Affordable Care Act Funding: An Analysis of Grant Programs under Health Care Reform

issue-brief-2012-09-coverThe Patient Protection and Affordable Care Act (ACA) is a comprehensive law with the potential to affect the health of Americans in many ways. The ACA reduces the number of uninsured Americans by expanding eligibility for Medicaid and offering tax credits for the purchase of private insurance.1 In addition, the ACA makes investments to expand access to care, reform the health care delivery system, implement broad private insurance reforms, and enhance the public health infrastructure.

Many of these reforms and investments are paid for through direct public funding included in the law. Specifically, the ACA includes much of the funding necessary for creating health insurance exchanges, growing the capacity of the healthcare workforce, expanding primary care capacity through community health centers, and several other initiatives. While many major ACA provisions, such as the insurance coverage expansions, will not go into effect until 2014, many others have already been implemented and funded through federal grants to state governments, community-based organizations, colleges, and local agencies.

This issue brief focuses on ACA grants that were awarded during a shortened fiscal year 2010 (March 23, 2010 to September 30, 2010) and fiscal year 2011 (October 1, 2010 to September 30, 2011). This brief also examines other current and planned grant spending in the ACA and how funds have been distributed to states for a variety of programs.


Spending Provisions

There are two types of federal spending, discretionary and mandatory (also known as non-discretionary). For both types, Congress must authorize an entity of the federal government to spend money for a specific purpose. Appropriations for mandatory spending are included in the original authorizing law and thus exempted from the annual budget process. On the other hand, Congress must appropriate funds for discretionary spending during the budget process. It is important to note that Congress is not required to appropriate the full amounts authorized for discretionary programs. Therefore, discretionary programs could receive less funding than was originally authorized in legislation.

The ACA includes both discretionary and mandatory spending to fund its programs, but many key ACA initiatives are funded through mandatory spending that does not require further Congressional approval. In total, the ACA included $101.25 billion in mandatory spending from fiscal years 2010 through 2019.2 By the end of fiscal year 2011, the U.S. Department of Health and Human Services (HHS) had awarded nearly $3.6 billion in grants under the ACA.3 Most grant programs under the ACA have been funded through mandatory spending.

The ACA contains a number of new funding sources, within the following categories:

  • Community-based prevention: Includes a series of programs to increase investment in the public health infrastructure. The primary source of funding for these programs is from the Prevention and Public Health Fund (PPHF) (§ 4002). PPHF was originally appropriated $15 billion over 10 years. As part of the Middle Class Tax Relief and Job Creation Act of 2012, the PPHF was cut to $9.75 billion.
  • Health centers: Includes funding for federally qualified health centers (FQHCs), the National Health Service Corps, and school-based health centers. FQHCs are federally-funded clinics (also called community health centers), which focus on providing primary care in underserved areas. FQHCs were appropriated $11 billion by the ACA for patient services, construction, and renovation (§ 10503). The National Health Service Corps, which brings health professionals to underserved areas, was appropriated $1.5 billion (§ 10503). School-based health centers, which connect medical services to students directly in schools, were appropriated $200 million over four years (§ 4101).
  • Health workforce: Includes a series of programs to increase the capacity of the primary care workforce. In FY2010, many workforce programs were funded by the Prevention and Public Health Fund. But in FY2011, workforce programs were funded largely through direct ACA appropriations; for example, health workforce demonstration grants, with $425 million in funding over five years (§ 5507).
  • Long-term care: Includes grant programs to support coordinated long-term care services. This includes an extension of the existing Medicaid “Money Follows the Person” demonstration for $2.7 billion over six years (§ 2403). Another example of funding includes grants to state Aging and Disability Resource Centers for $50 million over five years (§ 2405).
  • Market reform: Includes a series of grants to help states reform their private insurance markets. These grants were directly funded by the ACA to establish insurance exchanges, review health insurance premium rates, and provide insurance information to consumers. The rate review program was appropriated $250 million (§ 1003); the consumer information program was appropriated $30 million (§ 1002); and the secretary of HHS has discretion to appropriate the amount necessary for insurance exchange grants prior to 2015 (§ 1311). To date, approximately $1 billion has been awarded to states through insurance exchange grants.4
  • Maternal and child health: Includes multiple grant programs targeted to at-risk families and prevent teenage pregnancy. Examples include the Maternal, Infant, and Early Childhood Home Visiting program (§ 2951) and the Personal Responsibility Education Program (§ 2953). The Maternal, Infant, and Early Childhood Home Visiting program provides $1.5 billion in grants over five years for states and tribal organizations to implement an evidence-based program where nurses, social workers, and other health care professionals meet with low-income and at-risk families in their homes and provide evaluation, counseling, and health care services. The Personal Responsibility Education Program is a grant program to fund teen pregnancy prevention programs and related initiatives. This provision was appropriated $375 million over five years.
  • Medicaid & CHIP: Includes grant programs focused on the health of enrollees in Medicaid and the Children’s Health Insurance Program (CHIP). Examples of ACA-funded programs include Medicaid Prevention and Wellness Incentives for $100 million over five years (§ 4108) and the CHIP Childhood Obesity Demonstration Project for $25 million over five years (§ 4306).
  • Medicare: Includes a series of programs funded by the ACA to boost the effectiveness and efficiency of the Medicare program. This includes the creation of the new Center for Medicare and Medicaid Innovation, which is intended to conduct research and demonstration projects to improve efficiency and quality in Medicare, Medicaid and CHIP. The Center for Medicare and Medicaid Innovation was appropriated $10 billion over ten years (§ 3021). The ACA also funds other Medicare programs, including the Medicare Independence at Home Demonstration for $30 million over six years (§ 3024).

For a list of funding sources for select ACA programs by implementation year, see Appendix 1.

ACA Funding in Fiscal Year 2010

Awards were limited in FY2010 due to the shorter funding period (March 2010 to September 2010) and to allow time for HHS and other agencies to prepare for the increase in spending under the ACA. Of the ACA’s many grant programs, 36 were actively funded in FY2010.

HHS awarded a total of $1.03 billion in FY2010 to states and the District of Columbia. California and New York, received the most awards in 2010, with approximately $83 million and $66 million, respectively. The bottom two states were South Dakota and Wyoming, each receiving less than $6 million. The District of Columbia received the most funding per capita with $38.26. Figure 1 See Appendix 2 for full details of state-level funding.

FIGURE 1: FY2010 ACA Grant Funding by State

figure-1

The Prevention and Public Health Fund and the market reform provisions in the ACA funded most active grant programs. In anticipation of the need for expanded primary care capacity in 2014, HHS committed one-half of the FY2010 Prevention and Public Health Fund budget to health workforce development programs instead of traditional community-based public health programs. This investment in health workforce made workforce funding the largest category of grants ($503 million), more than twice as much as community-based prevention programs (approximately $209 million), the next largest category. Another prominent category of ACA funding was for maternal and child health programs, which received $116 million. Much of this funding was distributed to states for Maternal, Infant, and Early Childhood Home Visiting programs ($103 million).

FIGURE 2: FY2010 ACA Grant Funding by Funding Category

figure-2
Funding CategoryTotal Funding
Health Workforce$503,257,248
Community-based Prevention$208,585,809
Maternal and Child Health$116,312,534
Market Reform$94,788,294
Health Centers$52,282,684
Medicare$29,957,268
Long-Term Care$23,724,075
Total$1,028,907,912

State agencies were the leading recipient of ACA funding awards in FY2010, with nearly $414 million. These funds were used to support a wide variety of programs and initiatives, including Maternal, Infant, and Early Childhood Home Visiting programs ($85 million); health insurance exchange planning ($48 million); insurance premium reviews ($46 million); and personal responsibility pregnancy prevention ($44 million). Community-based health organizations, along with public and private colleges and universities, also received significant amounts of ACA funding, particularly to support primary care training and residency programs.

FIGURE 3: FY2010 ACA Grant Funding by Recipient Type

figure-3
Recipient TypeTotal Funding
State Agencies$413,566,073
Health & Community-based Organizations$225,577,854
State Colleges & Universities$214,741,842
Private Colleges & Universities$111,447,387
Local Agencies$51,739,532
Tribal Organizations$6,947,621
Other Organizations$4,887,603
Total$1,028,907,912

ACA Funding in Fiscal Year 2011

Nationally, ACA funding more than doubled in FY2011 to more than $2.5 billion as FY2011 was the first full fiscal year of ACA implementation. The number of actively funded grant programs under the ACA increased from 36 in FY2010 to 47 in FY2011. As in FY2010, California again received the most funding in FY2011, with nearly $258 million in grants.

Ohio, New York, Massachusetts, and Oregon each received grants totaling more than $100 million. Only two states—North Dakota and Delaware—were awarded less than $10 million. The District of Columbia again received the largest amount of funding per capita. See Appendix 2 for full details of state-level funding.

FIGURE 4: FY2011 ACA Grant Funding by State

figure-4

Funding for community health centers comprised the largest category of grant funding in FY2011 with more than $858 million. Much of this funding was awarded for capital expenditures, with $716 million awarded to community health centers and $94 million awarded to school-based health centers. The next largest category was for grants to states for programs to reform the private insurance industry ($595 million), including grants to continue planning and to begin establishing health insurance exchanges ($463 million). Community-based prevention programs were also awarded funding ($436 million) for a variety of programs, including nearly $108 million in Community Transformation Grants.

FIGURE 5: FY2011 ACA Grant Funding by Funding Category

figure-5
Funding CategoryTotal Funding
Health Centers$858,050,478
Market Reform$595,098,762
Community-based Prevention$435,659,620
Health Workforce$376,267,609
Maternal and Child Health$250,486,728
Long-Term Care$24,446,503
Medicaid & CHIP$20,042,057
Medicare$2,490,094
Total$2,562,541,851

In FY2011, state agencies again received the most ACA grant funding with more than $1.1 billion. More than one-third of this funding was awarded for state planning and implementation of health insurance exchanges ($427 million). State agencies were also awarded funds to continue operating Maternal, Infant, and Early Childhood Home Visiting programs ($216 million) and insurance premium Rate Review programs ($102 million). Similar to FY2010, community health centers continued to receive significant funding ($840 million), with most of funding for capital development ($632 million). Public and private colleges and universities experienced modest increases in funding from their FY2010 levels as Prevention and Public Health Fund funding shifted away from workforce training and toward traditional public health programs.

FIGURE 6: FY2011 ACA Grant Funding by Recipient Type

figure-6
Recipient TypeTotal Funding
State Agencies$1,156,079,315
Health & Community-based Organizations$839,988,927
State Colleges & Universities$295,074,140
Private Colleges & Universities$125,811,491
Local Agencies$123,335,806
Tribal Organizations$18,093,294
Other Organizations$4,158,878
Total$2,562,541,851

ACA Funding in the Future

The ACA includes nearly $4 billion in non-discretionary funding explicitly for FY2012, not including funding allocated across multiple years.5 Assuming that the ACA is implemented as planned, total spending is scheduled to increase over previous years as new grant programs are introduced and agencies are established. Of course, scheduled increases could change over time. For example, as part of the Middle Class Tax Relief and Job Creation Act of 2012, the Prevention and Public Health Fund was cut from $15 billion to $9.75 billion over its first 10 years to offset the costs of extending temporary tax cuts and preventing a large cut in Medicare payments to physicians.

Some states have also returned grant funding for ACA programs. Four states—Delaware, Florida, North Dakota, and Pennsylvania—experienced a drop in total ACA funding from FY2010 to FY2011 even though the ACA was in effect for all of FY2011. Oklahoma, Kansas, and Wisconsin were three of seven states to receive Early Innovator Grants to develop infrastructure for health insurance exchanges. Oklahoma returned its $54 million award, reducing its state total to $35.3 million.6 Kansas returned its grant, worth $31.5 million, dropping its total to $14.1 million.7 Wisconsin also returned its grant, worth $38 million, reducing its total to $41 million.8 These states cited a desire to maintain flexibility in the future as a primary reason for returning the awards. Although the return of these grants was announced in 2011, they will be reflected in the funding levels for FY2012.

Funding may also be affected by the sequestration process under the Budget Control Act of 2011, which was triggered by the failure of the Joint Select Committee on Deficit Reduction (also known as the “super committee”) to agree on a plan to decrease the federal deficit. The sequestration process aims to reduce the deficit by $1.2 trillion by cutting funding for certain domestic programs and defense spending from 2013 to 2021.9 The resulting cuts to non-defense spending will likely reduce funding for ACA programs. While ACA-funded initiatives are designed to influence the future delivery of health care, the size and nature of future ACA-funded programs remains uncertain.

Focus on Michigan: Analysis of ACA Funding Awarded to Michigan

The ACA in Michigan

The Affordable Care Act funds many of its programs through grants to state governments, community-based organizations, colleges, and local agencies. Many organizations across Michigan have been active in applying for and receiving grant funding to implement ACA reforms, improve health care access, and invest in the public health infrastructure.

For FY2010 and FY2011, Michigan received a total of $82.6 million in ACA grant awards. The largest category of funding was for health workforce training and development ($26.5 million) with funding for community health centers a close second ($26.1 million). The State of Michigan, including the Department of Community Health, received the most funding in this two-year period with $27.1 million; nearly triple the amount of the next highest recipient.

FIGURE 7: Top 10 Michigan Institutions Receiving ACA Grant Funding (FY2010-FY2011)

RecipientFunding Total
State of Michigan$27,106,892
Family Health Center, Inc.$9,670,241
University of Michigan$8,321,408
Cherry Street Services, Inc.$6,318,432
Wayne State University$5,736,624
Spectrum Health$3,823,980
Michigan State University$3,427,616
Center for Family Health, Inc.$3,400,000
Grand Valley State University$2,341,318
Inter-Tribal Council of Michigan, Inc.$2,075,080

ACA Funding in Michigan, Fiscal Year 2010

Michigan received more than $29 million in ACA grants in FY2010, ranking 10th in total state awards. Per-person, however, Michigan ranked 39th.

Funding in Michigan followed a pattern similar to the national level, with grants for the health workforce as the largest category by a large margin with $18.1 million. Many of these workforce grants were funded by the Prevention and Public Health Fund, which prioritized workforce development in FY2010.

FIGURE 8: Michigan FY2010 Grant Funding by Funding Category

figure-8
Funding CategoryFunding Total
Health Workforce$18,058,616
Community-based Prevention$3,280,678
Maternal and Child Health$2,633,673
Health Centers$2,359,646
Market Reform$1,999,772
Medicare$622,093
Long-Term Care$500,000
Total$29,454,478

Colleges and universities in Michigan received much of this health workforce grant funding, making this the largest recipient category. For example, funding was awarded to the University of Michigan ($4.5 million), Wayne State University ($3.1 million), and Michigan State University ($2.4 million) for health workforce development.

FIGURE 9: Michigan FY2010 Grant Funding by Recipient Category

figure-9
Recipient CategoryFunding Total
State Colleges & Universities$13,903,858
State Agencies$8,683,415
Health & Community-based Organizations$4,400,966
Private Colleges & Universities$1,463,377
Tribal Organizations$506,000
Local Agencies$496,862
Total$29,454,478

Michigan award highlights in FY2010 include:

  • Health Workforce
    • Nursing Education and Training: Michigan received 35 grant awards for nursing workforce development, totaling about $9.8 million. Notable awards include $1.4 million to University of Michigan-Flint, $1.4 million to Michigan State University, and $1.3 million to Wayne State University to expand advanced nursing education. Since nursing schools received a large number of the nursing-related grants, public and private universities received over half of the FY2010 funding in this category.
    • Primary Care Residency Expansion: Michigan received two awards aimed at increasing the number of residents trained in primary care. Spectrum Health received nearly $3.5 million, and the University of Michigan received nearly $1 million.
  • Community-based Prevention
    • Public Health: Michigan received four awards from the Prevention and Public Health Fund for traditional public health programs. The Michigan Department of Community Health received $135,438 for HIV testing, $493,670 to expand laboratory capacity, and $400,000 for public health infrastructure improvements.
    • Teen Pregnancy Prevention: The Michigan Department of Community Health received a $1.7 million award to fund its Personal Responsibility Education Program to educate youth to prevent pregnancy and sexually transmitted infections.
  • Health Centers and National Health Service Corps
    • Nurse Managed Health Clinic: The University of Michigan received nearly $1.5 million for a nurse-managed health clinic to expand primary care access in medically-underserved areas.
  • Maternal and Child Health
    • Early Childhood Home Visitation: The Michigan Department of Community Health received a $2.1 million award to implement a Maternal, Infant, and Early Childhood Home Visiting program.
  • Market Reform
    • Health Insurance Exchange Planning: Along with 48 other states, the State of Michigan received about $1 million for planning activities related to a state health insurance exchange.
    • Insurance Review: The Michigan Office of Financial and Insurance Regulation received $1 million to review and approve premium increases for health insurance coverage.
  • Other Notable Funding
    • Money Follows the Person (MFP): The State of Michigan was awarded $400,000 to transition Medicaid beneficiaries from nursing homes to community-based care. The ACA did not directly appropriate this funding; rather it authorized the use of existing MFP appropriations to fund the grant program.

The top 10 recipients of ACA grants in FY2010 were:

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ACA Funding in Michigan, Fiscal Year 2011

Michigan received $53 million in FY2011, nearly double the amount received in FY2010. However, Michigan’s grant totals fell relative to other states, from 10th to 14th. Per capita grant funding also declined from 39th to 44th nationally.

Health centers were the largest source of funding to Michigan in FY2011 with $23.7 million, mirroring national trends. Figure 10 Much of this funding went toward capital development of community health centers ($18.7 million). School-based health centers were also awarded $4 million for capital development.

FIGURE 10: Michigan FY2011 Grant Funding by Funding Category

figure-10
Funding CategoryFunding Total
Health Centers$23,734,556
Community-based Prevention$9,703,329
Health Workforce$8,441,153
Maternal and Child Health$6,109,549
Market Reform$5,118,000
Total$53,106,587

Non-profit community health organizations, many of whom operate health centers, were the largest type of funding recipient in FY2011. Figure 11 For example, funding was awarded to Family Health Center, Inc. ($9.4 million), Cherry Street Services, Inc. ($5.9 million), and Center for Family Health, Inc. ($3.4 million) for capital development of community health centers.

FIGURE 11: Michigan FY2011 Grant Funding by Recipient Category

figure-11
Recipient CategoryFunding Total
Health & Community-based Organizations$23,068,278
State Agencies$18,423,477
State Colleges & Universities$6,785,378
Tribal Organizations$2,074,080
Local Agencies$1,849,599
Private Colleges & Universities$905,775
Total$53,106,587

Michigan’s FY2011 award highlights include:

  • Community-based Prevention
    • Public Health: The Michigan Department of Community Health received five awards through the Prevention and Public Health Fund to support public health programs. Awards included nearly $2.5 million for new increased laboratory capacity and $1.2 million for immunization program improvements.
    • Community Transformation: Michigan received two community transformation grants, part of a national $100 million initiative in FY2011 to promote healthy lifestyles through community collaboration. The Sault Ste. Marie Tribe of Chippewa Indians received $883,445, and Spectrum Health received $333,321.
    • Teen Pregnancy Prevention: Michigan received two awards to support its Personal Responsibility Education Programs to educate youth to prevent pregnancy and sexually transmitted infections. The Michigan Department of Community Health received a $1.7 million, and the Inter-Tribal Council of Michigan received $408,690.
  • Health Centers
    • Community Health Centers: Approximately 35 percent, or about $18.7 million, of its total ACA-related funding in Michigan went for capital development of community health centers (see Figure 2). These grants were awarded to Family Health Center, Inc. ($9.4 million), Cherry Street Services, Inc. ($5.9 million), and Center for Family Health, Inc. ($3.4 million).
    • School-Based Health Centers: Michigan received 12 grants totaling nearly $4 million for school-based health centers across Michigan to use for capital expenditures.
  • Maternal and Child Health
    • Maternal, Infant, and Early Childhood Home Visiting program: The Michigan Department of Community Health received $5.6 million for its nurse home visitation program.
  • Market Reform
    • Consumer Assistance Program: The Michigan Office of Financial and Insurance Regulation received $1.1 million for its Consumer Assistance Program. This program helps health insurance beneficiaries address disputes with insurance plans regarding coverage and benefits.
    • Insurance Review: The Michigan Office of Financial and Insurance Regulation received additional funding of nearly $4 million to review and approve premium increases for health insurance coverage.
  • Other Notable Funding
    • State Demonstration to Integrate Care of Dual Eligible Individuals: Michigan was one of 15 states to receive $1 million from the Center for Medicare and Medicaid Innovation for a demonstration project to develop a person-centered care model for individuals enrolled in both Medicare and Medicaid (dual-eligibles).
    • Multi-Payer Advanced Primary Care Practice Demonstration: Michigan was one of eight states selected for the Centers for Medicare and Medicaid Services (CMS) Multi-Payer Advanced Primary Care Practice demonstration project. Although not technically a direct ACA budget appropriation, the three-year project is expected to result in budget neutrality for Medicare and provide approximately $23 million per year in additional Medicare funds, along with funds from other payers, for enhanced care coordination and integrated care.10 The multi-payer project was originally created under the CMS, but is now run by the newly created Center for Medicare and Medicaid Innovation. The project focuses on how the patient-centered medical home model can improve care. In Michigan, the project is known as the Michigan Primary Care Transformation Project, or MiPCT.

The top 10 recipients of ACA grants in FY2011 were:

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Michigan received limited or no funding in the following categories of FY2011 funding:

  • State Planning and Establishment Grants: Health insurance exchange planning grants continued to be awarded in 2011. HHS awarded $280 million to 14 states (not including Michigan) that applied in 2011 and were early adopters in the exchange effort.
  • Federally Qualified Health Centers: While Michigan was successful in the first round of funding in early FY2011, the state was shut out of the second round of awards during the latter half of FY2011 as HHS began prioritizing areas with large rural and migrant populations.

    ACA Funding in Michigan, Fiscal Year 2012 and Beyond

    As implementation of the ACA continues, Michigan is expected to continue to receive federal grants to support programs and initiatives. On November 29, 2011, Michigan was awarded a Level One Establishment grant of $9.8 million to conduct additional analysis and planning for a health insurance exchange. This funding was subsequently blocked by Michigan’s legislative appropriations process.

    However, Michigan has received other funding for FY2012, including $183,000 in awards for school-based health centers. If the ACA remains in effect as planned, Michigan can expect to receive more funding before the end of FY2012, as the application process moves along for other ACA programs.

Appendix

FIGURE A1: Funding Sources of Select ACA Programs by Year (in millions of dollars)

SectionTitleFY10FY11FY12FY13FY14FY15FY16FY17FY18FY19Total
§1002, §1003, & §1311Market Reform$280TBD
Grants to states to help establish insurance exchanges, review health insurance policies, and provide consumers insurance information(Plus sums for exchange grants for FY2010 through FY2014 as necessary)
§2951Maternal, Infant, and Early Childhood Home Visiting program$100$250$350$400$400$1,500
Grants to support home visitation and primary care for infants and young children at the local and tribal level
§2953Personal Responsibility Education Program Grants$75$75$75$75$75$375
Grants for teen pregnancy prevention programs and related initiatives
§3021(a)Center for Medicare and Medicaid Innovation$5$10,005
CMI conducts research and demonstration projects to improve efficacy and quality in Medicare, Medicaid and CHIP(Plus $10 billion total for FY2011 through FY2019)
§4002Prevention and Public Health Fund$500$750$1,000$1,000$1,000$1,000$1,000$1,000$1,250$1,250$9,750
General fund to support grant programs focused on improving public health infrastructure and workforce development
§5601 & §10503Federally Qualified Health Centers$1,000$1,200$1,500$2,200$3,600$11,000
Planning and expansion grants to increase the number of FQHCs nationwide(Plus $1.5 billion total for community health center construction and renovation for FY2011 through FY2015)
§6301(e)Patient-Centered Outcomes Research Institute$10$50$150$150$150$150$150$150$150$150TBD
The PCORI funds studies of clinical effectiveness of various treatments(Plus the net revenue from a fee levied on insurance policies and health plans for FY2013 through FY2019)

FIGURE A2: Grant Funding by State (FY2010–FY2011)11

State2010 Total2010 Ranking2011 Total2011 Ranking2010 Per Capita2010 Per Capita Ranking2011 Per Capita2011 Per Capita Ranking2010–2011 Total Change
Alabama$17,124,01924$23,422,28337$3.5828$4.884537%
Alaska$8,689,44843$18,561,65043$12.232$25.685114%
Arizona$17,135,70323$45,214,55722$2.6844$6.9738164%
Arkansas$15,409,30427$25,230,59635$5.2815$8.592964%
California$83,370,6881$257,867,3861$2.2449$6.8440209%
Colorado$17,456,19722$39,514,68924$3.4730$7.7231126%
Connecticut$18,654,52220$43,815,93823$5.2216$12.2420135%
Delaware$7,324,40647$6,698,71050$8.166$7.3835-9%
District of Columbia$23,019,16116$34,111,80030$38.261$55.20148%
Florida$45,952,8233$39,514,27225$2.4447$2.0751-14%
Georgia$19,833,92118$36,574,85826$2.0550$3.734884%
Hawaii$10,311,44135$28,078,76134$7.587$20.4210172%
Idaho$7,681,28145$17,735,42044$4.9017$11.1924131%
Illinois$37,582,0557$93,700,9256$2.9340$7.2836149%
Indiana$15,494,84226$50,136,60517$2.3948$7.6932224%
Iowa$8,796,28341$29,324,63433$2.8941$9.5827233%
Kansas$8,958,46839$45,590,83721$3.1438$15.8814409%
Kentucky$12,370,88731$51,102,45016$2.8543$11.7022313%
Louisiana$18,973,03719$34,589,31429$4.1923$7.563382%
Maine$9,568,50336$24,573,80636$7.208$18.5013157%
Maryland$14,972,95829$58,376,02213$2.5945$10.0225290%
Massachusetts$39,250,7336$124,861,4834$5.9913$18.9511218%
Michigan$29,454,47810$53,106,58714$2.9839$5.384480%
Minnesota$15,152,15928$32,551,77632$2.8642$6.0941115%
Mississippi$9,381,45137$36,089,69928$3.1637$12.1221285%
Missouri$20,147,01117$60,040,62912$3.3634$9.9926198%
Montana$11,907,31832$18,764,59742$12.033$18.801258%
Nebraska$10,936,21633$21,064,33039$5.9914$11.432393%
Nevada$10,567,39534$16,241,46546$3.9124$5.964254%
New Hampshire$8,702,59142$16,172,09847$6.6111$12.271986%
New Jersey$30,719,3589$33,953,67731$3.4929$3.854711%
New Mexico$8,874,01840$49,016,30018$4.3121$23.548452%
New York$66,564,0732$146,544,5752$3.4432$7.5334120%
North Carolina$35,413,5088$69,445,47511$3.7125$7.193796%
North Dakota$7,387,09346$6,305,95051$10.984$9.2228-15%
Ohio$29,040,67311$144,260,1153$2.5246$12.5018397%
Oklahoma$17,594,09321$89,305,8247$4.6918$23.557408%
Oregon$13,200,87630$111,889,2375$3.4531$28.903748%
Pennsylvania$43,412,2585$36,453,08927$3.4233$2.8650-16%
Rhode Island$7,234,00748$22,497,16238$6.8710$21.409211%
South Carolina$16,891,65725$19,563,11740$3.6526$4.184616%
South Dakota$5,663,12350$10,622,51049$6.969$12.891688%
Tennessee$28,247,82512$52,083,86915$4.4519$8.133084%
Texas$43,668,5844$76,731,18010$1.7451$2.994976%
Utah$9,258,62638$19,532,53241$3.3535$6.9339111%
Vermont$6,219,27449$14,988,24548$9.945$23.936141%
Virginia$25,320,79513$46,549,35320$3.1636$5.754384%
Washington$24,126,10614$85,854,8648$3.5927$12.5717256%
West Virginia$8,128,52644$48,059,52919$4.3920$25.904491%
Wisconsin$24,054,80215$79,024,4159$4.2322$13.8415229%
Wyoming$3,709,33851$17,232,65645$6.5812$30.332365%
Total$1,028,907,912$2,562,541,851$3.33$8.22149%

Suggested citation: Fangmeier, Joshua; Tommasulo, Peter; Eller, Patrice; Udow-Phillips, Marianne. Affordable Care Act Funding: An Analysis of Grant Programs under Health Care Reform. September 2012. Center for Healthcare Research & Transformation. Ann Arbor, MI.

  1. The ACA expands coverage in 2014 through tax credits for private insurance and increasing eligibility for Medicaid. The estimated gross cost of this coverage expansion is $975 from FY2011 to FY2019, according to the Congressional Budget Office Report “CBO’s Analysis of the Major Health Care Legislation Enacted in March 2010” from March 2011. Since these provisions are funded outside federal budget process, they are not included in non-discretionary appropriations.
  2. Based on CHRT calculations from the Congressional Research Service report “Appropriations and Fund Transfers in the Patient Protection and Affordable Care Act” from February 2011. Appropriations for state grants for health insurance exchange planning and implementation are not included, since the Secretary of HHS has discretion to spend amounts necessary for these grants. As of May 16, 2012, HHS had awarded nearly $1 billion in planning and implementation grants for health insurance exchanges.
  3. Tracking Accountability in Government Grants System (TAGGS)
  4. As of May 16, 2012, HHS has awarded approximately$ 849 million in Level One and Level Two funding, $117 million in Early Innovator grants, and $47 million in exchange planning grants.
  5. Based on CHRT calculations from the Congressional Research Service report “Appropriations and Fund Transfers in the Patient Protection and Affordable Care Act” from February 2011.
  6. Oklahoma Gov. Mary Falling announced on April 14, 2011 that Oklahoma would return its $54 million Early Innovator Grant.
  7. Kansas Gov. Sam Brownback announced on August 9, 2011 that Kansas would return its $31.5 million Early Innovator grant.
  8. Wisconsin Gov. Scott Walker announced on January 18, 2012 that Wisconsin would return its $38 million Early Innovator Grant.
  9. The $1.2 trillion sequester includes $492 billion in defense cuts, $492 billion in non-defense discretionary funding cuts, and $216 billion in reduced debt serving costs.
  10. Medicare funding estimate provided by the staff of the Michigan Primary Care Transformation Project (MiPCT).
  11. Tracking Accountability in Government Grants System (TAGGS).