Expired and expiring ACA provisions

Most of the media coverage surrounding the Affordable Care Act (ACA)—also known as Obamacare or the 2010 health care reform law—seems to focus on how the law is being implemented, how it might be repealed, or whether the courts will strike it down. In the midst of all this debate, it is sometimes easy to forget that many programs and funding streams contained in the legislation were temporary. In fact, a number of provisions of the bill have already expired or are set to expire in the near future, some of which never received funding.

What types of programs are expiring?

The most well-known portions of the law are considered permanent and have no expiration date. Portions of the law that will remain in place, barring congressional repeal or a U.S. Supreme Court ruling declaring the legislation unconstitutional, include those pertaining to the state insurance exchanges; the individual and employer mandates; insurance reforms, including removal of annual and lifetime limits, essential benefits package, allowing children to stay on their parents’ plans until age 26, and so on; and Medicaid expansion, to name a few.

Of the expiring provisions, only a few affect so-called mandatory funding—that is, spending that happens automatically without additional congressional action. This includes items such as the recently expired incentive payment for primary care physicians in Medicaid.

Most of the expired and expiring provisions fall into the category of so-called discretionary programs. Discretionary spending is authorized by Congress but must be funded separately through the annual appropriations process. More than 50 discretionary programs authorized through the ACA have already expired, and more are set to do so this year. Many of these initiatives have never received funding.* Examples include some initiatives that the American College of Surgeons (ACS) has supported—for instance, the Pediatric Subspecialty Loan Repayment Program, which was not funded prior to expiring at the end of federal fiscal year 2014.

How will expiring provisions affect rural surgeons and their patients?

The ACA authorizes a Medicare incentive payment program for major surgical procedures provided by general surgeons in Health Professional Shortage Areas (HPSAs). This initiative, which is intended to increase access to surgical care in shortage areas, is called the HPSA Surgical Incentive Payment program (HSIP) and is commonly known as the general surgery bonus program. The 10 percent bonus applies to major operations (defined as 10-day and 90-day global procedures) provided by a surgeon who is enrolled in Medicare with a primary specialty code of 02 (general surgeon) and must take place in either a primary care or mental health HPSA. Surgeons began receiving this incentive payment after January 1, 2011, but it is set to expire at the end of this year.

The College will advocate to preserve and extend this program so rural patients will continue to have access to surgical care in shortage areas.

What do expiring ACA provisions mean for trauma care?

The ACA reauthorized and expanded several trauma programs. Unfortunately, despite the efforts of the ACS and a number of other stakeholder organizations, the four trauma programs included in the bill have not received funding and are now expired or expiring. Of the four programs authorized in the bill, two expired on September 30, 2014—the end of the last fiscal year. These programs would have provided grants to states for planning, implementing, and developing trauma care systems, and pilot projects to design, implement, and evaluate innovative models of emergency care systems. The other two provisions were the Trauma Care Center Grants designed to maintain the core missions of trauma centers, compensate them for losses from uncompensated care, and provide emergency support to centers at risk of closure; and the Trauma Service Availability Grants used by states to address shortfalls in trauma services and improve access to essential lifesaving care, which will expire on September 30.

The College has long advocated for funding to support trauma care, and the ACS Division of Advocacy and Health Policy is working with champions in Congress to reauthorize these programs so that efforts to secure funding can continue. For example, in the 113th Congress, the House of Representatives passed ACS-supported legislation, the Trauma Systems and Regionalization of Emergency Care Reauthorization Act, but the bill stalled in the Senate.

The legislation has been reintroduced in the 114th Congress as H.R. 648, along with companion legislation, the Access to Life-Saving Trauma Care for All Americans Act, H.R. 647. The House Committee on Energy and Commerce has reviewed and approved both bills. At press time, they were headed to the House floor, where they were likely to be passed with little opposition. The College is working diligently to inform senators of the importance of these programs in order to facilitate their passage. Enactment of this legislation is only the first step. If these bills achieve passage and are signed by the president, ACS advocacy efforts will shift to the appropriations process to try to secure funding for these important programs.

How can surgeons help advocate for extending these important programs?

Surgeons can help by letting their representatives and senators know that these programs are important to them and their patients. The College provides many educational programs and resources to facilitate this type of activity, including the following:

  • The annual Leadership & Advocacy Summit, which will take place April 18–24 this year (more information can be found on the ACS website)
  • The SurgeonsVoice website, which contains issue briefs and draft e-mail communications to send to your congressional delegation
  • Occasional e-mail alerts regarding time-sensitive votes

Consider taking advantage of these opportunities to let Congress know which ACA and other health care programs are important to you and the patients you serve.


*Congressional Research Service. Discretionary Spending Under the Affordable Care Act (ACA). Available at: www.fas.org/sgp/crs/misc/R41390.pdf. Accessed February 19, 2015.

Ollapally V. What surgeons should know about…Incentive payments for operations furnished in HPSAs. Bull Am Coll Surg. 2011;96(4):12-13.

American College of Surgeons website. Trauma and EMS: Trauma bills reintroduced in the House. Available at: www.facs.org/advocacy/federal/trauma-and-ems. Accessed February 19, 2015.

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