abuse, including prevention-focused activities, improper payment reduction, provider education, data analysis, audits, investigations, and enforcement. Second, the three-year rolling average return on investment for Health Care Fraud and Abuse Control law enforcement activities is $5 to $1. In FY 2016 alone, $3.3 billion was recovered, including $1.7 billion returned to the Medicare Trust Funds and $235.2 million in Federal Medicaid recoveries returned to the Treasury. PROGRAM HIGHLIGHT Key Program Integrity Initiatives • • • Third, CMS actuaries conservatively project that for every new dollar spent by HHS to combat health care fraud about $2 is saved or avoided. Medicaid Data Systems: Both the Office of Inspector General and the Government Accountability Office have highlighted inadequacies in Medicaid data and data systems as a significant program integrity concern for Medicaid. The Budget will invest in Medicaid data systems to address these concerns and help States to better fulfill their responsibilities to address fraud, waste, and abuse in Medicaid. Medicaid Financial Management and Oversight Program: CMS funding specialists partnered with States to avert $666 million in questionable reimbursements and recovered $230 million in questionable costs in 2016. The Budget would invest additional funding to better support this effort. Medicare Program Integrity: The Budget reduces provider burden while protecting the Medicare Trust Funds by: modernizing Medicare documentation standards for medical review; enhancing provider education efforts; and improving provider interactions with CMS by consolidating provider portal entry points into CMS systems, and enhancing visibility into their current and historic billing and audits. MEDICAID INTEGRITY PROGRAM The Medicaid Integrity Program was established by the Deficit Reduction Act of 2005, which appropriated $75 million in FY 2009 and for each year thereafter. The Patient Protection and Affordable Care Act later increased appropriations for FY 2011 and future years by inflation. States have the primary responsibility for combating fraud, waste, and abuse in the Medicaid program, but the Medicaid Integrity Program plays an important role supporting state efforts, including through contracting with eligible entities to carry out activities such as reviews, audits, identification of overpayments, education activities, and technical support to states. The Medicaid Integrity Program works in coordination with Medicaid program integrity activities funded through Health Care Fraud and Abuse Control. 58 Centers for Medicare & Medicaid Services Medicaid 2018 +/-2017 2016 2017 2018 Total Net Outlays, Current Law /2 351,106 17,175 368,281 357,628 20,828 378,455 386,762 20,808 407,570 +29,134 -20 +29,115 Total Net Outlays, Proposed Law /2 — 368,281 — 378,455 -3,857 403,713 -3,857 +25,258 dollars in millions Current Law Benefits /1 State Administration Proposed Law Legislative Proposals 1/ Includes outlays from the Vaccines for Children Program, administered by the Centers for Disease Control and Prevention. 2/ Totals may not add due to rounding Medicaid is the primary source of medical assistance for millions of low-income and disabled Americans, providing health coverage to many of those who would otherwise be unable to obtain health insurance. In Fiscal Year (FY) 2016, more than one in five individuals were enrolled in Medicaid for at least one month during the year, and in FY 2018, over 76 million people on average will receive health care coverage through Medicaid under current law. Medicare & Medicaid Services (CMS) Office of the Actuary estimates total Federal and State Medicaid spending will be nearly $1.1 trillion by FY 2027, comprising 3.5 percent of the Nation’s gross domestic product. States are required to cover individuals who meet certain minimum categorical and financial eligibility standards. Medicaid beneficiaries include children; pregnant women; adults in families with dependent children; the aged, blind, and/or disabled; and individuals who meet certain minimum income eligibility criteria that vary by category. States also have the flexibility to extend coverage to higher income groups, including medically needy individuals through waivers and amended State plans. Medically needy individuals are those individuals who do not meet the income standards of the categorical eligibility groups but incur large medical expenses and would otherwise qualify for Medicaid. HOW MEDICAID WORKS Although the Federal Government establishes general guidelines for the program, States design, implement, and administer their own Medicaid programs. The Federal Government matches State expenditures on medical assistance based on the Federal Medical Assistance Percentage, which can be no lower than 50 percent. In FY 2018, the Federal share of current law Medicaid outlays is expected to be approximately $407.6 billion. Without reforms, the Centers for Centers for Medicare & Medicaid Services 59 Under Medicaid, States must cover certain medical services and are provided the flexibility to offer additional benefits to beneficiaries. Medicaid also covers most of the costs of providing long-term care services. Medicare and private health insurance often furnish only limited coverage of these benefits. Medicaid Enrollment (person-years in millions) Aged 65 and Over Blind and Disabled Children Adults Territories Total /1 2016 5.7 10.6 28.1 26.5 1.4 72.3 2017 5.8 10.6 28.2 27.8 1.4 73.8 2018 6.0 10.7 30 28.4 1.4 76.5 2018 +/- 2017 +0.2 +0.1 +1.8 +0.6 — +2.7 RECENT PROGRAM DEVELOPMENTS Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) MACRA permanently authorized the Qualified Individual and Transitional Medical Assistance programs and extended Express Lane Eligibility authority through September 2017. The law also delayed Medicaid Disproportionate Share Hospital reductions until FY 2018 and applied an additional reduction in FY 2025. Source: CMS Office of the Actuary estimates. 1/ Totals may not add due to rounding. FY 2015—Percentage of Medicaid Beneficiaries vs. Federal Medical Assistance Expenditures by Eligibility Group /1 /2 100% Children, 19% 90% 80% Children, 41% 70% Adults, 26% Percentage 60% 50% 40% Adults, 36% Blind/Disabled, 40% 30% 20% Blind/Disabled, 15% 10% 0% Aged, 16% Aged, 8% People Served Expenditures Source: CMS Office of the Actuary 1/ Totals and components exclude Disproportionate Share Hospital expenditures, territorial enrollees and expenditures, and financial adjustments. 2/ Percentages may not add to 100% due to rounding. 60 Centers for Medicare & Medicaid Services 21st Century Cures Act of 2016 This law expands access to comprehensive medical care for children receiving inpatient psychiatric hospital services, requires States to implement an electronic visit verification system for personal care and home health services, and accelerates the implementation of a limit on Federal reimbursement for durable medical equipment from January 1, 2019, to January 1, 2018. to give States the flexibility they need to achieve better health outcomes for patients while putting Medicaid on a more sustainable fiscal trajectory. [$610 billion in Medicaid savings over 10 years] PROGRAM UPDATE Letter to Governors from Secretary Price and CMS Administrator Verma 2018 LEGISLATIVE PROPOSALS On March 14, 2017, Secretary Price and CMS Administrator Verma sent a letter to all 50 State governors committing to “…usher in a new era for the federal and state Medicaid partnership” and to “…empower all States to advance the next wave of innovative solutions to Medicaid’s challenges.” The Administration also supports legislation to build on the tools provided within existing authorities to further expand State flexibility in how they spend their Medicaid dollars. The letter notes several key areas of focus for the Administration: The FY 2018 Budget puts Medicaid on a path to fiscal stability by restructuring Medicaid financing and reforming medical liability laws. In total, the Budget includes a net savings to Medicaid of $627 billion over 10 years, not including additional savings to Medicaid as a result of the Administration’s plan to repeal and replace Obamacare with solutions that focus Medicaid on the most vulnerable Americans—the elderly, people with disabilities, children, and pregnant women—those Medicaid was intended to serve. 1. 2. 3. Reform Medicaid Funding to States and Provide Additional Flexibility The Budget provides additional flexibility to States and reforms the fiscal structure of Medicaid, allowing a choice between a per capita cap or a block grant beginning in FY 2020. Rigid and outdated Federal rules and requirements prevent States from prioritizing Federal resources to their most vulnerable populations and from innovating and testing new ideas that will improve access to care and health outcomes. This proposal will free States to advance solutions that best serve their unique populations—for example, encouraging work, promoting personal responsibility, and meeting the spectrum of diverse needs of their Medicaid populations. States, as administrators of the program, are in the best position to assess the unique needs of their populations. The Administration is determined to work with Congress to put in place a plan Centers for Medicare & Medicaid Services 4. 5. Improving Federal and State program management; Supporting innovative approaches to increase employment and community engagement; Aligning Medicaid and private insurance policies for non-disabled adults; Providing reasonable timelines and processes for home and community-based services transformation; and Providing States with more tools to address the opioid epidemic. The full letter to governors is available at the following URL: https://www.hhs.gov/sites/default/files/sec-price-admin-verma-ltr.pdf Medical Liability Reform The Budget includes a set of proposals to reform medical liability, which will reduce medical malpractice costs and the practice of defensive medicine, while supporting State efforts to reduce Medicaid costs. See the Budget in Brief Overview for proposal descriptions. [$399 million in Medicaid savings over 10 years] 61 Medicaid Direct Primary Care Initiative NEW INITIATIVE Starting in FY 2018, the Department looks forward to collaborating with States to expand Medicaid Direct Primary Care (DPC), which provides an enhanced focus on direct physician-patient relationships through enrolling Medicaid patients in DPC practices. These practices enhance physicians’ focus on patient care by simplifying health care payments for patients and physicians. DPC arrangements also often include benefits such as extended visits and electronic communication, which allows for improved patient access to primary care services. DPC arrangements have the potential to improve Medicaid in the following manner: • Increasing access. While approximately 70 percent of physicians are accepting new Medicaid patients nationally, there is wide variation across States and one-third of physicians still do not accept Medicaid patients. Specialists are also more likely to take Medicaid patients than primary care physicians. Moreover, many physicians refuse to treat Medicaid patients for various reasons including low reimbursement rates. • Supporting positive health outcomes for Medicaid patients. While limited, data available for patient outcomes for patients in DPC practices has been relatively positive. The American Journal of Managed Care evaluated a DPC group with practices in many States, and data illustrated positive patient outcomes with decreases in preventable hospital use that resulted in considerable savings. • Putting patients and doctors in more control of health care. DPC practices will support the vital role primary care plays in patient health, including providing preventive services, monitoring health conditions, and improving the crucial physician-patient relationship. By creating DPC practices that would encourage affordable care for patients, these patient-centered reforms would help build a more innovative and responsive health care system—one that empowers patients and ensures they and their doctor have the freedom to make health care decisions without bureaucratic interference or influence. Working with States and primary care physicians, HHS will support the development of DPC practices, identify barriers to their entry into Medicaid, and outline flexibilities under existing authorities to facilitate these innovative approaches to strengthening the relationships between patients and physicians. 62 Centers for Medicare & Medicaid Services Medicaid FY 2018 Medicaid Legislative Proposals 2018 2018 -2022 2018 -2027 — -70,000 -610,000 Medicaid Interactions Medical Liability Reform (Medicaid Impact) /1 Extend CHIP Funding through 2019 (Medicaid Impact) /2 Extend Special Immigrant Visa Program (Medicaid Impact) /3 -62 -3,800 5 -399 -16,700 49 -399 -16,700 94 Total Outlays, Legislative Proposals /4 -3,857 -87,050 -627,005 dollars in millions Medicaid Fiscal Sustainability and Flexibility Reform Medicaid Funding to States and Provide Additional Flexibility 1/ 2/ 3/ 4/ See the Budget in Brief Overview for proposal descriptions. See Children’s Health Insurance Program chapter for proposal description. This proposal is included in the State Department’s FY 2018 Budget Request. Totals may not add due to rounding. Centers for Medicare & Medicaid Services 63 Children’s Health Insurance Program dollars in millions Current Law Children's Health Insurance Program (CHIP) Child Enrollment Contingency Fund Total Outlays, Current Law Proposed Law CHIP Legislative Proposals /1 Total Outlays, Proposed Law 2016 2017 2018 2018 +/- 2017 14,305 53 14,358 16,655 224 16,879 12,017 0 12,017 -4,638 -224 -4,862 — 14,358 — 16,879 1,400 13,417 +1,400 -3,462 1/ This score reflects the impact on CHIP. The net Federal cost of the proposal is -$5.8 billion over 10 years, which reflects impacts to CHIP ($13.9 billion) and interactions with Medicaid (-$16.7 billion) and other Federal programs and accounts (-$3.0 billion). See Medicaid chapter for Medicaid impact. The Children’s Health Insurance Program (CHIP) was originally created under the Balanced Budget Act of 1997. In 2009, CHIP was reauthorized under the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA), which provided an additional $44 billion in funding through Fiscal Year (FY) 2013 and created several new initiatives to improve and increase enrollment in the program. Most recently, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) extended funding for the program through FY 2017. The Budget proposes an additional two-year extension of CHIP, through FY 2019. Since September 1999, every State, the District of Columbia, and all five Territories have approved CHIP plans. States have a high degree of flexibility in designing their programs. They can implement CHIP by expanding Medicaid, creating a separate program, or a combination of both approaches. As of January 1, 2017, there were 14 Medicaid expansion programs, two separate programs, and 40 combination programs among the States, District of Columbia, and Territories. In FY 2016, the Centers for Medicare & Medicaid Services (CMS) Office of the Actuary estimated that 9.2 million individuals received health insurance funded through CHIP allotments at some point during the year. Approximately 6.3 million individuals were enrolled in CHIP on average throughout the year. HOW CHIP WORKS A Child Enrollment Contingency Fund was established for States that predict a funding shortfall based on higher than expected enrollment. The Contingency Fund received an initial appropriation of $2.1 billion in FY 2009 and is invested in interest bearing securities of the United States. Payments from the fund are currently authorized through FY 2017. CHIP is a partnership between the Federal Government and States and Territories to help provide low-income children under age 19 with health insurance coverage so they can access health care. In general, CHIP reaches children whose families have incomes too high to qualify for Medicaid but too low to afford private health insurance. RECENT PROGRAM DEVELOPMENTS States with an approved CHIP plan are eligible to receive an enhanced Federal matching rate, which will range from 65 to 85 percent. Beginning in FY 2016, and effective through FY 2019, each State’s enhanced Federal matching rate increased by up to 23 percentage points to cover between 88 and 100 percent of total costs for child health care services and program administration, drawn from a capped allotment. Financing Current law provides an increase in each State’s enhanced Federal match rate by 23 percentage points, not to exceed a total match rate of 100 percent, between FY 2016 and FY 2019. Eligibility and Coverage States use a Modified Adjusted Gross Income standard to determine eligibility for coverage under a State’s 64 Centers for Medicare & Medicaid Services CHIP program. States can offer continuous eligibility for 12 months regardless of changes in family income, fast track enrollment using Express Lane Eligibility authority, and enroll children who are eligible for family coverage under a state employee health plan into CHIP. grants for children who are American Indian/Alaska Native, and $4 million is dedicated to the National Enrollment Campaign. Outlay totals for Outreach and Enrollment Grants are reflected in the State Grants and Demonstrations chapter. Improving Quality CHIPRA provided $225 million over five years for activities that improve child health quality in Medicaid and CHIP, and 18 States (across 10 grants) participated in CHIPRA Quality Demonstrations to test ways to strengthen the quality of and access to children’s health care through a variety of health care delivery and measurement approaches at both the provider and patient levels. The Protecting Access to Medicare Act of 2014 allocates $15 million of Adult Health Quality funding for the pediatric quality measures program, and MACRA provided an additional $20 million in new funding for the program. Enrollment and Retention Outreach MACRA provided new funding and extends the Outreach and Enrollment Program for two years through FY 2017. Originally enacted under CHIPRA and extended by the Patient Protection and Affordable Care Act, the Outreach and Enrollment Program provides grants and a national campaign to improve outreach and enrollment to children who are eligible for but unenrolled in Medicaid and CHIP. Of the total $40 million appropriation under MACRA, $32 million is dedicated to outreach and enrollment grants, $4 million is dedicated to outreach and enrollment NEW INITIATIVE NEW INITIATIVE Budget Extends CHIP Funding for an Additional Two Years The passage of MACRA ensured continued comprehensive coverage for CHIP children through FY 2017. Extending CHIP for an additional two years through FY 2019 will save a net $5.8 billion. Dollars in Millions Extend CHIP Funding for Two Additional Years FYs 2018-2027 (10 year) -5,815 CHIP Impact (non-add) (HHS) Medicaid Impact (non-add) (HHS) Other Federal Impacts (non-add) (Treasury) 13,900 -16,700 -3,015 Extend the Child Enrollment Contingency Fund for Two Years 0 Total Net Federal Cost of CHIP Proposals Centers for Medicare & Medicaid Services -5,815 65 CHIP PROPOSALS This funding extension would also cap the level at which States could receive the CHIP enhanced Federal matching rate at 250 percent of the Federal Poverty Level. These provisions would return the focus of CHIP to the most vulnerable and low-income children. Extend CHIP Funding through FY 2019 The Budget proposes to extend funding for CHIP for two additional years through FY 2019. Extending CHIP funding for two years provides stability to States and families while the future of the program is addressed alongside other health reforms. The Budget also proposes a series of improvements that rebalance the State-Federal partnership and increase State flexibility. This proposal also extends the Child Enrollment Contingency Fund through FY 2019. Under current law, States were required to transition children ages 6 to 18 in families with incomes between 100 and 133 percent of the Federal Poverty Level off of CHIP to Medicaid. The Budget proposes allowing States to move these children back into CHIP. Without Congressional action, CMS estimates States will begin to experience funding shortfalls in December 2017 and all States will run out of funding before the end of FY 2018. This proposal ends the 23 percentage point increase in the enhanced Federal match rate and the current law maintenance of effort requirement after FY 2017. 66 Centers for Medicare & Medicaid Services Children’s Health Insurance Program FY 2018 CHIP Legislative Proposals (negative numbers reflect savings and positive numbers reflect costs) dollars in millions 2018 2018 -2022 2018 -2027 CHIP Proposals Extend CHIP funding through FY 2019 /1 CHIP Impact (non-add) Medicaid Impact (non-add) Other Federal Impacts (non-add) Extend the Child Enrollment Contingency Fund through FY 2019 Total Outlays, CHIP Proposals /1 /2 1,400 1,400 -3,800 41 0 1,400 13,900 13,900 -16,700 -3,015 0 13,900 13,900 13,900 -16,700 -3,015 0 13,900 1/ This score reflects the impact on CHIP. The net Federal cost of the proposal is -$5.8 billion over 10 years, which reflects impacts to CHIP ($13.9 billion) and interactions with Medicaid (-$16.7 billion) and other Federal programs and accounts (-$3.0 billion). 2/ Totals may not add due to rounding. Centers for Medicare & Medicaid Services 67 State Grants and Demonstrations dollars in millions Current Law Budget Authority /1 Medicaid Integrity Program /2 Money Follows the Person Demonstration Money Follows the Person Evaluations Demonstration Program to Improve Community Mental Health Services Children’s Health Insurance Program (CHIP) Outreach and Enrollment Grants Total, Current Law Budget Authority Current Law Outlays /3 Medicaid Integrity Program /2 Money Follows the Person Demonstration Money Follows the Person Evaluations Demonstration Program to Improve Community Mental Health Services CHIP Outreach and Enrollment Grants /5 Incentives for Prevention of Chronic Diseases in Medicaid /4 Medicaid Emergency Psychiatric Demonstration /4 Emergency Services for Undocumented Aliens /4 /6 Total, Current Law Outlays 2016 2017 2018 2018 +/- 2017 77 418 1 23 40 559 78 — — — — 78 86 — — — — 86 +8 — — — — +8 73 450 1 8 6 12 1 2 553 80 425 1 7 14 9 — 1 537 86 425 — 4 13 6 — — 534 +6 — -1 -3 -1 -3 — -1 -3 1/ The Budget Authority table does not include Funding for the Territories due to a rescission in this program. 2/ Budget authority for the Medicaid Integrity Program is adjusted annually by Consumer Price Index for All Urban Consumers and outlays include some spending from prior year budget authority. This program is also described in the Program Integrity chapter. 3/ The following programs/laws were excluded from the Current Law Outlays table (either because outlays were less than $1 million or were rescinded): Ticket to Work and Work Incentives Improvement Act, the National Clearinghouse for Long-Term Care Information, and the Psychiatric Residential Treatment Facilities Demonstration. 4/ Outlays are from prior year budget authority. 5/ See CHIP chapter for additional information about this program. 6/ On December 28, 2015, the Centers for Medicare & Medicaid Services announced the sunsetting of this program at the end of Fiscal Year 2016. The State Grants and Demonstrations account funds a diverse set of program activities, including activities that were authorized in the Patient Protection and Affordable Care Act, the Children’s Health Insurance Program Reauthorization Act (CHIPRA), the Deficit Reduction Act of 2005, and the Ticket to Work and Work Incentives Improvement Act of 1999. Such activities include strengthening Medicaid program integrity, supporting enrollment of children into Medicaid and the Children’s Health Insurance Program (CHIP) through funding for outreach activities, and promoting prevention and wellness by providing grants to States to prevent chronic diseases. outreach and enrollment to children who are eligible for but unenrolled in Medicaid and CHIP. Of the total $40 million appropriation under MACRA, $32 million is dedicated to outreach and enrollment grants, $4 million is dedicated to outreach and enrollment grants for children who are American Indian/Alaska Native, and $4 million is dedicated to the National Enrollment Campaign. Medicaid Integrity Program The Medicaid Integrity Program was established by the Deficit Reduction Act of 2005, which appropriated $75 million in FY 2009 and for each year thereafter. Congress later increased appropriations for FY 2011 and future years by inflation. Enrollment and Retention Outreach The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) provided new funding and extended the Outreach and Enrollment Program for two years through Fiscal Year (FY) 2017. Originally enacted under CHIPRA, the Outreach and Enrollment Program provides grants and a national campaign to improve States have the primary responsibility for combating fraud, waste, and abuse in the Medicaid program, but the Medicaid Integrity Program plays an important role supporting State efforts, including through contracting with eligible entities to carry out activities such as 68 Centers for Medicare & Medicaid Services Centers for Medicare & Medicaid Services reviews, audits, identification of overpayments, education activities, and technical support to States. The Medicaid Integrity Program works in coordination with Medicaid program integrity activities funded through the Health Care Fraud and Abuse Control program. matching rate to help eligible individuals transition from a qualified institutional setting to a qualified home or community based setting. Demonstration Program to Improve Community Mental Health Services Section 223 of the Protecting Access to Medicare Act created this demonstration program for States to implement from FYs 2017-2019. The program provides an enhanced Federal Medicaid match rate for certified community behavioral health clinics with the aim of improving access to behavioral health services for Medicaid beneficiaries. Money Follows the Person Demonstration This demonstration, extended by the Patient Protection and Affordable Care Act through FY 2016, helps States support individuals to achieve independence. While all the money has been obligated, States have continued to operate this demonstration since 2007. States that are awarded competitive grants receive an enhanced Medicaid Centers for Medicare & Medicaid Services 69 Program Management dollars in millions Discretionary Administration Program Operations Federal Administration Survey and Certification Research Total, Discretionary Budget Authority /1 /2 Mandatory Administration /3 Obamacare American Recovery and Reinvestment Act Medicare Improvements for Patients and Providers Act 2016 2017 2018 2018 +/- 2017 2,821 733 397 2,817 733 397 2,441 723 406 -376 -10 +9 20 3,971 20 3,967 18 3,588 -2 -379 0 61 3 1 0 3 1 0 3 - Protecting Access to Medicare Act (2014) Improving Medicare Post-Acute Care Transformation (2014) Medicare Access and CHIP Reauthorization Act Total, Mandatory /1 Reimbursable Administration Medicare and Medicaid Reimbursable Administration /3 Exchange-Related Reimbursable Administration /5 Risk Corridor Collections 6 20 216 305 6 20 196 225 6 19 163 191 -1 -33 -34 680 1,154 362 427 1,309 103 514 1,188 103 +87 -122 - Subtotal, Reimbursable Administration 2,196 1,839 1,805 -34 0 0 6,472 0 0 6,031 26 26 5,610 +26 +26 -448 6,238 6,495 6,340 -155 Proposed Law (Discretionary) Offsetting Collections /6 Subtotal, Proposed Law Program Level, Proposed Law Full-Time Equivalents /7 1/ Totals may not add due to rounding. 2/ Reflects the annualized level of the Continuing Resolution that ended April 28, 2017, including the across the board reduction, the 21st Century Cures Act, and directed transfers. 3/ Includes the following user fees: Clinical Laboratory Improvement Amendments of 1988, sale of research data, coordination of benefits for the Medicare prescription drug program, MA/prescription drug program education campaign, recovery audit contractors, and provider enrollment fees. 4/ The FY 2016 Zika Response and Preparedness Act (P.L. 114-223) provided $387 million in supplemental resources to the Public Health and Social Services Emergency Fund for Zika response and preparedness activities, of which $75 million was allocated for CMS for FYs 2016 and 2017. 5/ Includes user fees charged to issuers in Federally-facilitated Exchanges, State-based Exchanges using the Federal platform, and risk adjustment. 6/ Include a proposal for one new discretionary offsetting collection. Please see Survey and Certification section for more information. 7/ Full-Time equivalent (FTE) totals include FTE from other funding sources: Health Care Fraud and Abuse Control Program (HCFAC), state grants, reimbursables, and mandatory appropriations. CMS will fund the following FTE from other sources: FY 2016 = 1,720; FY 2017 = 1,970; and FY 2018 = 1,970. 70 Centers for Medicare & Medicaid Services • The FY 2018 discretionary budget request for CMS Program Management is $3.6 billion, a decrease of $379 million below the FY 2017 Annualized Continuing Resolution level. This request will enable CMS to continue to effectively administer Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP). The FY 2018 Budget reflects CMS’s key priorities to: reduce costs through contract efficiencies; prioritize customer service; invest in program integrity; stabilize and streamline Exchanges; and strengthen the Federal workforce. • BUDGET ACCOUNT SUMMARIES Program Operations The Program Operations request is $2.4 billion, a decrease of $375 million below the FY 2017 Annualized Continuing Resolution level. The Program Operations account funds essential contractor, information technology, and outreach activities necessary to administer Medicare, Medicaid, CHIP, and private insurance programs. Top priority activities for FY 2018 include: • • • Ongoing Medicare Contractor Operations: Approximately 36 percent, or $885 million, of the FY 2018 Program Operations request supports ongoing Medicare contractor operations. This workload includes processing 1.3 billion Medicare Part A and B claims, enrolling providers in the Medicare program, handling provider reimbursement services, processing 4.8 million first-level appeals, responding to provider inquiries, educating providers about the program, and administering the participating physicians/supplier program. Medicare Appeals: The Budget includes $87 million to timely process about 970,000 provider and beneficiary claim appeals at the second level of appeals. Information Technology Systems and Support: The Budget includes $329 million for non-Exchange information technology systems and other support, including cybersecurity, allowing the agency to protect the valuable consumer health data of millions of Americans from outside threats. Additionally, CMS continues to transition to the use of shared systems, which allow for greater efficiency and reliability agency wide. Centers for Medicare & Medicaid Services Medicaid and CHIP Operations: The Budget requests $45 million to fund administrative activities to improve Medicaid and CHIP program operations, including the modernization of data systems. Exchanges: The Budget includes $471 million in requested budget authority for the Exchanges, $453 million of which supports Program Operations activities such as eligibility, call center operations, and information technology. In addition, CMS anticipates collecting approximately $1.2 billion in user fee revenues to support Exchange activities. The total estimated program level, including sources in other accounts, is $1.7 billion. Federal Administration For FY 2018, the Budget requests $723 million for CMS Federal administrative costs, $10 million below the FY 2017 Annualized Continuing Resolution level. Of this total, $651 million will support a direct full-time equivalent level of 4,370, a decrease of 155 full-time equivalents below the current level. With this level of PROGRAM HIGHLIGHT Survey and Certification Frequencies Type of Facility Long-Term Care Facilities (statutory) 2017 Every Year (100%) 2018 Every Year (100%) Home Health Agencies (statutory) Every 3 Years (33.3%) Every 3 Years (33.3%) Hospice (statutory) Every 3 Years (33.3%) Every 3 Years (33.3%) Every 3.9 Years (25.6%) Every 4 Years (25%) 1.5% Per Year 1.0% Per Year ESRD Facilities Every 3.8 Years (26.3%) Every 4 Years (25.0%) Ambulatory Surgical Centers Every 4.7 Years (21.3%) Every 4 Years (25.0%) Every 12 Years (8.3%) Every 11 Years (9.1%) Every 12 Years (8.3%) Every 10 Years (10.0%) Non-Accredited Hospitals Accredited Hospitals Community Mental Health Centers and Rural Health Clinics Outpatient Physical Therapy, Outpatient Rehabilitation, Portable X-Ray 71 staff, CMS will be able to support operations. The reduction in workforce will occur through natural attrition across CMS. revisit poor performers, while creating an incentive for facilities to correct deficiencies and ensure quality of care. The Budget assumes a five month lag for collecting fees in the initial FY 2018 year of operation. [$26 million in user fee revenue in FY 2018] Survey and Certification The FY 2018 Survey and Certification request is $406 million, a $9 million increase over the FY 2017 Annualized Continuing Resolution level. The increased funding level is needed to maintain survey frequency levels due to growing numbers of participating facilities and improved quality and safety standards. CMS expects States to complete over 23,800 initial surveys and re-certifications and over 56,200 visits in response to complaints in FY 2018. Research For FY 2018, the Budget requests $18 million for Research—$2 million below the FY 2017 Annualized CR level—to maintain the Medicare Current Beneficiary Survey and other research databases which support Medicare rate-setting. CROSSCUTTING SUMMARIES PERFORMANCE HIGHLIGHT National Medicare Education Program Total FY 2018 program level for the National Medicare Education Program is $366 million, including $255 million in budget authority. In order to ensure that beneficiaries have accurate and up-to-date information on their coverage options and covered benefits, beneficiary education remains a top priority for CMS. Reducing Unnecessary Antipsychotic Drug Use in Nursing Homes The CMS survey and certification budget aims to improve dementia care in nursing homes by decreasing the percentage of long-stay nursing home residents receiving an antipsychotic medication. Antipsychotic medications have common and dangerous side effects when misused to treat the behavioral and psychological symptoms of dementia. In calendar year 2011, 23.9 percent of long-stay nursing home residents received an antipsychotic medication. In calendar year 2015, CMS exceeded its target of 19.9 percent to finish the year at 17.1 percent. CMS set the calendar year 2018 target rate at 15.7 percent. Of the total program level, $279.8 million, or 77 percent, supports the 1-800-MEDICARE call center, which provides beneficiaries with access to customer service representatives who are trained to answer questions regarding the Medicare program. The request will support approximately 27 million calls with an average-speed-to-answer of less than five minutes. Beneficiaries can also use 1-800-MEDICARE to report fraud allegations. Over 87 percent of the request will go to State survey agencies or Federal direct survey costs. Surveys include mandated Federal inspections of long-term care facilities (i.e., nursing homes), home health agencies, hospices, as well as Federal inspections of other key facilities. All facilities participating in the Medicare and Medicaid programs must undergo inspection when entering the program and on a regular basis thereafter. The request also includes $50.5 million for beneficiary materials, the majority of which will fund the Medicare & You handbook. The Budget also proposes to levy a fee for survey and certification revisits that occur as a result of deficiencies found during initial certification, recertification, or substantiated complaints surveys. The fee would provide CMS with an increased ability to 72 Centers for Medicare & Medicaid Services PROGRAM HIGHLIGHT National Medicare & You Education Program (NMEP) FY 2018 Program Level (dollars in millions) Activity 2017 2018 Beneficiary Materials (e.g., Handbook) 54.9 50.5 1-800-MEDICARE and Beneficiary Claims Contact Center 294.7 279.8 Internet 20.1 20.1 Community-Based Outreach 1.9 2.1 Program Support Services/National Ad Campaign 9.0 13.2 380.6 365.7 Total, NMEP Program Level /1 1/ Includes funding from Program Management, user fees, and Quality Improvement Organizations. Centers for Medicare & Medicaid Services 73 Administration for Children and Families 2016 2017 /1 2018 Budget Authority 34,217 34,841 31,700 Discretionary Budget Authority 18,870 19,284 14,482 53,087 54,125 46,182 dollars in millions Mandatory Total, ACF Budget Authority 1/ Reflects the annualized level of the Continuing Resolution that ended April 28, 2017, including the across the board reduction, the 21st Century Cures Act, and directed transfers. The Administration for Children and Families promotes the economic and social well-being of children, youth, families, and communities, focusing particular attention on vulnerable populations such as children in low-income families, refugees, and Native Americans. The FY 2018 Budget request for the Administration for Children and Families (ACF) is $46.2 billion. ACF works in partnership with States and communities that provide critical assistance to vulnerable families while helping families and children achieve a path to success. ACF’s Budget supports enabling more parents to find work and achieve self-sufficiency, lifting their families out of poverty and promoting the school readiness of their children. This effort includes combating child poverty, helping families facing financial crises or extreme poverty, supporting working families with access to quality child care, improving outcomes for children and families involved in the child welfare system, increasing child support payments to families, and continuing to support Head Start. Funds are also included for programs that serve runaway and homeless youth and victims of domestic violence, dating violence, and human trafficking. ACF FY 2018 Budget Other ACF Programs Child Support 7% Enforcement 9% Temporary Assistance for Needy Families 33% Foster Care and Permanency 19% Child Care and Development Fund 12% 74 Head Start 20% Administration for Children and Families Administration for Children and Families: Discretionary 2016 2017 /1 2018 2018 +/− 2017 Head Start 9,168 9,151 9,168 +17 Child Care and Development Block Grant (discretionary) 2,761 2,756 2,761 +5 11,929 11,906 11,929 +23 119 119 119 -- Child Abuse Prevention 98 98 98 -- Child Welfare Programs 326 325 316 -9 Chafee Education & Training for Foster Youth 43 43 43 -- Adoption and Guardianship Incentives 38 38 38 -- dollars in millions Early Childhood Programs Subtotal, Early Childhood Programs Programs for Vulnerable Populations Runaway and Homeless Youth Programs Native Americans Programs 50 50 50 -- Family Violence Prevention and Services Programs 158 158 159 +1 Promoting Safe and Stable Families (discretionary) 60 60 60 -- 892 891 883 -8 Refugee Programs Transitional and Medical Services 490 489 320 -169 Unaccompanied Alien Children 948 1,396 948 -448 Refugee Support Services /2 203 202 159 -43 34 34 29 -5 1,675 2,122 1,457 -665 3,390 3,384 -- -3,384 715 714 -- -714 Subtotal, Programs for Vulnerable Populations Other Refugee Programs Subtotal, Refugee Programs Discontinued Programs Low Income Home Energy Assistance Program Community Services Block Grant Other Community Services Programs 55 55 -- -55 4,161 4,153 -- -4,153 Other ACF Programs Social Services Research & Demonstration 7 7 7 -- Disaster Human Services Case Management 2 2 2 -- 205 205 205 -- 213 213 213 -- $18,870 $19,284 $14,482 -$4,802 1,334 1,352 1,320 -32 Subtotal, Discontinued Programs Federal Administration Subtotal, Other ACF Programs Total Discretionary Budget Authority Full-Time Equivalents 1/ Reflects the annualized level of the Continuing Resolution that ended April 28, 2017, including the across the board reduction, the 21st Century Cures Act, and directed transfers. 2/ Includes funding for Social Services and Targeted Assistance for FY 2016 and FY 2017. The Budget proposes to combine these programs into a new Refugee Supportive Services program in FY 2018. Administration for Children and Families 75 ACF provides work supports that families need as they endeavor to become self-sufficient. The Fiscal Year (FY) 2018 Budget requests almost $14.5 billion, a decrease of $4.8 billion relative to the FY 2017 Continuing Resolution. The FY 2018 Budget prioritizes funding for early care and education programs for children, which are valuable resources for families, making it possible for them to seek and maintain employment and participate in job-related training. Continuing Resolution. Child Welfare Programs ACF provides funds to State and Tribal child welfare programs to promote positive outcomes for children and families involved in child welfare. Activities include supporting at-risk families, promoting the well-being of children in foster care, and training to ensure a well-qualified child welfare workforce. ACF research supports the demonstration of promising new practices and training for caseworkers. PROVIDING WORK SUPPORTS FOR FAMILIES Head Start and Child Care, frequently referred to as early care and education programs, allow parents and caregivers to build or maintain their self-sufficiency while ensuring their children receive high-quality care and education. The FY 2018 request preserves funding for Head Start and Child Care relative to FY 2016 levels, for a total investment of $14.8 billion (including $2.9 billion in mandatory child care funds). Nearly 1.4 million children will be served by the child care investments, and nearly 890,000 children will be served by Head Start. The Budget requests a total of $316 million for these activities, a decrease of $9 million below the FY 2017 Continuing Resolution. This funding level prioritizes direct service programs and makes a targeted reduction to technical assistance efforts in the Adoption Opportunities Program. Native Americans The Administration for Native Americans in ACF serves Native Americans, including Federally recognized tribes and Native Hawaiian organizations. ACF promotes self-sufficiency for Native Americans by competitively funding community-based projects that foster the development of stable, diversified local economies to provide jobs, promote community and economic wellbeing, encourage community partnerships, and reduce dependency. Funds also support the preservation of native languages and the environmental protection of Tribally-controlled lands. The FY 2018 Budget includes $50 million to support these activities, the same as the FY 2017 Continuing Resolution. SERVING VULNERABLE CHILDREN AND FAMILIES The FY 2018 Budget preserves funding for services to the most vulnerable children and families, including runaway and homeless youth and victims of child abuse and family violence. Runaway and Homeless Youth Youth experiencing homelessness face the possibility of exploitation, victimization, and other long-lasting, negative outcomes. The FY 2018 Budget continues to support emergency shelter, transitional housing, and street outreach programs for young people who experience homelessness through a $119 million investment, the same as the FY 2017 Continuing Resolution. At this level, more than 34,000 youth will receive emergency shelter or transitional housing and an array of supportive services. Family Violence Prevention and Services The Family Violence Prevention and Services Program is the primary Federal funding stream for shelter and supportive services for victims of family violence and their dependents. The Budget includes $159 million for the program, preserving essential Federal support for these activities, including $1 million for an Alaska Native Tribal Resource Center. Within this amount, the Budget maintains funding for the National Domestic Violence Hotline at $8 million. The Hotline receives an average of 25,000 calls and 163,000 website visits each month. Child Abuse Prevention ACF supports programs, research, and monitoring systems that prevent child abuse and neglect while ensuring that children who are victims receive treatment and care. Funds are provided to States and Tribes for child abuse investigations, prevention activities, and research into the causes, prevention, and treatment of child abuse. The Budget requests $98 million for these activities, the same as the FY 2017 76 Administration for Children and Families REFUGEES, ENTRANTS, AND UNACCOMPANIED ALIEN CHILDREN apprehended by immigration authorities. Children remain in the Office of Refugee Resettlement’s custody until they can be released to an appropriate sponsor while they await their immigration proceedings. The monthly number of unaccompanied children referred to ACF has decreased rapidly since December of 2016 and is now at a five-year low. In response to this trend, ACF has closed the temporary shelters that operated earlier in FY 2017 and is reducing standard permanent bed capacity to match the lower number of children in care. The Budget requests $948 million for this program, $448 million less than the FY 2017 Continuing Resolution. While the history of this program shows that referral levels can fluctuate considerably, the Administration does not anticipate a significant increase in referrals in FY 2018. Refugees and Other New Arrivals ACF works with State and local governments and a large network of nongovernmental organizations to provide services to refugees and other eligible new entrants like asylees to help them become self-sufficient, integrated members of American society. The Budget includes $320 million to continue to provide up to eight months of cash and medical assistance for 98,000 new arrivals, including 50,000 refugees. The Budget also includes $159 million to provide English language skills, job training, and translation services to refugees and other new arrivals in FY 2018. ACF proposes to combine the two programs that currently deliver these services, achieving greater efficiencies and reducing the administrative burden on States. The Budget includes $29 million to identify and serve victims of trafficking and provide medical and psychological services to survivors of torture. Studies suggest that 44 percent of refugees/asylees have experienced torture. Funding for both programs is maintained at their FY 2017 Continuing Resolution levels. No funds are included for Preventive Health grants (-$5 million less than the FY 2017 Continuing Resolution) as these services can also be provided through other ACF refugee programs. PROGRAM ELIMINATIONS Low Income Home Energy Assistance Program (LIHEAP) The FY 2018 Budget eliminates funding for LIHEAP, for a savings of $3.4 billion. LIHEAP is unable to demonstrate strong performance outcomes. Utility companies, as well as State and local governments, provide significant heating and cooling assistance and the majority of States prohibit utilities from discontinuing heating during the winter months. Community Services Programs The FY 2018 Budget discontinues funding for the Community Services Block Grant and the Community Economic Development, Rural Community Facilities, and Assets for Independence Programs, for a savings of $769 million. Unaccompanied Alien Children HHS is legally required to take custody of all unaccompanied alien children who are referred to ACF’s Office of Refugee Resettlement after being Monthly Referral of Unaccompanied Alien Children to ACF Care 12000 10000 FY12 8000 FY13 FY14 6000 FY15 4000 FY16 FY17 2000 0 Oct Nov Dec Administration for Children and Families Jan Feb Mar April 77 May June July Aug Sep EVALUATION AND INNOVATION The Community Services Block Grant accounts for only five percent of total funding received by the local agencies that benefit from these funds. In addition, grantees can continue receiving funds even if they have not demonstrated strong performance, because the formula for distribution is not directly tied to local agency performance. Research and Demonstration Research, evaluation, and the demonstration of new approaches to providing services allow ACF to improve the efficiency and efficacy of its programs. Current projects include continued use of behavioral science to examine program interventions and address research gaps in the understanding of family self-sufficiency and stability. The FY 2018 Budget includes $7 million, which is the same as the FY 2017 Continuing Resolution. To reduce duplication of programming across the Federal Government, the Budget does not request funding for Community Economic Development or Rural Community Facilities. Federal Administration The Budget includes $205 million, the same as the FY 2017 Continuing Resolution, to cover the cost of administering programs across ACF, including staffing and other fixed administrative expenses, such as office space and the development and maintenance of information technology. The Budget also proposes to discontinue the Assets for Independence Program. Historically, the Assets for Independence Program has failed to use all of the funds appropriated for the program. 78 Administration for Children and Families Administration for Children and Families: Mandatory dollars in millions Current Law Budget Authority Child Care Entitlement to States Child Care and Development Fund (non-add) /2 Child Support Enforcement and Family Support Children's Research and Technical Assistance /3 Foster Care and Permanency Promoting Safe and Stable Families (mandatory only) /4 Social Services Block Grant Temporary Assistance for Needy Families (TANF) TANF Contingency Fund /5 Subtotal, TANF (non-add) Total, Current Law Budget Authority Proposed Law Budget Authority Child Care Entitlement to States Child Care and Development Fund (non-add) /2 Child Support Enforcement and Family Support Children’s Research and Technical Assistance /5 Foster Care and Permanency Promoting Safe and Stable Families (mandatory only) Social Services Block Grant /6 TANF TANF Contingency Fund Subtotal, TANF (non-add) Total, Proposed Law Budget Authority 1/ 2/ 3/ 4/ 5/ 6/ 2016 2017 /1 2018 2018 +/− 2017 2,917 5,678 4,125 49 7,665 472 1,669 16,737 583 17,320 34,217 2,917 5,673 4,167 35 8,254 461 1,662 16,737 608 17,345 34,841 2,917 5,678 4,395 39 8,728 345 1,700 16,739 608 17,347 35,471 — +5 +228 +4 +474 -116 +38 +2 — +2 +630 2,917 5,678 4,125 49 7,665 472 1,669 16,737 583 17,320 34,217 2,917 5,673 4,167 35 8,254 461 1,662 16,737 608 17,345 34,841 2,917 5,678 4,286 54 8,746 495 85 15,117 -15,117 31,700 — +5 +119 +19 +492 +34 -1,577 -1,620 -608 -2,228 -3,141 Reflects the annualized level of the Continuing Resolution that ended April 28, 2017, including the across the board reduction, the 21st Century Cures Act, and directed transfers. The Child Care and Development Fund includes mandatory funding from the Child Care Entitlement to States and discretionary funding from the Child Care and Development Block Grant. Includes $15 million in mandatory funds transferred from the TANF Contingency Fund for Welfare Research in FY 2016. The total for Promoting Safe and Stable Families includes Abstinence Education and the Personal Responsibility Education Program, with a proposed reauthorization in FY 2018. In addition, there is a discretionary appropriation of $60 million for PSSF in FY 2016, FY 2017, and FY 2018. Includes $15 million in mandatory funds transferred from TANF for Welfare Research in FY 2018. The proposed law reflects the reauthorization of the Health Profession Opportunity Grants. CHILD CARE ENTITLEMENT TO STATES The Fiscal Year (FY) 2018 Budget requests $31.7 billion for the Administration for Children and Families (ACF) mandatory programs. ACF serves the nation’s most vulnerable populations through mandatory programs including Temporary Assistance for Needy Families, Child Care Entitlement to States, Child Support Enforcement, Foster Care, Adoption Assistance, Guardianship Assistance, Independent Living, and Promoting Safe and Stable Families. Administration for Children and Families The Child Care Entitlement to States was created by the welfare reform law enacted in 1996, which directly appropriates annual mandatory child care funding for States and tribes. The program requires States to spend at least 70 percent of mandatory child care funding on families receiving Temporary Assistance for Needy Families, transitioning from Temporary Assistance for Needy Families, or at risk of becoming eligible for Temporary Assistance for Needy Families. 79 States must also spend a minimum percentage of all child care funds to improve the quality and availability of healthy and safe child care for all families. Together with the Child Care and Development Block Grant, the program provides funding to States to help families access and afford child care. and replacement fund to build model child support systems and applications. This would enable States and tribal child support programs to replace out-of-date child support systems with a customizable uniform model system, improving efficiency and reducing long-term costs for States, tribal child support programs, and the Federal Government. An enhanced federal match rate of 90 percent would incentivize States to modernize more quickly and avoid system failure. The savings result from efficiencies these model systems would create in the process of replacing multiple legacy state child support systems. This proposal reflects the benefits of private sector approaches of operating government programs. The FY 2018 Budget provides $2.9 billion for the Child Care Entitlement to States. Total child care funding for the Child Care and Development Fund, which includes mandatory and discretionary child care funding, is $5.7 billion in FY 2018. In FY 2018, the request would enable nearly 1.4 million children to receive child care assistance through this State-administered program. CHILD SUPPORT ENFORCEMENT AND FAMILY SUPPORT PROGRAMS CHILDREN’S RESEARCH AND TECHNICAL ASSISTANCE Children’s Research and Technical Assistance supports state child support programs by disseminating information and providing training and technical assistance, including assistance with State automated systems and training of staff. Children’s Research and Technical Assistance also operates the Federal Parent Locator Service, which assists States in locating absent parents to establish, enforce, or modify orders for child support, custody, and visitation. Child Support is a joint Federal, State, tribal, and local partnership that seeks to ensure financial and emotional support for children from both parents by locating non-custodial parents, establishing paternity, and establishing and enforcing child support orders. The Budget requests $4.3 billion in budget authority in FY 2018 for Child Support Enforcement and Family Support Programs. Child Support collected $32.4 billion in FY 2015, the last year from which data is available, a return of $5.26 per dollar invested in the program. In FY 2015, paternity was established for 1.5 million parents (100 percent of Title IV-D non-marital births), and child support orders were established for 86 percent of cases. Additionally, Child Support operates several demonstration projects to increase employment and child support payment rates among non-custodial parents. In FY 2015, the Tribal Child Support Program oversaw 59 comprehensive tribal IV-D programs, including two new comprehensive programs and an additional three start-up tribal programs. The FY 2018 President’s Budget includes $37 million in this account, devoted to training and technical assistance ($12.3 million) and operating the Federal Parent Locator Service ($24.6 million). FOSTER CARE AND PERMANENCY The Budget requests $8.7 billion for the Foster Care, Adoption Assistance, Guardianship Assistance, and Independent Living programs. These programs, authorized by title IV-E of the Social Security Act, support safety and permanence for children separated from their families and prepare older foster youth for independence. The Budget promotes strong families and responsible parenting by engaging more parents in payment of child support, improving enforcement tools, and transitioning more responsibility to the States. These proposals are estimated to save $698 million over 10 years. Supplemental Security Income and the Supplemental Nutrition Assistance Program realize savings of $527 million collectively. Funding primarily goes to States for board and care payments for children in foster care who are eligible for title IV-E funding, as well as to the Chafee Foster Care Independence Program, which offers assistance to current and former foster youth aged 16-21 in obtaining education, employment, and life skills for self-sufficiency. The Foster Care program also works with tribal agencies to help strengthen their child welfare systems. In addition, the Budget includes $833 million in net savings over 10 years for a technology enhancement 80 Administration for Children and Families PROMOTING SAFE AND STABLE FAMILIES low-income families gain self-sufficiency through paid employment. Furthermore, the proposal represents the Administration’s commitment to focus limited taxpayer dollars on the outcomes, not inputs, of programs to ensure they are effectively helping low-income families. The Budget includes $495 million in total for the mandatory portion of the Promoting Safe and Stable Families program. These funds provide formula grants to States to provide services to families, to address child safety at home, and to provide supportive services for reunifying and adoptive families. Funding also supports Regional Partnership Grants, a competitive grant program that reduces the risk of foster care due to parental substance abuse. The Budget proposes to reauthorize Promoting Safe and Stable Families (title IV-B) through FY 2022 at $345 million per year. TEMPORARY ASSISTANCE FOR NEEDY FAMILIES Temporary Assistance for Needy Families provides States, Territories, and eligible Tribes the opportunity to design creative programs to help families transition from welfare to self-sufficiency. States have tremendous flexibility in determining how to use their Temporary Assistance for Needy Families dollars to meet their citizen’s needs and get them back on their feet. States now spend much less on cash assistance payments than during the early years of Temporary Assistance for Needy Families implementation and more on education and training, child care, and other work supports. This account includes two other programs, the Personal Responsibility Education Program and Abstinence Education. The Personal Responsibility Education Program provides formula grants to States to educate adolescents on pregnancy prevention, sexually transmitted diseases, and adulthood preparation subjects such as relationship skills and financial literacy. Abstinence Education provides formula grants to States to support programs that present ways teens can develop healthy and positive relationships and promote reasons to delay sexual activity. Projects focus on youth who are homeless, in foster care, live in rural areas or areas with high teen birth rates, or come from racial or ethnic minority groups with disparities in teen birth rates. The Budget proposes to reauthorize both programs through FY 2019 at the current levels of $75 million per year for each program, which will cost $300 million. The Budget proposes $15.1 billion for the Temporary Assistance for Needy Families State and Territory Family Assistance Grants, to build on the successes of welfare reform and to strengthen and re-focus Temporary Assistance for Needy Families as an effective anti-poverty program that fosters child and family well-being through job-readiness programs and employment opportunities programs. This request aligns with the proposal to zero-fund the Social Services Block Grant. States will continue to have broad flexibility in determining how to spend their remaining Temporary Assistance for Needy Families block grant funds, including a focus on welfare-to-work activities. The budget includes a legislative proposal to fund Welfare Research and the Census Bureau Survey of Income Program Participation, at $15 million and $10 million respectively, through a $25 million setaside from the Temporary Assistance for Needy Families block grant. SOCIAL SERVICES BLOCK GRANT The FY 2018 Budget eliminates funding for the Social Services Block Grant for a savings of $1.4 billion in FY 2018 and $16.7 billion over ten years. The Social Services Block Grant provides funding that is duplicative of resources available through other federal programs and has not demonstrated its effectiveness in reducing dependency on welfare and supporting self-sufficiency. As a 2011 U.S. Government Accountability Office report pointed out, the Social Services Block Grant is fragmented, provides duplicative or overlapping services, and has limited accountability. The Social Services Block Grant essentially offers a no-strings-attached approach to taxpayer funds. Eliminating the Social Services Block Grant aligns with the Administration’s goal of supporting welfare programs that effectively help Administration for Children and Families The Budget also proposes to eliminate the Temporary Assistance for Needy Families Contingency Fund, saving $6 billion dollars over 10 years. While the intent of the Contingency Fund is to assist States experiencing increased demand for cash assistance during economic declines, recent experience has demonstrated that the Contingency Fund is an ineffective mechanism for responding to economic downturns. This proposal advances the Administration’s goal of reducing duplication and increasing the effectiveness and 81 efficiency of federal benefit spending programs. The Administration looks forward to working with Congress to ensure Temporary Assistance for Needy Families resources are targeted to families that are temporarily in need of additional support while maintaining welfare reform’s emphasis on gainful employment. 82 Administration for Children and Families Administration for Children and Families: Mandatory FY 2018 ACF Mandatory Outlays dollars in millions Current Outlays Child Care Entitlement to States Child Care and Development Fund (non-add) /2 Child Support Enforcement and Family Support Children's Research and Technical Assistance Foster Care and Permanency Promoting Safe and Stable Families (mandatory only) /3 Social Services Block Grant Sandy Supplemental /4 Temporary Assistance for Needy Families (TANF) TANF Contingency Fund Subtotal, TANF (non-add) Total, Current Law Outlays Proposed Law Outlays Child Care Entitlement to States Child Care and Development Fund (non-add) /2 Child Support Enforcement and Family Support Children’s Research and Technical Assistance (mandatory only) Foster Care and Permanency Promoting Safe and Stable Families (mandatory only) /3 Social Services Block Grant /5 Sandy Supplemental /4 Temporary Assistance for Needy Families (TANF) TANF Contingency Fund Subtotal, TANF (non-add) Total, Proposed Law Outlays 1/ 2/ 3/ 4/ 5/ 2016 2017/1 2018 2018 +/− 2017 2,788 5,306 4,079 67 7,700 421 1,780 96 15,624 572 16,196 33,031 2,968 5,693 4,266 52 8,025 465 1,699 64 16,504 616 17,120 34,595 2,946 5,718 4,412 42 8,439 451 1,770 — 16,628 618 17,246 35,306 -22 +25 +146 -10 +414 -14 +71 -64 +124 +2 +126 +711 2,788 5,306 4,079 67 7,700 421 1,780 96 15,624 572 16,196 33,031 2,968 5,693 4,266 52 8,025 465 1,699 64 16,504 616 17,120 34,595 2,946 5,718 4,302 57 8,457 454 362 — 15,395 51 15,446 32,024 -22 +25 +36 +5 +432 -11 -1337 -64 -1,119 -565 -1,674 -2,645 Reflects the annualized level of the Continuing Resolution that ended April 28, 2017, including the across the board reduction, the 21st Century Cures Act, and directed transfers. The Child Care and Development Fund includes mandatory funding from the Child Care Entitlement to States and discretionary funding from the Child Care and Development Block Grant. The total for Promoting Safe and Stable Families includes Abstinence Education, the Personal Responsibility Education Program. In addition, there is a discretionary appropriation of $60 million for this account in 2016, FY 2017 and FY 2018. The Disaster Relief Appropriations Act of 2013 provided $500 million in funding for Social Services Block Grant to aid in the recovery from Hurricane Sandy. The proposed law reflects the reauthorization of the Health Profession Opportunity Grants. Administration for Children and Families 83 Administration for Children and Families: Mandatory FY 2018 ACF Mandatory Legislative Proposals 2018 2018 -2022 2018 -2027 -21 -110 -131 -259 -609 -868 -698 -833 -1,532 1 2 3 136 136 272 136 141 277 Health Profession Opportunity Grant Foster Care and Permanency /3 Social Services Block Grant Subtotal, Social Services Block Grant (non-add) 3 18 -1,411 -1,390 170 109 -8,194 -7,915 170 224 -16,694 -16,300 Welfare Research and Census SIPP Set-Aside Temporary Assistance for Needy Families (TANF) TANF Contingency Fund Subtotal, TANF (non-add) 25 -1,243 -567 -1,785 125 -7,581 -2,999 -10,455 250 -15,866 -6,039 -21,655 -3,303 -18,968 -39,211 dollars in millions Proposed Law Outlays Strengthening Child Support Enforcement and Establishment /1 Technology Enhancement and Replacement Fund Subtotal, Child Support (non-add) Abstinence Education Personal Responsibility Education Program Subtotal, PSSF (non-add)/2 Total Outlays, ACF Legislative Proposals 1/ 2/ 3/ The Child Support outlays in this table are net of estimated savings in the Supplemental Nutrition Assistance Program ($418 million over 10 years) and the Supplemental Security Income program ($109 million over 10 years), which would result from this proposal. These outlays include the cost of $175 million over 10 years from Federal Offsetting Collections. Costs of extending PREP and Abstinence Education through FY 2019. There is not cost for reauthorizing PSSF through FY 2022. Reflects interaction effects from proposal to eliminate SSBG. 84 Administration for Children and Families Administration for Community Living 2016 2017 /1 2018 2018 +/- 2017 Home & Community-Based Supportive Services 348 348 348 -- Nutrition Services 835 833 833 -- Native American Nutrition & Supportive Services 31 31 31 -- Preventive Health Services 20 20 20 -- Chronic Disease Self-Management 8 8 5 -3 Falls Prevention 5 5 5 -- dollars in millions Health and Independence Services Aging Network Support Activities Subtotal, Health and Independence Caregiver Services Family Caregiver Support Services Native American Caregiver Support Services Alzheimer’s Disease Program Lifespan Respite Care 10 10 10 -- 1,257 1,255 1,252 -3 150 150 150 -- 8 8 8 -- 19 19 19 -- 3 3 3 -- 180 180 180 -- 16 16 16 -- 5 5 5 -- Senior Medicare Patrol Program (HCFAC) 18 18 18 -- Elder Rights Support Activities 12 12 12 -- 51 51 51 -- 0 0 45 +45 State Councils on Developmental Disabilities 73 73 0 -73 Developmental Disabilities Protection and Advocacy 39 39 39 -- Projects of National Significance 10 10 8 -2 University Centers for Excellence in Developmental Disabilities 39 39 39 -- Nat’l Institute on Disability, Independent Living, & Rehab. Research 104 104 95 -9 Independent Living 101 101 78 -23 Traumatic Brain Injury 9 9 3 -6 Limb Loss Resource Center 3 3 0 -3 Paralysis Resource Center 8 8 0 -8 386 386 307 -79 Subtotal, Caregiver Services Protection of Vulnerable Older Adults Long Term Care Ombudsman Program Prevention of Elder Abuse & Neglect Subtotal, Protection of Vulnerable Older Adults Disability Programs, Research and Services Partnerships for Innovation, Inclusion, and Independence Subtotal, Disability Programs, Research and Services Administration for Community Living 85 2016 2017 2018 2018 +/-2017 Voting Access for People With Disabilities (HAVA) 5 5 5 -- Aging and Disability Resource Centers 6 6 6 -- State Health Insurance Assistance Program 52 52 0 -52 Assistive Technology 34 34 32 -2 MIPPA Programs (Mandatory) 38 35 38 +2 135 132 81 -52 40 40 38 -2 2,048 2,042 1,907 -135 -83 -81 -56 -25 1,965 1,961 1,851 -110 196 199 187 -12 dollars in millions Consumer Information, Access and Outreach Subtotal, Consumer Information, Access and Outreach Other Programs, Total, and Less Funds From Other Sources Program Administration Total, Program Level Less Funds from Other Sources Total, Budget Authority Full-time Equivalents 1/ Reflects the annualized level of the Continuing Resolution that ended April 28, 2017, including the across the board reduction, the 21st Century Cures Act, and directed transfers. The Administration for Community Living works to maximize the independence, well-being, and health of older adults, people with disabilities across the lifespan, and their families and caregivers. Since its creation in 2012, the Administration for Community Living (ACL) has helped increase access to community supports, while focusing attention and resources on the unique needs and strengths of the populations served. Americans stay healthy, independent, and living in their communities. Nutrition Services Programs The Budget requests $833 million for Nutrition Services—the same level as the FY 2017 Continuing Resolution—which includes funding for Congregate Meals, Home-Delivered Meals, and the Nutrition Services Incentive Program. ACL’s nutrition programs help ensure that millions of older Americans have access to meals, nutrition screening and education, and the opportunity to engage socially with others in their communities. This funding represents the vast majority of Federal funding for nutrition services for seniors, and in combination with State and local contributions, the Budget will support 216 million congregate and home-delivered meals for approximately 2.3 million older adults nation-wide, as well as 5.8 million meals to over 100,000 Native American seniors. The Fiscal Year (FY) 2018 Budget requests $1.9 billion for ACL, which is $135 million below the FY 2017 Continuing Resolution. The Budget prioritizes funding for critical programs that help support older Americans, individuals living with disabilities, and their caregivers and connect them with direct services across the United States. Consistent with the President’s priorities, the Budget also maximizes Federal investments by promoting efficiencies and supporting evidence-based approaches. MAINTAINING HEALTH AND INDEPENDENCE FOR OLDER ADULTS Home and Community-Based Supports The Budget also includes a total of $368 million for Home and Community-Based Supportive Services and Preventive Health Services, which maintains funding at the FY 2017 Continuing Resolution level. The Home and Community-Based Supportive Services Program The United States population over age 60 is projected to increase by 20 percent between 2014 and 2020, from 64.8 million to 77.6 million people. The Budget preserves funding for essential community-based services and supports that assist efforts to help older 86 Administration for Community Living provides formula grants to States and Territories to fund a broad array of services that enable seniors to remain in their homes. These services include—but are not limited to—transportation assistance, case management, adult day care, and in-home services. In the most recent fiscal year for which data is available, the program provided over 9.9 million hours of care for dependent adults in a group setting and 23.6 million rides to doctors’ offices, senior centers, meal sites, and other locations. Program provide caregivers with a range of support services such as counseling, respite care, and training. In FY 2018, the Family Caregiver Support program will support approximately 850,000 family caregivers with respite care services, access assistance services, counseling and training. The Lifespan Respite Care program focuses on easing the burdens of caregiving by helping States develop more efficient, evidence-based, and cost-effective methods to improve quality and access to respite care. These caregiver programs enable individuals across the lifespan to stay at home longer and enjoy greater independence, which can translate into lower costs when institutional care is avoided. The Preventive Health Services Program also provides formula grants to States and Territories to fund evidence-based programs that educate older adults about the importance of healthy lifestyles to help prevent or delay chronic disease and disability. Alzheimer’s Disease In FY 2018, the Budget maintains funding for Alzheimer’s Disease activities at $19 million, consolidating all related Alzheimer’s Disease activities across ACL into a single grant program. An estimated 5.2 million individuals in the United States are living with Alzheimer’s Disease and related dementias; that number is expected to increase by about 40 percent by 2025. Consolidating similar Alzheimer’s Disease activities into a single grant program will provide greater flexibility to States, Territories, Tribes, and localities to meet the needs of their communities. Other Programs The Budget maintains funding at a total of $51 million for other health and independence services, which provide a range of services designed to ensure the safety and well-being of seniors who are in danger of being mistreated, neglected, or exploited in both at-home and institutional settings. The Budget also maintains mandatory funding for the State Health Insurance Assistance Program, Aging and Disability Resource Centers, Area Agencies on Aging, and the National Center for Benefits Outreach and Enrollment. These programs provide funding for targeted one-on-one counseling and outreach to low-income and rural populations to assist with Medicare enrollment. The National Center for Benefits Outreach and Enrollment supports an online enrollment benefit tool as well as a nation-wide network of 59 Benefits Enrollment Centers that help connect low-income populations to public benefits. IMPROVING THE LIVES OF INDIVIDUALS WITH DISABILITIES ACL is dedicated to ensuring that individuals with disabilities and their families are able to fully participate in and contribute to all aspects of community life. Through partnerships with States, Territories, communities, and non-profit organizations, ACL works to improve opportunities for people with disabilities to access quality services and supports, achieve economic self-sufficiency, and experience equality and inclusion in all facets of community life. SUPPORTING CAREGIVERS The Budget includes $161 million to fund three programs designed to support and provide services to family and other informal caregivers, the same as the FY 2017 Continuing Resolution. Research has shown that these caregivers make an important economic contribution to the care of people needing long-term services and supports. Without them, the cost and burden to the Nation’s long-term care system would be substantial. Protection and Advocacy The Budget requests $39 million to maintain funding for the Developmental Disabilities Protection and Advocacy Program. Protection and Advocacy Systems work at the State level to protect individuals with developmental disabilities by investigating incidents of abuse and neglect, and pursuing legal, administrative, or other appropriate remedies. The National Family Caregiver Support Program and the Native American Caregiver Support Services Administration for Community Living 87 University Centers for Excellence The Budget also requests $39 million—the same funding level as the FY 2017 Continuing Resolution—to continue funding for University Centers for Excellence in Developmental Disabilities, a nationwide network that provides an array of interdisciplinary programs to improve the quality of services and supports for individuals with developmental disabilities and training for professionals. The Centers also advise Federal, State, and community policymakers about opportunities that can advance research related to the needs of individuals with developmental disabilities and their families as well as emerging issues in the field. PROGRAM HIGHLIGHT Nutrition Services Most participants reported that the ACL Nutrition Services programs had helped them to eat healthier foods, and up to 86 percent indicated the program had improved their health. Additionally, 63 percent of congregate and 93 percent of home-delivered meal participants reported that the program had helped them to live independently and remain in their own home. STREAMLINING PROGRAMS AND DELIVERY OF SERVICES Partnerships for Innovation, Inclusion, and Independence Finally, the Budget restructures activities carried out by the State Councils on Developmental Disabilities, Independent Living and Traumatic Brain Injury programs into a single state grant program. The Budget requests $45 million for the Partnerships for Innovation, Inclusion, and Independence program, which will combine these activities into a single statewide, cross-disability entity, promoting evidence-based approaches, efficiencies, and a more cohesive approach to disability partnerships. This restructuring of State council activities into a single grant program achieves $57 million in savings in FY 2018, while ensuring that States have the tools they need to coordinate care for individuals with disabilities. The Budget proposes to discontinue funding for programs whose activities could be carried out with existing funding streams to deliver services more efficiently. The FY 2018 Budget request achieves $63 million in savings by discontinuing discretionary funding for the Limb Loss Resource Center, the Paralysis Resource Center, and the State Health Insurance Assistance Program. The activities carried out by these programs are duplicative of other Federal efforts. Activities carried out by the Limb Loss and Paralysis Resource Centers will be merged into the National Institute on Disability, Independent Living and Rehabilitation Research and Aging and Disability Resource Centers. The Budget discontinues discretionary funding for the State Health Insurance Assistance Program leveraging alternative sources for Medicare beneficiaries to obtain access to reliable information to better understand and manage benefits. Other Disability Programs The FY 2018 Budget reduces funding for Projects of National Significance and the National Institute on Disability, Independent Living, and Rehabilitation Research to prioritize funding for direct service programs. The Budget requests $8 million for Projects of National Significance, which is $2 million below the funding level provided by the FY 2017 Continuing Resolution. The Budget includes $95 million—$9 million below the FY 2017 Continuing Resolution—for the National Institute on Disability, Independent Living, and Rehabilitation Research. Program Administration The Budget includes $38 million for program management and support activities. This funding supports rent, staff, and other administrative costs. 88 Administration for Community Living Office of the Secretary, General Departmental Management 2016 2017 /1 2018 456 455 305 2018 +/− 2017 -150 Public Health Service (PHS) Evaluation Funds 65 65 57 -8 Health Care Fraud and Abuse Control 7.5 7 10 +3 dollars in millions Budget Authority Proposed Mandatory Funding—Departmental Appeals Board Total, Program Level /2 Full-Time Equivalents -- -- 2 +2 528 527 374 -153 1,482 1,557 1,581 +24 1/ Reflects the annualized level of the Continuing Resolution that ended April 28, 2017, including the across the board reduction, the 21st Century Cures Act, and directed transfers. 2/ This table does not include funding or FTE for the Pregnancy Assistance Fund. The General Departmental Management budget line supports the Secretary’s role as chief policy officer and general manager of the Department. The Fiscal Year (FY) 2018 President’s Budget requests a program level of $374 million for General Departmental Management, a decrease of $153 million below the funding level provided in the FY 2017 Continuing Resolution. The Budget supports the Secretary's role in administering and overseeing the organization, programs, and activities of the Department. These efforts are carried out through 11 Staff Divisions within the Office of the Secretary. activities across the Department. This funding will allow the Office on Women’s Health to continue targeted grants and support the advancement of women’s health programs through the promotion and coordination of research, service delivery, and education. Funds will also allow the Office on Women’s Health to continue a state partnership initiative to reduce violence against women. These programs are also carried out throughout the divisions and offices of the Department, with other government organizations, and with consumer and health professional groups. OFFICE OF MINORITY HEALTH The Budget includes $57 million for the Office of Minority Health, the same as the funding level provided in FY 2017 Continuing Resolution. The Office of Minority Health will continue to lead, coordinate, and collaborate on minority health activities across the Department, including leadership in coordinating policies, programs, and resources to support implementation of the HHS Disparities Action Plan and the National Partnership for Action to End Health Disparities. SEXUAL RISK AVOIDANCE The Budget includes $10 million for Sexual Risk Avoidance education grants, the same as the funding level provided in the FY 2017 Continuing Resolution. This program supports an evidence-based approach defined as voluntarily refraining from non-marital sexual activity. DEPARTMENTAL APPEALS BOARD OFFICE ON WOMEN’S HEALTH The Budget includes $17 million for the Departmental Appeals Board, comprised of $15 million in discretionary budget authority and $2 million in proposed mandatory funding. This is an increase of $6 million above the funding level provided in the FY 2017 Continuing Resolution. The Departmental The Budget includes $32 million for the Office on Women’s Health, the same as the funding level provided in the FY 2017 Continuing Resolution. The Office on Women’s Health will continue to lead, coordinate, and collaborate on women’s health General Departmental Management 89 OTHER GENERAL DEPARTMENTAL MANAGEMENT Appeals Board provides high-quality adjudication and other conflict resolution services in administrative disputes involving HHS, including Medicare appeals. The Budget increase for FY 2018 will provide additional support to the Medicare Appeals Council to keep pace with the growing number of Medicare appeals. Within HHS, the Council provides the final administrative review of claims for entitlement to Medicare and individual claims for Medicare coverage, and payment filed by beneficiaries or health care providers and suppliers. The Budget includes $258 million for the remainder of the activities supported by General Departmental Management in the Office of the Secretary. The Budget funds leadership, policy, legal, and administrative guidance to Department components and includes funding to continue ongoing programmatic activities, including strengthening program integrity by reducing fraud, waste, and abuse. 90 General Departmental Management Office of the Secretary, Office of Medicare Hearings and Appeals dollars in millions 2016 2017 /1 2018 107 107 117 2018 +/− 2017 +10 -- -- 125 +125 107 107 242 +135 557 671 980 +309 Budget Authority Proposed Mandatory Funding Total Program Level Full-Time Equivalents 1/ Reflects the annualized level of the Continuing Resolution that ended April 28, 2017, including the across the board reduction, the 21st Century Cures Act, and directed transfers. The Office of Medicare Hearings and Appeals provides an independent forum for the fair and efficient adjudication of Medicare appeals for beneficiaries and other parties. This mission is carried out by a cadre of knowledgeable Administrative Law Judges exercising decisional independence under the Administrative Procedures Act with the support of a professional, legal, and administrative staff. The Fiscal Year (FY) 2018 Budget requests $242 million in program level funding for the Office of Medicare Hearings and Appeals (OMHA), an increase of $135 million over the funding provided in the FY 2017 Continuing Resolution. The increase outlined in the FY 2018 Budget request is composed of a $10 million increase in discretionary budget authority and a $125 million proposed mandatory funding increase. The Budget request also includes a legislative package to address the Medicare appeals backlog. request for a hearing from an appellant. Due to the overwhelming growth in its workload, OMHA has not been able to meet the 90-day time frame for case adjudication in some cases. It currently takes approximately 1,000 days for OMHA to adjudicate a non-beneficiary appeal. PROGRAM HIGHLIGHT Improving the Medicare Appeals Process The Department has a three-pronged approach to address the significant volume of new Medicare appeals and the current backlog of claims to be adjusted: OMHA administers hearings and appeals nation-wide for the Medicare program. OMHA began processing cases on July 1, 2005; since then, it has received approximately 1.7 million appeals for Medicare Parts A, B, C, and D, as well as for Medicare entitlement and eligibility. In FY 2011, OMHA began receiving additional appeals resulting from the permanent nation-wide expansion of the Recovery Audit program administered by the Centers for Medicare & Medicaid Services. These appeals, in addition to the more traditional Part A and B appeals, have contributed to OMHA’s significant workload increase. Despite efforts to mitigate the incoming workload, unsustainable appeal receipt volumes continued: FY 2014—474,000; FY 2015—240,000; and FY 2016—184,000. The slight decline in FY 2016 receipts was due to a contract protest which slowed the rate of receipts. Annual adjudication capacity in FYs 2014 and 2015 was 77,000 appeals. In FY 2016, OMHA adjudicated 87,000 appeals. 1. 2. 3. To address these challenges, OMHA has taken a number of administrative actions to reduce the pending appeals workload. For example, OMHA is pursuing alternative dispute resolution as an alternative to an Administrative Law Judge hearing. In addition, OMHA has made statistical sampling an option available to appellants, which has the potential Current law requires that Medicare appeals at the OMHA level be heard within 90 days after receipt of a Office of Medicare Hearings and Appeals Invest resources to increase adjudication capacity and implement new strategies to alleviate the current backlog; Take administrative actions to reduce the backlog of appeals and the number of new cases from entering the system or escalating to higher levels of appeal; and Propose legislative actions that provide additional funding and new authorities to address the backlog. 91 to resolve large numbers of cases based on representative samples. While helpful, these initiatives alone are insufficient to keep up with the dramatic growth in Medicare appeals. teleconference hearings, to offer appellants access to multiple hearing venues and services. The requested resources are critical for OMHA to respond to the backlog of unheard appeals while maintaining the quality and accuracy of its decisions. These resources are also essential to provide timely hearings for Medicare appellants. The Budget will increase OMHA adjudicatory capacity by adding up to 106 new Administrative Law Judge teams, which will result in 106,000 additional dispositions per year. OMHA will continue to utilize technology, such as video telephone and For more information about the Medicare appeals legislative proposals, please see the Medicare chapter. 92 Office of Medicare Hearings and Appeals Office of the Secretary, Office of the National Coordinator for Health Information Technology 2016 2017 /1 2018 Budget Authority 60 60 38 2018 +/- 2017 -22 Program Level 60 60 38 -22 176 190 164 -26 dollars in millions Full-time Equivalents 1/ Reflects the annualized level of the Continuing Resolution that ended April 28, 2017, including the across the board reduction, the 21st Century Cures Act, and directed transfers. The Office of the National Coordinator for Health Information Technology leads the Nation in transforming health and health care through the advancement of an interoperable health information technology infrastructure. The Office of the National Coordinator for Health Information Technology improves the health and well-being of individuals and communities through the use of technology and health information that is accessible when and where it matters most. POLICY COORDINATION The Office of the National Coordinator for Health Information Technology (ONC) leads the Government’s efforts to promote and coordinate the nation-wide use of health information technology and flow of electronic health data to transform health care. ONC serves as a resource to the entire health care community, aligning the needs of patients and providers with the innovation of health information technology (IT). ONC will continue to develop and coordinate Federal health IT policies through collaboration with a broad range of stakeholders in order to build the necessary foundation for an interoperable, learning health system that can support a wide variety of national priorities. NEW INITIATIVE The Fiscal Year (FY) 2018 Budget for ONC is $38 million, $22 million below the spending level appropriated through the FY 2017 Continuing Resolution. The Budget reflects ONC’s successful progress in increasing provider adoption rates, improving usability, and advancing interoperability in order to ensure the seamless and secure flow of health information. 21st Century Cures Act Implementation Improving interoperability and usability are priorities not just in ONC’s budget but also in the 21st Century Cures Act. The Cures Act directs ONC to implement activities that advance interoperability through continued work combating information blocking and building health IT exchanges. In FY 2018, ONC will continue to address and discourage information blocking by aggressively implementing ONC Certification Program rules, creating and promoting channels for reporting information blocking, and enforcing information blocking provisions required by the Cures Act. The certification program will continue its oversight responsibilities and will look to improve the surveillance of certified products for ongoing adherence to technical, security, and regulatory requirements for interoperability as well as the surveillance of any potential for information blocking. ONC’s budget focuses on two key priorities: interoperability of health information, and the usability of electronic health records. The interoperability of health information is central to the core mission of the Department of Health and Human Services to enhance and protect the health and well-being of all Americans. ONC’s FY 2018 Budget emphasizes ONC’s continued policy coordination work, utilizing ONC’s new Health IT Advisory Committee, as required by the 21st Century Cures Act. ONC will also focus on thwarting information blocking and prioritize its work on standards coordination, implementation, testing, and pilots to accelerate industry progress towards interoperability. Office of the National Coordinator for Health IT In FY 2018, ONC will combine its two Federal advisory committees into a single Health Information Technology Advisory Committee as directed by the 93 21st Century Cures Act. The Health Information Technology Advisory Committee will retain the task of providing policy and standards recommendations while focusing on three priority areas: achieving interoperability; promoting and protecting the privacy and security of health information, and facilitating secure access. interoperability through advancements to the ONC Health IT Certification Program, such as requiring as a condition of certification for health IT developers to attest that they do not engage in information blocking. Additionally, ONC will consult with stakeholders to develop reporting criteria that measure usability and security as part of a new electronic health record reporting program created by the 21st Century Cures Act. Through new authorities provided in the 21st Century Cures Act, ONC will work with the Office of Inspector General to investigate and issue penalties for developers, networks, and exchanges engaged in information blocking. By curbing this harmful practice, ONC will ensure that patients and providers have access to critical electronic health information. ONC will continue to publish the Interoperability Standards Advisory which coordinates the identification, assessment, and public awareness of interoperability standards and implementation specifications. This web-based resource is used by the health care industry to address specific interoperability needs, including—but not limited to—clinical, public health, and research purposes. ONC will continue to encourage the interoperable exchange of health information by convening public and private sector stakeholders to develop and support a trusted health IT exchange network, and enhance usability. ADOPTION AND MEANINGFUL USE ONC’s efforts have led to high health IT adoption rates across the country. As of 2015, more than 96 percent of hospitals and 78 percent of physician offices were using certified electronic health record technology. STANDARDS, INTEROPERABILITY, AND CERTIFICATION ONC develops standards and works closely with Federal agencies and other stakeholders to implement solutions that advance the seamless and secure flow of critical health information where and when it is needed most. ONC supports a variety of programs and efforts that underpin nationwide progress toward an interoperable learning health IT infrastructure that promotes the delivery of safe, efficient, cost-effective and high-quality care. As a result of ONC’s shifting agency priorities and renewed focus on core health IT functions, ONC will reduce adoption support activities such as the National Learning Consortium and the Consumer e-Health program and focus efforts on statutorily required planning, evaluation, and monitoring of interoperability. ONC also will continue to provide the latest information for patients, providers, and developers on its website, HealthIT.gov. The FY 2018 Budget continues to promote ONC Health IT Certification Program PROGRAM HIGHLIGHT The ONC Health IT Certification Program provides comprehensive, independent mechanisms to evaluate health IT for conformance to standards and functional requirements. ONC also maintains the Certified Health IT Product List, a publicly available list on ONC’s website of all health IT products certified through the ONC Health IT Certification Program. The list generates a Centers for Medicare and Medicaid Services (CMS) electronic health record identification number that is representative of the Certified Electronic Health Record Technology used to participate in several CMS payment programs. To date, there are over 800 health IT developers with over 4,000 unique products that have been certified against 2014 Edition Certification Criteria. ONC recently produced a new website to align with the 2015 Edition final rule’s additional data needs and to support greater transparency and open data accessibility. The new website includes additional functionality, such as advance search, product compare, and application programming interface methods to enable stakeholders to openly access and combine these data with their datasets. 94 Office of the National Coordinator for Health IT Office of the Secretary, Office for Civil Rights dollars in millions Program Level Full-Time Equivalents 2016 2017 /1 2018 39 39 33 2018 +/- 2017 -6 170 179 162 -17 1/ Reflects the annualized level of the Continuing Resolution that ended April 28, 2017, including the across the board Century Cures Act, and directed transfers. reduction, the 21st The Office for Civil Rights ensures equal, nondiscriminatory access to and receipt of all the Department’s services and the protection of privacy and security of health information, thereby contributing to the Department’s overall mission of improving the health and well-being of all Americans affected by its many programs. The Fiscal Year (FY) 2018 Budget request for the Office for Civil Rights (OCR) is $33 million, $6 million below the FY 2017 Continuing Resolution level. The Budget supports OCR’s essential programmatic focus as the primary defender of the public’s right to nondiscriminatory access to and receipt of HHS funded health and human services, conscience protections, consumer access to health information, and privacy and security protections for individually identifiable health information. In FY 2018, OCR will reduce overhead and non-personnel costs. OCR will also use civil monetary settlement funds to support Health Insurance Portability and Accountability Act (HIPAA) enforcement activities. OCR works with its Federal agency partners to ensure language accessibility and will continue to work with colleagues across the Department to ensure that all individuals, including those with limited English proficiency, have access to HHS-conducted programs and activities, and can obtain the health care, health coverage, and human services they need to lead fulfilling lives. OCR provides technical assistance and education to States and its Federal agency partners to ensure compliance with the Americans with Disabilities Act. OCR disseminates information, creates virtual learning communities, works on guidance documents, and provides webinars on topics such as housing and Medicaid services that provide individuals with disabilities opportunities to live in their communities. CIVIL RIGHTS General Authorities OCR works to safeguard individuals’ access to health care, health coverage, and human services without discrimination, as well as protecting conscience rights. In addition, OCR enforces civil rights protections with respect to race, color, national origin, disability, age, and sex discrimination in health programs that receive financial assistance or are administered by the Department. OCR also enforces protection of conscience rights of individuals, providers, and entities that object to abortion and sterilization procedures. HEALTH INFORMATION PRIVACY AND SECURITY General Authorities OCR administers and enforces the HIPAA Privacy, Security, and Breach Notification Rules. OCR is responsible for policy development through the issuance of regulations and guidance. OCR also provides outreach and technical assistance to the regulated community to ensure covered entities and business associates understand their compliance obligations and to the public to increase individuals’ awareness of their HIPAA rights and protections. Other Compliance Activities OCR reviews nearly 2,500 Medicare provider applicants a year to assess compliance with Federal civil rights requirements. Through its current formal agreements with 54 health care corporations, OCR ensures ongoing compliance in more than 4,600 facilities that serve over 11 million patients annually. Office for Civil Rights OCR enforces the HIPAA Rules by investigating complaints and conducting compliance reviews of alleged violations of the HIPAA Rules, providing technical assistance and obtaining corrective actions, as well as entering into resolution agreements or 95 issuing civil monetary penalties, where appropriate. OCR resolved more than 23,000 complaints of alleged HIPAA violations in FY 2016. corrective action plans, as well as imposing civil monetary penalties for violations of the HIPAA Rules. OCR retains these collections and expends some of such funds to support overall HIPAA enforcement activities. Settlements and Civil Monetary Penalties OCR has authority to enter into resolution agreements that include payment of a resolution amount and 96 Office for Civil Rights Office of the Secretary, Office of Inspector General 2016 2017 /1 2018 Discretionary Appropriation /2 77 76 68 2018 +/- 2017 -8 Health Care Fraud and Abuse Control Program (HCFAC) 11 11 12 +1 Discretionary HCFAC 67 67 74 +7 188 186 204 +18 343 341 359 +18 1,575 1,590 1,677 +87 dollars in millions Mandatory HCFAC Total Funding, All Sources Full-time Equivalents 1/ Reflects the annualized level of the Continuing Resolution that ended April 28, 2017, including the across the board reduction, the 21st Century Cures Act, and directed transfers. 2/ Includes the $1.5 million permissive transfer from the Food and Drug Administration appropriation in FY 2016 and FY 2017. The mission of the Office of Inspector General is to protect the integrity of Department of Health and Human Services programs as well as the health and welfare of the people they serve. The President’s fiscal year (FY) 2018 Budget requests $359 million for the Office of Inspector General (OIG), an increase of $18 million above the FY 2017 Continuing Resolution. These funds will enable OIG to target oversight efforts and ensure efficient and effective use of resources within the programs. • OIG’s areas of oversight fall into two broad categories: Public Health and Human Services Oversight and Medicare and Medicaid Oversight. • PUBLIC HEALTH AND HUMAN SERVICES OVERSIGHT • OIG uses funding from its discretionary budget authority to conduct program integrity and enforcement activities for HHS programs and operations. OIG will continue to review activities for any evidence of fraud, waste, and abuse and oversee new and emerging issues related to HHS’s international and domestic response to public health concerns and new cyber security threats facing the Department. The FY 2018 Budget request for Public Health and Human Services Oversight is $68 million, which will support the following investments to strengthen the integrity of HHS programs including: • MEDICARE AND MEDICAID OVERSIGHT Through its multi-disciplinary oversight work, OIG saves taxpayer dollars and works to ensure that patients receive medically appropriate care in the Nation’s largest health care programs—Medicare and Medicaid. OIG relies on principles of prevention, detection, and enforcement to address fraud, waste, and abuse in Protecting HHS Grants from Fraud, Waste and Abuse: OIG will continue focus on grant oversight efforts on high risk grant programs, including Office of Inspector General grants for services to children and substance abuse grant funding provided under the 21st Century Cures Act for opioid abuse prevention and treatment programs. Oversight of Indian Health Services: OIG will continue oversight of quality of care and program administration. Public Health Emergencies: OIG will continue oversight of HHS grants for emergency preparedness and provide training and education to promote preparedness and prevent fraud, waste, and abuse. Ensuring Privacy and Security Information: OIG will work to increase oversight and investigative response to threats from computer hacking groups intent on compromising systems and releasing sensitive data. OIG conducts general security control audits of information and technology supporting HHS programs and conducts network and web application penetration testing to assess HHS’s network security to determine vulnerability. 97 these programs. Two key focus areas are sound fiscal management of the programs and ensuring that beneficiaries have access to quality care in the right setting as determined by the beneficiary and his or her medical providers. care, and the increase in complexity and technical sophistication of fraud schemes. OIG will continue its work from FY 2017 to address fraud, waste, and abuse in prescription drugs, including abuse and diversion of opioids. OIG protects these programs and their beneficiaries using a multidisciplinary approach and through important partnerships, including with the Department of Justice and State Medicaid Fraud Control Units. Fraudulent providers often cheat both Medicare and Medicaid (and their beneficiaries), and thus OIG fraud-fighting and patient protection activities often have cross-cutting impacts. The Health Insurance Portability and Accountability Act (HIPAA) established the HCFAC Program to combat fraud, waste, and abuse in health care. The funds OIG receives under HIPAA are dedicated to activities relating to Medicare and Medicaid. Overall, HCFAC funding constitutes the major portion of OIG’s annual operating budget. Prescription Drug Abuse and Fraud Prevention Authorities Opioid abuse and abuse of prescriptions for non-controlled potentiator drugs that enhance the euphoric effects of opioids endanger patients, communities, and taxpayer dollars. The FY 2018 Budget request for OIG includes $290.7 million for Medicare and Medicaid oversight, an increase of $26.4 million over the FY 2017 Continuing Resolution. Additional HCFAC funding will provide OIG with resources to increase investigations into fraudulent prescribing and dispensing of opioids, including forensic accounting and medical record reviews to increase the number of investigated cases and their expedient investigation and prosecution. OIG will further enhance its data analytics capabilities for identifying aberrant opioid prescribing or dispensing patterns and target interventions to combat prescription drug abuse. OIG uses its legal authorities including law enforcement authorities, data analytics, investigation, audit, and evaluation capabilities, to strengthen the Administration’s fight against opioid abuse. OIG addresses prescription drug fraud along the entire supply chain, from manufacturers who make and promote products to physicians and pharmacies. The FY 2018 Budget supports the Administration’s priorities of addressing fraud, waste, and abuse in Federal health care programs and strengthening the fight against opioid abuse in this country. OIG’s work reflects issues of access and affordability, increased Medicare and Medicaid enrollment and spending, innovations in health care and data analytics, quality of 98 Office of Inspector General Public Health and Social Services Emergency Fund 2016 /1 2017 /2 2018 2018 +/- 2017 25 50 255 6 540 25 50 254 6 511 25 50 227 6 512 ---27 -1 510 15 31 1,431 509 15 31 1,400 510 15 31 1,375 1 ---25 Other Office of the Secretary Security and Strategic Information (OSSI) /3 Cybersecurity /3 Subtotal, Other Office of the Secretary 8 50 58 8 50 58 8 72 81 -22 +22 Pandemic Influenza No-Year Funding Annual Funding Subtotal, Other Office of the Secretary 40 32 72 40 32 72 175 32 207 +135 -+135 1,561 1,561 714 1,530 1,533 750 1,663 1,663 780 +133 +133 +30 dollars in millions Assistant Secretary for Preparedness and Response (ASPR) Preparedness and Emergency Operations National Disaster Medical System Hospital Preparedness Medical Reserve Corps Biomedical Advanced Research and Development Authority Project BioShield Policy and Planning Operations Subtotal, ASPR Program Level Total Program Level, PHSSEF Total Budget Authority, PHSSEF Full-time Equivalents 1/ In addition, the FY 2016 Zika Response and Preparedness Act provided $387 million in supplemental resources for Zika response and preparedness activities, including $245 million for BARDA, $75 million for CMS, and $66 million for HRSA. 2/ Reflects the annualized level of the Continuing Resolution that ended April 28, 2017, including the across the board reduction, the 21st Century Cures Act, and directed transfers. 3/ Totals reflect a realignment of $1.04 million from Cybersecurity to OSSI to support the cyber threat activities carried out by OSSI. The Public Health and Social Services Emergency Fund directly supports the nation’s ability to prepare for, respond to, and recover from the health consequences of naturally occurring and man-made threats. Within the Office of the Secretary, the Public Health and Social Services Emergency Fund directly supports efforts across the Government to safeguard the public and improve the Nation’s preparedness for acts of terrorism, natural disasters, and other threats to public health. The Fiscal Year (FY) 2018 Budget includes $1.7 billion, an increase of $133 million above FY 2017, Public Health and Social Services Emergency Fund to maintain and build on the Department’s capacity to address biodefense and cybersecurity needs, support state and local preparedness, and respond to emerging influenza viruses with pandemic potential. 99 BIOTERRORISM AND EMERGENCY PREPAREDNESS and policy development for a wide range of public health incidents. The Department supports bioterrorism and emergency preparedness activities within the Office of the Secretary and across programs and agencies to enhance the Nation’s ability to prepare for, respond to, and recover from, a wide range of natural and man-made threats to public health. The Public Health and Social Services Emergency Fund supports the Department’s cross-cutting efforts to strengthen public health and medical preparedness, provide direct response to emergency situations, develop and procure medical countermeasures, and coordinate emergency preparedness policy and planning efforts across the Department of Health and Human Services (HHS). The FY 2018 Budget includes $1.6 billion for ASPR, an increase of $110 million above the FY 2017 Continuing Resolution. The Budget prioritizes resources to support critical biodefense programs and maintain essential support for pandemic influenza preparedness and response. These investments fulfill a unique Federal role where no other entity is active in protecting the health and safety of the United States population. The Budget includes $512 million—an increase of $1 million above the FY 2017 Continuing Resolution— for ASPR’s Biomedical Advanced Research and Development Authority (BARDA) to support the development of medical countermeasures that can mitigate potential health effects of chemical, biological, radiological, and nuclear agents and emerging infectious diseases. BARDA transitions medical product candidates, such as vaccines, antivirals, diagnostics, and medical devices, from early development into advanced development and regulatory approval. To maintain a robust product development pipeline and meet national demands during a public health emergency, BARDA routinely collaborates with Federal agencies and leverages unique public-private partnerships. These partnerships rely on core services that BARDA provides to aid medical countermeasure developers, including assistance with clinical study protocols and final product manufacturing. EMERGENCY RESPONSE FUND The FY 2018 Budget proposes the establishment of an Emergency Response Fund to enable a swift response to emerging public health threats that have significant potential to affect the health and security of United States citizens. In addition to current transfer authority, HHS would have Department-wide transfer authority to support the Fund in the case of a natural or man-made disaster or threat. This Fund would be available to receive a transfer of up to one percent of any HHS account, without any limitation on the total, for use in emergency preparedness and response. Through this mechanism, HHS would have the ability to respond quickly when public health threats arise, as learned through previous public health threats such as Ebola and Zika. Such a fund will help bridge the Department’s response in situations that exceed the planned scope of preparedness and response programs and activities or where the emergency occurs late in the fiscal year. Since its inception, BARDA has directly supported the development of over 80 chemical, biological, radiological, and nuclear medical countermeasure product candidates. The FY 2018 Budget will maintain a robust pipeline of candidate products that will transition to Project BioShield, and expand the portfolio of candidate products to address chemical, radiological, nuclear, and biological threats, including viral hemorrhagic fever viruses. BARDA also supports countermeasures to address influenza viruses. These efforts will attempt to address remaining gaps for these threats. Multiple candidates in the advanced development program will progress into Phase II and Phase III clinical studies, including broad spectrum antimicrobials, new treatments for radiation illnesses and thermal burns, and next-generation vaccines. ASSISTANT SECRETARY FOR PREPAREDNESS AND RESPONSE The Assistant Secretary for Preparedness and Response (ASPR) is tasked with fulfilling HHS’s responsibilities as the lead Federal agency for public health emergency preparedness and response. ASPR fulfills these responsibilities by strengthening existing public health systems across the Nation, increasing the capacity of State and local governments to respond to public health threats, expanding advanced research, development and procurement of medical countermeasures, and providing operational leadership The Budget includes $510 million—an increase of $1 million above the FY 2017 Continuing Resolution— for Project BioShield to support late-stage 100 Public Health and Social Services Emergency Fund development and procurement of high priority and novel medical countermeasures for the Strategic National Stockpile within the Centers for Disease Control and Prevention (CDC). At this funding level, BARDA will build on investments in the medical countermeasure development pipeline by purchasing promising products that are sufficiently mature and ready for use during a public health emergency. In FY 2018, Project BioShield will support the late-stage development and procurement of three new medical countermeasures, including products to address biological pathogens and antimicrobial resistance; lung injury resulting from exposure to chemical agents; and an intravenous formulation of a smallpox antiviral. In addition, the FY 2018 Budget will sustain the development and procurement of Ebola vaccines and therapeutics and the next generation anthrax vaccine, as well as maintain preparedness levels for chemical, smallpox, and nuclear medical countermeasures. Administration (FDA) approval, and BARDA anticipates an additional three products will be approved by FDA in FY 2018, in addition to five new products supported under Project BioShield. The sustainment of Project BioShield is fundamental in supporting the Nation’s ability to prepare for and respond to acts of terrorism, biological outbreaks such as Ebola, and other public health threats. Sustainment of the capabilities and capacity to manufacture these life-saving products is key to the continued success of Project BioShield. The Budget includes $192 million—the same as the FY 2017 Continuing Resolution—to continue BARDA’s efforts to combat antibiotic-resistant bacteria. BARDA’s broad spectrum antimicrobial program will continue to leverage partnerships with public and private partners to develop products that directly support the government-wide National Action Plan for Combating Antibiotic-Resistant Bacteria. Most recently, BARDA has collaborated with the National Institutes of Health and the private sector to launch the Combating Antibiotic Resistant Bacteria Biopharmaceutical Accelerator (CARB-X), a trans-Atlantic public-private partnership focused on preclinical discovery and development of new antimicrobial products. To maximize the use of Since its inception, Project BioShield has supported the development and procurement of 21 novel medical countermeasures to address a wide range of threats such as anthrax, smallpox, botulism, viral hemorrhagic fever, and chemical, radiological, and nuclear agents. Six products have achieved Food and Drug PROGRAM HIGHLIGHT Hospital Preparedness Program The Hospital Preparedness Program (HPP) enables health care systems to save lives during emergencies that exceed the day-to-day capacity of health and emergency response systems. The program has identified key reforms that, once implemented in FY 2018, will allow the program to be more efficient and effective in delivering results and protecting the health and lives of Americans. One primary reform that will be implemented by the Hospital Preparedness Program is to transition to a competitive cooperative agreement program, by directing funds to States, jurisdictions, and Territories with the greatest need with respect to disaster preparedness. The introduction of a competitive cooperative agreement process will foster innovation and offer new opportunities for improved emergency preparedness and response, ensuring that the United States health care delivery system is better able to respond to emergencies that impact the public’s health. Additionally, the Hospital Preparedness Program will use risk-scores which identify the potential hazards and vulnerabilities, to direct resources to the States, jurisdictions, and Territories with the greatest need. The Hospital Preparedness Program’s risk score incorporates FEMA’s State and Homeland Security Program risk score, accounting for a range of factors including population and threat of terrorism. HPP will also incorporate a thorough assessment to account for natural disaster risk. Additionally, the program has identified methods that would directly link the cooperative agreement awards to performance. This new approach holds awardees accountable for improving performance by withholding funds from awardees that fail to deliver results. The Hospital Preparedness Program enhances health care delivery system capabilities to ensure they have the training and resources available to respond to public health and medical emergencies swiftly and effectively. The reforms to this program work in concert to ensure that the Hospital Preparedness Program is delivering critical results for the American people in the most efficient and effective manner possible. Public Health and Social Services Emergency Fund 101 resources, the Budget proposes authority to transfer resources between ASPR’s advanced research and development and Project BioShield programs. This authority will better enable ASPR to manage resources across the advanced development and procurement stages to most effectively bring medical countermeasures through the pipeline. PROGRAM HIGHLIGHT Pandemic Influenza: H7N9 Response Since the winter of 2016, a new strain of the H7N9 avian influenza virus, called the Yangtze River Delta lineage, has been circulating among birds in live poultry markets in China. This new lineage has led to more human cases of H7N9 infection in China than any prior H7N9 epidemic wave, with 623 human infections reported as of May 1, 2017. In addition, a growing number of viruses in this lineage have displayed genetic and antigenic changes that indicate greater pathology and greater resistance to current antiviral treatments. While the current risk to the United States public’s health posed by these new H7N9 viruses is low, the Department’s ongoing influenza risk assessment process has concluded that the pandemic potential is concerning. The Hospital Preparedness Program increases the ability of local, State and regional health care and emergency response systems to save lives during emergencies. Funding incentivizes diverse and often competitive health care organizations with differing priorities and objectives to work together through health care coalitions. Health care coalitions enable communities to develop comprehensive and collaborative health care response plans, ensure communities have the adequate health care resources and trained personnel to respond to a disaster, and conduct joint planning, exercises, and trainings to ensure operational readiness should disaster strike. The Budget includes $227 million, a decrease of $27 million below the FY 2017 Continuing Resolution, for ASPR’s Hospital Preparedness Program. The Hospital Preparedness Program works collaboratively with the CDC Public Health Emergency Preparedness program. The Hospital Preparedness Program focuses on incentivizing the private health care sector to prepare and respond while CDC’s Public Health Emergency Preparedness program focuses on strengthening the preparedness of the State and local governmental public health. These two programs complement each other to ensure that both the health care delivery system and public health departments are able to prepare for, respond to, and rapidly recover from, disasters. This year, the two programs will implement changes to improve the overall efficiency of each program. These reforms include a greater emphasis on risk assessment, which will direct resources to States and jurisdictions with the greatest need. Additionally, the programs will innovate through competition, funding the most effective preparedness strategies and aligning awardees more closely with program missions to improve the Nation’s health. Lastly, the new reforms will use these resources wisely and with accountability by tying continued funds to performance, providing awards to those recipients who are demonstrating results, and improving the overall capabilities of emergency preparedness and response systems. To meet pandemic preparedness goals for the new H7N9 viral lineage, BARDA is collaborating with private industry and partners from the Public Health Emergency Medical Countermeasures Enterprise to develop a new H7N9 vaccine for the National Pre-pandemic Influenza Vaccine Stockpile. Using pandemic influenza appropriations, the Department is able to streamline this process by utilizing technology improvements in the development of vaccine seed strains as well as expanded domestic vaccine manufacturing surge capacity to procure vaccine in the event of a pandemic. the National Disaster Medical System. The National Disaster Medical System consists of approximately 5,000 intermittent Federal employees who stand ready to deploy as trained medical teams to provide essential medical services in communities across the nation when a disaster or public health emergency occurs. Each deployment not only provides trained medical professionals to support the response efforts, but also sends the necessary medical supplies and equipment to ensure the impacted community has the tools necessary to expedite recovery efforts. To improve the efficiency and effectiveness of the program, the National Disaster Medical System has restructured responder requirements and team configurations so that the deployed teams are better able to meet the needs of the States and localities impacted by a disaster. The FY 2018 Budget maintains ASPR’s management of the Medical Reserve Corps by providing $6 million to support these activities, which is the same as the FY 2017 Continuing Resolution. Complementing the National Disaster Medical System, the Medical Reserve The FY 2018 Budget maintains $50 million to support 102 Public Health and Social Services Emergency Fund Corps consists of over 200,000 volunteers, organized into almost 1,000 community-based groups, ready to serve within their locality to build community resilience through education and prevention activities, improve local preparedness, response, and recovery capabilities, and provide behavioral health support, when necessary. Additionally, the FY 2018 Budget supports ASPR’s Office of Emergency Management which manages the necessary assets to support ASPR’s response activities while coordinating the logistics necessary to ensure that each of ASPR’s preparedness and response efforts have the right resources in the right place at the right time. $1 million was made from Cybersecurity to the Office of Security and Strategic Information to support cyber threat activities. The Office of Security and Strategic Information keeps Americans safe by integrating and synthesizing information on public health, terrorism, homeland security, and other health threats for HHS activities. The program increases the Department’s security awareness by developing and implementing strategies to reduce national security threats. The Office coordinates information sharing and safeguarding not only across HHS, but also with the Director of National Intelligence, other Federal partners, and agencies within the intelligence community. PANDEMIC INFLUENZA Cybersecurity The FY 2018 Budget includes $72 million for the HHS cybersecurity program, $22 million above the FY 2017 Continuing Resolution. The Department’s cybersecurity efforts are critical to protecting HHS’s mission. The program works to ensure that HHS is able to address the evolving cyber threats and protect the Department’s sensitive information. The cybersecurity program will continue its operations to detect, manage, and remediate cybersecurity risks. The cybersecurity program has a unique Federal role, maintaining the security of information for other HHS entities. The activities of the cybersecurity program safeguard the Department’s unique data, ranging from FDA’s proprietary information, CMS’s financial records, and extensive personal health information across the Department. The additional resources will in part be directed to expand HHS’s capability to share cybersecurity threat indicators and information across the Federal and private health care spaces to better protect the security of such data. The continued emergence of novel influenza viruses with human pandemic potential demonstrates the critical need for pandemic influenza preparedness activities, including the production of influenza countermeasures. Previous investments in domestic influenza vaccine manufacturing facilities and pre-pandemic influenza vaccine stockpiles have successfully increased the Department’s capacity to respond to emerging and evolving influenza viruses that pose a significant threat to public health. The FY 2018 Budget continues to invest in this critical capacity within HHS with a total of $207 million, an increase of $135 million above the FY 2017 Continuing Resolution, to support influenza vaccine manufacturing and stockpiling, international preparedness, and the advanced development of novel influenza vaccines, antivirals, and diagnostics. These efforts are supported by BARDA and the Office of Policy and Planning within ASPR and through the Office of Global Affairs. BARDA is currently supporting the manufacturing and stockpiling of a new vaccine in response to the H7N9 avian influenza virus in China, which has caused 623 human infections during its fifth epidemic wave, the largest epidemic wave of the virus to date. DEPARTMENT-WIDE INFORMATION SECURITY Security and Strategic Information The FY 2018 Budget includes $8 million for the Office of Security and Strategic Information. A realignment of Public Health and Social Services Emergency Fund 103 ABBREVIATIONS AND ACRONYMS HHS A ACF ACL AHRQ AIDS ASPR ATSDR AWARE Administration for Children and Families Administration for Community Living Agency for Healthcare Research and Quality Acquired Immune Deficiency Syndrome Assistant Secretary for Preparedness and Response Agency for Toxic Substances and Disease Registry Advancing Wellness and Resiliency in Education HIPAA HIV HIV/AIDS HPP HRSA I IHS IT B BARDA BRAIN CDC CHIP CHIPRA CMS Biomedical Advanced Research and Development Authority Brain Research through Advancing Innovative Neurotechnologies Lifeline LIHEAP MACRA Combating Antibiotic Resistant Bacteria Biopharmaceutical Accelerator Centers for Disease Control and Prevention Children’s Health Insurance Program NIH NIRSQ NMEP Children’s Health Insurance Program Reauthorization Act Centers for Medicare & Medicaid Services National Institutes of Health National Institute for Research on Safety and Quality National Medicare & You Education Program O OCR OIG OMHA Direct Primary Care ONC Food and Drug Administration Full-Time Equivalent Fiscal Year PAYGO PHS Office for Civil Rights Office of Inspector General Office of Medicare Hearings and Appeals Office of the National Coordinator for Health Information Technology P Pay-As-You-Go Act of 2010 Public Health Service S H HCFAC Medicare Access and CHIP Reauthorization Act N F FDA FTE FY National Suicide Prevention Lifeline Low Income Home Energy Assistance Program M D DPC Indian Health Service Information Technology L C CARB-X Department of Health and Human Services Health Insurance Portability and Accountability Act Human Immunodeficiency Virus Human Immunodeficiency Virus/ Acquired Immune Deficiency Syndrome Hospital Preparedness Program Health Resources and Services Administration SAMHSA Health Care Fraud and Abuse Control 104 Substance Abuse and Mental Health Services Administration Abbreviations and Acronyms