Preliminary Estimate of Effects on Direct Spending and Revenues for Title V, Subtitle B, of Senate Amendment 4333, a Substitute for

H.R. 4213, the American Jobs and

Closing Tax Loopholes Act of 2010
(As introduced on June 9, 2010)
Assumed enactment July 1, 2010
By fiscal year, in billions of dollars.

2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2010- 2010-
2015 2020

Changes in Direct Spending Outlays

Part I Physician Payment Update 1/

511 Physician Payment Update 3.1 16.3 21.3 5.9 -2.5 -1.8 -1.4 -0.5 0.4 1.1 1.4 42.3 43.3

Part II Extension of Expiring Provisions 1/

521 MMA Section 508 Reclassifications 0 0.3 * 0 0 0 0 0 0 0 0 0.3 0.3
522 Medicare Work Geographic Adjustment Floor 0 0.4 0.2 0 0 0 0 0 0 0 0 0.6 0.6
523 Exceptions Process for Medicare Therapy Caps 0.3 0.5 0.2 0 0 0 0 0 0 0 0 1.1 1.1
524 Payment for Technical Component of Certain Physician Pathology
Services * 0.1 * 0 0 0 0 0 0 0 0 0.1 0.1
525 Ambulance Add-Ons * 0.1 * 0 0 0 0 0 0 0 0 0.1 0.1
526 Physician Fee Schedule Mental Health Add-On Payment * * * 0 0 0 0 0 0 0 0 0.1 0.1
527 Outpatient Hold Harmless Provision 0 0.2 0.1 0 0 0 0 0 0 0 0 0.3 0.3
528 Medicare Reasonable Costs Payments for Certain Clinical
Diagnostic Laboratory Tests Furnished to Hospital Patients in
Certain Rural Areas 0 * * * 0 0 0 0 0 0 0 * *
529 Qualifying Individual (QI) Program 0 0.6 0.2 0 0 0 0 0 0 0 0 0.8 0.8
530 Transitional Medical Assistance (TMA) 0 0.2 0.5 * 0 0 0 0 0 0 0 0.8 0.8
531 DRA Court Improvement Grants 0 * * * * 0 0 0 0 0 0 * *

Part III Changes to the Patient Protection and Affordable Care Act and Additional Provisions

Subpart A Changes to the Patient Protection and Affordable Care Act and Additional Provisions
541 Expansion of Affordability Exception to Individual Mandate 2/ 0 0 0 0 0.3 -0.3 -0.7 -0.2 -0.8 -1.2 -1.2 -0.1 -4.2
542 Replacement of Medicaid Primary Care Payment Cliff 0 0 0 -0.7 -0.2 0.4 0.3 * -0.1 0 0 -0.5 -0.3
543 CMS-IRS data match 2/ 0 0 * * -0.1 -0.1 -0.1 -0.1 -0.1 -0.1 -0.1 -0.2 -0.4
544 Funding for claims processing 0.1 0.1 0 0 0 0 0 0 0 0 0 0.2 0.2

Subpart B Medical Liability Reform (interacted with other provisions) 0 -0.4 -1.3 -2.5 -4.1 -5.4 -6.2 -6.7 -7.2 -7.6 -8.1 -13.9 -49.7

INTERACTIONS
Medicare DSH Interaction with Coverage Provisions 0 0 0 0 * 0.2 0.3 0.4 0.4 0.5 0.5 0.2 2.5
Medicare Advantage Interaction 0.1 0.8 5.4 1.5 -0.6 -0.4 -0.3 * 0.1 0.3 0.2 6.8 7.2
Premium Interactions 0 -2.8 -4.6 -1.3 0.7 0.5 0.4 0.1 -0.1 -0.3 -0.3 -7.6 -7.8
TRICARE Interaction 0.1 0.3 0.4 0.1 * * * * * * * 0.8 0.8
IPAB Interaction 0 0 0 0 0 0 0 0 0.9 0.6 0.7 0 2.2

Total, Changes in On-Budget Direct Spending 3.7 16.7 22.6 2.9 -6.6 -7.0 -7.7 -7.0 -6.3 -6.6 -6.9 32.3 -2.2
Total, Changes in Unified-Budget Direct Spending 3.7 16.7 22.6 2.9 -6.6 -7.0 -7.7 -7.0 -6.3 -6.6 -6.9 32.3 -2.2

Congressional Budget Office Page 1 of 2 June 10, 2010

Preliminary Estimate of Effects on Direct Spending and Revenues for Title V, Subtitle B, of Senate Amendment 4333, a Substitute for H.R. 4213, the American Jobs and
Closing Tax Loopholes Act of 2010
(As introduced on June 9, 2010)
Assumed enactment July 1, 2010
By fiscal year, in billions of dollars.

2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2010- 2010-
2015 2020

Changes in Revenues

On-Budget
Coverage Provisions 2/ 0 0 0 0 -0.2 -0.1 0.3 1.2 1.6 1.5 1.5 -0.3 5.8
Medical Liability Provisions 0 0.2 0.6 1.0 1.1 1.1 1.5 1.6 1.2 1.2 1.2 4.0 10.6
Subtotal, On-budget revenues 0 0.2 0.6 1.0 0.9 1.1 1.7 2.8 2.8 2.7 2.7 3.7 16.4

Off-Budget
Coverage Provisions 2/ 0 0 0 0 -0.1 0.2 0.1 * 0.4 0.4 0.4 0.1 1.4
Medical Liability Provisions 0 * * * 0.3 0.5 0.2 0.2 0.5 0.5 0.5 0.8 2.7
Subtotal, Off-budget revenues 0 * * * 0.2 0.7 0.3 0.2 0.9 0.9 0.9 0.9 4.1

Total, Changes in Unified-Budget Revenues 0 0.2 0.6 1.0 1.1 1.7 2.0 3.0 3.7 3.6 3.6 4.6 20.4

Changes in Deficits
Changes in on-budget deficits 3.7 16.4 22.0 2.0 -7.4 -8.0 -9.5 -9.8 -9.1 -9.3 -9.6 28.6 -18.6
Changes in unified budget deficits 3.7 16.4 22.0 2.0 -7.7 -8.7 -9.7 -10.0 -10.1 -10.2 -10.5 27.8 -22.7

Memorandum
Effects on Deficits (combined effects on direct spending outlays and revenues) of:
Coverage Provisions (unified budget) 3/ 0 0 0 0 0.6 -0.2 -0.7 -1.0 -2.4 -2.6 -2.6 0.4 -8.9
Medical Liability Provisions (unified budget) 0 -0.6 -1.9 -3.5 -5.6 -7.1 -7.9 -8.5 -8.8 -9.3 -9.8 -18.6 -63.0

NOTES:
" * " is between $50 million and -$50 million.
Components may not sum to totals because of rounding.

1/ Estimates for individual sections do not include MA, Part B premiums, Medicaid, TRICARE, or IPAB interactions.
2/ Included in table provided by the Joint Committee on Taxation.
3/ Includes interaction with Medicare payments to disproportionate share hospitals.

CHIP = Children's Health Insurance Program; CMS = Centers for Medicare & Medicaid Services; FMAP = federal medical assistance percentage;
IPAB = Independent Payment Advisory Board; RUG-IV = Resource Utilization Group, version four.

Total Spending for Section 511: Physician payment update - including estimated
interactions with Medicare Advantage, Medicaid, TRICARE, Part B Premiums, and IPAB 3.1 14.7 22.5 6.2 -2.4 -1.8 -1.4 -0.5 0.4 1.0 1.3 42.3 43.2

Congressional Budget Office Page 2 of 2 June 10, 2010