~» Congressional Budget Office \y Nonpartisan Analysis for the U.S. Congress aad Sa "BUDGET SPOTLIGHT ©Orhan Cam/Shutterstock.com APRIL | 2023 The Medicare and Medicaid Improvement Funds: Budgetary History and Projections In 2008, lawmakers established the Medicare Improvement Fund and the Medicaid Improvement Fund. Since then, more than 30 laws adding or removing resources for the funds have been enacted. Medicare and the federal component of Medicaid are administered by the Centers for Medicare & Medicaid Services (CMS) within the Department of Health and Human Services (HHS). CMS has not spent money from either fund since their establishment. Medicare is a federal health insurance program for people age 65 or older and for younger people with long-term disabilities or end-stage renal disease. The purpose of the Medicare Improvement Fund is to generally improve the original Medicare program (the parts that provide hospital and medical insurance, commonly known as Parts A and B), in ways that may include adjusting the amounts that Medicare pays to health care providers and suppliers. The fund has $180 million available to spend for services furnished during and after 2022. Medicaid is a joint federal-state program that covers acute and long-term health care for groups of low-income people, chiefly families with dependent children, elderly people (those age 65 or older), nonelderly people with disabilities, and-at the discretion of individual states-other non- elderly adults whose family income is up to 138 percent of the federal poverty guidelines. The Medicaid Improvement Fund was established to improve management of the Medicaid program in ways that may include oversight of contracts and contractors and evaluation of certain projects. It was expanded in recent years to support computer systems for processing health insurance claims. Currently, the fund has $7 billion available to spend in 2028 and later. The Congressional Budget Office periodically reviews federal spending on Medicare and Medicaid while preparing the federal budget projections (or baseline) that the agency uses to produce estimates of the budgetary effects of legislation (cost estimates). This Budget Spotlight describes features of the Medicare and Medicaid improvement funds and how the funds are accounted for in CBO's baseline and cost estimates. Notes: Unless this report indicates otherwise, all years referred to are federal fiscal years, which run from October 1 to September 30 and are designated by the calendar year in which they end. All amounts are in nominal dollars {in other words, not adjusted for inflation). This brief is one of a series of reports examining trends in funding and spending for particular federal programs and how CBO accounis for those trends when preparing its baseline and cost estimates. 2 THE MEDICARE AND MEDICAID IMPROVEMENT FUNDS APRIL 2023 How Are Resources Provided to the Improvement Funds? Legislation specifies how much is available to be spent from each fund. Outlays from the funds are classified as mandatory spending. The amounts spent from the Medicare Improvement Fund are to be drawn from Medicare's Hospital Insurance (HI) Trust Fund and its Supplementary Medical Insurance (SMI) Trust Fund. 'The amounts spent from the Medicaid Improvement Fund are to come from the general fund of the Treasury. To obligate any portion of the funds (in other words, to increase payment rates or take other actions that would result in outlays), the Secretary of HHS must deter- mine that the available amounts are sufficient to cover the intended activity, and the Chief Actuary of CMS and the "appropriate budget officer" must certify that determination. What Are the Authorized Uses of the Funds? 'The original purpose of the Medicare fund was "to make improvements under the original [Medicare] fee-for- service program under parts A [Hospital Insurance] and B [Medical Insurance] for individuals entitled to, or enrolled for, benefits under part A or enrolled under part B."' The Congress has since amended the name and purpose of the fund several times; the last change to the purpose of the fund was made in October 2014. Today, the purpose is similar to that in the 2008 statute, but the permissible activities have been expanded to include "adjustments to payments for items and services fur- nished by providers of services and suppliers under such original Medicare fee-for-service program."" In other words, the funding may be used to make improvements to Medicare's hospital and medical insurance programs in ways that may include adjusting the amounts that Medicare pays to health care providers. Originally, the Medicaid Improvement Fund was to be used to improve program management, conduct over- sight of contracts and contractors, or evaluate demon- stration projects (projects that explore new approaches on a small scale for potential wider use). The purpose of the fund was expanded by the HEALTHY KIDS Act (Public Law 115-120, division C), which added use for state activities relating to designing, devel- oping, installing, or operating computer systems for 1. Sec. 7002 of Supplemental Appropriations Act, 2008, Public Law 110-252, 122 Stat. 2323, 2394. 2. 42 U.S.C. §1395iii(@) (2018 & Supp.). processing Medicaid claims electronically. Subsequently, the Continuing Appropriations Act, 2020, and Health Extenders Act of 2019 (PL. 116-59) eliminated fund- ing for the originally enacted goal of improving "the management of the Medicaid program by the Centers for Medicare & Medicaid Services, including oversight of contracts and contractors and evaluation of demon- stration projects," although that goal remains part of the fund's statutory purpose.' When Are Funds Available to Be Spent? Legislation specifies when money can be spent from the funds. For both funds, that period of availability has often been well after the year in which the legislation making the funds available was enacted.' For example, when the Medicare Improvement Fund was established in 2008, funds were available for services furnished during 2014. The length of time between the date of leg- islation and the year in which amounts in the Medicare Improvement Fund are first available has tended to decrease (see Figure 1). Not until enactment of the Consolidated Appropriations Act, 2021 (PL. 116-260), in December 2020, were funds available for services per- formed in the then-current fiscal year. Currently, funds are available to the Medicare fund to be spent during and after 2022. Likewise, funding for the Medicaid Improvement Fund has often been unavailable until after the year in which the enabling legislation was enacted (see Figure 2). That is true for both the funding available for the original statutory purpose (under 42 U.S.C. §1396w-1(b)(1)), referred to in this report as general funds, and the fund- ing available for computer systems (under 42 U.S.C. §1396w-1(b)(3)(A)), referred to as additional funds. When the fund was established in 2008, funds were available for 2014 through 2018. Not until 2023 was the year specified in the statute for the availability of the Medicaid Improvement Fund's general funds the current fiscal year; however, the amount currently designated is zero. In January 2018, when a separate category of funding was made available for state activities relating 3. Sec. 7002(b) of Supplemental Appropriations Act, 2008, PL. 110-252, 122 Stat. at 2395; 42 U.S.C. §1396w-1(a) (2018 & Supp.). 4. Since the establishment of the funds, CMS has had the authority to obligate the amounts in them before the period specified in law. 42 U.S.C. §1395iii(b) (3); 1396w-1(b)(2) (2018 & Supp.). The agency has never exercised that authority. This Budget Spotlight does not account for potential use of that authority. APRIL 2023 THE MEDICARE AND MEDICAID IMPROVEMENT FUNDS 3 Figure 1. Date Funding Was Enacted for the Medicare Improvement Fund Versus Year Funds Were First Available, by Enacting Legislation ae se Sai Ae gat apt of oe P.L. 110-252 Oo P.L. 110-275 oO P.L. 110-379 Oo P.L. 111-5 Oo P.L. 111-118 P.L. 111-148 @ @ @ @ O--__------® »oo--_-_6 P.L. 111-309 O--_----_-® O---__-* O------® Oo--_---_* Oo P.L. 112-240 P.L. 113-82 P.L. 113-93 P.L. 113-185 P.L. 114-10 OO P.L. 114-60 Oo-__--_® P.L. 114-113 O-__® P.L. 114-115 O-____"--_* P.L. 114-198 o-___----_-® P.L. 114-255 O-__® P.L. 115-63 O--__® P.L. 115-123 O--_-_----* P.L. 116-260 @0 P.L. 117-43 eo P.L. 117-70 eo P.L. 117-71 @e-_o P.L. 117-86 @e-_o P.L. 117-103 e-_o P.L. 117-159 @-o P.L. 117-180 @e-o P.L. 117-229 @e--_o P.L. 117-328 @e--_o l 1 1 1 1 2008 2010 2012 2014 2016 2018 2020 2022 2024 %& Funding Level Set to Zero Data source: Congressional Budget Office. See www.cbo.gov/publication/59055#data. The open circles show when legislation specifying funding for the fund was enacted. The solid circles show the first year in which the legislation made funds available for expenditure. Table 1 identifies the titles of all 29 laws. P.L. 111-148 set the funding for 2014 at zero but set a positive funding level for 2015. P.L. 111- 309 reduced the funding level for 2015, and PLL. 112-240 set it to zero. Subsequently, P.L 113-82 removed references to 2014 and 2015 and made funds available for 2017. Not until fiscal year 2021 was the year specified in the statute for the availability of funds in the Medicare Improvement Fund the current fiscal year. to computer systems for processing insurance claims How Has Funding for the Medicare electronically, that additional funding was designated Improvement Fund Changed Over for availability in 2023 and thereafter. And when the Time? Consolidated Appropriations Act, 2023 (PL. 117-328), In 2008, $2.2 billion was made available (to be drawn enacted in December 2022, made $7 billion available from the Medicare trust funds) to be spent by the for such purposes, availability of funds was delayed Medicare Improvement Fund for services furnished until 2028, during 2014. Since then, a positive amount of fund- ing has been specified (typically for use in future years) 4 THE MEDICARE AND MEDICAID IMPROVEMENT FUNDS APRIL 2023 Figure 2. Date Funding Was Enacted for the Medicaid Improvement Fund Versus Year Funds Were First Available, by Enacting Legislation and Type of Funds yes st 6 oe es wees os?" we" P.L. 110-252 o-____---® P.L.111-8 o-_----® P.L.111-127 o------_-® Saal: P.L. 111-148 o---_--_* oo ri aXe a qu a P.L. 114-198 o--_-_Y-Y-® 0% o™ eg po P.L. 115-120 oo P.L. 115-123 Oo--_-_>*-* P.L. 115-271 Oo----@----* P.L. 116-3 Oo---e---* P.L. 116-29 O-@-_--** P.L. 116-59 o--+? P.L. 116-69 o*K"® P.L. 116-159 o--_*-® P.L. 116-215 o--_*--® P.L. 116-260 o--_*--* P.L. 117-328 +o-_____---_-® L 1 1 1 1 2008 2010 2012 2014 2016 1 1 1 1 1 J 2018 2020 2022 2024 2026 2028 2030 Funding Level Set to Zero Data source: Congressional Budget Office. See www.cbo.gov/publication/59055#data. The open circles show when legislation specifying funding for the fund was enacted. The solid circles show the first year in which the legislation made funds available for expenditure. "General Funds" refers to funding available to the Medicaid Improvement Fund under 42 U.S.C. §1396w-1(b)(1) for improving program management, conducting oversight, or evaluating demonstration projects; "Additional Funds" refers to funding available under 42 U.S.C. §1396w-1(b)(3)(A) for state activities relating to computer systems for processing insurance claims; P.L. 115-120 was the first law to provide such funding. Not until fiscal year 2023 was the year specified in the statute for the availability of the general funds the current fiscal year; however, the current funding is zero. Table 2 identifies the titles of all 16 laws. during some portion of all but two fiscal years. 'The amount of funding available has been changed 28 times since the fund was established. Specifically, lawmakers have increased the amount of funding available to the Medicare Improvement Fund 11 times and decreased it 17 times (see Table 1). The Medicare Improvements for Patients and Providers Act of 2008 (PL. 110-275) and the Patient Protection and Affordable Care Act (PL. 111-148) enacted in 2010 made the largest changes, respectively increasing and decreasing the amount of available funding by approximately $20 bil- lion (see Figure 3). APRIL 2023 THE MEDICARE AND MEDICAID IMPROVEMENT FUNDS %& Table 1. Changes in the Amount of Funding for the Medicare Improvement Fund Millions of Dollars Date Funding Changein PublicLaw Title Enacted Amount Funding 110-252 Supplemental Appropriations Act, 2008 06/30/08 2,220 2,220 110-275 Medicare Improvements for Patients and Providers Act of 2008 07/15/08 22,120 19,900 110-379 QI Program Supplemental Funding Act of 2008 10/08/08 22,190 70 111-5 American Recovery and Reinvestment Act of 2009 02/17/09 22,290 100 111-118 Department of Defense Appropriations Act, 2010 12/19/09 21,290 -1,000 111-148 Patient Protection and Affordable Care Act 03/23/10 550 ~-s--20,740 111-309 Medicare and Medicaid Extenders Act of 2010 12/15/10 275 -275 112-240 American Taxpayer Relief Act of 2012 01/02/13 0 -275 113-82 An act to ensure that the reduced annual cost-of-living adjustment to the retired pay of members and former members of the Armed Forces under the age of 62 required by the Bipartisan Budget Act of 2013 will not apply to members or former members who first became members prior to January 1, 2014, and for other purposes 02/15/14 2,300 2,300 113-93 Protecting Access to Medicare Act of 2014 04/01/14 0 -2,300 113-185 IMPACT Act of 2014 10/06/14 195 195 114-10 Medicare Access and CHIP Reauthorization Act of 2015 04/16/15 0 -195 114-60 Protecting Affordable Coverage for Employees Act 10/07/15 205 205 114-113 Consolidated Appropriations Act, 2016 12/18/15 5 -200 114-115 Patient Access and Medicare Protection Act 12/28/15 0 5 114-198 Comprehensive Addiction and Recovery Act of 2016 07/22/16 140 140 114-255 21st Century Cures Act 12/13/16 270 130 115-63 Disaster Tax Relief and Airport and Airway Extension Act of 2017 09/29/17 220 -50 115-123 Bipartisan Budget Act of 2018 02/09/18 0 -220 116-260 Consolidated Appropriations Act, 2021 12/27/20 165 165 117-43 Extending Government Funding and Delivering Emergency Assistance Act 09/30/21 69 -96 117-70 Further Extending Government Funding Act 12/03/21 56 -13 117-71 Protecting Medicare and American Farmers From Sequester Cuts Act 12/10/21 101 45 117-86 Further Additional Extending Government Funding Act 02/18/22 99 -2 117-103 Consolidated Appropriations Act, 2022 03/15/22 5 -94 117-159 Bipartisan Safer Communities Act 06/25/22 7,500 7,495 117-180 Continuing Appropriations and Ukraine Supplemental Appropriations Act, 2023 09/30/22 7,308 -192 117-229 Further Continuing Appropriations and Extensions Act, 2023 12/16/22 7,278 -30 117-328 Consolidated Appropriations Act, 2023 12/29/22 180 -7,098 Data source: Congressional Budget Office. See www.cbo.gov/publication/59055#data. Amounts displayed reflect changes in total funding available to the fund as specified by legislation. They do not reflect delays to when funds are available for expenditure and are not adjusted for the effects of inflation. From its establishment in 2008 through March 2010, expenditure in any year. In June 2022, funding rose the amount in the Medicare fund ranged from briefly from zero to $7.5 billion before falling again in $2.2 billion to $22.3 billion and averaged $21.6 bil- December of that year. As of the publication of this docu- lion. From March 2010 through June 2022, funding ment, $180 million is available to be drawn from the HI averaged $157 million. During two fiscal years in that and SMI trust funds for improvement activities relating period (2019 and 2020), no funding was available for to Medicare services furnished during and after 2022. 6 THE MEDICARE AND MEDICAID IMPROVEMENT FUNDS APRIL 2023 Figure 3. Funding Levels and Major Changes in Funding for the Medicare Improvement Fund Billions of Dollars 25 , +$19.9 PL110-275 20 F Funding levels for the Medicare Improvement 15 7 Fund have varied greatly. Funding has generally been less than $500 million 10 + +$7.5 P.L. 117-4 59 but has periodically been increased and decreased 5 L $2.2 +$2.3 by billions of dollars. P.L. 110-252 P.L, 113-82 \ -$20.7 "- -§2.3 -$7.1 PL. 117-328 é 6 PL. 111-148 P.L. 113-93 i | v 0 2007 2009 2011 2013 2015 2017 2019 2021 2023 Data source: Congressional Budget Office. See www.cbo.gov/publication/59055#data. Funding levels and changes in funding levels displayed reflect total amounts made available to the fund by legislation. They do not reflect delays to when funds are available for expenditure and are not adjusted for the effects of inflation. PLL. 110-252 = Supplemental Appropriations Act, 2008; P.L. 110-275 = Medicare Improvements for Patients and Providers Act of 2008; PLL. 111-148 = Patient Protection and Affordable Care Act; P.L. 113-82 = An act to ensure that the reduced annual cost-of-living adjustment to the retired pay of members and former members of the Armed Forces under the age of 62 required by the Bipartisan Budget Act of 2013 will not apply to members or former members who first became members prior to January 1, 2014, and for other purposes; P.L. 113-93 = Protecting Access to Medicare Act of 2014; PLL. 117-159 = Bipartisan Safer Communities Act; P.L. 117-328 = Consolidated Appropriations Act, 2023. How Has Funding for the Medicaid improvement Fund Changed Over Time? The Medicaid Improvement Fund was established with $250 million in initial funds-$100 million available for expenditure in 2014 and $150 million available for the period from 2015 through 2018. Since the fund's establishment, funding has been specified (typically for use in future years) during some portion of all but six fiscal years (2011 through 2015, and 2022) and the amount of funding available has been changed 15 times. Specifically, lawmakers have increased the amount of available funding 8 times and decreased it 7 times (see Table 2). The greatest changes stemmed from the Consolidated Appropriations Act, 2021 (PL. 116-260), which decreased the amount of available funding by $3.5 billion, and the Consolidated Appropriations Act, 2023 (PL. 117-328), which increased funding by $7.0 billion (see Figure 4). Funding averaged $512 million from 2008 to March 2010 and $6 million from March 2010 to September 2019 (no funding was available during most of that period). Funding levels have varied between zero and $7 billion since September 2019. Have Outlays Been Made From Either improvement Fund? No funds have been spent by CMS from either improve- ment fund since their establishment in 2008. How Does CBO's Baseline Account for Future Spending From the Improvement Funds? CBO's baseline is a set of detailed projections of fed- eral spending, revenues, deficits or surpluses, and debt for the current year and the decade that follows. Those projections inform policymakers about budgetary trends and the nation's fiscal condition under current law; they APRIL 2023 THE MEDICARE AND MEDICAID IMPROVEMENT FUNDS "7 Table 2. Changes in the Amount of Funding for the Medicaid Improvement Fund Millions of Dollars Date Funding Changein PublicLaw Title Enacted Amount Funding 110-252 Supplemental Appropriations Act, 2008 06/30/08 250 250 111-8 Omnibus Appropriations Act, 2009 03/11/09 700 450 111-127 Emergency Aid to American Survivors of the Haiti Earthquake Act 01/27/10 610 -90 111-148 Patient Protection and Affordable Care Act 03/23/10 0 -610 114-198 Comprehensive Addiction and Recovery Act of 2016 07/22/16 5 5 115-120 Division C, HEALTHY KIDS Act 01/22/18 985 980 115-123 Bipartisan Budget Act of 2018 02/09/18 0 -985 115-271 SUPPORT for Patients and Communities Act 10/24/18 31 31 116-3 Medicaid Extenders Act of 2019 01/24/19 6 -25 116-29 An act to provide for a 2-week extension of the Medicaid community mental health services demonstration program, and for other purposes 07/05/19 1 5 116-59 Continuing Appropriations Act, 2020, and Health Extenders Act of 2019 09/27/19 2,387 2,386 116-69 Further Continuing Appropriations Act, 2020, and Further Health Extenders Act of 2019 11/21/19 1,960 -427 116-159 Continuing Apprpriations Act, 2021 and Other Extensions Act 10/01/20 3,446 1,486 116-215 Further Continuing Appropriations Act, 2021, and Other Extensions Act 12/11/20 3,464 18 116-260 Consolidated Appropriations Act, 2021 12/27/20 0 -3,464 117-328 Consolidated Appropriations Act, 2023 12/29/22 7,000 7,000 Data source: Congressional Budget Office. See www.cbo.gov/publication/59055#data. Amounts displayed reflect changes in total funding available to the fund under 42 U.S.C. §1396w-1(b)(1) and 42 U.S.C. §1396w-1(b)(3)(A), as specified by legislation. They do not reflect delays to when funds are available for expenditure and are not adjusted for the effects of inflation. are not meant to predict future outcomes, because they cannot account for future legislation.' Rather, they are meant to provide a benchmark that policymakers can use to assess the potential effects of policy decisions. Most of the principles and rules that govern how the baseline is formulated are set in law, such as in the Balanced Budget and Emergency Deficit Control Act of 1985 (PL. 99-177) and in the Congressional Budget Act of 1974 (PL. 93-344). If current law includes funding for the improvement funds, CBO's baseline projections of the Medicare and Medicaid programs reflect the assumption that funding will be spent on the purposes specified in law. CBO also projects that CMS would eventually spend 5. Congressional Budget Office, CBO Explains How It Develops the Budget Baseline (April 2023), www.cbo.gov/publication/58916. all the available funding-generally within five years of the initial year in which funding is first available. For example, in its February 2023 baseline, CBO included $7 billion in spending from the Medicaid Improvement Fund, spread over the 2028-2031 period, because the Consolidated Appropriations Act, 2023, made $7 billion available starting in 2028. CBO's projections of how quickly funds would be spent are based on the agency's analysis of how CMS has spent other funds provided for administrative activities. How Does CBO Estimate the Budgetary Effects of Changes to the Improvement Funds? Because CBO assumes that CMS would eventually spend all the funding available in the improvement funds, the agency estimates that legislative proposals to reduce the available amounts would reduce the federal 8 THE MEDICARE AND MEDICAID IMPROVEMENT FUNDS APRIL 2023 Figure 4. Funding Levels and Major Changes in Funding for the Medicaid Improvement Fund Billions of Dollars 7 - J) a +§7.0 P.L. 117-328 +$1.5 P.L. 116-159 \ +$2.4 PL. 116-59 \ -$3.5 | P.L116-260 ote v 2007 2009 2011 2013 2015 2017 2019 2021 2023 Data source: Congressional Budget Office. See www.cbo.gov/publication/59055#data. Funding levels and changes in funding levels displayed reflect total amounts available to the fund under 42 U.S.C. §1396w-1(b)(1} and 42 U.S.C. §1396w-1(b)(3)(A), as specified by legislation. Funding levels and changes do not reflect delays to when funds are available for expenditure and are not adjusted for the effects of inflation. PLL. 116-59 = Continuing Appropriations Act, 2020, and Health Extenders Act of 2019; PLL. 116-159 = Continuing Apprpriations Act, 2021 and Other Extensions Act; PL. 116-260 = Consolidated Appropriations Act, 2021; P.L. 117-328 = Consolidated Appropriations Act, 2023. budget deficit.6 Conversely, the agency estimates that proposals to increase the available amounts would 6. Congressional Budget Office, CBO Describes lis Cost-Estimating Process (April 2023), www.cbo.gov/publication/59003. Funding levels for the Medicaid Improvement Fund have varied greatly. Funding has frequently been zero and generally been less than $1 billion. increase the deficit. (For examples, see Table 3, which focuses on CBO's estimates for legislation enacted during calendar year 2022 that amended the amount of avail- able funding for the improvement funds.) APRIL 2023 THE MEDICARE AND MEDICAID IMPROVEMENT FUNDS Table 3. Estimated Budgetary Effects of Legislation Amending the Medicare and Medicaid Improvement Funds During Calendar Year 2022 Change in Millions of Dollars Net Effect on Medicare Medicaid All Other the Deficit Date Improvement Improvement Direct (Millions of PublicLaw Title Enacted Fund Fund Spending Revenues dollars) 117-86 Further Additional Extending Government Funding Act? 02/18/22 -2 0 2 na. 0 117-103 Division P, Health Provisions, Consolidated Appropriations Act, 2022° 03/15/22 -94 0 50 -44 0 117-159 Bipartisan Safer Communities Act' 06/25/22 7,495 0 -12,265 12 -4,782 117-180 Division D, Health and Human Services Extensions, Continuing Appropriations and Ukraine Supplemental Appropriations Act, 2023° 09/30/22 -192 0 192 * 0 117-229 Division C, Health and Human Services, Further Continuing Appropriations and Extensions Act, 2023° 12/16/22 -30 0 30 na. 0 117-328 Division FF, Health and Human Services, Consolidated Appropriations Act, 2023' 12/29/22 -7,098 7,000 -8,289 821 -9,208 Data source: Congressional Budget Office. See www.cbo.gov/publication/59055#data. n.a. = not applicable; * = between zero and $500,000. a. See Congressional Budget Office, cost estimate for H.R. 6617, the Further Additional Extending Government Funding Act (February 7, 2022), www.cbo.gov/ publication/57830. . See Congressional Budget Office, cost estimate for H.R. 2471, the Consolidated Appropriations Act, 2022 (March 14, 2022), www.cbo.gov/publication/57928. . See Congressional Budget Office, "Estimated Budgetary Effects of S. 2938, the Bipartisan Safer Communities Act" (June 22, 2022), www.cbo.gov/ publication/58238. . See Congressional Budget Office, cost estimate for Senate Amendment Number 5745 to H.R. 6833, the Continuing Appropriations and Ukraine Supplemental Appropriations Act, 2023 (September 28, 2022), www.cbo.gov/publication/58538. . See Congressional Budget Office, "Estimated Discretionary Appropriations Under Division A of the Further Continuing Appropriations and Extensions Act, 2023" (December 14, 2022), www.cbo.gov/publication/58866. See Congressional Budget Office, "CBO Estimate for Divisions O Through MM of H.R. 2617, the Consolidated Appropriations Act, 2023" (January 12, 2023), www.cbo.gov/publication/58901. This document was prepared to enhance the transparency of the work of the Congressional Budget Office. In keeping with CBO's mandate to provide objective, impartial analysis, the document makes no recommendations. Stuart Hammond and Russell Krupen wrote the document with major contributions and coordination from Ann E. Futrell and with guidance from Chad Chirico and Paul Masi. Mark Hadley, Jeffrey Kling, and Robert Sunshine reviewed the report. Lora Engdahl edited it, and Casey Labrack created the graphics and prepared the text for publication. This budget spotlight is available at www.cbo.gov/publication/59055. CBO seeks feedback to make its work as useful as possible. Please send comments to communications@cbo.gov. Phillip L. Swagel Director