An amendment printed in Part C of House Report 111-330 to codify the Hyde Amendment in H.R. 3962. The amendment prohibits federal funds for abortion services in the public option. It also prohibits individuals who receive affordability credits from purchasing a plan that provides elective abortions. However, it allows individuals, both who receive affordability credits and who do not, to separately purchase with their own funds plans that cover elective abortions. It also clarifies that private plans may still offer elective abortions.

AFFORDABLE HEALTH CARE FOR AMERICA ACT

Mr. WAXMAN. Mr. Speaker, pursuant to House Resolution 903, I call up
the bill (H.R. 3962) to provide affordable, quality health care for all
Americans and reduce the growth in health care spending, and for other
purposes, and ask for its immediate consideration in the House.
The Clerk read the title of the bill.
The SPEAKER pro tempore. Pursuant to House Resolution 903, the
amendment printed in part A of House Report 111-330, perfected by the
modification printed in part B of the report is adopted and the bill,
as amended, is considered read.
The text of the bill, as amended, is as follows:

H.R. 3962

Be it enacted by the Senate and House of Representatives of
the United States of America in Congress assembled,

SECTION 1. SHORT TITLE; TABLE OF DIVISIONS, TITLES, AND
SUBTITLES.

(a) Short Title.--This Act may be cited as the ``Affordable
Health Care for America Act''.
(b) Table of Divisions, Titles, and Subtitles.--This Act is
divided into divisions, titles, and subtitles as follows:

DIVISION A--AFFORDABLE HEALTH CARE CHOICES

TITLE I--IMMEDIATE REFORMS
TITLE II--PROTECTIONS AND STANDARDS FOR QUALIFIED HEALTH BENEFITS PLANS
Subtitle A--General Standards
Subtitle B--Standards Guaranteeing Access to Affordable Coverage
Subtitle C--Standards Guaranteeing Access to Essential Benefits
Subtitle D--Additional Consumer Protections
Subtitle E--Governance
Subtitle F--Relation to Other Requirements; Miscellaneous
TITLE III--HEALTH INSURANCE EXCHANGE AND RELATED PROVISIONS
Subtitle A--Health Insurance Exchange
Subtitle B--Public Health Insurance Option

[[Page H12624]]

Subtitle C--Individual Affordability Credits
TITLE IV--SHARED RESPONSIBILITY
Subtitle A--Individual Responsibility
Subtitle B--Employer Responsibility
TITLE V--AMENDMENTS TO INTERNAL REVENUE CODE OF 1986
Subtitle A--Shared Responsibility
Subtitle B--Credit for Small Business Employee Health Coverage Expenses
Subtitle C--Disclosures To Carry Out Health Insurance Exchange
Subsidies
Subtitle D--Other Revenue Provisions

DIVISION B--MEDICARE AND MEDICAID IMPROVEMENTS

TITLE I--IMPROVING HEALTH CARE VALUE
Subtitle A--Provisions related to Medicare part A
Subtitle B--Provisions Related to Part B
Subtitle C--Provisions Related to Medicare Parts A and B
Subtitle D--Medicare Advantage Reforms
Subtitle E--Improvements to Medicare Part D
Subtitle F--Medicare Rural Access Protections
TITLE II--MEDICARE BENEFICIARY IMPROVEMENTS
Subtitle A--Improving and Simplifying Financial Assistance for Low
Income Medicare Beneficiaries
Subtitle B--Reducing Health Disparities
Subtitle C--Miscellaneous Improvements
TITLE III--PROMOTING PRIMARY CARE, MENTAL HEALTH SERVICES, AND
COORDINATED CARE
TITLE IV--QUALITY
Subtitle A--Comparative Effectiveness Research
Subtitle B--Nursing Home Transparency
Subtitle C--Quality Measurements
Subtitle D--Physician Payments Sunshine Provision
Subtitle E--Public Reporting on Health Care-Associated Infections
TITLE V--MEDICARE GRADUATE MEDICAL EDUCATION
TITLE VI--PROGRAM INTEGRITY
Subtitle A--Increased funding to fight waste, fraud, and abuse
Subtitle B--Enhanced penalties for fraud and abuse
Subtitle C--Enhanced Program and Provider Protections
Subtitle D--Access to Information Needed to Prevent Fraud, Waste, and
Abuse
TITLE VII--MEDICAID AND CHIP
Subtitle A--Medicaid and Health Reform
Subtitle B--Prevention
Subtitle C--Access
Subtitle D--Coverage
Subtitle E--Financing
Subtitle F--Waste, Fraud, and Abuse
Subtitle G--Puerto Rico and the Territories
Subtitle H--Miscellaneous
TITLE VIII--REVENUE-RELATED PROVISIONS
TITLE IX--MISCELLANEOUS PROVISIONS

DIVISION C--PUBLIC HEALTH AND WORKFORCE DEVELOPMENT

TITLE I--COMMUNITY HEALTH CENTERS
TITLE II--WORKFORCE
Subtitle A--Primary Care Workforce
Subtitle B--Nursing Workforce
Subtitle C--Public Health Workforce
Subtitle D--Adapting Workforce to Evolving Health System Needs
TITLE III--PREVENTION AND WELLNESS
TITLE IV--QUALITY AND SURVEILLANCE
TITLE V--OTHER PROVISIONS
Subtitle A--Drug Discount for Rural and Other Hospitals; 340B Program
Integrity
Subtitle B--Programs
Subtitle C--Food and Drug Administration
Subtitle D--Community Living Assistance Services and Supports
Subtitle E--Miscellaneous

DIVISION D--INDIAN HEALTH CARE IMPROVEMENT

TITLE I--AMENDMENTS TO INDIAN LAWS
TITLE II--IMPROVEMENT OF INDIAN HEALTH CARE PROVIDED UNDER THE SOCIAL
SECURITY ACT

DIVISION A--AFFORDABLE HEALTH CARE CHOICES

SEC. 100. PURPOSE; TABLE OF CONTENTS OF DIVISION; GENERAL
DEFINITIONS.

(a) Purpose.--
(1) In general.--The purpose of this division is to provide
affordable, quality health care for all Americans and reduce
the growth in health care spending.
(2) Building on current system.--This division achieves
this purpose by building on what works in today's health care
system, while repairing the aspects that are broken.
(3) Insurance reforms.--This division--
(A) enacts strong insurance market reforms;
(B) creates a new Health Insurance Exchange, with a public
health insurance option alongside private plans;
(C) includes sliding scale affordability credits; and
(D) initiates shared responsibility among workers,
employers, and the Government;
so that all Americans have coverage of essential health
benefits.
(4) Health delivery reform.--This division institutes
health delivery system reforms both to increase quality and
to reduce growth in health spending so that health care
becomes more affordable for businesses, families, and
Government.
(b) Table of Contents of Division.--The table of contents
of this division is as follows:

Sec. 100. Purpose; table of contents of division; general definitions.

TITLE I--IMMEDIATE REFORMS

Sec. 101. National high-risk pool program.
Sec. 102. Ensuring value and lower premiums.
Sec. 103. Ending health insurance rescission abuse.
Sec. 104. Sunshine on price gouging by health insurance issuers.
Sec. 105. Requiring the option of extension of dependent coverage for
uninsured young adults.
Sec. 106. Limitations on preexisting condition exclusions in group
health plans in advance of applicability of new
prohibition of preexisting condition exclusions.
Sec. 107. Prohibiting acts of domestic violence from being treated as
preexisting conditions.
Sec. 108. Ending health insurance denials and delays of necessary
treatment for children with deformities.
Sec. 109. Elimination of lifetime limits.
Sec. 110. Prohibition against postretirement reductions of retiree
health benefits by group health plans.
Sec. 111. Reinsurance program for retirees.
Sec. 112. Wellness program grants.
Sec. 113. Extension of COBRA continuation coverage.
Sec. 114. State Health Access Program grants.
Sec. 115. Administrative simplification.

TITLE II--PROTECTIONS AND STANDARDS FOR QUALIFIED HEALTH BENEFITS PLANS

Subtitle A--General Standards

Sec. 201. Requirements reforming health insurance marketplace.
Sec. 202. Protecting the choice to keep current coverage.

Subtitle B--Standards Guaranteeing Access to Affordable Coverage

Sec. 211. Prohibiting preexisting condition exclusions.
Sec. 212. Guaranteed issue and renewal for insured plans and
prohibiting rescissions.
Sec. 213. Insurance rating rules.
Sec. 214. Nondiscrimination in benefits; parity in mental health and
substance abuse disorder benefits.
Sec. 215. Ensuring adequacy of provider networks.
Sec. 216. Requiring the option of extension of dependent coverage for
uninsured young adults.
Sec. 217. Consistency of costs and coverage under qualified health
benefits plans during plan year.

Subtitle C--Standards Guaranteeing Access to Essential Benefits

Sec. 221. Coverage of essential benefits package.
Sec. 222. Essential benefits package defined.
Sec. 223. Health Benefits Advisory Committee.
Sec. 224. Process for adoption of recommendations; adoption of benefit
standards.

Subtitle D--Additional Consumer Protections

Sec. 231. Requiring fair marketing practices by health insurers.
Sec. 232. Requiring fair grievance and appeals mechanisms.
Sec. 233. Requiring information transparency and plan disclosure.
Sec. 234. Application to qualified health benefits plans not offered
through the Health Insurance Exchange.
Sec. 235. Timely payment of claims.
Sec. 236. Standardized rules for coordination and subrogation of
benefits.
Sec. 237. Application of administrative simplification.
Sec. 238. State prohibitions on discrimination against health care
providers.
Sec. 239. Protection of physician prescriber information.
Sec. 240. Dissemination of advance care planning information.

Subtitle E--Governance

Sec. 241. Health Choices Administration; Health Choices Commissioner.
Sec. 242. Duties and authority of Commissioner.
Sec. 243. Consultation and coordination.
Sec. 244. Health Insurance Ombudsman.

Subtitle F--Relation to Other Requirements; Miscellaneous

Sec. 251. Relation to other requirements.
Sec. 252. Prohibiting discrimination in health care.
Sec. 253. Whistleblower protection.
Sec. 254. Construction regarding collective bargaining.
Sec. 255. Severability.
Sec. 256. Treatment of Hawaii Prepaid Health Care Act.
Sec. 257. Actions by State attorneys general.
Sec. 258. Application of State and Federal laws regarding abortion.
Sec. 259. Nondiscrimination on abortion and respect for rights of
conscience.
Sec. 260. Authority of Federal Trade Commission.
Sec. 261. Construction regarding standard of care.
Sec. 262. Restoring application of antitrust laws to health sector
insurers.
Sec. 263. Study and report on methods to increase EHR use by small
health care providers.

[[Page H12625]]

Sec. 264. Performance Assessment and Accountability; Application of
GPRA

TITLE III--HEALTH INSURANCE EXCHANGE AND RELATED PROVISIONS

Subtitle A--Health Insurance Exchange

Sec. 301. Establishment of Health Insurance Exchange; outline of
duties; definitions.
Sec. 302. Exchange-eligible individuals and employers.
Sec. 303. Benefits package levels.
Sec. 304. Contracts for the offering of Exchange-participating health
benefits plans.
Sec. 305. Outreach and enrollment of Exchange-eligible individuals and
employers in Exchange-participating health benefits plan.
Sec. 306. Other functions.
Sec. 307. Health Insurance Exchange Trust Fund.
Sec. 308. Optional operation of State-based health insurance exchanges.
Sec. 309. Interstate health insurance compacts.
Sec. 310. Health insurance cooperatives.
Sec. 311. Retention of DOD and VA authority.

Subtitle B--Public Health Insurance Option

Sec. 321. Establishment and administration of a public health insurance
option as an Exchange-qualified health benefits plan.
Sec. 322. Premiums and financing.
Sec. 323. Payment rates for items and services.
Sec. 324. Modernized payment initiatives and delivery system reform.
Sec. 325. Provider participation.
Sec. 326. Application of fraud and abuse provisions.
Sec. 327. Application of HIPAA insurance requirements.
Sec. 328. Application of health information privacy, security, and
electronic transaction requirements.
Sec. 329. Enrollment in public health insurance option is voluntary.
Sec. 330. Enrollment in public health insurance option by Members of
Congress.
Sec. 331. Reimbursement of Secretary of Veterans Affairs.

Subtitle C--Individual Affordability Credits

Sec. 341. Availability through Health Insurance Exchange.
Sec. 342. Affordable credit eligible individual.
Sec. 343. Affordability premium credit.
Sec. 344. Affordability cost-sharing credit.
Sec. 345. Income determinations.
Sec. 346. Special rules for application to territories.
Sec. 347. No Federal payment for undocumented aliens.

TITLE IV--SHARED RESPONSIBILITY

Subtitle A--Individual Responsibility

Sec. 401. Individual responsibility.

Subtitle B--Employer Responsibility

Part 1--Health Coverage Participation Requirements

Sec. 411. Health coverage participation requirements.
Sec. 412. Employer responsibility to contribute toward employee and
dependent coverage.
Sec. 413. Employer contributions in lieu of coverage.
Sec. 414. Authority related to improper steering.
Sec. 415. Impact study on employer responsibility requirements.
Sec. 416. Study on employer hardship exemption.

Part 2--Satisfaction of Health Coverage Participation Requirements

Sec. 421. Satisfaction of health coverage participation requirements
under the Employee Retirement Income Security Act of
1974.
Sec. 422. Satisfaction of health coverage participation requirements
under the Internal Revenue Code of 1986.
Sec. 423. Satisfaction of health coverage participation requirements
under the Public Health Service Act.
Sec. 424. Additional rules relating to health coverage participation
requirements.

TITLE V--AMENDMENTS TO INTERNAL REVENUE CODE OF 1986

Subtitle A--Provisions Relating to Health Care Reform

Part 1--Shared Responsibility

subpart a--individual responsibility

Sec. 501. Tax on individuals without acceptable health care coverage.

subpart b--employer responsibility

Sec. 511. Election to satisfy health coverage participation
requirements.
Sec. 512. Health care contributions of nonelecting employers.

Part 2--Credit for Small Business Employee Health Coverage Expenses

Sec. 521. Credit for small business employee health coverage expenses.

Part 3--Limitations on Health Care Related Expenditures

Sec. 531. Distributions for medicine qualified only if for prescribed
drug or insulin.
Sec. 532. Limitation on health flexible spending arrangements under
cafeteria plans.
Sec. 533. Increase in penalty for nonqualified distributions from
health savings accounts.
Sec. 534. Denial of deduction for federal subsidies for prescription
drug plans which have been excluded from gross income.

Part 4--Other Provisions to Carry Out Health Insurance Reform

Sec. 541. Disclosures to carry out health insurance exchange subsidies.
Sec. 542. Offering of exchange-participating health benefits plans
through cafeteria plans.
Sec. 543. Exclusion from gross income of payments made under
reinsurance program for retirees.
Sec. 544. CLASS program treated in same manner as long-term care
insurance.
Sec. 545. Exclusion from gross income for medical care provided for
Indians.

Subtitle B--Other Revenue Provisions

Part 1--General Provisions

Sec. 551. Surcharge on high income individuals.
Sec. 552. Excise tax on medical devices.
Sec. 553. Expansion of information reporting requirements.
Sec. 554. Repeal of Worldwide Allocation of Interest.
Sec. 555. Exclusion of Unprocessed fuel from the Cellulosic Biofuel
Producer Credit.

Part 2--Prevention of Tax Avoidance

Sec. 561. Limitation on treaty benefits for certain deductible
payments.
Sec. 562. Codification of economic substance doctrine; penalties.
Sec. 563. Certain large or publicly traded persons made subject to a
more likely than not standard for avoiding penalties on
underpayments.

Part 3--Parity in Health Benefits

Sec. 571. Certain health related benefits applicable to spouses and
dependents extended to eligible beneficiaries.
(c) General Definitions.--Except as otherwise provided, in
this division:
(1) Acceptable coverage.--The term ``acceptable coverage''
has the meaning given such term in section 302(d)(2).
(2) Basic plan.--The term ``basic plan'' has the meaning
given such term in section 303(c).
(3) Commissioner.--The term ``Commissioner'' means the
Health Choices Commissioner established under section 241.
(4) Cost-sharing.--The term ``cost-sharing'' includes
deductibles, coinsurance, copayments, and similar charges,
but does not include premiums, balance billing amounts for
non-network providers, or spending for non-covered services.
(5) Dependent.--The term ``dependent'' has the meaning
given such term by the Commissioner and includes a spouse.
(6) Employment-based health plan.--The term ``employment-
based health plan''--
(A) means a group health plan (as defined in section
733(a)(1) of the Employee Retirement Income Security Act of
1974);
(B) includes such a plan that is the following:
(i) Federal, state, and tribal governmental plans.--A
governmental plan (as defined in section 3(32) of the
Employee Retirement Income Security Act of 1974), including a
health benefits plan offered under chapter 89 of title 5,
United States Code.
(ii) Church plans.--A church plan (as defined in section
3(33) of the Employee Retirement Income Security Act of
1974); and
(C) excludes coverage described in section 302(d)(2)(E)
(relating to TRICARE).
(7) Enhanced plan.--The term ``enhanced plan'' has the
meaning given such term in section 303(c).
(8) Essential benefits package.--The term ``essential
benefits package'' is defined in section 222(a).
(9) Exchange-participating health benefits plan.--The term
``Exchange-participating health benefits plan'' means a
qualified health benefits plan that is offered through the
Health Insurance Exchange and may be purchased directly from
the entity offering the plan or through enrollment agents and
brokers.
(10) Family.--The term ``family'' means an individual and
includes the individual's dependents.
(11) Federal poverty level; fpl.--The terms ``Federal
poverty level'' and ``FPL'' have the meaning given the term
``poverty line'' in section 673(2) of the Community Services
Block Grant Act (42 U.S.C. 9902(2)), including any revision
required by such section.
(12) Health benefits plan.--The term ``health benefits
plan'' means health insurance coverage and an employment-
based health plan and includes the public health insurance
option.
(13) Health insurance coverage.--The term ``health
insurance coverage'' has the meaning given such term in
section 2791 of the Public Health Service Act, but does not
include coverage in relation to its provision of excepted
benefits--
(A) described in paragraph (1) of subsection (c) of such
section; or

[[Page H12626]]

(B) described in paragraph (2), (3), or (4) of such
subsection if the benefits are provided under a separate
policy, certificate, or contract of insurance.
(14) Health insurance issuer.--The term ``health insurance
issuer'' has the meaning given such term in section
2791(b)(2) of the Public Health Service Act.
(15) Health insurance exchange.--The term ``Health
Insurance Exchange'' means the Health Insurance Exchange
established under section 301.
(16) Indian.--The term ``Indian'' has the meaning given
such term in section 4 of the Indian Health Care Improvement
Act (24 U.S.C. 1603).
(17) Indian health care provider.--The term ``Indian health
care provider'' means a health care program operated by the
Indian Health Service, an Indian tribe, tribal organization,
or urban Indian organization as such terms are defined in
section 4 of the Indian Health Care Improvement Act (25
U.S.C. 1603).
(18) Medicaid.--The term ``Medicaid'' means a State plan
under title XIX of the Social Security Act (whether or not
the plan is operating under a waiver under section 1115 of
such Act).
(19) Medicaid eligible individual.--The term ``Medicaid
eligible individual'' means an individual who is eligible for
medical assistance under Medicaid.
(20) Medicare.--The term ``Medicare'' means the health
insurance programs under title XVIII of the Social Security
Act.
(21) Plan sponsor.--The term ``plan sponsor'' has the
meaning given such term in section 3(16)(B) of the Employee
Retirement Income Security Act of 1974.
(22) Plan year.--The term ``plan year'' means--
(A) with respect to an employment-based health plan, a plan
year as specified under such plan; or
(B) with respect to a health benefits plan other than an
employment-based health plan, a 12-month period as specified
by the Commissioner.
(23) Premium plan; premium-plus plan.--The terms ``premium
plan'' and ``premium-plus plan'' have the meanings given such
terms in section 303(c).
(24) QHBP offering entity.--The terms ``QHBP offering
entity'' means, with respect to a health benefits plan that
is--
(A) a group health plan (as defined, subject to subsection
(d), in section 733(a)(1) of the Employee Retirement Income
Security Act of 1974), the plan sponsor in relation to such
group health plan, except that, in the case of a plan
maintained jointly by 1 or more employers and 1 or more
employee organizations and with respect to which an employer
is the primary source of financing, such term means such
employer;
(B) health insurance coverage, the health insurance issuer
offering the coverage;
(C) the public health insurance option, the Secretary of
Health and Human Services;
(D) a non-Federal governmental plan (as defined in section
2791(d) of the Public Health Service Act), the State or
political subdivision of a State (or agency or
instrumentality of such State or subdivision) which
establishes or maintains such plan; or
(E) a Federal governmental plan (as defined in section
2791(d) of the Public Health Service Act), the appropriate
Federal official.
(25) Qualified health benefits plan.--The term ``qualified
health benefits plan'' means a health benefits plan that--
(A) meets the requirements for such a plan under title II
and includes the public health insurance option; and
(B) is offered by a QHBP offering entity that meets the
applicable requirements of such title with respect to such
plan.
(26) Public health insurance option.--The term ``public
health insurance option'' means the public health insurance
option as provided under subtitle B of title III.
(27) Service area; premium rating area.--The terms
``service area'' and ``premium rating area'' mean with
respect to health insurance coverage--
(A) offered other than through the Health Insurance
Exchange, such an area as established by the QHBP offering
entity of such coverage in accordance with applicable State
law; and
(B) offered through the Health Insurance Exchange, such an
area as established by such entity in accordance with
applicable State law and applicable rules of the Commissioner
for Exchange-participating health benefits plans.
(28) State.--The term ``State'' means the 50 States and the
District of Columbia and includes--
(A) for purposes of title I, Puerto Rico, the Virgin
Islands, Guam, American Samoa, and the Northern Mariana
Islands; and
(B) for purposes of titles II and III, as elected under and
subject to section 346, Puerto Rico, the Virgin Islands,
Guam, American Samoa, and the Northern Mariana Islands.
(29) State medicaid agency.--The term ``State Medicaid
agency'' means, with respect to a Medicaid plan, the single
State agency responsible for administering such plan under
title XIX of the Social Security Act.
(30) Y1, y2, etc.--The terms ``Y1'', ``Y2'', ``Y3'',
``Y4'', ``Y5'', and similar subsequently numbered terms, mean
2013 and subsequent years, respectively.

TITLE I--IMMEDIATE REFORMS

SEC. 101. NATIONAL HIGH-RISK POOL PROGRAM.

(a) In General.--The Secretary of Health and Human Services
(in this section referred to as the ``Secretary'') shall
establish a temporary national high-risk pool program (in
this section referred to as the ``program'') to provide
health benefits to eligible individuals during the period
beginning on January 1, 2010, and, subject to subsection
(h)(3)(B), ending on the date on which the Health Insurance
Exchange is established.
(b) Administration.--The Secretary may carry out this
section directly or, pursuant to agreements, grants, or
contracts with States, through State high-risk pool programs
provided that the requirements of this section are met. ``For
a State without a high-risk pool program, the Secretary may
work with the State to coordinate with other forms of
coverage expansions, such as State public-private
partnerships.''.
(c) Eligibility.--For purposes of this section, the term
``eligible individual'' means an individual ``who meets the
requirements of subsection (i)(1)''.
(1) who--
(A) is not eligible for--
(i) benefits under title XVIII, XIX, or XXI of the Social
Security Act; or
(ii) coverage under an employment-based health plan (not
including coverage under a COBRA continuation provision, as
defined in section 107(d)(1)); and
(B) who--
(i) is an eligible individual under section 2741(b) of the
Public Health Service Act; or
(ii) is medically eligible for the program by virtue of
being an individual described in subsection (d) at any time
during the 6-month period ending on the date the individual
applies for high-risk pool coverage under this section;
(2) who is the spouse or dependent of an individual who is
described in paragraph (1);
(3) who has not had health insurance coverage or coverage
under an employment-based health plan for at least the 6-
month period immediately preceding the date of the
individual's application for high-risk pool coverage under
this section; ``or.''
(4) who on or after October 29, 2009, had employment-based
retiree health coverage (as defined in subsection (i)) and
the annual increase in premiums for such individual under
such coverage (for any coverage period beginning on or after
such date) exceeds such excessive percentage as the Secretary
shall specify.
For purposes of paragraph (1)(A)(ii), a person who is in a
waiting period as defined in section 2701(b)(4) of the Public
Health Service Act shall not be considered to be eligible for
coverage under an employment-based health plan.
(d) Medically Eligible Requirements.--For purposes of
subsection (c)(1)(B)(ii), an individual described in this
subsection is an individual--
(1) who, during the 6-month period ending on the date the
individual applies for high-risk pool coverage under this
section applied for individual health insurance coverage
and--
(A) was denied such coverage because of a preexisting
condition or health status; or
(B) was offered such coverage--
(i) under terms that limit the coverage for such a
preexisting condition; or
(ii) at a premium rate that is above the premium rate for
high risk pool coverage under this section; or
(2) who has an eligible medical condition as defined by the
Secretary.
In making a determination under paragraph (1) of whether an
individual was offered individual coverage at a premium rate
above the premium rate for high risk pool coverage, the
Secretary shall make adjustments to offset differences in
premium rating that are attributable solely to differences in
age rating.
(e) Enrollment.--To enroll in coverage in the program, an
individual shall--
(1) submit to the Secretary an application for
participation in the program, at such time, in such manner,
and containing such information as the Secretary shall
require;
(2) attest ``, consistent with subsection (i)(2),'' that
the individual is an eligible individual and is a resident of
one of the 50 States or the District of Columbia; and
(3) if the individual had other prior health insurance
coverage or coverage under an employment-based health plan
during the previous 6 months, provide information as to the
nature and source of such coverage and reasons for its
discontinuance.
(f) Protection Against Dumping Risks by Insurers.--
(1) In general.--The Secretary shall establish criteria for
determining whether health insurance issuers and employment-
based health plans have discouraged an individual from
remaining enrolled in prior coverage based on that
individual's health status.
(2) Sanctions.--An issuer or employment-based health plan
shall be responsible for reimbursing the program for the
medical expenses incurred by the program for an individual
who, based on criteria established by the Secretary, the
Secretary finds was encouraged by the issuer to disenroll
from health benefits coverage prior to enrolling in the
program. The criteria shall include at least the following
circumstances:
(A) In the case of prior coverage obtained through an
employer, the provision by the employer, group health plan,
or the issuer of money or other financial consideration for
disenrolling from the coverage.
(B) In the case of prior coverage obtained directly from an
issuer or under an employment-based health plan--

[[Page H12627]]

(i) the provision by the issuer or plan of money or other
financial consideration for disenrolling from the coverage;
or
(ii) in the case of an individual whose premium for the
prior coverage exceeded the premium required by the program
(adjusted based on the age factors applied to the prior
coverage)--

(I) the prior coverage is a policy that is no longer being
actively marketed (as defined by the Secretary) by the
issuer; or
(II) the prior coverage is a policy for which duration of
coverage form issue or health status are factors that can be
considered in determining premiums at renewal.

(3) Construction.--Nothing in this subsection shall be
construed as constituting exclusive remedies for violations
of criteria established under paragraph (1) or as preventing
States from applying or enforcing such paragraph or other
provisions under law with respect to health insurance
issuers.
(g) Covered Benefits, Cost-sharing, Premiums, and Consumer
Protections.--
(1) Premium.--The monthly premium charged to eligible
individuals for coverage under the program--
(A) may vary by age so long as the ratio of the highest
such premium to the lowest such premium does not exceed the
ratio of 2 to 1;
(B) shall be set at a level that does not exceed 125
percent of the prevailing standard rate for comparable
coverage in the individual market; and
(C) shall be adjusted for geographic variation in costs.
Health insurance issuers shall provide such information as
the Secretary may require to determine prevailing standard
rates under this paragraph. The Secretary shall establish
standard rates in consultation with the National Association
of Insurance Commissioners.
(2) Covered benefits.--Covered benefits under the program
shall be determined by the Secretary and shall be consistent
with the basic categories in the essential benefits package
described in section 222. Under such benefits package--
(A) the annual deductible for such benefits may not be
higher than $1,500 for an individual or such higher amount
for a family as determined by the Secretary;
(B) there may not be annual or lifetime limits; and
(C) the maximum cost-sharing with respect to an individual
(or family) for a year shall not exceed $5,000 for an
individual (or $10,000 for a family).
(3) No preexisting condition exclusion periods.--No
preexisting condition exclusion period shall be imposed on
coverage under the program.
(4) Appeals.--The Secretary shall establish an appeals
process for individuals to appeal a determination of the
Secretary--
(A) with respect to claims submitted under this section;
and
(B) with respect to eligibility determinations made by the
Secretary under this section.
(5) State contribution, maintenance of effort.--As a
condition of providing health benefits under this section to
eligible individual residing in a State--
(A) in the case of a State in which a qualified high-risk
pool (as defined under section 2744(c)(2) of the Public
Health Service Act) was in effect as of July 1, 2009, the
Secretary shall require the State make a maintenance of
effort payment each year that the high-risk pool is in effect
equal to an amount not less than the amount of all sources of
funding for high-risk pool coverage made by that State in the
year ending July 1, 2009; and
(B) in the case of a State which required health insurance
issuers to contribute to a State high-risk pool or similar
arrangement for the assessment against such issuers for pool
losses, the State shall maintain such a contribution
arrangement among such issuers.
(6) Limiting program expenditures.--The Secretary shall,
with respect to the program--
(A) establish procedures to protect against fraud, waste,
and abuse under the program; and
(B) provide for other program integrity methods.
(7) Treatment as creditable coverage.--Coverage under the
program shall be treated, for purposes of applying the
definition of ``creditable coverage'' under the provisions of
title XXVII of the Public Health Service Act, part 6 of
subtitle B of title I of Employee Retirement Income Security
Act of 1974, and chapter 100 of the Internal Revenue Code of
1986 (and any other provision of law that references such
provisions) in the same manner as if it were coverage under a
State health benefits risk pool described in section
2701(c)(1)(G) of the Public Health Service Act.
(h) Funding; Termination of Authority.--
(1) In general.--There is appropriated to the Secretary,
out of any moneys in the Treasury not otherwise appropriated,
$5,000,000,000 to pay claims against (and administrative
costs of) the high-risk pool under this section in excess of
the premiums collected with respect to eligible individuals
enrolled in the high-risk pool. Such funds shall be available
without fiscal year limitation.
(2) Insufficient funds.--If the Secretary estimates for any
fiscal year that the aggregate amounts available for payment
of expenses of the high-risk pool will be less than the
amount of the expenses, the Secretary shall make such
adjustments as are necessary to eliminate such deficit,
including reducing benefits, increasing premiums, or
establishing waiting lists.
(3) Termination of authority.--
(A) In general.--Except as provided in subparagraph (B),
coverage of eligible individuals under a high-risk pool shall
terminate as of the date on which the Health Insurance
Exchange is established.
(B) Transition to exchange.--The Secretary shall develop
procedures to provide for the transition of eligible
individuals who are enrolled in health insurance coverage
offered through a high-risk pool established under this
section to be enrolled in acceptable coverage. Such
procedures shall ensure that there is no lapse in coverage
with respect to the individual and may extend coverage
offered through such a high-risk pool beyond 2012 if the
Secretary determines necessary to avoid such a lapse.
(i) Application and Verification of Requirement of
Citizenship or Lawful Presence in the United States.--
(1) Requirement.--No individual shall be an eligible
individual under this section unless the individual is a
citizen or national of the United States or is lawfully
present in a State in the United States (other than as a
nonimmigrant described in a subparagraph (excluding
subparagraphs (K), (T), (U), and (V)) of section 101(a)(15)
of the Immigration and Nationality Act.)
(2) Application of verification process for affordability
credit.--The provisions of paragraphs (4) (other than
subparagraphs (F) and (H)(i)) and (5)(A) of section 341(b),
and of subsections (v) (other than paragraph (3)) and (x) of
section 205 of the Social Security Act, shall apply to the
verification of eligibility of an eligible individual by the
Secretary (or by a State agency approved by the Secretary)
for benefits under this section in the same manner as such
provisions apply to the verification of eligibility of a
affordable credit eligible individual for affordability
credits by the Commissioner under section 341(b). The
agreement referred to in section 205(v)(2)(A) of the Social
Security Act (as applied under this paragraph) shall also
provide for funding, to be payable for the amount made
available under subsection (h)(1), to the Commissioner of
Social Security in such amount as is agreed to by such
Commissioner and the Secretary.
(j) Employment-based Retiree Health Coverage.--In this
section, the term ``employment-based retiree health
coverage'' means health insurance or other coverage of health
care costs (whether provided by voluntary insurance or
pursuant to statutory or contractual obligation) for
individuals (or for such individuals and their spouses and
dependents) under a group health plan based on their status
as retired participants in such plan.

SEC. 102. ENSURING VALUE AND LOWER PREMIUMS.

(a) Group Health Insurance Coverage.--Title XXVII of the
Public Health Service Act is amended by inserting after
section 2713 the following new section:

``SEC. 2714. ENSURING VALUE AND LOWER PREMIUMS.

``(a) In General.--Each health insurance issuer that offers
health insurance coverage in the small or large group market
shall provide that for any plan year in which the coverage
has a medical loss ratio below a level specified by the
Secretary (but not less than 85 percent), the issuer shall
provide in a manner specified by the Secretary for rebates to
enrollees of the amount by which the issuer's medical loss
ratio is less than the level so specified.
``(b) Implementation.--The Secretary shall establish a
uniform definition of medical loss ratio and methodology for
determining how to calculate it based on the average medical
loss ratio in a health insurance issuer's book of business
for the small and large group market. Such methodology shall
be designed to take into account the special circumstances of
smaller plans, different types of plans, and newer plans. In
determining the medical loss ratio, the Secretary shall
exclude State taxes and licensing or regulatory fees. Such
methodology shall be designed and exceptions shall be
established to ensure adequate participation by health
insurance issuers, competition in the health insurance
market, and value for consumers so that their premiums are
used for services.
``(c) Sunset.--Subsections (a) and (b) shall not apply to
health insurance coverage on and after the first date that
health insurance coverage is offered through the Health
Insurance Exchange.''.
(b) Individual Health Insurance Coverage.--Such title is
further amended by inserting after section 2753 the following
new section:

``SEC. 2754. ENSURING VALUE AND LOWER PREMIUMS.

``The provisions of section 2714 shall apply to health
insurance coverage offered in the individual market in the
same manner as such provisions apply to health insurance
coverage offered in the small or large group market except to
the extent the Secretary determines that the application of
such section may destabilize the existing individual
market.''.
(c) Immediate Implementation.--The amendments made by this
section shall apply in the group and individual market for
plan years beginning on or after January 1, 2010, or as soon
as practicable after such date.

SEC. 103. ENDING HEALTH INSURANCE RESCISSION ABUSE.

(a) Clarification Regarding Application of Guaranteed
Renewability of Individual

[[Page H12628]]

and Group Health Insurance Coverage.--Sections 2712 and 2742
of the Public Health Service Act (42 U.S.C. 300gg-12, 300gg-
42) are each amended--
(1) in its heading, by inserting ``AND CONTINUATION IN
FORCE, INCLUDING PROHIBITION OF RESCISSION,'' after
``GUARANTEED RENEWABILITY''; and
(2) in subsection (a), by inserting ``, including without
rescission,'' after ``continue in force''.
(b) Secretarial Guidance Regarding Rescissions.--
(1) Group health insurance market.--Section 2712 of such
Act (42 U.S.C. 300gg-12) is amended by adding at the end the
following:
``(f) Rescission.--A health insurance issuer may rescind
group health insurance coverage only upon clear and
convincing evidence of fraud described in subsection (b)(2),
under procedures that provide for independent, external
third-party review.''.
(2) Individual health market.--Section 2742 of such Act (42
U.S.C. 300gg-42) is amended by adding at the end the
following:
``(f) Rescission.--A health insurance issuer may rescind
individual health insurance coverage only upon clear and
convincing evidence of fraud described in subsection (b)(2),
under procedures that provide for independent, external
third-party review.''.
(3) Guidance.--The Secretary of Health and Human Services,
no later than 90 days after the date of the enactment of this
Act, shall issue guidance implementing the amendments made by
paragraphs (1) and (2), including procedures for independent,
external third-party review.
(c) Opportunity for Independent, External Third-party
Review in Certain Cases.--
(1) Individual market.--Subpart 1 of part B of title XXVII
of such Act (42 U.S.C. 300gg-41 et seq.) is amended by adding
at the end the following:

``SEC. 2746. OPPORTUNITY FOR INDEPENDENT, EXTERNAL THIRD-
PARTY REVIEW IN CASES OF RESCISSION.

``(a) Notice and Review Right.--If a health insurance
issuer determines to rescind health insurance coverage for an
individual in the individual market, before such rescission
may take effect the issuer shall provide the individual with
notice of such proposed rescission and an opportunity for a
review of such determination by an independent, external
third-party under procedures specified by the Secretary under
section 2742(f).
``(b) Independent Determination.--If the individual
requests such review by an independent, external third-party
of a rescission of health insurance coverage, the coverage
shall remain in effect until such third party determines that
the coverage may be rescinded under the guidance issued by
the Secretary under section 2742(f).''.
(2) Application to group health insurance.--Such title is
further amended by adding after section 2702 the following
new section:

``SEC. 2703. OPPORTUNITY FOR INDEPENDENT, EXTERNAL THIRD-
PARTY REVIEW IN CASES OF RESCISSION.

``The provisions of section 2746 shall apply to group
health insurance coverage in the same manner as such
provisions apply to individual health insurance coverage,
except that any reference to section 2742(f) is deemed a
reference to section 2712(f).''.
(d) Effective Date.--The amendments made by this section
shall take effect on the date of the enactment of this Act
and shall apply to rescissions occurring on and after July 1,
2010, with respect to health insurance coverage issued
before, on, or after such date.

SEC. 104. SUNSHINE ON PRICE GOUGING BY HEALTH INSURANCE
ISSUERS.

(a) Initial Premium Review Process.--
(1) In General.--The Secretary of Health and Human
Services, in conjunction with States, shall establish a
process for the annual review, beginning with 2010 and
subject to subsection (c)(3)(A), of increases in premiums for
health insurance coverage.
(2) Justification and Disclosure.--Such process shall
require health insurance issuers to submit a justification
for any premium increase prior to implementation of the
increase. Such issuers shall prominently post such
information on their websites. The Secretary shall ensure the
public disclosure of information on such increase and
justifications for all health insurance issuers.
(b) Continuing Premium Review Process.--
(1) Informing commissioner of premium increase patterns.--
As a condition of receiving a grant under subsection (c)(1),
a State, through its Commissioner of Insurance, shall--
(A) provide the Health Choices commissioner with
information about trends in premium increases in health
insurance coverage in premium rating areas in the State; and
(B) make recommendations, as appropriate, to such
Commissioner about whether particular health insurance
issuers should be excluded from participation in the Health
Insurance Exchange based on a pattern of excessive or
unjustified premium increases.
(2) Commissioner authority regarding exchange
participation.--In making determinations concerning entering
into contracts with QHBP offering entities for the offering
of Exchange-participating health plans under section 304, the
Commissioner shall take into account the information and
recommendations provided under paragraph (1).
(3) Monitoring by commissioner of premium increases.--
(A) In general.--Beginning in 2014, the Commissioner, in
conjunction with the States and in place of the monitoring by
the Secretary under subsection (a)(1) and consistent with the
provisions of subsection (a)(2), shall monitor premium
increases of health insurance coverage offered inside the
Health Insurance Exchange under section 304 and outside of
the Exchange.
(B) Consideration in opening exchange.--In determining
under section 302(e)(4) whether to make additional larger
employers eligible to participate in the Health Insurance
Exchange, the Commissioner shall take into account any excess
of premium growth outside the Exchange as compared to the
rate of such growth inside the Exchange, including
information reported by the States.
(c) Grants in Support of Process.--
(1) Premium review grants during 2010 through 2014.--The
Secretary shall carry out a program of grants to States
during the 5-year period beginning with 2010 to assist them
in carrying out subsection (a), including--
(A) in reviewing and, if appropriate under State law,
approving premium increases for health insurance coverage;
and
(B) in providing information and recommendations to the
Commissioner under subsection (b)(1).
(2) Funding.--
(A) In general.--Out of any funds in the Treasury not
otherwise appropriated, there are appropriated to the
Secretary $1,000,000,000, to be available for expenditure for
grants under paragraph (1) and subparagraph (B).
(B) Further availability for insurance reform and consumer
protection grants.--If the amounts appropriated under
subparagraph (A) are not fully obligated under grants under
paragraph (1) by the end of 2014, any remaining funds shall
remain available to the Secretary for grants to States for
planning and implementing the insurance reforms and consumer
protections under title II.
(C) Allocation.--The Secretary shall establish a formula
for determining the amount of any grant to a State under this
subsection. Under such formula--
(i) the Secretary shall consider the number of plans of
health insurance coverage offered in each State and the
population of the State; and
(ii) no State qualifying for a grant under paragraph (1)
shall receive less than $1,000,000, or more than $5,000,000
for a grant year.

SEC. 105. REQUIRING THE OPTION OF EXTENSION OF DEPENDENT
COVERAGE FOR UNINSURED YOUNG ADULTS.

(a) Under Group Health Plans.--
(1) PHSA.--Title XXVII of the Public Health Service Act is
amended by inserting after section 2702 the following new
section:

``SEC. 2703. REQUIRING THE OPTION OF EXTENSION OF DEPENDENT
COVERAGE FOR UNINSURED YOUNG ADULTS.

``(a) In General.--A group health plan and a health
insurance issuer offering health insurance coverage in
connection with a group health plan that provides coverage
for dependent children shall make available such coverage, at
the option of the participant involved, for one or more
qualified children (as defined in subsection (b)) of the
participant.
``(b) Qualified Child Defined.--In this section, the term
`qualified child' means, with respect to a participant in a
group health plan or group health insurance coverage, an
individual who (but for age) would be treated as a dependent
child of the participant under such plan or coverage and
who--
``(1) is under 27 years of age; and
``(2) is not enrolled as a participant, beneficiary, or
enrollee (other than under this section, section 2746, or
section 704 of the Employee Retirement Income Security Act of
1974) under any health insurance coverage or group health
plan.
``(c) Premiums.--Nothing in this section shall be construed
as preventing a group health plan or health insurance issuer
with respect to group health insurance coverage from
increasing the premiums otherwise required for coverage
provided under this section consistent with standards
established by the Secretary based upon family size.''.
(2) Employee retirement income security act of 1974.--
(A) In general.--Part 7 of subtitle B of title I of the
Employee Retirement Income Security Act of 1974 is amended by
inserting after section 703 the following new section:

``SEC. 704. REQUIRING THE OPTION OF EXTENSION OF DEPENDENT
COVERAGE FOR UNINSURED YOUNG ADULTS.

``(a) In General.--A group health plan and a health
insurance issuer offering health insurance coverage in
connection with a group health plan that provides coverage
for dependent children shall make available such coverage, at
the option of the participant involved, for one or more
qualified children (as defined in subsection (b)) of the
participant.
``(b) Qualified Child Defined.--In this section, the term
`qualified child' means, with respect to a participant in a
group health plan or group health insurance coverage, an
individual who (but for age) would be treated as a dependent
child of the participant under such plan or coverage and
who--
``(1) is under 27 years of age; and
``(2) is not enrolled as a participant, beneficiary, or
enrollee (other than under this section) under any health
insurance coverage or group health plan.
``(c) Premiums.--Nothing in this section shall be construed
as preventing a group health plan or health insurance issuer
with respect to group health insurance coverage

[[Page H12629]]

from increasing the premiums otherwise required for coverage
provided under this section consistent with standards
established by the Secretary based upon family size.''.
(B) Clerical amendment.--The table of contents of such Act
is amended by inserting after the item relating to section
703 the following new item:

``Sec. 704. Requiring the option of extension of dependent coverage for
uninsured young adults.''.
(3) IRC.--
(A) In general.--Subchapter A of chapter 100 of the
Internal Revenue Code of 1986 is amended by adding at the end
the following new section:

``SEC. 9804. REQUIRING THE OPTION OF EXTENSION OF DEPENDENT
COVERAGE FOR UNINSURED YOUNG ADULTS.

``(a) In General.--A group health plan that provides
coverage for dependent children shall make available such
coverage, at the option of the participant involved, for one
or more qualified children (as defined in subsection (b)) of
the participant.
``(b) Qualified Child Defined.--In this section, the term
`qualified child' means, with respect to a participant in a
group health plan, an individual who (but for age) would be
treated as a dependent child of the participant under such
plan and who--
``(1) is under 27 years of age; and
``(2) is not enrolled as a participant, beneficiary, or
enrollee (other than under this section, section 704 of the
Employee Retirement Income Security Act of 1974, or section
2704 or 2746 of the Public Health Service Act) under any
health insurance coverage or group health plan.
``(c) Premiums.--Nothing in this section shall be construed
as preventing a group health plan from increasing the
premiums otherwise required for coverage provided under this
section consistent with standards established by the
Secretary based upon family size.''.
(B) Clerical amendment.--The table of sections of such
chapter is amended by inserting after the item relating to
section 9803 the following:

``Sec. 9804. Requiring the option of extension of dependent coverage
for uninsured young adults.''.
(b) Individual Health Insurance Coverage.--Title XXVII of
the Public Health Service Act is amended by inserting after
section 2745 the following new section:

``SEC. 2746. REQUIRING THE OPTION OF EXTENSION OF DEPENDENT
COVERAGE FOR UNINSURED YOUNG ADULTS.

``The provisions of section 2703 shall apply to health
insurance coverage offered by a health insurance issuer in
the individual market in the same manner as they apply to
health insurance coverage offered by a health insurance
issuer in connection with a group health plan in the small or
large group market.''.
(c) Effective Dates.--
(1) Group health plans.--The amendments made by subsection
(a) shall apply to group health plans for plan years
beginning on or after January 1, 2010.
(2) Individual health insurance coverage.--Section 2746 of
the Public Health Service Act, as inserted by subsection (b),
shall apply with respect to health insurance coverage
offered, sold, issued, renewed, in effect, or operated in the
individual market on or after January 1, 2010.

SEC. 106. LIMITATIONS ON PREEXISTING CONDITION EXCLUSIONS IN
GROUP HEALTH PLANS IN ADVANCE OF APPLICABILITY
OF NEW PROHIBITION OF PREEXISTING CONDITION
EXCLUSIONS.

(a) Amendments to the Employee Retirement Income Security
Act of 1974.--
(1) Reduction in look-back period.--Section 701(a)(1) of
the Employee Retirement Income Security Act of 1974 (29
U.S.C. 1181(a)(1)) is amended by striking ``6-month period''
and inserting ``30-day period''.
(2) Reduction in permitted preexisting condition limitation
period.--Section 701(a)(2) of such Act (29 U.S.C. 1181(a)(2))
is amended by striking ``12 months'' and inserting ``3
months'', and by striking ``18 months'' and inserting ``9
months''.
(3) Sunset of interim limitation.--Section 701 of such Act
(29 U.S.C. 1181) is amended by adding at the end the
following new subsection:
``(h) Termination.--This section shall cease to apply to
any group health plan as of the date that such plan becomes
subject to the requirements of section 211 of the (relating
to prohibiting preexisting condition exclusions).''.
(b) Amendments to the Internal Revenue Code of 1986.--
(1) Reduction in look-back period.--Section 9801(a)(1) of
the Internal Revenue Code of 1986 is amended by striking ``6-
month period'' and inserting ``30-day period''.
(2) Reduction in permitted preexisting condition limitation
period.--Section 9801(a)(2) of such Code is amended by
striking ``12 months'' and inserting ``3 months'', and by
striking ``18 months'' and inserting ``9 months''.
(3) Sunset of interim limitation.--Section 9801 of such
Code is amended by adding at the end the following new
subsection:
``(g) Termination.--This section shall cease to apply to
any group health plan as of the date that such plan becomes
subject to the requirements of section 211 of the
``Affordable Health Care for America Act'' (relating to
prohibiting preexisting condition exclusions).''.
(c) Amendments to Public Health Service Act.--
(1) Reduction in look-back period.--Section 2701(a)(1) of
the Public Health Service Act (42 U.S.C. 300gg(a)(1)) is
amended by striking ``6-month period'' and inserting ``30-day
period''.
(2) Reduction in permitted preexisting condition limitation
period.--Section 2701(a)(2) of such Act (42 U.S.C.
300gg(a)(2)) is amended by striking ``12 months'' and
inserting ``3 months'', and by striking ``18 months'' and
inserting ``9 months''.
(3) Sunset of interim limitation.--Section 2701 of such Act
(42 U.S.C. 300gg) is amended by adding at the end the
following new subsection:
``(h) Termination.--This section shall cease to apply to
any group health plan as of the date that such plan becomes
subject to the requirements of section 211 of the (relating
to prohibiting preexisting condition exclusions).''.
(4) Miscellaneous technical amendment.--Section 2702(a)(2)
of such Act (42 U.S.C. 300gg-1) is amended by striking
``701'' and inserting ``2701''.
(d) Effective Date.--
(1) In general.--Except as provided in paragraph (2), the
amendments made by this section shall apply with respect to
group health plans for plan years beginning on or after
January 1, 2010.
(2) Special rule for collective bargaining agreements.--In
the case of a group health plan maintained pursuant to 1 or
more collective bargaining agreements between employee
representatives and 1 or more employers ratified before the
date of the enactment of this Act, the amendments made by
this section shall not apply to plan years beginning before
the earlier of--
(A) the date on which the last of the collective bargaining
agreements relating to the plan terminates (determined
without regard to any extension thereof agreed to after the
date of the enactment of this Act);
(B) 3 years after the date of the enactment of this Act.

SEC. 107. PROHIBITING ACTS OF DOMESTIC VIOLENCE FROM BEING
TREATED AS PREEXISTING CONDITIONS.

(a) ERISA.--Section 701(d)(3) of the Employee Retirement
Income Security Act of 1974 (29 U.S.C. ) is amended--
(1) in the heading, by inserting ``or domestic violence''
after ``pregnancy''; and
(2) by inserting ``or domestic violence'' after ``relating
to pregnancy''.
(b) PHSA.--
(1) Group market.--Section 2701(d)(3) of the Public Health
Service Act (42 U.S.C. 300gg(d)(3)) is amended--
(A) in the heading, by inserting ``or domestic violence''
after ``pregnancy''; and
(B) by inserting ``or domestic violence'' after ``relating
to pregnancy''.
(2) Individual market.--Title XXVII of such Act is amended
by inserting after section 2753 the following new section:

``SEC. 2754. PROHIBITION ON DOMESTIC VIOLENCE AS PREEXISTING
CONDITION.

``A health insurance issuer offering health insurance
coverage in the individual market may not, on the basis of
domestic violence, impose any preexisting condition exclusion
(as defined in section 2701(b)(1)(A)) with respect to such
coverage.''.
(c) IRC.--Section 9801(d)(3) of the Internal Revenue Code
of 1986 is amended--
(1) in the heading, by inserting ``or domestic violence''
after ``pregnancy''; and
(2) by inserting ``or domestic violence'' after ``relating
to pregnancy''.
(d) Effective Dates.--
(1) Except as otherwise provided in this subsection, the
amendments made by this section shall apply with respect to
group health plans (and health insurance issuers offering
group health insurance coverage) for plan years beginning on
or after January 1, 2010.
(2) The amendment made by subsection (b)(2) shall apply
with respect to health insurance coverage offered, sold,
issued, renewed, in effect, or operated in the individual
market on or after such date.

SEC. 108. ENDING HEALTH INSURANCE DENIALS AND DELAYS OF
NECESSARY TREATMENT FOR CHILDREN WITH
DEFORMITIES.

(a) Amendments to the Employee Retirement Income Security
Act of 1974.--
(1) In general.--Subpart B of part 7 of subtitle B of title
I of the Employee Retirement Income Security Act of 1974 is
amended by adding at the end the following new section:

``SEC. 715. STANDARDS RELATING TO BENEFITS FOR MINOR CHILD'S
CONGENITAL OR DEVELOPMENTAL DEFORMITY OR
DISORDER.

``(a) Requirements for Treatment for Children With
Deformities.--
``(1) In general.--A group health plan, and a health
insurance issuer offering group health insurance coverage,
that provides coverage for surgical benefits shall provide
coverage for outpatient and inpatient diagnosis and treatment
of a minor child's congenital or developmental deformity,
disease, or injury. A minor child shall include any
individual who is 21 years of age or younger.
``(2) Treatment defined.--
``(A) In general.--In this section, the term `treatment'
includes reconstructive surgical procedures (procedures that
are generally performed to improve function, but may also be
performed to approximate a normal appearance) that are
performed on abnormal structures of the body caused by
congenital defects, developmental abnormalities, trauma,
infection, tumors, or disease, including--

[[Page H12630]]

``(i) procedures that do not materially affect the function
of the body part being treated; and
``(ii) procedures for secondary conditions and follow-up
treatment.
``(B) Exception.--Such term does not include cosmetic
surgery performed to reshape normal structures of the body to
improve appearance or self-esteem.
``(b) Notice.--A group health plan under this part shall
comply with the notice requirement under section 713(b)
(other than paragraph (3)) with respect to the requirements
of this section.''.
(2) Conforming amendment.--
(A) Subsection (c) of section 731 of such Act is amended by
striking ``section 711'' and inserting ``sections 711 and
715''.
(B) The table of contents in section 1 of such Act is
amended by inserting after the item relating to section 714
the following new item:

``Sec. 715. Standards relating to benefits for minor child's congenital
or developmental deformity or disorder.''.
(b) Amendments to the Internal Revenue Code of 1986.--
(1) In general.--Subchapter B of chapter 100 of the
Internal Revenue Code of 1986 is amended by adding at the end
the following new section:

``SEC. 9814. STANDARDS RELATING TO BENEFITS FOR MINOR CHILD'S
CONGENITAL OR DEVELOPMENTAL DEFORMITY OR
DISORDER.

``(a) Requirements for Treatment for Children With
Deformities.--A group health plan that provides coverage for
surgical benefits shall provide coverage for outpatient and
inpatient diagnosis and treatment of a minor child's
congenital or developmental deformity, disease, or injury. A
minor child shall include any individual who is 21 years of
age or younger.
``(b) Treatment Defined.--
``(1) In general.--In this section, the term `treatment'
includes reconstructive surgical procedures (procedures that
are generally performed to improve function, but may also be
performed to approximate a normal appearance) that are
performed on abnormal structures of the body caused by
congenital defects, developmental abnormalities, trauma,
infection, tumors, or disease, including--
``(A) procedures that do not materially affect the function
of the body part being treated, and
``(B) procedures for secondary conditions and follow-up
treatment.
``(2) Exception.--Such term does not include cosmetic
surgery performed to reshape normal structures of the body to
improve appearance or self-esteem.''.
(2) Clerical amendment.--The table of sections for
subchapter B of chapter 100 of such Code is amended by adding
at the end the following new item:

``Sec. 9814. Standards relating to benefits for minor child's
congenital or developmental deformity or disorder.''.
(c) Amendments to the Public Health Service Act.--
(1) In general.--Subpart 2 of part A of title XXVII of the
Public Health Service Act is amended by adding at the end the
following new section:

``SEC. 2708. STANDARDS RELATING TO BENEFITS FOR MINOR CHILD'S
CONGENITAL OR DEVELOPMENTAL DEFORMITY OR
DISORDER.

``(a) Requirements for Treatment for Children With
Deformities.--
``(1) In general.--A group health plan, and a health
insurance issuer offering group health insurance coverage,
that provides coverage for surgical benefits shall provide
coverage for outpatient and inpatient diagnosis and treatment
of a minor child's congenital or developmental deformity,
disease, or injury. A minor child shall include any
individual who is 21 years of age or younger.
``(2) Treatment defined.--
``(A) In general.--In this section, the term `treatment'
includes reconstructive surgical procedures (procedures that
are generally performed to improve function, but may also be
performed to approximate a normal appearance) that are
performed on abnormal structures of the body caused by
congenital defects, developmental abnormalities, trauma,
infection, tumors, or disease, including--
``(i) procedures that do not materially affect the function
of the body part being treated; and
``(ii) procedures for secondary conditions and follow-up
treatment.
``(B) Exception.--Such term does not include cosmetic
surgery performed to reshape normal structures of the body to
improve appearance or self-esteem.
``(b) Notice.--A group health plan under this part shall
comply with the notice requirement under section 715(b) of
the Employee Retirement Income Security Act of 1974 with
respect to the requirements of this section as if such
section applied to such plan.''.
(2) Individual health insurance.--Subpart 2 of part B of
title XXVII of the Public Health Service Act, as amended by
section 161(b), is further amended by adding at the end the
following new section:

``SEC. 2755. STANDARDS RELATING TO BENEFITS FOR MINOR CHILD'S
CONGENITAL OR DEVELOPMENTAL DEFORMITY OR
DISORDER.

``The provisions of section 2708 shall apply to health
insurance coverage offered by a health insurance issuer in
the individual market in the same manner as such provisions
apply to health insurance coverage offered by a health
insurance issuer in connection with a group health plan in
the small or large group market.''.
(3) Conforming amendments.--
(A) Section 2723(c) of such Act (42 U.S.C. 300gg-23(c)) is
amended by striking ``section 2704'' and inserting ``sections
2704 and 2708''.
(B) Section 2762(b)(2) of such Act (42 U.S.C. 300gg-
62(b)(2)) is amended by striking ``section 2751'' and
inserting ``sections 2751 and 2755''.
(d) Effective Dates.--
(1) The amendments made by this section shall apply with
respect to group health plans (and health insurance issuers
offering group health insurance coverage) for plan years
beginning on or after January 1, 2010.
(2) The amendment made by subsection (c)(2) shall apply
with respect to health insurance coverage offered, sold,
issued, renewed, in effect, or operated in the individual
market on or after such date.
(e) Coordination.--Section 104(1) of the Health Insurance
Portability and Accountability Act of 1996 is amended by
striking ``(and the amendments made by this subtitle and
section 401)'' and inserting ``, part 7 of subtitle B of
title I of the Employee Retirement Income Security Act of
1974, parts A and C of title XXVII of the Public Health
Service Act, and chapter 100 of the Internal Revenue Code of
1986''.

SEC. 109. ELIMINATION OF LIFETIME LIMITS.

(a) Amendments to the Employee Retirement Income Security
Act of 1974.--
(1) In general.--Subpart B of part 7 of subtitle B of title
I of the Employee Retirement Income Security Act of 1974 (29
U.S.C. 1185 et seq.), as amended by section 108, is amended
by adding at the end the following:

``SEC. 716. ELIMINATION OF LIFETIME AGGREGATE LIMITS.

``(a) In General.--A group health plan and a health
insurance issuer providing health insurance coverage in
connection with a group health plan, may not impose an
aggregate dollar lifetime limit with respect to benefits
payable under the plan or coverage.
``(b) Definition.--In this section, the term `aggregate
dollar lifetime limit' means, with respect to benefits under
a group health plan or health insurance coverage offered in
connection with a group health plan, a dollar limitation on
the total amount that may be paid with respect to such
benefits under the plan or health insurance coverage with
respect to an individual or other coverage unit on a lifetime
basis.''.
(2) Clerical amendment.--The table of contents in section 1
of such Act, is amended by inserting after the item relating
to section 715 the following new item:

``Sec. 716. Elimination of lifetime aggregate limits.''.
(b) Amendments to the Internal Revenue Code of 1986.--
(1) In general.--Subchapter B of chapter 100 of the
Internal Revenue Code of 1986, as amended by section 108(b),
is amended by adding at the end the following new section:

``SEC. 9815. ELIMINATION OF LIFETIME AGGREGATE LIMITS.

``(a) In General.--A group health plan may not impose an
aggregate dollar lifetime limit with respect to benefits
payable under the plan.
``(b) Definition.--In this section, the term `aggregate
dollar lifetime limit' means, with respect to benefits under
a group health plan a dollar limitation on the total amount
that may be paid with respect to such benefits under the plan
with respect to an individual or other coverage unit on a
lifetime basis.''.
(2) Clerical amendment.--The table of sections for
subchapter B of chapter 100 of such Code, as amended by
section 108(b), is amended by adding at the end the following
new item:

``Sec. 9854. Standards relating to benefits for minor child's
congenital or developmental deformity or disorder.''.
(c) Amendment to the Public Health Service Act Relating to
the Group Market.--
(1) In general.--Subpart 2 of part A of title XXVII of the
Public Health Service Act (42 U.S.C. 300gg-4 et seq.) as
amended by section 108(c)(1), is amended by adding at the end
the following:

``SEC. 2709. ELIMINATION OF LIFETIME AGGREGATE LIMITS.

``(a) In General.--A group health plan and a health
insurance issuer providing health insurance coverage in
connection with a group health plan, may not impose an
aggregate dollar lifetime limit with respect to benefits
payable under the plan or coverage.
``(b) Definition.--In this section, the term `aggregate
dollar lifetime limit' means, with respect to benefits under
a group health plan or health insurance coverage, a dollar
limitation on the total amount that may be paid with respect
to such benefits under the plan or health insurance coverage
with respect to an individual or other coverage unit on a
lifetime basis.''.
(2) Individual market.--Subpart 2 of part B of title XXVII
of the Public Health Service Act (42 U.S.C. 300gg-51 et
seq.), as amended by section 108(c)(2), is amended by adding
at the end the following:

``SEC. 2756. ELIMINATION OF LIFETIME AGGREGATE LIMITS.

``The provisions of section 2709 shall apply to health
insurance coverage offered by a health insurance issuer in
the individual

[[Page H12631]]

market in the same manner as they apply to health insurance
coverage offered by a health insurance issuer in connection
with a group health plan in the small or large group
market.''.
(d) Effective Dates.--
(1) The amendments made by this section shall apply with
respect to group health plans (and health insurance issuers
offering group health insurance coverage) for plan years
beginning on or after January 1, 2010.
(2) The amendment made by subsection (c)(2) shall apply
with respect to health insurance coverage offered, sold,
issued, renewed, in effect, or operated in the individual
market on or after such date.

SEC. 110. PROHIBITION AGAINST POSTRETIREMENT REDUCTIONS OF
RETIREE HEALTH BENEFITS BY GROUP HEALTH PLANS.

(a) In General.--Part 7 of subtitle B of title I of the
Employee Retirement Income Security Act of 1974, as amended
by sections 108 and 109, is amended by inserting after
section 716 the following new section:

``SEC. 717. PROTECTION AGAINST POSTRETIREMENT REDUCTION OF
RETIREE HEALTH BENEFITS.

``(a) In General.--Every group health plan shall contain a
provision which expressly bars the plan, or any fiduciary of
the plan, from reducing the benefits provided under the plan
to a retired participant, or beneficiary of such participant,
if such reduction affects the benefits provided to the
participant or beneficiary as of the date the participant
retired for purposes of the plan and such reduction occurs
after the participant's retirement unless such reduction is
also made with respect to active participants. Nothing in
this section shall prohibit a plan from enforcing a total
aggregate cap on amounts paid for retiree health coverage
that is part of the plan at the time of retirement.
``(b) No Reduction.--Notwithstanding that a group health
plan may contain a provision reserving the general power to
amend or terminate the plan or a provision specifically
authorizing the plan to make post-retirement reductions in
retiree health benefits, it shall be prohibited for any group
health plan, whether through amendment or otherwise, to
reduce the benefits provided to a retired participant or the
participant's beneficiary under the terms of the plan if such
reduction of benefits occurs after the date the participant
retired for purposes of the plan and reduces benefits that
were provided to the participant, or the participant's
beneficiary, as of the date the participant retired unless
such reduction is also made with respect to active
participants.
``(c) Reduction Described.-- For purposes of this section,
a reduction in benefits--
``(1) with respect to premiums occurs under a group health
plan when a participant's (or beneficiary's) share of the
total premium (or, in the case of a self-insured plan, the
costs of coverage) of the plan substantially increases; or
``(2) with respect to other cost-sharing and benefits under
a group health plan occurs when there is a substantial
decrease in the actuarial value of the benefit package under
the plan.
For purposes of this section, the term `substantial' means an
increase in the total premium share or a decrease in the
actuarial value of the benefit package that is greater than 5
percent.''
(b) Conforming Amendment.--The table of contents in section
1 of such Act, as amended by sections 108 and 109, is amended
by inserting after the item relating to section 716 the
following new item:

``Sec. 717. Protection against postretirement reduction of retiree
health benefits.''.
(c) Waiver.--An employer may, in a form and manner which
shall be prescribed by the Secretary of Labor, apply for a
waiver from this provision if the employer can reasonably
demonstrate that meeting the requirements of this section
would impose an undue hardship on the employer.
(d) Effective Date.--The amendments made by this section
shall take effect on the date of the enactment of this Act.

SEC. 111. REINSURANCE PROGRAM FOR RETIREES.

(a) Establishment.--
(1) In general.--Not later than 90 days after the date of
the enactment of this Act, the Secretary of Health and Human
Services shall establish a temporary reinsurance program (in
this section referred to as the ``reinsurance program'') to
provide reimbursement to assist participating employment-
based plans with the cost of providing health benefits to
retirees and to eligible spouses, surviving spouses and
dependents of such retirees.
(2) Definitions.--For purposes of this section:
(A) The term ``eligible employment-based plan'' means a
group health plan or employment-based health plan that--
(i) is --

(I) maintained by one or more employers (including without
limitation any State or political subdivision thereof, or any
agency or instrumentality of any of the foregoing), former
employers or employee organizations or associations, or a
voluntary employees' beneficiary association, or a committee
or board of individuals appointed to administer such plan; or
(II) a multiemployer plan (as defined in section 3(37) of
the Employee Retirement Income Security Act of 1974); and

(ii) provides health benefits to retirees.
(B) The term ``health benefits'' means medical, surgical,
hospital, prescription drug, and such other benefits as shall
be determined by the Secretary, whether self-funded or
delivered through the purchase of insurance or otherwise.
(C) The term ``participating employment-based plan'' means
an eligible employment-based plan that is participating in
the reinsurance program.
(D) The term ``retiree'' means, with respect to a
participating employment-benefit plan, an individual who--
(i) is 55 years of age or older;
(ii) is not eligible for coverage under title XVIII of the
Social Security Act; and
(iii) is not an active employee of an employer maintaining
the plan or of any employer that makes or has made
substantial contributions to fund such plan.
(E) The term ``Secretary'' means Secretary of Health and
Human Services.
(b) Participation.--To be eligible to participate in the
reinsurance program, an eligible employment-based plan shall
submit to the Secretary an application for participation in
the program, at such time, in such manner, and containing
such information as the Secretary shall require.
(c) Payment.--
(1) Submission of claims.--
(A) In general.--Under the reinsurance program, a
participating employment-based plan shall submit claims for
reimbursement to the Secretary which shall contain
documentation of the actual costs of the items and services
for which each claim is being submitted.
(B) Basis for claims.--Each claim submitted under
subparagraph (A) shall be based on the actual amount expended
by the participating employment-based plan involved within
the plan year for the appropriate employment based health
benefits provided to a retiree or to the spouse, surviving
spouse, or dependent of a retiree. In determining the amount
of any claim for purposes of this subsection, the
participating employment-based plan shall take into account
any negotiated price concessions (such as discounts, direct
or indirect subsidies, rebates, and direct or indirect
remunerations) obtained by such plan with respect to such
health benefits. For purposes of calculating the amount of
any claim, the costs paid by the retiree or by the spouse,
surviving spouse, or dependent of the retiree in the form of
deductibles, copayments, and coinsurance shall be included
along with the amounts paid by the participating employment-
based plan.
(2) Program payments and limit.--If the Secretary
determines that a participating employment-based plan has
submitted a valid claim under paragraph (1), the Secretary
shall reimburse such plan for 80 percent of that portion of
the costs attributable to such claim that exceeds $15,000,
but is less than $90,000. Such amounts shall be adjusted each
year based on the percentage increase in the medical care
component of the Consumer Price Index (rounded to the nearest
multiple of $1,000) for the year involved.
(3) Use of payments.--Amounts paid to a participating
employment-based plan under this subsection shall only be
used to reduce the costs of health care provided by the plan
by reducing premium costs for the employer or employee
association maintaining the plan, and reducing premium
contributions, deductibles, copayments, coinsurance, or other
out-of-pocket costs for plan participants and beneficiaries.
Where the benefits are provided by an employer to members of
a represented bargaining unit, the allocation of payments
among these purposes shall be subject to collective
bargaining. Amounts paid to the plan under this subsection
shall not be used as general revenues by the employer or
employee association maintaining the plan or for any other
purposes. The Secretary shall develop a mechanism to monitor
the appropriate use of such payments by such plans.
(4) Appeals and program protections.--The Secretary shall
establish--
(A) an appeals process to permit participating employment-
based plans to appeal a determination of the Secretary with
respect to claims submitted under this section; and
(B) procedures to protect against fraud, waste, and abuse
under the program.
(5) Audits.--The Secretary shall conduct annual audits of
claims data submitted by participating employment-based plans
under this section to ensure that they are in compliance with
the requirements of this section.
(d) Retiree Reserve Trust Fund.--
(1) Establishment.--
(A) In general.--There is established in the Treasury of
the United States a trust fund to be known as the ``Retiree
Reserve Trust Fund'' (referred to in this section as the
``Trust Fund''), that shall consist of such amounts as may be
appropriated or credited to the Trust Fund as provided for in
this subsection to enable the Secretary to carry out the
reinsurance program. Such amounts shall remain available
until expended.
(B) Funding.--There are hereby appropriated to the Trust
Fund, out of any moneys in the Treasury not otherwise
appropriated, an amount requested by the Secretary as
necessary to carry out this section, except that the total of
all such amounts requested shall not exceed $10,000,000,000.
(C) Appropriations from the trust fund.--
(i) In general.--Amounts in the Trust Fund are appropriated
to provide funding to carry out the reinsurance program and
shall be used to carry out such program.

[[Page H12632]]

(ii) Limitation to available funds.--The Secretary has the
authority to stop taking applications for participation in
the program or take such other steps in reducing expenditures
under the reinsurance program in order to ensure that
expenditures under the reinsurance program do not exceed the
funds available under this subsection.

SEC. 112. WELLNESS PROGRAM GRANTS.

(a) Allowance of Grant.--
(1) In general.--For purposes of this section, the
Secretaries of Health and Human Services and Labor shall
jointly award wellness grants as determined under this
section. Wellness program grants shall be awarded to small
employers (as defined by the Secretary) for any plan year in
an amount equal to 50 percent of the costs paid or incurred
by such employers in connection with a qualified wellness
program during the plan year. For purposes of the preceding
sentence, in the case of any qualified wellness program
offered as part of an employment-based health plan, only
costs attributable to the qualified wellness program and not
to the health plan, or health insurance coverage offered in
connection with such a plan, may be taken into account.
(2) Limitations.--
(A) Period.--A wellness grant awarded to an employer under
this section shall be for up to 3 years.
(B) Amount.--The amount of the grant under paragraph (1)
for an employer shall not exceed--
(i) the product of $150 and the number of employees of the
employer for any plan year; and
(ii) $50,000 for the entire period of the grant.
(b) Qualified Wellness Program.--For purposes of this
section:
(1) Qualified wellness program.--The term ``qualified
wellness program'' means a program that --
(A) includes any 3 wellness components described in
subsection (c); and
(B) is to be certified jointly by the Secretary of Health
and Human Services and the Secretary of Labor, in
coordination with the Director of the Centers for Disease
Control and Prevention, as a qualified wellness program under
this section.
(2) Programs must be consistent with research and best
practices.--
(A) In general.--The Secretary of Health and Human Services
and the Secretary of Labor shall not certify a program as a
qualified wellness program unless the program--
(i) is consistent with evidence-based research and best
practices, as identified by persons with expertise in
employer health promotion and wellness programs;
(ii) includes multiple, evidence-based strategies which are
based on the existing and emerging research and careful
scientific reviews, including the Guide to Community
Preventative Services, the Guide to Clinical Preventative
Services, and the National Registry for Effective Programs,
and
(iii) includes strategies which focus on prevention and
support for employee populations at risk of poor health
outcomes.
(B) Periodic updating and review.--The Secretaries of
Health and Human Services and Labor, in consultation with
other appropriate agencies shall jointly establish procedures
for periodic review, evaluation, and update of the programs
under this subsection.
(3) Health literacy and accessibility.--The Secretaries of
Health and Human Services and Labor shall jointly, as part of
the certification process--
(A) ensure that employers make the programs culturally
competent, physically and programmatically accessible
(including for individuals with disabilities), and
appropriate to the health literacy needs of the employees
covered by the programs;
(B) require a health literacy component to provide special
assistance and materials to employees with low literacy
skills, limited English and from underserved populations; and
(C) require the Secretaries to compile and disseminate to
employer health plans information on model health literacy
curricula, instructional programs, and effective intervention
strategies.
(c) Wellness Program Components.--For purposes of this
section, the wellness program components described in this
subsection are the following:
(1) Health awareness component.--A health awareness
component which provides for the following:
(A) Health education.--The dissemination of health
information which addresses the specific needs and health
risks of employees.
(B) Health screenings.--The opportunity for periodic
screenings for health problems and referrals for appropriate
follow-up measures.
(2) Employee engagement component.--An employee engagement
component which provides for the active engagement of
employees in worksite wellness programs through worksite
assessments and program planning, onsite delivery,
evaluation, and improvement efforts.
(3) Behavioral change component.--A behavioral change
component which encourages healthy living through counseling,
seminars, on-line programs, self-help materials, or other
programs which provide technical assistance and problem
solving skills. Such component may include programs relating
to--
(A) tobacco use;
(B) obesity;
(C) stress management;
(D) physical fitness;
(E) nutrition;
(F) substance abuse;
(G) depression; and
(H) mental health promotion.
(4) Supportive environment component.--A supportive
environment component which includes the following:
(A) On-site policies.--Policies and services at the
worksite which promote a healthy lifestyle, including
policies relating to--
(i) tobacco use at the worksite;
(ii) the nutrition of food available at the worksite
through cafeterias and vending options;
(iii) minimizing stress and promoting positive mental
health in the workplace; and
(iv) the encouragement of physical activity before, during,
and after work hours.
(d) Participation Requirement.--No grant shall be allowed
under subsection (a) unless the Secretaries of Health and
Human Services and Labor, in consultation with other
appropriate agencies, jointly certify, as a part of any
certification described in subsection (b), that each wellness
program component of the qualified wellness program--
(1) shall be available to all employees of the employer;
(2) shall not mandate participation by employees; and
(3) may provide a financial reward for participation of an
individual in such program so long as such reward is not tied
to the premium or cost-sharing of the individual under the
health benefits plan.
(e) Privacy Protections.--Data gathered for purposes of the
employer wellness program may be used solely for the purposes
of administering the program. The Secretaries of Health and
Human Services and Labor shall develop standards to ensure
such data remain confidential and are not used for purposes
beyond those for administering the program.
(f) Certain Costs Not Included.--For purposes of this
section, costs paid or incurred by an employer for food or
health insurance shall not be taken into account under
subsection (a).
(g) Outreach.--The Secretaries of Health and Human Services
and Labor, in conjunction with other appropriate agencies and
members of the business community, shall jointly institute an
outreach program to inform businesses about the availability
of the wellness program grant as well as to educate
businesses on how to develop programs according to recognized
and promising practices and on how to measure the success of
implemented programs.
(h) Effective Date.--This section shall take effect on July
1, 2010.
(i) Authorization of Appropriations.--There are authorized
to be appropriated such sums as are necessary to carry out
this section.

SEC. 113. EXTENSION OF COBRA CONTINUATION COVERAGE.

(a) Extension of Current Periods of Continuation
Coverage.--
(1) In general.--In the case of any individual who is,
under a COBRA continuation coverage provision, covered under
COBRA continuation coverage on or after the date of the
enactment of this Act, the required period of any such
coverage which has not subsequently terminated under the
terms of such provision for any reason other than the
expiration of a period of a specified number of months shall,
notwithstanding such provision and subject to subsection (b),
extend to the earlier of the date on which such individual
becomes eligible for acceptable coverage or the date on which
such individual becomes eligible for health insurance
coverage through the Health Insurance Exchange (or a State-
based Health Insurance Exchange operating in a State or group
of States).
(2) Notice.--As soon as practicable after the date of the
enactment of this Act, the Secretary of Labor, in
consultation with the Secretary of the Treasury and the
Secretary of Health and Human Services, shall, in
consultation with administrators of the group health plans
(or other entities) that provide or administer the COBRA
continuation coverage involved, provide rules setting forth
the form and manner in which prompt notice to individuals of
the continued availability of COBRA continuation coverage to
such individuals under paragraph (1).
(b) Continued Effect of Other Terminating Events.--
Notwithstanding subsection (a), any required period of COBRA
continuation coverage which is extended under such subsection
shall terminate upon the occurrence, prior to the date of
termination otherwise provided in such subsection, of any
terminating event specified in the applicable continuation
coverage provision other than the expiration of a period of a
specified number of months.
(c) Access to State Health Benefits Risk Pools.--This
section shall supersede any provision of the law of a State
or political subdivision thereof to the extent that such
provision has the effect of limiting or precluding access by
a qualified beneficiary whose COBRA continuation coverage has
been extended under this section to a State health benefits
risk pool recognized by the Commissioner for purposes of this
section solely by reason of the extension of such coverage
beyond the date on which such coverage otherwise would have
expired.
(d) Definitions.--For purposes of this section--
(1) COBRA continuation coverage.--The term ``COBRA
continuation coverage''

[[Page H12633]]

means continuation coverage provided pursuant to part 6 of
subtitle B of title I of the Employee Retirement Income
Security Act of 1974 (other than under section 609), title
XXII of the Public Health Service Act, section 4980B of the
Internal Revenue Code of 1986 (other than subsection (f)(1)
of such section insofar as it relates to pediatric vaccines),
or section 905a of title 5, United States Code, or under a
State program that provides comparable continuation coverage.
Such term does not include coverage under a health flexible
spending arrangement under a cafeteria plan within the
meaning of section 125 of the Internal Revenue Code of 1986.
(2) COBRA continuation provision.--The term ``COBRA
continuation provision'' means the provisions of law
described in paragraph (1).

SEC. 114. STATE HEALTH ACCESS PROGRAM GRANTS.

(a) In General.--The Secretary of Health and Human Services
(in this section referred to as the ``Secretary'') shall
provide grants to States (as defined for purposes of title
XIX of the Social Security Act) to establish programs to
expand access to affordable health care coverage for the
uninsured populations in that State in a manner consistent
with reforms to take effect under this division in Y1.
(b) Types of Programs.--The types of programs for which
grants are available under subsection (a) include the
following:
(1) State insurance exchanges.--State insurance exchanges
that develop new, less expensive, portable benefit packages
for small employers and part-time and seasonal workers.
(2) Community coverage program.--Community coverage with
shared responsibility between employers, governmental or
nonprofit entity, and the individual.
(3) Reinsurance plan program.--Reinsurance plans that
subsidize a certain share of carrier losses within a certain
risk corridor health insurance premium assistance.
(4) Transparent marketplace program.--Transparent
marketplace that provides an organized structure for the sale
of insurance products such as a Web exchange or portal.
(5) Automated enrollment program.--Statewide or automated
enrollment systems for public assistance programs.
(6) Innovative strategies.--Innovative strategies to insure
low-income childless adults.
(7) Purchasing collaboratives.--Not-for-profit business,
consumer collaborative that provides direct contract health
care service purchasing options for group plan sponsors.
(c) Eligibility and Administration.--
(1) Implementation of key statutory or regulatory
changes.--In order to be awarded a grant under this section
for a program, a State shall demonstrate that--
(A) it has achieved the key State and local statutory or
regulatory changes required to begin implementing the new
program within 1 year after the initiation of funding under
the grant; and
(B) it will be able to sustain the program without Federal
funding after the end of the period of the grant.
(2) Ineligibility.--A State that has already developed a
comprehensive health insurance access program is not eligible
for a grant under this section.
(3) Application required.--No State shall receive a grant
under this section unless the State has approved by the
Secretary such an application, in such form and manner as the
Secretary specifies.
(4) Administration based on current program.--The program
under this section is intended to build on the State Health
Access Program funded under the Omnibus Appropriations Act,
2009 (Public Law 111-8).
(d) Funding Limitations.--
(1) In general.--A grant under this section shall--
(A) only be available for expenditures before Y1; and
(B) only be used to supplement, and not supplant, funds
otherwise provided.
(2) Matching fund requirement.--
(A) In general.--Subject to subparagraph (B), no grant may
be awarded to a State unless the State demonstrates the
seriousness of its effort by matching at least 20 percent of
the grant amount through non-Federal resources, which may be
a combination of State, local, private dollars from insurers,
providers, and other private organizations.
(B) Waiver.--The Secretary may waive the requirement of
subparagraph (A) if the State demonstrates to the Secretary
financial hardship in complying with such requirement.
(e) Study.--The Secretary shall review, study, and
benchmark the progress and results of the programs funded
under this section.
(f) Report.--Each State receiving a grant under this
section shall submit to the Secretary a report on best
practices and lessons learned through the grant to inform the
health reform coverage expansions under this division
beginning in Y1.
(g) Funding.--There are authorized to be appropriated such
sums as may be necessary to carry out this section.

SEC. 115. ADMINISTRATIVE SIMPLIFICATION.

(a) Standardizing Electronic Administrative Transactions.--
(1) In general.--Part C of title XI of the Social Security
Act (42 U.S.C. 1320d et seq.) is amended by inserting after
section 1173 the following new sections:

``SEC. 1173A. STANDARDIZE ELECTRONIC ADMINISTRATIVE
TRANSACTIONS.

``(a) Standards for Financial and Administrative
Transactions.--
``(1) In general.--The Secretary shall adopt and regularly
update standards consistent with the goals described in
paragraph (2).
``(2) Goals for financial and administrative
transactions.--The goals for standards under paragraph (1)
are that such standards shall, to the extent practicable--
``(A) be unique with no conflicting or redundant standards;
``(B) be authoritative, permitting no additions or
constraints for electronic transactions, including companion
guides;
``(C) be comprehensive, efficient and robust, requiring
minimal augmentation by paper transactions or clarification
by further communications;
``(D) enable the real-time (or near real-time)
determination of an individual's financial responsibility at
the point of service and, to the extent possible, prior to
service, including whether the individual is eligible for a
specific service with a specific physician at a specific
facility, on a specific date or range of dates, include
utilization of a machine-readable health plan beneficiary
identification card or similar mechanism;
``(E) enable, where feasible, near real-time adjudication
of claims;
``(F) provide for timely acknowledgment, response, and
status reporting applicable to any electronic transaction
deemed appropriate by the Secretary;
``(G) describe all data elements (such as reason and remark
codes) in unambiguous terms, not permit optional fields,
require that data elements be either required or conditioned
upon set values in other fields, and prohibit additional
conditions except where required by (or to implement) State
or Federal law or to protect against fraud and abuse; and
``(H) harmonize all common data elements across
administrative and clinical transaction standards.
``(3) Time for adoption.--Not later than 2 years after the
date of the enactment of this section, the Secretary shall
adopt standards under this section by interim, final rule.
``(4) Requirements for specific standards.--The standards
under this section shall be developed, adopted, and enforced
so as to--
``(A) clarify, refine, complete, and expand, as needed, the
standards required under section 1173;
``(B) require paper versions of standardized transactions
to comply with the same standards as to data content such
that a fully compliant, equivalent electronic transaction can
be populated from the data from a paper version;
``(C) enable electronic funds transfers, in order to allow
automated reconciliation with the related health care payment
and remittance advice;
``(D) require timely and transparent claim and denial
management processes, including uniform claim edits, uniform
reason and remark denial codes, tracking, adjudication, and
appeal processing;
``(E) require the use of a standard electronic transaction
with which health care providers may quickly and efficiently
enroll with a health plan to conduct the other electronic
transactions provided for in this part; and
``(F) provide for other requirements relating to
administrative simplification as identified by the Secretary,
in consultation with stakeholders.
``(5) Building on existing standards.--In adopting the
standards under this section, the Secretary shall consider
existing and planned standards.
``(6) Implementation and enforcement.--Not later than 6
months after the date of the enactment of this section, the
Secretary shall submit to the appropriate committees of
Congress a plan for the implementation and enforcement, by
not later than 5 years after such date of enactment, of the
standards under this section. Such plan shall include--
``(A) a process and timeframe with milestones for
developing the complete set of standards;
``(B) a proposal for accommodating necessary changes
between version changes and a process for upgrading standards
as often as annually by interim, final rulemaking;
``(C) programs to provide incentives for, and ease the
burden of, implementation for certain health care providers,
with special consideration given to such providers serving
rural or underserved areas and ensure coordination with
standards, implementation specifications, and certification
criteria being adopted under the HITECH Act;
``(D) programs to provide incentives for, and ease the
burden of, health care providers who volunteer to participate
in the process of setting standards for electronic
transactions;
``(E) an estimate of total funds needed to ensure timely
completion of the implementation plan; and
``(F) an enforcement process that includes timely
investigation of complaints, random audits to ensure
compliance, civil monetary and programmatic penalties for
noncompliance consistent with existing laws and regulations,
and a fair and reasonable appeals process building off of
enforcement provisions under this part, and concurrent State
enforcement jurisdiction.
The Secretary may promulgate an annual audit and
certification process to ensure that all health plans and
clearinghouses are

[[Page H12634]]

both syntactically and functionally compliant with all the
standard transactions mandated pursuant to the administrative
simplification provisions of this part and the Health
Insurance Portability and Accountability Act of 1996.
``(b) Limitations on Use of Data.--Nothing in this section
shall be construed to permit the use of information collected
under this section in a manner that would violate State or
Federal law.
``(c) Protection of Data.--The Secretary shall ensure
(through the promulgation of regulations or otherwise) that
all data collected pursuant to subsection (a) are used and
disclosed in a manner that meets the HIPAA privacy and
security law (as defined in section 3009(a)(2) of the Public
Health Service Act), including any privacy or security
standard adopted under section 3004 of such Act.

``SEC. 1173B. INTERIM COMPANION GUIDES, INCLUDING OPERATING
RULES.

``(a) In General.--The Secretary shall adopt a single,
binding, comprehensive companion guide, that includes
operating rules for each X12 Version 5010 transaction
described in section 1173(a)(2), to be effective until the
new version of these transactions which comply with section
1173A are adopted and implemented.
``(b) Companion Guide and Operating Rules Development.--In
adopting such interim companion guide and rules, the
Secretary shall comply with section 1172, except that a
nonprofit entity that meets the following criteria shall also
be consulted:
``(1) The entity focuses its mission on administrative
simplification.
``(2) The entity uses a multistakeholder process that
creates consensus-based companion guides, including operating
rules using a voting process that ensures balanced
representation by the critical stakeholders (including health
plans and health care providers) so that no one group
dominates the entity and shall include others such as
standards development organizations, and relevant Federal or
State agencies.
``(3) The entity has in place a public set of guiding
principles that ensure the companion guide and operating
rules and process are open and transparent.
``(4) The entity coordinates its activities with the HIT
Policy Committee, and the HIT Standards Committee
(established under title XXX of the Public Health Service
Act) and complements the efforts of the Office of the
National Healthcare Coordinator and its related health
information exchange goals.
``(5) The entity incorporates the standards issued under
Health Insurance Portability and Accountability Act of 1996
and this part, and in developing the companion guide and
operating rules does not change the definition, data
condition or use of a data element or segment in a standard,
add any elements or segments to the maximum defined data set,
use any codes or data elements that are either marked `not
used' in the standard's implementation specifications or are
not in the standard's implementation specifications, or
change the meaning or intent of the standard's implementation
specifications.
``(6) The entity uses existing market research and proven
best practices.
``(7) The entity has a set of measures that allow for the
evaluation of their market impact and public reporting of
aggregate stakeholder impact.
``(8) The entity supports nondiscrimination and conflict of
interest policies that demonstrate a commitment to open,
fair, and nondiscriminatory practices.
``(9) The entity allows for public reviews and comment on
updates of the companion guide, including the operating
rules.
``(c) Implementation.--The Secretary shall adopt a single,
binding companion guide, including operating rules under this
section, for each transaction, to become effective with the
X12 Version 5010 transaction implementation, or as soon
thereafter as feasible. The companion guide, including
operating rules for the transactions for eligibility for
health plan and health claims status under this section shall
be adopted not later than October 1, 2011, in a manner such
that such set of rules is effective beginning not later than
January 1, 2013. The companion guide, including operating
rules for the remainder of the transactions described in
section 1173(a)(2) shall be adopted not later than October 1,
2012, in a manner such that such set of rules is effective
beginning not later than January 1, 2014.''.
(2) Definitions.--Section 1171 of such Act (42 U.S.C.
1320d) is amended--
(A) in paragraph (1), by inserting ``, and associated
operational guidelines and instructions, as determined
appropriate by the Secretary'' after ``medical procedure
codes''; and
(B) by adding at the end the following new paragraph:
``(10) Operating rules.--The term `operating rules' means
business rules for using and processing transactions, such as
service level requirements, which do not impact the
implementation specifications or other data content
requirements.''.
(3) Conforming amendment.--Section 1179(a) of such Act (42
U.S.C. 1320d-8(a)) is amended, in the matter before paragraph
(1)--
(A) by inserting ``on behalf of an individual'' after
``1978)''; and
(B) by inserting ``on behalf of an individual'' after ``for
a financial institution'' and
(b) Standards for Claims Attachments and Coordination of
Benefits.--
(1) Standard for health claims attachments.--Not later than
1 year after the date of the enactment of this Act, the
Secretary of Health and Human Services shall promulgate an
interim, final rule to establish a standard for health claims
attachment transaction described in section 1173(a)(2)(B) of
the Social Security Act (42 U.S.C. 1320d-2(a)(2)(B)) and
coordination of benefits.
(2) Revision in processing payment transactions by
financial institutions.--
(A) In general.--Section 1179 of the Social Security Act
(42 U.S.C. 1320d-8) is amended, in the matter before
paragraph (1)--
(i) by striking ``or is engaged'' and inserting ``and is
engaged''; and
(ii) by inserting ``(other than as a business associate for
a covered entity)'' after ``for a financial institution''.
(B) Compliance date.--The amendments made by subparagraph
(A) shall apply to transactions occurring on or after such
date (not later than January 1, 2014) as the Secretary of
Health and Human Services shall specify.
(c) Standards for First Report of Injury.--Not later than
January 1, 2014, the Secretary of Health and Human Services
shall promulgate an interim final rule to establish a
standard for the first report of injury transaction described
in section 1173(a)(2)(G) of the Social Security Act (42
U.S.C. 1320d-2(a)(2)(G)).
(d) Unique Health Plan Identifier.--Not later October 1,
2012, the Secretary of Health and Human Services shall
promulgate an interim final rule to establish a unique health
plan identifier described in section 1173(b) of the Social
Security Act (42 U.S.C. 1320d-2(b)) based on the input of the
National Committee of Vital and Health Statistics and
consultation with health plans, health care providers, and
other interested parties.
(e) Expansion of Electronic Transactions in Medicare.--
Section 1862(a) of the Social Security Act (42 U.S.C.
1395y(a)) is amended--
(1) in paragraph (23), by striking ``or'' at the end;
(2) in paragraph (24), by striking the period and inserting
``; or''; and
(3) by inserting after paragraph (24) the following new
paragraph:
``(25) subject to subsection (h), not later than January 1,
2015, for which the payment is other than by electronic funds
transfer (EFT) so long as the Secretary has adopted and
implemented a standard for electronic funds transfer under
section 1173A.''.
(f) Expansion of Penalties.--Section 1176 of such Act (42
U.S.C. 1320d-5) is amended by adding at the end the following
new subsection:
``(c) Expansion of Penalty Authority.--The Secretary may,
in addition to the penalties provided under subsections (a)
and (b), provide for the imposition of penalties for
violations of this part that are comparable--
``(1) in the case of health plans, to the sanctions the
Secretary is authorized to impose under part C or D of title
XVIII in the case of a plan that violates a provision of such
part; or
``(2) in the case of a health care provider, to the
sanctions the Secretary is authorized to impose under part A,
B, or D of title XVIII in the case of a health care provider
that violations a provision of such part with respect to that
provider.''.

TITLE II--PROTECTIONS AND STANDARDS FOR QUALIFIED HEALTH BENEFITS PLANS

Subtitle A--General Standards

SEC. 201. REQUIREMENTS REFORMING HEALTH INSURANCE
MARKETPLACE.

(a) Purpose.--The purpose of this title is to establish
standards to ensure that new health insurance coverage and
employment-based health plans that are offered meet standards
guaranteeing access to affordable coverage, essential
benefits, and other consumer protections.
(b) Requirements for Qualified Health Benefits Plans.--On
or after the first day of Y1, a health benefits plan shall
not be a qualified health benefits plan under this division
unless the plan meets the applicable requirements of the
following subtitles for the type of plan and plan year
involved:
(1) Subtitle B (relating to affordable coverage).
(2) Subtitle C (relating to essential benefits).
(3) Subtitle D (relating to consumer protection).
(c) Terminology.--In this division:
(1) Enrollment in employment-based health plans.--An
individual shall be treated as being ``enrolled'' in an
employment-based health plan if the individual is a
participant or beneficiary (as such terms are defined in
section 3(7) and 3(8), respectively, of the Employee
Retirement Income Security Act of 1974) in such plan.
(2) Individual and group health insurance coverage.--The
terms ``individual health insurance coverage'' and ``group
health insurance coverage'' mean health insurance coverage
offered in the individual market or large or small group
market, respectively, as defined in section 2791 of the
Public Health Service Act.
(d) Treatment of Qualified Direct Primary Care Medical Home
Plans.--The Commissioner may permit a qualified health
benefits plan to provide coverage through a qualified direct
primary care medical home plan so long as the qualified
health benefits plan meets all requirements that are
otherwise applicable and the services covered by the medical
home plan are coordinated with the QHBP offering entity.

[[Page H12635]]

SEC. 202. PROTECTING THE CHOICE TO KEEP CURRENT COVERAGE.

(a) Grandfathered Health Insurance Coverage Defined.--
Subject to the succeeding provisions of this section, for
purposes of establishing acceptable coverage under this
division, the term ``grandfathered health insurance
coverage'' means individual health insurance coverage that is
offered and in force and effect before the first day of Y1 if
the following conditions are met:
(1) Limitation on new enrollment.--
(A) In general.--Except as provided in this paragraph, the
individual health insurance issuer offering such coverage
does not enroll any individual in such coverage if the first
effective date of coverage is on or after the first day of
Y1.
(B) Dependent coverage permitted.--Subparagraph (A) shall
not affect the subsequent enrollment of a dependent of an
individual who is covered as of such first day.
(2) Limitation on changes in terms or conditions.--Subject
to paragraph (3) and except as required by law, the issuer
does not change any of its terms or conditions, including
benefits and cost-sharing, from those in effect as of the day
before the first day of Y1.
(3) Restrictions on premium increases.--The issuer cannot
vary the percentage increase in the premium for a risk group
of enrollees in specific grandfathered health insurance
coverage without changing the premium for all enrollees in
the same risk group at the same rate, as specified by the
Commissioner.
(b) Grace Period for Current Employment-Based Health
Plans.--
(1) Grace period.--
(A) In general.--The Commissioner shall establish a grace
period whereby, for plan years beginning after the end of the
5-year period beginning with Y1, an employment-based health
plan in operation as of the day before the first day of Y1
must meet the same requirements as apply to a qualified
health benefits plan under section 201, including the
essential benefit package requirement under section 221.
(B) Exception for limited benefits plans.--Subparagraph (A)
shall not apply to an employment-based health plan in which
the coverage consists only of one or more of the following:
(i) Any coverage described in section 3001(a)(1)(B)(ii)(IV)
of division B of the American Recovery and Reinvestment Act
of 2009 (Public Law 111-5).
(ii) Excepted benefits (as defined in section 733(c) of the
Employee Retirement Income Security Act of 1974), including
coverage under a specified disease or illness policy
described in paragraph (3)(A) of such section.
(iii) Such other limited benefits as the Commissioner may
specify.

In no case shall an employment-based health plan in which the
coverage consists only of one or more of the coverage or
benefits described in clauses (i) through (iii) be treated as
acceptable coverage under this division.
(2) Transitional treatment as acceptable coverage.--During
the grace period specified in paragraph (1)(A), an
employment-based health plan (which may be a high deducible
health plan, as defined in section 223(c)(2) of the Internal
Revenue Code of 1986) that is described in such paragraph
shall be treated as acceptable coverage under this division.
(c) Limitation on Individual Health Insurance Coverage.--
(1) In general.--Individual health insurance coverage that
is not grandfathered health insurance coverage under
subsection (a) may only be offered on or after the first day
of Y1 as an Exchange-participating health benefits plan.
(2) Separate, excepted coverage permitted.--Nothing in--
(A) paragraph (1) shall prevent the offering of excepted
benefits described in section 2791(c) of the Public Health
Service Act so long as such benefits are offered outside the
Health Insurance Exchange and are priced separately from
health insurance coverage; and
(B) this division shall be construed--
(i) to prevent the offering of a stand-alone plan that
offers coverage of excepted benefits described in section
2791(c)(2)(A) of the Public Health Service Act (relating to
limited scope dental or vision benefits) for individuals and
families from a State-licensed dental and vision carrier; or
(ii) as applying requirements for a qualified health
benefits plan to such a stand-alone plan that is offered and
priced separately from a qualified health benefits plan.

Subtitle B--Standards Guaranteeing Access to Affordable Coverage

SEC. 211. PROHIBITING PREEXISTING CONDITION EXCLUSIONS.

A qualified health benefits plan may not impose any
preexisting condition exclusion (as defined in section
2701(b)(1)(A) of the Public Health Service Act) or otherwise
impose any limit or condition on the coverage under the plan
with respect to an individual or dependent based on any of
the following: health status, medical condition, claims
experience, receipt of health care, medical history, genetic
information, evidence of insurability, disability, or source
of injury (including conditions arising out of acts of
domestic violence) or any similar factors.

SEC. 212. GUARANTEED ISSUE AND RENEWAL FOR INSURED PLANS AND
PROHIBITING RESCISSIONS.

The requirements of sections 2711 (other than subsections
(e) and (f)) and 2712 (other than paragraphs (3), and (6) of
subsection (b) and subsection (e)) of the Public Health
Service Act, relating to guaranteed availability and
renewability of health insurance coverage, shall apply to
individuals and employers in all individual and group health
insurance coverage, whether offered to individuals or
employers through the Health Insurance Exchange, through any
employment-based health plan, or otherwise, in the same
manner as such sections apply to employers and health
insurance coverage offered in the small group market, except
that such section 2712(b)(1) shall apply only if, before
nonrenewal or discontinuation of coverage, the issuer has
provided the enrollee with notice of nonpayment of premiums
and there is a grace period during which the enrollee has an
opportunity to correct such nonpayment. Rescissions of such
coverage shall be prohibited except in cases of fraud as
defined in section 2712(b)(2) of such Act.

SEC. 213. INSURANCE RATING RULES.

(a) In General.--The premium rate charged for a qualified
health benefits plan that is health insurance coverage may
not vary except as follows:
(1) Limited age variation permitted.--By age (within such
age categories as the Commissioner shall specify) so long as
the ratio of the highest such premium to the lowest such
premium does not exceed the ratio of 2 to 1.
(2) By area.--By premium rating area (as permitted by State
insurance regulators or, in the case of Exchange-
participating health benefits plans, as specified by the
Commissioner in consultation with such regulators).
(3) By family enrollment.--By family enrollment (such as
variations within categories and compositions of families) so
long as the ratio of the premium for family enrollment (or
enrollments) to the premium for individual enrollment is
uniform, as specified under State law and consistent with
rules of the Commissioner.
(b) Actuarial Value of Optional Service Coverage.--
(1) In general.--The Commissioner shall estimate the basic
per enrollee, per month cost, determined on an average
actuarial basis, for including coverage under a basic plan of
the services described in section 222(e)(4)(A).
(2) Considerations.--In making such estimate the
Commissioner--
(A) may take into account the impact on overall costs of
the inclusion of such coverage, but may not take into account
any cost reduction estimated to result from such services,
including prenatal care, delivery, or postnatal care;
(B) shall estimate such costs as if such coverage were
included for the entire population covered; and
(C) may not estimate such a cost at less than $1 per
enrollee, per month.
(c) Study and Reports.--
(1) Study.--The Commissioner, in coordination with the
Secretary of Health and Human Services and the Secretary of
Labor, shall conduct a study of the large-group-insured and
self-insured employer health care markets. Such study shall
examine the following:
(A) The types of employers by key characteristics,
including size, that purchase insured products versus those
that self-insure.
(B) The similarities and differences between typical
insured and self-insured health plans.
(C) The financial solvency and capital reserve levels of
employers that self-insure by employer size.
(D) The risk of self-insured employers not being able to
pay obligations or otherwise becoming financially insolvent.
(E) The extent to which rating rules are likely to cause
adverse selection in the large group market or to encourage
small and midsize employers to self-insure.
(2) Reports.--Not later than 18 months after the date of
the enactment of this Act, the Commissioner shall submit to
Congress and the applicable agencies a report on the study
conducted under paragraph (1). Such report shall include any
recommendations the Commissioner deems appropriate to ensure
that the law does not provide incentives for small and
midsize employers to self-insure or create adverse selection
in the risk pools of large group insurers and self-insured
employers. Not later than 18 months after the first day of
Y1, the Commissioner shall submit to Congress and the
applicable agencies an updated report on such study,
including updates on such recommendations.

SEC. 214. NONDISCRIMINATION IN BENEFITS; PARITY IN MENTAL
HEALTH AND SUBSTANCE ABUSE DISORDER BENEFITS.

(a) Nondiscrimination in Benefits.--A qualified health
benefits plan shall comply with standards established by the
Commissioner to prohibit discrimination in health benefits or
benefit structures for qualifying health benefits plans,
building from section 702 of the Employee Retirement Income
Security Act of 1974, section 2702 of the Public Health
Service Act, and section 9802 of the Internal Revenue Code of
1986.
(b) Parity in Mental Health and Substance Abuse Disorder
Benefits.--To the extent such provisions are not superceded
by or inconsistent with subtitle C, the provisions of section
2705 (other than subsections (a)(1), (a)(2), and (c)) of the
Public Health Service Act shall apply to a qualified health
benefits plan, regardless of whether it is offered in the
individual or group market, in the same manner as such
provisions apply to health insurance coverage offered in the
large group market.

[[Page H12636]]

SEC. 215. ENSURING ADEQUACY OF PROVIDER NETWORKS.

(a) In General.--A qualified health benefits plan that uses
a provider network for items and services shall meet such
standards respecting provider networks as the Commissioner
may establish to assure the adequacy of such networks in
ensuring enrollee access to such items and services and
transparency in the cost-sharing differentials among
providers participating in the network and policies for
accessing out-of-network providers.
(b) Internet Access to Information.--A qualified health
benefits plan that uses a provider network shall provide a
current listing of all providers in its network on its
Website and such data shall be available on the Health
Insurance Exchange Website as a part of the basic information
on that plan. The Commissioner shall also establish an on-
line system whereby an individual may select by name any
medical provider (as defined by the Commissioner) and be
informed of the plan or plans with which that provider is
contracting.
(c) Provider Network Defined.--In this division, the term
``provider network'' means the providers with respect to
which covered benefits, treatments, and services are
available under a health benefits plan.

SEC. 216. REQUIRING THE OPTION OF EXTENSION OF DEPENDENT
COVERAGE FOR UNINSURED YOUNG ADULTS.

(a) In General.--A qualified health benefits plan shall
make available, at the option of the principal enrollee under
the plan, coverage for one or more qualified children (as
defined in subsection (b)) of the enrollee.
(b) Qualified Child Defined.--In this section, the term
``qualified child'' means, with respect to a principal
enrollee in a qualified health benefits plan, an individual
who (but for age) would be treated as a dependent child of
the enrollee under such plan and who--
(1) is under 27 years of age; and
(2) is not enrolled in a health benefits plan other than
under this section.
(c) Premiums.--Nothing in this section shall be construed
as preventing a qualified health benefits plan from
increasing the premiums otherwise required for coverage
provided under this section consistent with standards
established by the Commissioner based upon family size under
section 213(a)(3).

SEC. 217. CONSISTENCY OF COSTS AND COVERAGE UNDER QUALIFIED
HEALTH BENEFITS PLANS DURING PLAN YEAR.

In the case of health insurance coverage offered under a
qualified health benefits plan, if the coverage decreases or
the cost-sharing increases, the issuer of the coverage shall
notify enrollees of the change at least 90 days before the
change takes effect (or such shorter period of time in cases
where the change is necessary to ensure the health and safety
of enrollees).

Subtitle C--Standards Guaranteeing Access to Essential Benefits

SEC. 221. COVERAGE OF ESSENTIAL BENEFITS PACKAGE.

(a) In General.--A qualified health benefits plan shall
provide coverage that at least meets the benefit standards
adopted under section 224 for the essential benefits package
described in section 222 for the plan year involved.
(b) Choice of Coverage.--
(1) Non-exchange-participating health benefits plans.--In
the case of a qualified health benefits plan that is not an
Exchange-participating health benefits plan, such plan may
offer such coverage in addition to the essential benefits
package as the QHBP offering entity may specify.
(2) Exchange-participating health benefits plans.--In the
case of an Exchange-participating health benefits plan, such
plan is required under section 203 to provide specified
levels of benefits and, in the case of a plan offering a
premium-plus level of benefits, provide additional benefits.
(3) Continuation of offering of separate excepted benefits
coverage.--Nothing in this division shall be construed as
affecting the offering outside of the Health Insurance
Exchange and under State law of health benefits in the form
of excepted benefits (described in section 202(b)(1)(B)(ii))
if such benefits are offered under a separate policy,
contract, or certificate of insurance.
(c) Clinical Appropriateness.--Nothing in this Act shall be
construed to prohibit a group health plan or health insurance
issuer from using medical management practices so long as
such management practices are based on valid medical evidence
and are relevant to the patient whose medical treatment is
under review.
(d) Provision of Benefits.--Nothing in this division shall
be construed as prohibiting a qualified health benefits plan
from subcontracting with stand-alone health insurance issuers
or insurers for the provision of dental, vision, mental
health, and other benefits and services.

SEC. 222. ESSENTIAL BENEFITS PACKAGE DEFINED.

(a) In General.--In this division, the term ``essential
benefits package'' means health benefits coverage, consistent
with standards adopted under section 224, to ensure the
provision of quality health care and financial security,
that--
(1) provides payment for the items and services described
in subsection (b) in accordance with generally accepted
standards of medical or other appropriate clinical or
professional practice;
(2) limits cost-sharing for such covered health care items
and services in accordance with such benefit standards,
consistent with subsection (c);
(3) does not impose any annual or lifetime limit on the
coverage of covered health care items and services;
(4) complies with section 215(a) (relating to network
adequacy); and
(5) is equivalent in its scope of benefits, as certified by
Office of the Actuary of the Centers for Medicare & Medicaid
Services, to the average prevailing employer-sponsored
coverage in Y1.

In order to carry out paragraph (5), the Secretary of Labor
shall conduct a survey of employer-sponsored coverage to
determine the benefits typically covered by employers,
including multiemployer plans, and provide a report on such
survey to the Health Benefits Advisory Committee and to the
Secretary of Health and Human Services.
(b) Minimum Services To Be Covered.--Subject to subsection
(d), the items and services described in this subsection are
the following:
(1) Hospitalization.
(2) Outpatient hospital and outpatient clinic services,
including emergency department services.
(3) Professional services of physicians and other health
professionals.
(4) Such services, equipment, and supplies incident to the
services of a physician's or a health professional's delivery
of care in institutional settings, physician offices,
patients' homes or place of residence, or other settings, as
appropriate.
(5) Prescription drugs.
(6) Rehabilitative and habilitative services.
(7) Mental health and substance use disorder services,
including behavioral health treatments.
(8) Preventive services, including those services
recommended with a grade of A or B by the Task Force on
Clinical Preventive Services and those vaccines recommended
for use by the Director of the Centers for Disease Control
and Prevention.
(9) Maternity care.
(10) Well-baby and well-child care and oral health, vision,
and hearing services, equipment, and supplies for children
under 21 years of age.
(11) Durable medical equipment, prosthetics, orthotics and
related supplies.
(c) Requirements Relating to Cost-Sharing and Minimum
Actuarial Value.--
(1) No cost-sharing for preventive services.--There shall
be no cost-sharing under the essential benefits package for--
(A) preventive items and services recommended with a grade
of A or B by the Task Force on Clinical Preventive Services
and those vaccines recommended for use by the Director of the
Centers for Disease Control and Prevention; or
(B) well-baby and well-child care.
(2) Annual limitation.--
(A) Annual limitation.--The cost-sharing incurred under the
essential benefits package with respect to an individual (or
family) for a year does not exceed the applicable level
specified in subparagraph (B).
(B) Applicable level.--The applicable level specified in
this subparagraph for Y1 is not to exceed $5,000 for an
individual and not to exceed $10,000 for a family. Such
levels shall be increased (rounded to the nearest $100) for
each subsequent year by the annual percentage increase in the
enrollment-weighted average of premium increases for basic
plans applicable to such year, except that Secretary shall
adjust such increase to ensure that the applicable level
specified in this subparagraph meets the minimum actuarial
value required under paragraph (3).
(C) Use of copayments.--In establishing cost-sharing levels
for basic, enhanced, and premium plans under this subsection,
the Secretary shall, to the maximum extent possible, use only
copayments and not coinsurance.
(3) Minimum actuarial value.--
(A) In general.--The cost-sharing under the essential
benefits package shall be designed to provide a level of
coverage that is designed to provide benefits that are
actuarially equivalent to approximately 70 percent of the
full actuarial value of the benefits provided under the
reference benefits package described in subparagraph (B).
(B) Reference benefits package described.--The reference
benefits package described in this subparagraph is the
essential benefits package if there were no cost-sharing
imposed.
(d) Assessment and Counseling for Domestic Violence.--The
Secretary shall support the need for an assessment and brief
counseling for domestic violence as part of a behavioral
health assessment or primary care visit and determine the
appropriate coverage for such assessment and counseling.
(e) Abortion Coverage Prohibited as Part of Minimum
Benefits Package.--
(1) Prohibition of required coverage.--The Health Benefits
Advisory Committee may not recommend under section 223(b),
and the Secretary may not adopt in standards under section
224(b), the services described in paragraph (4)(A) or (4)(B)
as part of the essential benefits package and the
Commissioner may not require such services for qualified
health benefits plans to participate in the Health Insurance
Exchange.
(2) Voluntary choice of coverage by plan.--In the case of a
qualified health benefits plan, the plan is not required (or
prohibited) under this Act from providing coverage of
services described in paragraph (4)(A) or (4)(B) and the QHBP
offering entity shall determine whether such coverage is
provided.

[[Page H12637]]

(3) Coverage under public health insurance option.--The
public health insurance option shall provide coverage for
services described in paragraph (4)(B). Nothing in this Act
shall be construed as preventing the public health insurance
option from providing for or prohibiting coverage of services
described in paragraph (4)(A).
(4) Abortion services.--
(A) Abortions for which public funding is prohibited.--The
services described in this subparagraph are abortions for
which the expenditure of Federal funds appropriated for the
Department of Health and Human Services is not permitted,
based on the law as in effect as of the date that is 6 months
before the beginning of the plan year involved.
(B) Abortions for which public funding is allowed.--The
services described in this subparagraph are abortions for
which the expenditure of Federal funds appropriated for the
Department of Health and Human Services is permitted, based
on the law as in effect as of the date that is 6 months
before the beginning of the plan year involved.
(f) Report Regarding Inclusion of Oral Health Care in
Essential Benefits Package.--Not later than 1 year after the
date of the enactment of this Act, the Secretary of Health
and Human Services shall submit to Congress a report
containing the results of a study determining the need and
cost of providing accessible and affordable oral health care
to adults as part of the essential benefits package.

SEC. 223. HEALTH BENEFITS ADVISORY COMMITTEE.

(a) Establishment.--
(1) In general.--There is established a private-public
advisory committee which shall be a panel of medical and
other experts to be known as the Health Benefits Advisory
Committee to recommend covered benefits and essential,
enhanced, and premium plans.
(2) Chair.--The Surgeon General shall be a member and the
chair of the Health Benefits Advisory Committee.
(3) Membership.--The Health Benefits Advisory Committee
shall be composed of the following members, in addition to
the Surgeon General:
(A) Nine members who are not Federal employees or officers
and who are appointed by the President.
(B) Nine members who are not Federal employees or officers
and who are appointed by the Comptroller General of the
United States in a manner similar to the manner in which the
Comptroller General appoints members to the Medicare Payment
Advisory Commission under section 1805(c) of the Social
Security Act.
(C) Such even number of members (not to exceed 8) who are
Federal employees and officers, as the President may appoint.
Such initial appointments shall be made not later than 60
days after the date of the enactment of this Act.
(4) Terms.--Each member of the Health Benefits Advisory
Committee shall serve a 3-year term on the Committee, except
that the terms of the initial members shall be adjusted in
order to provide for a staggered term of appointment for all
such members.
(5) Participation.--The membership of the Health Benefits
Advisory Committee shall at least reflect providers, patient
representatives, employers (including small employers),
labor, health insurance issuers, experts in health care
financing and delivery, experts in oral health care, experts
in racial and ethnic disparities, experts on health care
needs and disparities of individuals with disabilities,
representatives of relevant governmental agencies, and at
least one practicing physician or other health professional
and an expert in child and adolescent health and shall
represent a balance among various sectors of the health care
system so that no single sector unduly influences the
recommendations of such Committee.
(b) Duties.--
(1) Recommendations on benefit standards.--The Health
Benefits Advisory Committee shall recommend to the Secretary
of Health and Human Services (in this subtitle referred to as
the ``Secretary'') benefit standards (as defined in paragraph
(5)), and periodic updates to such standards. In developing
such recommendations, the Committee shall take into account
innovation in health care and consider how such standards
could reduce health disparities.
(2) Deadline.--The Health Benefits Advisory Committee shall
recommend initial benefit standards to the Secretary not
later than 1 year after the date of the enactment of this
Act.
(3) State input.--The Health Benefits Advisory Committee
shall examine the health coverage laws and benefits of each
State in developing recommendations under this subsection and
may incorporate such coverage and benefits as the Committee
determines to be appropriate and consistent with this Act.
The Health Benefits Advisory Committee shall also seek input
from the States and consider recommendations on how to ensure
quality of health coverage in all States.
(4) Public input.--The Health Benefits Advisory Committee
shall allow for public input as a part of developing
recommendations under this subsection.
(5) Benefit standards defined.--In this subtitle, the term
``benefit standards'' means standards respecting--
(A) the essential benefits package described in section
222, including categories of covered treatments, items and
services within benefit classes, and cost-sharing consistent
with subsection (e) of such section; and
(B) the cost-sharing levels for enhanced plans and premium
plans (as provided under section 303(c)) consistent with
paragraph (5).
(6) Levels of cost-sharing for enhanced and premium
plans.--
(A) Enhanced plan.--The level of cost-sharing for enhanced
plans shall be designed so that such plans have benefits that
are actuarially equivalent to approximately 85 percent of the
actuarial value of the benefits provided under the reference
benefits package described in section 222(c)(3)(B).
(B) Premium plan.--The level of cost-sharing for premium
plans shall be designed so that such plans have benefits that
are actuarially equivalent to approximately 95 percent of the
actuarial value of the benefits provided under the reference
benefits package described in section 222(c)(3)(B).
(c) Operations.--
(1) Per diem pay.--Each member of the Health Benefits
Advisory Committee shall receive travel expenses, including
per diem in accordance with applicable provisions under
subchapter I of chapter 57 of title 5, United States Code,
and shall otherwise serve without additional pay.
(2) Members not treated as federal employees.--Members of
the Health Benefits Advisory Committee shall not be
considered employees of the Federal Government solely by
reason of any service on the Committee, except such members
shall be considered to be within the meaning of section
202(a) of title 18, United States Code, for the purposes of
disclosure and management of conflicts of interest.
(3) Application of faca.--The Federal Advisory Committee
Act (5 U.S.C. App.), other than section 14, shall apply to
the Health Benefits Advisory Committee.
(d) Publication.--The Secretary shall provide for
publication in the Federal Register and the posting on the
Internet Website of the Department of Health and Human
Services of all recommendations made by the Health Benefits
Advisory Committee under this section.

SEC. 224. PROCESS FOR ADOPTION OF RECOMMENDATIONS; ADOPTION
OF BENEFIT STANDARDS.

(a) Process for Adoption of Recommendations.--
(1) Review of recommended standards.--Not later than 45
days after the date of receipt of benefit standards
recommended under section 223 (including such standards as
modified under paragraph (2)(B)), the Secretary shall review
such standards and shall determine whether to propose
adoption of such standards as a package.
(2) Determination to adopt standards.--If the Secretary
determines--
(A) to propose adoption of benefit standards so recommended
as a package, the Secretary shall, by regulation under
section 553 of title 5, United States Code, propose adoption
of such standards; or
(B) not to propose adoption of such standards as a package,
the Secretary shall notify the Health Benefits Advisory
Committee in writing of such determination and the reasons
for not proposing the adoption of such recommendation and
provide the Committee with a further opportunity to modify
its previous recommendations and submit new recommendations
to the Secretary on a timely basis.
(3) Contingency.--If, because of the application of
paragraph (2)(B), the Secretary would otherwise be unable to
propose initial adoption of such recommended standards by the
deadline specified in subsection (b)(1), the Secretary shall,
by regulation under section 553 of title 5, United States
Code, propose adoption of initial benefit standards by such
deadline.
(4) Publication.--The Secretary shall provide for
publication in the Federal Register of all determinations
made by the Secretary under this subsection.
(b) Adoption of Standards.--
(1) Initial standards.--Not later than 18 months after the
date of the enactment of this Act, the Secretary shall,
through the rulemaking process consistent with subsection
(a), adopt an initial set of benefit standards.
(2) Periodic updating standards.--Under subsection (a), the
Secretary shall provide for the periodic updating of the
benefit standards previously adopted under this section.
(3) Requirement.--The Secretary may not adopt any benefit
standards for an essential benefits package or for level of
cost-sharing that are inconsistent with the requirements for
such a package or level under sections 222 (including
subsection (e)) and 223(b)(5).

Subtitle D--Additional Consumer Protections

SEC. 231. REQUIRING FAIR MARKETING PRACTICES BY HEALTH
INSURERS.

The Commissioner shall establish uniform marketing
standards that all QHBP offering entities shall meet with
respect to qualified health benefits plans that are health
insurance coverage.

SEC. 232. REQUIRING FAIR GRIEVANCE AND APPEALS MECHANISMS.

(a) In General.--A QHBP offering entity shall provide for
timely grievance and appeals mechanisms with respect to
qualified health benefits plans that the Commissioner shall
establish consistent with this section. The Commissioner
shall establish time limits for each of such mechanisms and
implement them in a manner that is protective to the needs of
patients.
(b) Internal Claims and Appeals Process.--Under a qualified
health benefits plan

[[Page H12638]]

the QHBP offering entity shall provide an internal claims and
appeals process that initially incorporates the claims and
appeals procedures (including urgent claims) set forth at
section 2560.503-1 of title 29, Code of Federal Regulations,
as published on November 21, 2000 (65 Fed. Reg. 70246) and
shall update such process in accordance with any standards
that the Commissioner may establish.
(c) External Review Process.--
(1) In general.--The Commissioner shall establish an
external review process (including procedures for expedited
reviews of urgent claims) that provides for an impartial,
independent, and de novo review of denied claims under this
division.
(2) Requiring fair grievance and appeals mechanisms.--A
determination made, with respect to a qualified health
benefits plan offered by a QHBP offering entity, under the
external review process established under this subsection
shall be binding on the plan and the entity.
(d) Time Limits.--The Commissioner shall establish time
limits for each of these processes and implement them in a
manner that is protective to the patient.
(e) Construction.--Nothing in this section shall be
construed as affecting the availability of judicial review
under State law for adverse decisions under subsection (b) or
(c), subject to section 251.

SEC. 233. REQUIRING INFORMATION TRANSPARENCY AND PLAN
DISCLOSURE.

(a) Accurate and Timely Disclosure.--
(1) For exchange-participating health benefits plans.--A
QHBP offering entity offering an Exchange-participating
health benefits plan shall comply with standards established
by the Commissioner for the accurate and timely disclosure to
the Commissioner and the public of plan documents, plan terms
and conditions, claims payment policies and practices,
periodic financial disclosure, data on enrollment, data on
disenrollment, data on the number of claims denials, data on
rating practices, information on cost-sharing and payments
with respect to any out-of-network coverage, and other
information as determined appropriate by the Commissioner.
(2) Employment-based health plans.--The Secretary of Labor
shall update and harmonize the Secretary's rules concerning
the accurate and timely disclosure to participants by group
health plans of plan disclosure, plan terms and conditions,
and periodic financial disclosure with the standards
established by the Commissioner under paragraph (1).
(3) Use of plain language.--
(A) In general.--The disclosures under paragraphs (1) and
(2) shall be provided in plain language.
(B) Definition.--In this paragraph, the term ``plain
language'' means language that the intended audience,
including individuals with limited English proficiency, can
readily understand and use because that language is concise,
well-organized, and follows other best practices of plain
language writing.
(C) Guidance.--The Commissioner and the Secretary of Labor
shall jointly develop and issue guidance on best practices of
plain language writing.
(4) Information on rights.--The information disclosed under
this subsection shall include information on enrollee and
participant rights under this division.
(5) Cost-sharing transparency.--A qualified health benefits
plan shall allow individuals to learn the amount of cost-
sharing (including deductibles, copayments, and coinsurance)
under the individual's plan or coverage that the individual
would be responsible for paying with respect to the
furnishing of a specific item or service by a participating
provider in a timely manner upon request. At a minimum, this
information shall be made available to such individual via an
Internet Website and other means for individuals without
access to the Internet.
(b) Contracting Reimbursement.--A qualified health benefits
plan shall comply with standards established by the
Commissioner to ensure transparency to each health care
provider relating to reimbursement arrangements between such
plan and such provider.
(c) Pharmacy Benefit Managers Transparency Requirements.--
(1) In general.--If a QHBP offering entity contracts with a
pharmacy benefit manager or other entity (in this subsection
referred to as a ``PBM'') to manage prescription drug
coverage or otherwise control prescription drug costs under a
qualified health benefits plan, the PBM shall provide at
least annually to the Commissioner and to the QHBP offering
entity offering such plan the following information, in a
form and manner to be determined by the Commissioner:
(A) Information on the number and total cost of
prescriptions under the contract that are filled via mail
order and at retail pharmacies.
(B) An estimate of aggregate average payments under the
contract, per prescription (weighted by prescription volume),
made to mail order and retail pharmacies, and the average
amount, per prescription, that the PBM was paid by the plan
for prescriptions filled at mail order and retail
pharmacists.
(C) An estimate of the aggregate average payment per
prescription (weighted by prescription volume) under the
contract received from pharmaceutical manufacturers,
including all rebates, discounts, prices concessions, or
administrative, and other payments from pharmaceutical
manufacturers, and a description of the types of payments,
and the amount of these payments that were shared with the
plan, and a description of the percentage of prescriptions
for which the PBM received such payments.
(D) Information on the overall percentage of generic drugs
dispensed under the contract at retail and mail order
pharmacies, and the percentage of cases in which a generic
drug is dispensed when available.
(E) Information on the percentage and number of cases under
the contract in which individuals were switched because of
PBM policies or at the direct or indirect control of the PBM
from a prescribed drug that had a lower cost for the QHBP
offering entity to a drug that had a higher cost for the QHBP
offering entity, the rationale for these switches, and a
description of the PBM policies governing such switches.
(2) Confidentiality of information.--Information disclosed
by a PBM to the Commissioner or a QHBP offering entity under
this subsection is confidential and shall not be disclosed by
the Commissioner or the QHBP offering entity in a form which
discloses the identity of a specific PBM or prices charged by
such PBM or a specific retailer, manufacturer, or wholesaler,
except only by the Commissioner--
(A) to permit State or Federal law enforcement authorities
to use the information provided for program compliance
purposes and for the purpose of combating waste, fraud, and
abuse;
(B) to permit the Comptroller General, the Medicare Payment
Advisory Commission, or the Secretary of Health and Human
Services to review the information provided; and
(C) to permit the Director of the Congressional Budget
Office to review the information provided.
(3) Annual public report.--On an annual basis, the
Commissioner shall prepare a public report providing
industrywide aggregate or average information to be used in
assessing the overall impact of PBMs on prescription drug
prices and spending. Such report shall not disclose the
identity of a specific PBM, or prices charged by such PBM, or
a specific retailer, manufacturer, or wholesaler, or any
other confidential or trade secret information.
(4) Penalties.--The provisions of subsection (b)(3)(C) of
section 1927 shall apply to a PBM that fails to provide
information required under subsection (a) or that knowingly
provides false information in the same manner as such
provisions apply to a manufacturer with an agreement under
such section that fails to provide information under
subsection (b)(3)(A) of such section or knowingly provides
false information under such section, respectively.

SEC. 234. APPLICATION TO QUALIFIED HEALTH BENEFITS PLANS NOT
OFFERED THROUGH THE HEALTH INSURANCE EXCHANGE.

The requirements of the previous provisions of this
subtitle shall apply to qualified health benefits plans that
are not being offered through the Health Insurance Exchange
only to the extent specified by the Commissioner.

SEC. 235. TIMELY PAYMENT OF CLAIMS.

A QHBP offering entity shall comply with the requirements
of section 1857(f) of the Social Security Act with respect to
a qualified health benefits plan it offers in the same manner
as a Medicare Advantage organization is required to comply
with such requirements with respect to a Medicare Advantage
plan it offers under part C of Medicare.

SEC. 236. STANDARDIZED RULES FOR COORDINATION AND SUBROGATION
OF BENEFITS.

The Commissioner shall establish standards for the
coordination and subrogation of benefits and reimbursement of
payments in cases of qualified health benefits plans
involving individuals and multiple plan coverage.

SEC. 237. APPLICATION OF ADMINISTRATIVE SIMPLIFICATION.

A QHBP offering entity is required to comply with
administrative simplification provisions under part C of
title XI of the Social Security Act with respect to qualified
health benefits plans it offers.

SEC. 238. STATE PROHIBITIONS ON DISCRIMINATION AGAINST HEALTH
CARE PROVIDERS.

This Act (and the amendments made by this Act) shall not be
construed as superseding laws, as they now or hereinafter
exist, of any State or jurisdiction designed to prohibit a
qualified health benefits plan from discriminating with
respect to participation, reimbursement, covered services,
indemnification, or related requirements under such plan
against a health care provider that is acting within the
scope of that provider's license or certification under
applicable State law.

SEC. 239. PROTECTION OF PHYSICIAN PRESCRIBER INFORMATION.

(a) Study.--The Secretary of Health and Human Services
shall conduct a study on the use of physician prescriber
information in sales and marketing practices of
pharmaceutical manufacturers.
(b) Report.--Based on the study conducted under subsection
(a), the Secretary shall submit to Congress a report on
actions needed to be taken by the Congress or the Secretary
to protect providers from biased marketing and sales
practices.

SEC. 240. DISSEMINATION OF ADVANCE CARE PLANNING INFORMATION.

(a) In General.--The QHBP offering entity --
(1) shall provide for the dissemination of information
related to end-of-life planning

[[Page H12639]]

to individuals seeking enrollment in Exchange-participating
health benefits plans offered through the Exchange;
(2) shall present such individuals with--
(A) the option to establish advanced directives and
physician's orders for life sustaining treatment according to
the laws of the State in which the individual resides; and
(B) information related to other planning tools; and
(3) shall not promote suicide, assisted suicide,
euthanasia, or mercy killing.
The information presented under paragraph (2) shall not
presume the withdrawal of treatment and shall include end-of-
life planning information that includes options to maintain
all or most medical interventions.
(b) Construction.-- Nothing in this section shall be
construed--
(1) to require an individual to complete an advanced
directive or a physician's order for life sustaining
treatment or other end-of-life planning document;
(2) to require an individual to consent to restrictions on
the amount, duration, or scope of medical benefits otherwise
covered under a qualified health benefits plan; or
(3) to promote suicide, assisted suicide, euthanasia, or
mercy killing.
(c) Advanced Directive Defined.--In this section, the term
``advanced directive'' includes a living will, a comfort care
order, or a durable power of attorney for health care.
(d) Prohibition on the Promotion of Assisted Suicide.--
(1) In general.--Subject to paragraph (3), information
provided to meet the requirements of subsection (a)(2) shall
not include advanced directives or other planning tools that
list or describe as an option suicide, assisted suicide,
euthanasia, or mercy killing, regardless of legality.
(2) Construction.--Nothing in paragraph (1) shall be
construed to apply to or affect any option to--
(A) withhold or withdraw of medical treatment or medical
care;
(B) withhold or withdraw of nutrition or hydration; and
(C) provide palliative or hospice care or use an item,
good, benefit, or service furnished for the purpose of
alleviating pain or discomfort, even if such use may increase
the risk of death, so long as such item, good, benefit, or
service is not also furnished for the purpose of causing, or
the purpose of assisting in causing, death, for any reason.
(3) No preemption of state law.--Nothing in this section
shall be construed to preempt or otherwise have any effect on
State laws regarding advance care planning, palliative care,
or end-of-life decision-making.

Subtitle E--Governance

SEC. 241. HEALTH CHOICES ADMINISTRATION; HEALTH CHOICES
COMMISSIONER.

(a) In General.--There is hereby established, as an
independent agency in the executive branch of the Government,
a Health Choices Administration (in this division referred to
as the ``Administration'').
(b) Commissioner.--
(1) In general.--The Administration shall be headed by a
Health Choices Commissioner (in this division referred to as
the ``Commissioner'') who shall be appointed by the
President, by and with the advice and consent of the Senate.
(2) Compensation; etc.--The provisions of paragraphs (2),
(5), and (7) of subsection (a) (relating to compensation,
terms, general powers, rulemaking, and delegation) of section
702 of the Social Security Act (42 U.S.C. 902) shall apply to
the Commissioner and the Administration in the same manner as
such provisions apply to the Commissioner of Social Security
and the Social Security Administration.
(c) Inspector General.--For provision establishing an
Office of the Inspector General for the Health Choices
Administration, see section 1647.

SEC. 242. DUTIES AND AUTHORITY OF COMMISSIONER.

(a) Duties.--The Commissioner is responsible for carrying
out the following functions under this division:
(1) Qualified plan standards.--The establishment of
qualified health benefits plan standards under this title,
including the enforcement of such standards in coordination
with State insurance regulators and the Secretaries of Labor
and the Treasury.
(2) Health insurance exchange.--The establishment and
operation of a Health Insurance Exchange under subtitle A of
title III.
(3) Individual affordability credits.--The administration
of individual affordability credits under subtitle C of title
III, including determination of eligibility for such credits.
(4) Additional functions.--Such additional functions as may
be specified in this division.
(b) Promoting Accountability.--
(1) In general.--The Commissioner shall undertake
activities in accordance with this subtitle to promote
accountability of QHBP offering entities in meeting Federal
health insurance requirements, regardless of whether such
accountability is with respect to qualified health benefits
plans offered through the Health Insurance Exchange or
outside of such Exchange.
(2) Compliance examination and audits.--
(A) In general.--The Commissioner shall, in coordination
with States, conduct audits of qualified health benefits plan
compliance with Federal requirements.   Such audits may
include random compliance audits and targeted audits in
response to complaints or other suspected noncompliance.
(B) Recoupment of costs in connection with examination and
audits.--The Commissioner is authorized to recoup from
qualified health benefits plans reimbursement for the costs
of such examinations and audit of such QHBP offering
entities.
(c) Data Collection.--The Commissioner shall collect data
for purposes of carrying out the Commissioner's duties,
including for purposes of promoting quality and value,
protecting consumers, and addressing disparities in health
and health care and may share such data with the Secretary of
Health and Human Services.
(d) Sanctions Authority.--
(1) In general.--In the case that the Commissioner
determines that a QHBP offering entity violates a requirement
of this title, the Commissioner may, in coordination with
State insurance regulators and the Secretary of Labor,
provide, in addition to any other remedies authorized by law,
for any of the remedies described in paragraph (2).
(2) Remedies.--The remedies described in this paragraph,
with respect to a qualified health benefits plan offered by a
QHBP offering entity, are--
(A) civil money penalties of not more than the amount that
would be applicable under similar circumstances for similar
violations under section 1857(g) of the Social Security Act;
(B) suspension of enrollment of individuals under such plan
after the date the Commissioner notifies the entity of a
determination under paragraph (1) and until the Commissioner
is satisfied that the basis for such determination has been
corrected and is not likely to recur;
(C) in the case of an Exchange-participating health
benefits plan, suspension of payment to the entity under the
Health Insurance Exchange for individuals enrolled in such
plan after the date the Commissioner notifies the entity of a
determination under paragraph (1) and until the Secretary is
satisfied that the basis for such determination has been
corrected and is not likely to recur; or
(D) working with State insurance regulators to terminate
plans for repeated failure by the offering entity to meet the
requirements of this title.
(e) Standard Definitions of Insurance and Medical Terms.--
The Commissioner shall provide for the development of
standards for the definitions of terms used in health
insurance coverage, including insurance-related terms.
(f) Efficiency in Administration.--The Commissioner shall
issue regulations for the effective and efficient
administration of the Health Insurance Exchange and
affordability credits under subtitle C, including, with
respect to the determination of eligibility for affordability
credits, the use of personnel who are employed in accordance
with the requirements of title 5, United States Code, to
carry out the duties of the Commissioner or, in the case of
sections 308 and 341(b)(2), the use of State personnel who
are employed in accordance with standards prescribed by the
Office of Personnel Management pursuant to section 208 of the
Intergovernmental Personnel Act of 1970 (42 U.S.C. 4728).

SEC. 243. CONSULTATION AND COORDINATION.

(a) Consultation.--In carrying out the Commissioner's
duties under this division, the Commissioner, as appropriate,
shall consult at least with the following:
(1) State attorneys general and State insurance regulators,
including concerning the standards for health insurance
coverage that is a qualified health benefits plan under this
title and enforcement of such standards.
(2) The National Association of Insurance Commissioners,
including for purposes of using model guidelines established
by such association for purposes of subtitles B and D.
(3) Appropriate State agencies, specifically concerning the
administration of individual affordability credits under
subtitle C of title III and the offering of Exchange-
participating health benefits plans, to Medicaid eligible
individuals under subtitle A of such title.
(4) The Federal Trade Commission, specifically concerning
the development and issuance of guidance, rules, or standards
regarding fair marketing practices under section 231 or
otherwise, or any consumer disclosure requirements under
section 233 or otherwise.
(5) Other appropriate Federal agencies.
(6) Indian tribes and tribal organizations.
(b) Coordination.--
(1) In general.--In carrying out the functions of the
Commissioner, including with respect to the enforcement of
the provisions of this division, the Commissioner shall work
in coordination with existing Federal and State entities to
the maximum extent feasible consistent with this division and
in a manner that prevents conflicts of interest in duties and
ensures effective enforcement.
(2) Uniform standards.--The Commissioner, in coordination
with such entities, shall seek to achieve uniform standards
that adequately protect consumers in a manner that does not
unreasonably affect employers and insurers.

SEC. 244. HEALTH INSURANCE OMBUDSMAN.

(a) In General.--The Commissioner shall appoint within the
Health Choices Administration a Qualified Health Benefits
Plan Ombudsman who shall have expertise and experience in the
fields of health care and education of (and assistance to)
individuals.
(b) Duties.--The Qualified Health Benefits Plan Ombudsman
shall, in a linguistically appropriate manner--

[[Page H12640]]

(1) receive complaints, grievances, and requests for
information submitted by individuals through means such as
the mail, by telephone, electronically, and in person;
(2) provide assistance with respect to complaints,
grievances, and requests referred to in paragraph (1),
including--
(A) helping individuals determine the relevant information
needed to seek an appeal of a decision or determination;
(B) assistance to such individuals in choosing a qualified
health benefits plan in which to enroll;
(C) assistance to such individuals with any problems
arising from disenrollment from such a plan; and
(D) assistance to such individuals in presenting
information under subtitle C (relating to affordability
credits); and
(3) submit annual reports to Congress and the Commissioner
that describe the activities of the Ombudsman and that
include such recommendations for improvement in the
administration of this division as the Ombudsman determines
appropriate. The Ombudsman shall not serve as an advocate for
any increases in payments or new coverage of services, but
may identify issues and problems in payment or coverage
policies.

Subtitle F--Relation to Other Requirements; Miscellaneous

SEC. 251. RELATION TO OTHER REQUIREMENTS.

(a) Coverage Not Offered Through Exchange.--
(1) In general.--In the case of health insurance coverage
not offered through the Health Insurance Exchange (whether or
not offered in connection with an employment-based health
plan), and in the case of employment-based health plans, the
requirements of this title do not supercede any requirements
applicable under titles XXII and XXVII of the Public Health
Service Act, parts 6 and 7 of subtitle B of title I of the
Employee Retirement Income Security Act of 1974, or State
law, except insofar as such requirements prevent the
application of a requirement of this division, as determined
by the Commissioner.
(2) Construction.--Nothing in paragraphs (1) or (2) shall
be construed as affecting the application of section 514 of
the Employee Retirement Income Security Act of 1974.
(b) Coverage Offered Through Exchange.--
(1) In general.--In the case of health insurance coverage
offered through the Health Insurance Exchange--
(A) the requirements of this title do not supercede any
requirements (including requirements relating to genetic
information nondiscrimination and mental health parity)
applicable under title XXVII of the Public Health Service Act
or under State law, except insofar as such requirements
prevent the application of a requirement of this division, as
determined by the Commissioner; and
(B) individual rights and remedies under State laws shall
apply.
(2) Construction.--In the case of coverage described in
paragraph (1), nothing in such paragraph shall be construed
as preventing the application of rights and remedies under
State laws to health insurance issuers generally with respect
to any requirement referred to in paragraph (1)(A). The
previous sentence shall not be construed as providing for the
applicability of rights or remedies under State laws with
respect to requirements applicable to employers or other plan
sponsors in connection with arrangements which are treated as
group health plans under section 802(a)(1) of the Employee
Retirement Income Security Act of 1974.

SEC. 252. PROHIBITING DISCRIMINATION IN HEALTH CARE.

(a) In General.--Except as otherwise explicitly permitted
by this Act and by subsequent regulations consistent with
this Act, all health care and related services (including
insurance coverage and public health activities) covered by
this Act shall be provided without regard to personal
characteristics extraneous to the provision of high quality
health care or related services.
(b) Implementation.--To implement the requirement set forth
in subsection (a), the Secretary of Health and Human Services
shall, not later than 18 months after the date of the
enactment of this Act, promulgate such regulations as are
necessary or appropriate to insure that all health care and
related services (including insurance coverage and public
health activities) covered by this Act are provided (whether
directly or through contractual, licensing, or other
arrangements) without regard to personal characteristics
extraneous to the provision of high quality health care or
related services.

SEC. 253. WHISTLEBLOWER PROTECTION.

(a) Retaliation Prohibited.--No employer may discharge any
employee or otherwise discriminate against any employee with
respect to his compensation, terms, conditions, or other
privileges of employment because the employee (or any person
acting pursuant to a request of the employee)--
(1) provided, caused to be provided, or is about to provide
or cause to be provided to the employer, the Federal
Government, or the attorney general of a State information
relating to any violation of, or any act or omission the
employee reasonably believes to be a violation of any
provision of this Act or any order, rule, or regulation
promulgated under this Act;
(2) testified or is about to testify in a proceeding
concerning such violation;
(3) assisted or participated or is about to assist or
participate in such a proceeding; or
(4) objected to, or refused to participate in, any
activity, policy, practice, or assigned task that the
employee (or other such person) reasonably believed to be in
violation of any provision of this Act or any order, rule, or
regulation promulgated under this Act.
(b) Enforcement Action.--An employee covered by this
section who alleges discrimination by an employer in
violation of subsection (a) may bring an action governed by
the rules, procedures, legal burdens of proof, and remedies
set forth in section 40(b) of the Consumer Product Safety Act
(15 U.S.C. 2087(b)).
(c) Employer Defined.--As used in this section, the term
``employer'' means any person (including one or more
individuals, partnerships, associations, corporations,
trusts, professional membership organization including a
certification, disciplinary, or other professional body,
unincorporated organizations, nongovernmental organizations,
or trustees) engaged in profit or nonprofit business or
industry whose activities are governed by this Act, and any
agent, contractor, subcontractor, grantee, or consultant of
such person.
(d) Rule of Construction.--The rule of construction set
forth in section 20109(h) of title 49, United States Code,
shall also apply to this section.

SEC. 254. CONSTRUCTION REGARDING COLLECTIVE BARGAINING.

Nothing in this division shall be construed to alter or
supersede any statutory or other obligation to engage in
collective bargaining over the terms or conditions of
employment related to health care. Any plan amendment made
pursuant to a collective bargaining agreement relating to the
plan which amends the plan solely to conform to any
requirement added by this division shall not be treated as a
termination of such collective bargaining agreement.

SEC. 255. SEVERABILITY.

If any provision of this Act, or any application of such
provision to any person or circumstance, is held to be
unconstitutional, the remainder of the provisions of this Act
and the application of the provision to any other person or
circumstance shall not be affected.

SEC. 256. TREATMENT OF HAWAII PREPAID HEALTH CARE ACT.

(a) In General.--Subject to this section--
(1) nothing in this division (or an amendment made by this
division) shall be construed to modify or limit the
application of the exemption for the Hawaii Prepaid Health
Care Act (Haw. Rev. Stat. Sec. Sec.  393-1 et seq.) as
provided for under section 514(b)(5) of the Employee
Retirement Income Security Act of 1974 (29 U.S.C.
1144(b)(5)), and such exemption shall also apply with respect
to the provisions of this division; and
(2) for purposes of this division (and the amendments made
by this division), coverage provided pursuant to the Hawaii
Prepaid Health Care Act shall be treated as a qualified
health benefits plan providing acceptable coverage so long as
the Secretary of Labor determines that such coverage for
employees (taking into account the benefits and the cost to
employees for such benefits) is substantially equivalent to
or greater than the coverage provided for employees pursuant
to the essential benefits package.
(b) Coordination With State Law of Hawaii.--The
Commissioner shall, based on ongoing consultation with the
appropriate officials of the State of Hawaii, make
adjustments to rules and regulations of the Commissioner
under this division as may be necessary, as determined by the
Commissioner, to most effectively coordinate the provisions
of this division with the provisions of the Hawaii Prepaid
Health Care Act, taking into account any changes made from
time to time to the Hawaii Prepaid Health Care Act and
related laws of such State.

SEC. 257. ACTIONS BY STATE ATTORNEYS GENERAL.

Any State attorney general may bring a civil action in the
name of such State as parens patriae on behalf of natural
persons residing in such State, in any district court of the
United States or State court having jurisdiction of the
defendant to secure monetary or equitable relief for
violation of any provisions of this title or regulations
issued thereunder. Nothing in this section shall be construed
as affecting the application of section 514 of the Employee
Retirement Income Security Act of 1974.

SEC. 258. APPLICATION OF STATE AND FEDERAL LAWS REGARDING
ABORTION.

(a) No Preemption of State Laws Regarding Abortion.--
Nothing in this Act shall be construed to preempt or
otherwise have any effect on State laws regarding the
prohibition of (or requirement of) coverage, funding, or
procedural requirements on abortions, including parental
notification or consent for the performance of an abortion on
a minor.
(b) No Effect on Federal Laws Regarding Abortion.--
(1) In general.--Nothing in this Act shall be construed to
have any effect on Federal laws regarding--
(A) conscience protection;
(B) willingness or refusal to provide abortion; and
(C) discrimination on the basis of the willingness or
refusal to provide, pay for, cover, or refer for abortion or
to provide or participate in training to provide abortion.

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(c) No Effect on Federal Civil Rights Law.--Nothing in this
section shall alter the rights and obligations of employees
and employers under title VII of the Civil Rights Act of
1964.

SEC. 259. NONDISCRIMINATION ON ABORTION AND RESPECT FOR
RIGHTS OF CONSCIENCE.

(a) Nondiscrimination.--A Federal agency or program, and
any State or local government that receives Federal financial
assistance under this Act (or an amendment made by this Act),
may not--
(1) subject any individual or institutional health care
entity to discrimination; or
(2) require any health plan created or regulated under this
Act (or an amendment made by this Act) to subject any
individual or institutional health care entity to
discrimination,

on the basis that the health care entity does not provide,
pay for, provide coverage of, or refer for abortions.
(b) Definition.--In this section, the term ``health care
entity'' includes an individual physician or other health
care professional, a hospital, a provider-sponsored
organization, a health maintenance organization, a health
insurance plan, or any other kind of health care facility,
organization, or plan.
(c) Administration.--The Office for Civil Rights of the
Department of Health and Human Services is designated to
receive complaints of discrimination based on this section,
and coordinate the investigation of such complaints.

SEC. 260. AUTHORITY OF FEDERAL TRADE COMMISSION.

Section 6 of the Federal Trade Commission Act (15 U.S.C.
46) is amended by striking ``and prepare reports'' and all
that follows and inserting the following: ``and prepare
reports, and to share information under clauses (f) and (k),
relating to insurance. Notwithstanding section 4, the
Commission's authority shall include the authority to conduct
studies and prepare reports, and to share information under
clauses (f) and (k), relating to insurance, without regard to
whether the subject of such studies, reports, or information
is for-profit or not-for-profit entity.''.

SEC. 261. CONSTRUCTION REGARDING STANDARD OF CARE.

(a) In General.--The development, recognition, or
implementation of any guideline or other standard under a
provision described in subsection (b) shall not be construed
to establish the standard of care or duty of care owed by
health care providers to their patients in any medical
malpractice action or claim (as defined in section 431(7) of
the Health Care Quality Improvement Act of 1986 (42 U.S.C.
11151(7)).
(b) Provisions Described.--The provisions described in this
subsection are the following:
(1) Section 324 (relating to modernized payment initiatives
and delivery system reform under the public health option).
(2) The amendments made by section 1151 (relating to
reducing potentially preventable hospital readmissions).
(3) The amendments made by section 1751 (relating to health
care acquired conditions).
(4) Section 3131 of the Public Health Service Act (relating
to the Task Force on Clinical Preventive Services), added by
section 2301.
(5) Part D of title IX of the Public Health Service Act
(relating to implementation of best practices in the delivery
of health care), added by section 2401.
(c) Savings Clause for State Medical Mal-practice Laws.--
Nothing in this Act or the amendments made by this Act shall
be construed to modify or impair State law governing legal
standards or procedures used in medical malpractice cases,
including the authority of a State to make or implement such
laws.

SEC. 262. RESTORING APPLICATION OF ANTITRUST LAWS TO HEALTH
SECTOR INSURERS.

(a) Amendment to McCarran-Ferguson Act.--Section 3 of the
Act of March 9, 1945 (15 U.S.C. 1013), commonly known as the
McCarran-Ferguson Act, is amended by adding at the end the
following:
``(c)(1) Except as provided in paragraph (2), nothing
contained in this Act shall modify, impair, or supersede the
operation of any of the antitrust laws with respect to the
business of health insurance or the business of medical
malpractice insurance.
``(2) Paragraph (1) shall not apply to--
``(A) collecting, compiling, classifying, or disseminating
historical loss data;
``(B) determining a loss development factor applicable to
historical loss data; or
``(C) performing actuarial services if doing so does not
involve a restraint of trade.
``(3) For purposes of this subsection--
``(A) the term `antitrust laws' has the meaning given it in
subsection (a) of the first section of the Clayton Act,
except that such term includes section 5 of the Federal Trade
Commission Act to the extent that such section 5 applies to
unfair methods of competition;
``(B) the term `historical loss data' means information
respecting claims paid, or reserves held for claims reported,
by any person engaged in the business of insurance; and
``(C) the term `loss development factor' means an
adjustment to be made to the aggregate of losses incurred
during a prior period of time that have been paid, or for
which claims have been received and reserves are being held,
in order to estimate the aggregate of the losses incurred
during such period that will ultimately be paid.''.
(b) Related Provision.--For purposes of section 5 of the
Federal Trade Commission Act (15 U.S.C. 45) to the extent
such section applies to unfair methods of competition,
section 3(c) of the McCarran-Ferguson Act shall apply with
respect to the business of health insurance, and with respect
to the business of medical malpractice insurance, without
regard to whether such business is carried on for profit,
notwithstanding the definition of ``Corporation'' contained
in section 4 of the Federal Trade Commission Act.
(c) Related Preservation of Antitrust Laws.--Except as
provided in subsections (a) and (b), nothing in this Act, or
in the amendments made by this Act, shall be construed to
modify, impair, or supersede the operation of any of the
antitrust laws. For purposes of the preceding sentence, the
term ``antitrust laws'' has the meaning given it in
subsection (a) of the first section of the Clayton Act,
except that it includes section 5 of the Federal Trade
Commission Act to the extent that such section 5 applies to
unfair methods of competition.

SEC. 263. STUDY AND REPORT ON METHODS TO INCREASE EHR USE BY
SMALL HEALTH CARE PROVIDERS.

(a) Study.--The Secretary of Health and Human Services
shall conduct a study of potential methods to increase the
use of qualified electronic health records (as defined in
section 3000(13) of the Public Health Service Act) by small
health care providers. Such study shall consider at least the
following methods:
(1) Providing for higher rates of reimbursement or other
incentives for such health care providers to use electronic
health records (taking into consideration initiatives by
private health insurance companies and incentives provided
under Medicare under title XVIII of the Social Security Act,
Medicaid under title XIX of such Act, and other programs).
(2) Promoting low-cost electronic health record software
packages that are available for use by such health care
providers, including software packages that are available to
health care providers through the Veterans Administration and
other sources.
(3) Training and education of such health care providers on
the use of electronic health records.
(4) Providing assistance to such health care providers on
the implementation of electronic health records.
(b) Report.--Not later than December 31, 2013, the
Secretary of Health and Human Services shall submit to
Congress a report containing the results of the study
conducted under subsection (a), including recommendations for
legislation or administrative action to increase the use of
electronic health records by small health care providers that
include the use of both public and private funding sources.

SEC. 264. PREFORMANCE ASSESSMENT AND ACCOUNTABILITY:
APPLICATION OF GPRA.

(a) Application of GPRA.--Section 306 of title 5, United
States Code, and sections 1115, 1116, 1117, and 9703 of title
31 of such Code (originally enacted by the Government
Performance and Results Act of 1993, Public Law 103-62) apply
to the executive agencies established by this Act, including
the Health Choices Administration. Under such section 306,
each such executive agency is required to provide for a
strategic plan every 3 years.
(b) Improving Consumer Service and Streamlining
Procedures.--Every 3 years each such executive agency shall--
(1)(A) assess the quality of customer service provided, (B)
develop a strategy for improving such service, and (C)
establish standards for high-quality customer service; and
(2)(A) identify redundant rules, regulations, and
procedures, and (B) develop and implement a plan for
eliminating or streamlining such redundancies.

TITLE III--HEALTH INSURANCE EXCHANGE AND RELATED PROVISIONS

Subtitle A--Health Insurance Exchange

SEC. 301. ESTABLISHMENT OF HEALTH INSURANCE EXCHANGE; OUTLINE
OF DUTIES; DEFINITIONS.

(a) Establishment.--There is established within the Health
Choices Administration and under the direction of the
Commissioner a Health Insurance Exchange in order to
facilitate access of individuals and employers, through a
transparent process, to a variety of choices of affordable,
quality health insurance coverage, including a public health
insurance option.
(b) Outline of Duties of Commissioner.--In accordance with
this subtitle and in coordination with appropriate Federal
and State officials as provided under section 243(b), the
Commissioner shall--
(1) under section 304 establish standards for, accept bids
from, and negotiate and enter into contracts with, QHBP
offering entities for the offering of health benefits plans
through the Health Insurance Exchange, with different levels
of benefits required under section 303, and including with
respect to oversight and enforcement;
(2) under section 305 facilitate outreach and enrollment in
such plans of Exchange-eligible individuals and employers
described in section 302; and
(3) conduct such activities related to the Health Insurance
Exchange as required, including establishment of a risk
pooling mechanism under section 306 and consumer protections
under subtitle D of title II.

SEC. 302. EXCHANGE-ELIGIBLE INDIVIDUALS AND EMPLOYERS.

(a) Access to Coverage.--In accordance with this section,
all individuals are eligible

[[Page H12642]]

to obtain coverage through enrollment in an Exchange-
participating health benefits plan offered through the Health
Insurance Exchange unless such individuals are enrolled in
another qualified health benefits plan or certain other
acceptable coverage.
(b) Definitions.--In this division:
(1) Exchange-eligible individual.--The term ``Exchange-
eligible individual'' means an individual who is eligible
under this section to be enrolled through the Health
Insurance Exchange in an Exchange-participating health
benefits plan and, with respect to family coverage, includes
dependents of such individual.
(2) Exchange-eligible employer.--The term ``Exchange-
eligible employer'' means an employer that is eligible under
this section to enroll through the Health Insurance Exchange
employees of the employer (and their dependents) in Exchange-
eligible health benefits plans.
(3) Employment-related definitions.--The terms
``employer'', ``employee'', ``full-time employee'', and
``part-time employee'' have the meanings given such terms by
the Commissioner for purposes of this division.
(c) Transition.--Individuals and employers shall only be
eligible to enroll or participate in the Health Insurance
Exchange in accordance with the following transition
schedule:
(1) First year.--In Y1 (as defined in section 100(c))--
(A) individuals described in subsection (d)(1), including
individuals described in subsection (d)(3); and
(B) smallest employers described in subsection (e)(1).
(2) Second year.--In Y2--
(A) individuals and employers described in paragraph (1);
and
(B) smaller employers described in subsection (e)(2).
(3) Third and subsequent years.--In Y3--
(A) individuals and employers described in paragraph (2);
(B) small employers described in subsection (e)(3); and
(C) larger employers as permitted by the Commissioner under
subsection (e)(4).
(d) Individuals.--
(1) Individual described.--Subject to the succeeding
provisions of this subsection, an individual described in
this paragraph is an individual who--
(A) is not enrolled in coverage described in subparagraph
(C) or (D) of paragraph (2); and
(B) is not enrolled in coverage as a full-time employee (or
as a dependent of such an employee) under a group health plan
if the coverage and an employer contribution under the plan
meet the requirements of section 412.

For purposes of subparagraph (B), in the case of an
individual who is self-employed, who has at least 1 employee,
and who meets the requirements of section 412, such
individual shall be deemed a full-time employee described in
such subparagraph.
(2) Acceptable coverage.--For purposes of this division,
the term ``acceptable coverage'' means any of the following:
(A) Qualified health benefits plan coverage.--Coverage
under a qualified health benefits plan.
(B) Grandfathered health insurance coverage; coverage under
current group health plan.--Coverage under a grandfathered
health insurance coverage (as defined in subsection (a) of
section 202) or under a current group health plan (described
in subsection (b) of such section).
(C) Medicare.--Coverage under part A of title XVIII of the
Social Security Act.
(D) Medicaid.--Coverage for medical assistance under title
XIX of the Social Security Act, excluding such coverage that
is only available because of the application of subsection
(u), (z), or (aa), or (hh) of section 1902 of such Act.
(E) Members of the armed forces and dependents (including
tricare).--Coverage under chapter 55 of title 10, United
States Code, including similar coverage furnished under
section 1781 of title 38 of such Code.
(F) VA.--Coverage under the veteran's health care program
under chapter 17 of title 38, United States Code.
(G) Other coverage.--Such other health benefits coverage,
such as a State health benefits risk pool, as the
Commissioner, in coordination with the Secretary of the
Treasury, recognizes for purposes of this paragraph.

The Commissioner shall make determinations under this
paragraph in coordination with the Secretary of the Treasury.
(3) Continuing eligibility permitted.--
(A) In general.--Except as provided in subparagraph (B),
once an individual qualifies as an Exchange-eligible
individual under this subsection (including as an employee or
dependent of an employee of an Exchange-eligible employer)
and enrolls under an Exchange-participating health benefits
plan through the Health Insurance Exchange, the individual
shall continue to be treated as an Exchange-eligible
individual until the individual is no longer enrolled with an
Exchange-participating health benefits plan.
(B) Exceptions.--
(i) In general.--Subparagraph (A) shall not apply to an
individual once the individual becomes eligible for
coverage--

(I) under part A of the Medicare program;
(II) under the Medicaid program as a Medicaid-eligible
individual, except as permitted under clause (ii); or
(III) in such other circumstances as the Commissioner may
provide.

(ii) Transition period.--In the case described in clause
(i)(II), the Commissioner shall permit the individual to
continue treatment under subparagraph (A) until such limited
time as the Commissioner determines it is administratively
feasible, consistent with minimizing disruption in the
individual's access to health care.
(4) Transition for chip eligibles.--An individual who is
eligible for child health assistance under title XXI of the
Social Security Act for a period during Y1 shall not be an
Exchange-eligible individual during such period.
(e) Employers.--
(1) Smallest employer.--Subject to paragraph (5), smallest
employers described in this paragraph are employers with 25
or fewer employees.
(2) Smaller employers.--Subject to paragraph (5), smaller
employers described in this paragraph are employers that are
not smallest employers described in paragraph (1) and have 50
or fewer employees.
(3) Small employers.--Subject to paragraph (5), small
employers described in this paragraph are employers that are
not described in paragraph (1) or (2) and have 100 or fewer
employees.
(4) Larger employers.--
(A) In general.--Beginning with Y3, the Commissioner may
permit employers not described in paragraph (1), (2), or (3)
to be Exchange-eligible employers.
(B) Phase-in.--In applying subparagraph (A), the
Commissioner may phase-in the application of such
subparagraph based on the number of full-time employees of an
employer and such other considerations as the Commissioner
deems appropriate.
(5) Continuing eligibility.--Once an employer is permitted
to be an Exchange-eligible employer under this subsection and
enrolls employees through the Health Insurance Exchange, the
employer shall continue to be treated as an Exchange-eligible
employer for each subsequent plan year regardless of the
number of employees involved unless and until the employer
meets the requirement of section 411(a) through paragraph (1)
of such section by offering a group health plan and not
through offering an Exchange-participating health benefits
plan.
(6) Employer participation and contributions.--
(A) Satisfaction of employer responsibility.--For any year
in which an employer is an Exchange-eligible employer, such
employer may meet the requirements of section 412 with
respect to employees of such employer by offering such
employees the option of enrolling with Exchange-participating
health benefits plans through the Health Insurance Exchange
consistent with the provisions of subtitle B of title IV.
(B) Employee choice.--Any employee offered Exchange-
participating health benefits plans by the employer of such
employee under subparagraph (A) may choose coverage under any
such plan. That choice includes, with respect to family
coverage, coverage of the dependents of such employee.
(7) Affiliated groups.--Any employer which is part of a
group of employers who are treated as a single employer under
subsection (b), (c), (m), or (o) of section 414 of the
Internal Revenue Code of 1986 shall be treated, for purposes
of this subtitle, as a single employer.
(8) Treatment of multi-employer plans.--The plan sponsor of
a group health plan (as defined in section 773(a) of the
Employee Retirement Income Security Act of 1974) that is a
multi-employer plan (as defined in section 3(37) of such Act)
may obtain health insurance coverage with respect to
participants in the plan through the Exchange to the same
extent that an employer not described in paragraph (1) or (2)
is permitted by the Commissioner to obtain health insurance
coverage through the Exchange as an Exchange-eligible
employer.
(9) Other counting rules.--The Commissioner shall establish
rules relating to how employees are counted for purposes of
carrying out this subsection.
(f) Special Situation Authority.--The Commissioner shall
have the authority to establish such rules as may be
necessary to deal with special situations with regard to
uninsured individuals and employers participating as
Exchange-eligible individuals and employers, such as
transition periods for individuals and employers who gain, or
lose, Exchange-eligible participation status, and to
establish grace periods for premium payment.
(g) Surveys of Individuals and Employers.--The Commissioner
shall provide for periodic surveys of Exchange-eligible
individuals and employers concerning satisfaction of such
individuals and employers with the Health Insurance Exchange
and Exchange-participating health benefits plans.
(h) Exchange Access Study.--
(1) In general.--The Commissioner shall conduct a study of
access to the Health Insurance Exchange for individuals and
for employers, including individuals and employers who are
not eligible and enrolled in Exchange-participating health
benefits plans. The goal of the study is to determine if
there are significant groups and types of individuals and
employers who are not Exchange-eligible individuals or
employers, but who would have improved benefits and
affordability if made eligible for coverage in the Exchange.
(2) Items included in study.--Such study also shall
examine--
(A) the terms, conditions, and affordability of group
health coverage offered by employers and QHBP offering
entities outside of the

[[Page H12643]]

Exchange compared to Exchange-participating health benefits
plans; and
(B) the affordability-test standard for access of certain
employed individuals to coverage in the Health Insurance
Exchange.
(3) Report.--Not later than January 1 of Y3, in Y6, and
thereafter, the Commissioner shall submit to Congress a
report on the study conducted under this subsection and shall
include in such report recommendations regarding changes in
standards for Exchange eligibility for individuals and
employers.

SEC. 303. BENEFITS PACKAGE LEVELS.

(a) In General.--The Commissioner shall specify the
benefits to be made available under Exchange-participating
health benefits plans during each plan year, consistent with
subtitle C of title II and this section.
(b) Limitation on Health Benefits Plans Offered by Offering
Entities.--The Commissioner may not enter into a contract
with a QHBP offering entity under section 304(c) for the
offering of an Exchange-participating health benefits plan in
a service area unless the following requirements are met:
(1) Required offering of basic plan.--The entity offers
only one basic plan for such service area.
(2) Optional offering of enhanced plan.--If and only if the
entity offers a basic plan for such service area, the entity
may offer one enhanced plan for such area.
(3) Optional offering of premium plan.--If and only if the
entity offers an enhanced plan for such service area, the
entity may offer one premium plan for such area.
(4) Optional offering of premium-plus plans.--If and only
if the entity offers a premium plan for such service area,
the entity may offer one or more premium-plus plans for such
area.
All such plans may be offered under a single contract with
the Commissioner.
(c) Specification of Benefit Levels for Plans.--
(1) In general.--The Commissioner shall establish the
following standards consistent with this subsection and title
II:
(A) Basic, enhanced, and premium plans.--Standards for 3
levels of Exchange-participating health benefits plans:
basic, enhanced, and premium (in this division referred to as
a ``basic plan'', ``enhanced plan'', and ``premium plan'',
respectively).
(B) Premium-plus plan benefits.--Standards for additional
benefits that may be offered, consistent with this subsection
and subtitle C of title II, under a premium plan (such a plan
with additional benefits referred to in this division as a
``premium-plus
plan'').
(2) Basic plan.--
(A) In general.--A basic plan shall offer the essential
benefits package required under title II for a qualified
health benefits plan with an actuarial value of 70 percent of
the full actuarial value of the benefits provided under the
reference benefits package.
(B) Tiered cost-sharing for affordable credit eligible
individuals.--In the case of an affordable credit eligible
individual (as defined in section 342(a)(1)) enrolled in an
Exchange-participating health benefits plan, the benefits
under a basic plan are modified to provide for the reduced
cost-sharing for the income tier applicable to the individual
under section 324(c).
(3) Enhanced plan.--An enhanced plan shall offer, in
addition to the level of benefits under the basic plan, a
lower level of cost-sharing as provided under title II
consistent with section 223(b)(5)(A).
(4) Premium plan.--A premium plan shall offer, in addition
to the level of benefits under the basic plan, a lower level
of cost-sharing as provided under title II consistent with
section 223(b)(5)(B).
(5) Premium-plus plan.--A premium-plus plan is a premium
plan that also provides additional benefits, such as adult
oral health and vision care, approved by the Commissioner.
The portion of the premium that is attributable to such
additional benefits shall be separately specified.
(6) Range of permissible variation in cost-sharing.--The
Commissioner shall establish a permissible range of variation
of cost-sharing for each basic, enhanced, and premium plan,
except with respect to any benefit for which there is no
cost-sharing permitted under the essential benefits package.
Such variation shall permit a variation of not more than plus
(or minus) 10 percent in cost-sharing with respect to each
benefit category specified under section 222. Nothing in this
subtitle shall be construed as prohibiting tiering in cost-
sharing, including through preferred and participating
providers and prescription drugs. In applying this paragraph,
a health benefits plan may increase the cost-sharing by 10
percent within each category or tier, as applicable, and may
decrease or eliminate cost-sharing in any category or tier as
compared to the essential benefits package.
(d) Treatment of State Benefit Mandates.--Insofar as a
State requires a health insurance issuer offering health
insurance coverage to include benefits beyond the essential
benefits package, such requirement shall continue to apply to
an Exchange-participating health benefits plan, if the State
has entered into an arrangement satisfactory to the
Commissioner to reimburse the Commissioner for the amount of
any net increase in affordability premium credits under
subtitle C as a result of an increase in premium in basic
plans as a result of application of such requirement.
(e) Rules Regarding Coverage of and Affordability Credits
for Specified Services.--
(1) Assured availability of varied coverage through the
health insurance exchange.--The Commissioner shall assure
that, of the Exchange participating health benefits plans
offered in each premium rating area of the Health Insurance
Exchange--
(A) there is at least one such plan that provides coverage
of services described in subparagraphs (A) and (B) of section
222(e)(4); and
(B) there is at least one such plan that does not provide
coverage of services described in section 222(e)(4)(A) which
plan may also be one that does not provide coverage of
services described in section 222(e)(4)(B).
(2) Segregation of funds.--If a qualified health benefits
plan provides coverage of services described in section
222(e)(4)(A), the plan shall provide assurances satisfactory
to the Commissioner that--
(A) any affordability credits provided under subtitle C of
title II are not used for purposes of paying for such
services; and
(B) only premium amounts attributable to the actuarial
value described in section 213(b) are used for such purpose.

SEC. 304. CONTRACTS FOR THE OFFERING OF EXCHANGE-
PARTICIPATING HEALTH BENEFITS PLANS.

(a) Contracting Duties.--In carrying out section 301(b)(1)
and consistent with this subtitle:
(1) Offering entity and plan standards.--The Commissioner
shall--
(A) establish standards necessary to implement the
requirements of this title and title II for--
(i) QHBP offering entities for the offering of an Exchange-
participating health benefits plan; and
(ii) Exchange-participating health benefits plans; and
(B) certify QHBP offering entities and qualified health
benefits plans as meeting such standards and requirements of
this title and title II for purposes of this subtitle.
(2) Soliciting and negotiating bids; contracts.--
(A) Bid solicitation.--The Commissioner shall solicit bids
from QHBP offering entities for the offering of Exchange-
participating health benefits plans. Such bids shall include
justification for proposed premiums.
(B) Bid review and negotiation.--The Commissioner shall,
based upon a review of such bids including the premiums and
their affordability, negotiate with such entities for the
offering of such plans.
(C) Denial of excessive premiums.--The Commissioner shall
deny excessive premiums and premium increases.
(D) Contracts.--The Commissioner shall enter into contracts
with such entities for the offering of such plans through the
Health Insurance Exchange under terms (consistent with this
title) negotiated between the Commissioner and such entities.
(3) Federal acquisition regulation.--In carrying out this
subtitle, the Commissioner may waive such provisions of the
Federal Acquisition Regulation that the Commissioner
determines to be inconsistent with the furtherance of this
subtitle, other than provisions relating to confidentiality
of information. Competitive procedures shall be used in
awarding contracts under this subtitle to the extent that
such procedures are consistent with this subtitle.
(b) Standards for QHBP Offering Entities To Offer Exchange-
Participating Health Benefits Plans.--The standards
established under subsection (a)(1)(A) shall require that, in
order for a QHBP offering entity to offer an Exchange-
participating health benefits plan, the entity must meet the
following requirements:
(1) Licensed.--The entity shall be licensed to offer health
insurance coverage under State law for each State in which it
is offering such coverage.
(2) Data reporting.--The entity shall provide for the
reporting of such information as the Commissioner may
specify, including information necessary to administer the
risk pooling mechanism described in section 306(b) and
information to address disparities in health and health care.
(3) Affordability.--The entity shall provide for affordable
premiums.
(4) Implementing affordability credits.--The entity shall
provide for implementation of the affordability credits
provided for enrollees under subtitle C, including the
reduction in cost-sharing under section 344(c).
(5) Enrollment.--The entity shall accept all enrollments
under this subtitle, subject to such exceptions (such as
capacity limitations) in accordance with the requirements
under title II for a qualified health benefits plan. The
entity shall notify the Commissioner if the entity projects
or anticipates reaching such a capacity limitation that would
result in a limitation in enrollment.
(6) Risk pooling participation.--The entity shall
participate in such risk pooling mechanism as the
Commissioner establishes under section 306(b).
(7) Essential community providers.--With respect to the
basic plan offered by the entity, the entity shall include
within the plan network those essential community providers,
where available, that serve predominantly low-income,
medically-underserved individuals, such as health care
providers defined in section 340B(a)(4) of the Public Health
Service Act and providers described in section
1927(c)(1)(D)(i)(IV) of the Social Security Act (as amended
by section 221 of Public Law 111-8). The Commissioner shall

[[Page H12644]]

specify the extent to which and manner in which the previous
sentence shall apply in the case of a basic plan with respect
to which the Commissioner determines provides substantially
all benefits through a health maintenance organization, as
defined in section 2791(b)(3) of the Public Health Service
Act. This paragraph shall not be construed to require a basic
plan to contract with a provider if such provider refuses to
accept the generally applicable payment rates of such plan.
(8) Culturally and linguistically appropriate services and
communications.--The entity shall provide for culturally and
linguistically appropriate communication and health services.
(9) Special rules with respect to indian enrollees and
indian health care providers.--
(A) Choice of providers.--The entity shall--
(i) demonstrate to the satisfaction of the Commissioner
that it has contracted with a sufficient number of Indian
health care providers to ensure timely access to covered
services furnished by such providers to individual Indians
through the entity's Exchange-participating health benefits
plan; and
(ii) agree to pay Indian health care providers, whether
such providers are participating or nonparticipating
providers with respect to the entity, for covered services
provided to those enrollees who are eligible to receive
services from such providers at a rate that is not less than
the level and amount of payment which the entity would make
for the services of a participating provider which is not an
Indian health care provider.
(B) Special rule relating to indian health care
providers.--Provision of services by an Indian health care
provider exclusively to Indians and their dependents shall
not constitute discrimination under this Act.
(10) Program integrity standards.--The entity shall
establish and operate a program to protect and promote the
integrity of Exchange-participating health benefits plans it
offers, in accordance with standards and functions
established by the Commissioner.
(11) Additional requirements.--The entity shall comply with
other applicable requirements of this title, as specified by
the Commissioner, which shall include standards regarding
billing and collection practices for premiums and related
grace periods and which may include standards to ensure that
the entity does not use coercive practices to force providers
not to contract with other entities offering coverage through
the Health Insurance Exchange.
(c) Contracts.--
(1) Bid application.--To be eligible to enter into a
contract under this section, a QHBP offering entity shall
submit to the Commissioner a bid at such time, in such
manner, and containing such information as the Commissioner
may require.
(2) Term.--Each contract with a QHBP offering entity under
this section shall be for a term of not less than one year,
but may be made automatically renewable from term to term in
the absence of notice of termination by either party.
(3) Enforcement of network adequacy.--In the case of a
health benefits plan of a QHBP offering entity that uses a
provider network, the contract under this section with the
entity shall provide that if--
(A) the Commissioner determines that such provider network
does not meet such standards as the Commissioner shall
establish under section 215; and
(B) an individual enrolled in such plan receives an item or
service from a provider that is not within such network;
then any cost-sharing for such item or service shall be equal
to the amount of such cost-sharing that would be imposed if
such item or service was furnished by a provider within such
network.
(4) Oversight and enforcement responsibilities.--The
Commissioner shall establish processes, in coordination with
State insurance regulators, to oversee, monitor, and enforce
applicable requirements of this title with respect to QHBP
offering entities offering Exchange-participating health
benefits plans, including the marketing of such plans. Such
processes shall include the following:
(A) Grievance and complaint mechanisms.--The Commissioner
shall establish, in coordination with State insurance
regulators, a process under which Exchange-eligible
individuals and employers may file complaints concerning
violations of such standards.
(B) Enforcement.--In carrying out authorities under this
division relating to the Health Insurance Exchange, the
Commissioner may impose one or more of the intermediate
sanctions described in section 242(d).
(C) Termination.--
(i) In general.--The Commissioner may terminate a contract
with a QHBP offering entity under this section for the
offering of an Exchange-participating health benefits plan if
such entity fails to comply with the applicable requirements
of this title. Any determination by the Commissioner to
terminate a contract shall be made in accordance with formal
investigation and compliance procedures established by the
Commissioner under which--

(I) the Commissioner provides the entity with the
reasonable opportunity to develop and implement a corrective
action plan to correct the deficiencies that were the basis
of the Commissioner's determination; and
(II) the Commissioner provides the entity with reasonable
notice and opportunity for hearing (including the right to
appeal an initial decision) before terminating the contract.

(ii) Exception for imminent and serious risk to health.--
Clause (i) shall not apply if the Commissioner determines
that a delay in termination, resulting from compliance with
the procedures specified in such clause prior to termination,
would pose an imminent and serious risk to the health of
individuals enrolled under the qualified health benefits plan
of the QHBP offering entity.
(D) Construction.--Nothing in this subsection shall be
construed as preventing the application of other sanctions
under subtitle E of title II with respect to an entity for a
violation of such a requirement.
(5) Special rule related to cost-sharing and indian health
care providers.--The contract under this section with a QHBP
offering entity for a health benefits plan shall provide that
if an individual who is an Indian is enrolled in such a plan
and such individual receives a covered item or service from
an Indian health care provider (regardless of whether such
provider is in the plan's provider network), the cost-sharing
for such item or service shall be equal to the amount of
cost-sharing that would be imposed if such item or service--
(A) had been furnished by another provider in the plan's
provider network; or
(B) in the case that the plan has no such network, was
furnished by a non-Indian provider.
(6) National plan.--Nothing in this section shall be
construed as preventing the Commissioner from entering into a
contract under this subsection with a QHBP offering entity
for the offering of a health benefits plan with the same
benefits in every State so long as such entity is licensed to
offer such plan in each State and the benefits meet the
applicable requirements in each such State.
(d) No Discrimination on the Basis of Provision of
Abortion.--No Exchange participating health benefits plan may
discriminate against any individual health care provider or
health care facility because of its willingness or
unwillingness to provide, pay for, provide coverage of, or
refer for abortions.

SEC. 305. OUTREACH AND ENROLLMENT OF EXCHANGE-ELIGIBLE
INDIVIDUALS AND EMPLOYERS IN EXCHANGE-
PARTICIPATING HEALTH BENEFITS PLAN.

(a) In General.--
(1) Outreach.--The Commissioner shall conduct outreach
activities consistent with subsection (c), including through
use of appropriate entities as described in paragraph (3) of
such subsection, to inform and educate individuals and
employers about the Health Insurance Exchange and Exchange-
participating health benefits plan options. Such outreach
shall include outreach specific to vulnerable populations,
such as children, individuals with disabilities, individuals
with mental illness, and individuals with other cognitive
impairments.
(2) Eligibility.--The Commissioner shall make timely
determinations of whether individuals and employers are
Exchange-eligible individuals and employers (as defined in
section 302).
(3) Enrollment.--The Commissioner shall establish and carry
out an enrollment process for Exchange-eligible individuals
and employers, including at community locations, in
accordance with subsection (b).
(b) Enrollment Process.--
(1) In general.--The Commissioner shall establish a process
consistent with this title for enrollments in Exchange-
participating health benefits plans. Such process shall
provide for enrollment through means such as the mail, by
telephone, electronically, and in person.
(2) Enrollment periods.--
(A) Open enrollment period.--The Commissioner shall
establish an annual open enrollment period during which an
Exchange-eligible individual or employer may elect to enroll
in an Exchange-participating health benefits plan for the
following plan year and an enrollment period for
affordability credits under subtitle C. Such periods shall be
during September through November of each year, or such other
time that would maximize timeliness of income verification
for purposes of such subtitle. The open enrollment period
shall not be less than 30 days.
(B) Special enrollment.--The Commissioner shall also
provide for special enrollment periods to take into account
special circumstances of individuals and employers, such as
an individual who--
(i) loses acceptable coverage;
(ii) experiences a change in marital or other dependent
status;
(iii) moves outside the service area of the Exchange-
participating health benefits plan in which the individual is
enrolled; or
(iv) experiences a significant change in income.
(C) Enrollment information.--The Commissioner shall provide
for the broad dissemination of information to prospective
enrollees on the enrollment process, including before each
open enrollment period. In carrying out the previous
sentence, the Commissioner may work with other appropriate
entities to facilitate such provision of information.
(3) Automatic enrollment for non-medicaid eligible
individuals.--
(A) In general.--The Commissioner shall provide for a
process under which individuals

[[Page H12645]]

who are Exchange-eligible individuals described in
subparagraph (B) are automatically enrolled under an
appropriate Exchange-participating health benefits plan. Such
process may involve a random assignment or some other form of
assignment that takes into account the health care providers
used by the individual involved or such other relevant
factors as the Commissioner may specify.
(B) Subsidized individuals described.--An individual
described in this subparagraph is an Exchange-eligible
individual who is either of the following:
(i) Affordability credit eligible individuals.--The
individual--

(I) has applied for, and been determined eligible for,
affordability credits under subtitle C;
(II) has not opted out from receiving such affordability
credit; and
(III) does not otherwise enroll in another Exchange-
participating health benefits plan.

(ii) Individuals enrolled in a terminated plan.--The
individual who is enrolled in an Exchange-participating
health benefits plan that is terminated (during or at the end
of a plan year) and who does not otherwise enroll in another
Exchange-participating health benefits plan.
(4) Direct payment of premiums to plans.--Under the
enrollment process, individuals enrolled in an Exchange-
participating health benefits plan shall pay such plans
directly, and not through the Commissioner or the Health
Insurance Exchange.
(c) Coverage Information and Assistance.--
(1) Coverage information.--The Commissioner shall provide
for the broad dissemination of information on Exchange-
participating health benefits plans offered under this title.
Such information shall be provided in a comparative manner,
and shall include information on benefits, premiums, cost-
sharing, quality, provider networks, and consumer
satisfaction.
(2) Consumer assistance with choice.--To provide assistance
to Exchange-eligible individuals and employers, the
Commissioner shall--
(A) provide for the operation of a toll-free telephone
hotline to respond to requests for assistance and maintain an
Internet Web site through which individuals may obtain
information on coverage under Exchange-participating health
benefits plans and file complaints;
(B) develop and disseminate information to Exchange-
eligible enrollees on their rights and responsibilities;
(C) assist Exchange-eligible individuals in selecting
Exchange-participating health benefits plans and obtaining
benefits through such plans; and
(D) ensure that the Internet Web site described in
subparagraph (A) and the information described in
subparagraph (B) is developed using plain language (as
defined in section 233(a)(2)).
(3) Use of other entities.--In carrying out this
subsection, the Commissioner may work with other appropriate
entities to facilitate the dissemination of information under
this subsection and to provide assistance as described in
paragraph (2).
(d) Coverage for Certain Newborns Under Medicaid.--
(1) In general.--In the case of a child born in the United
States who at the time of birth is not otherwise covered
under acceptable coverage, for the period of time beginning
on the date of birth and ending on the date the child
otherwise is covered under acceptable coverage (or, if
earlier, the end of the month in which the 60-day period,
beginning on the date of birth, ends), the child shall be
deemed--
(A) to be a Medicaid eligible individual for purposes of
this division and Medicaid; and
(B) to be automatically enrolled in Medicaid as a
traditional Medicaid eligible individual (as defined in
section 1943(c) of the Social Security Act).
(2) Extended treatment as medicaid eligible individual.--In
the case of a child described in paragraph (1) who at the end
of the period referred to in such paragraph is not otherwise
covered under acceptable coverage, the child shall be deemed
(until such time as the child obtains such coverage or the
State otherwise makes a determination of the child's
eligibility for medical assistance under its Medicaid plan
pursuant to section 1943(b)(1) of the Social Security Act) to
be a Medicaid eligible individual described in section
1902(l)(1)(B) of such Act.
(e) Medicaid Coverage for Medicaid Eligible Individuals.--
(1) Medicaid enrollment obligation.--An individual may
apply, in the manner described in section 341(b)(1), for a
determination of whether the individual is a Medicaid-
eligible individual. If the individual is determined to be so
eligible, the Commissioner, through the Medicaid memorandum
of understanding under paragraph (2), shall provide for the
enrollment of the individual under the State Medicaid plan in
accordance with such memorandum of understanding. In the case
of such an enrollment, the State shall provide for the same
periodic redetermination of eligibility under Medicaid as
would otherwise apply if the individual had directly applied
for medical assistance to the State Medicaid agency.
(2) Coordinated enrollment with state through memorandum of
understanding.--The Commissioner, in consultation with the
Secretary of Health and Human Services, shall enter into a
memorandum of understanding with each State with respect to
coordinating enrollment of individuals in Exchange-
participating health benefits plans and under the State's
Medicaid program consistent with this section and to
otherwise coordinate the implementation of the provisions of
this division with respect to the Medicaid program. Such
memorandum shall permit the exchange of information
consistent with the limitations described in section
1902(a)(7) of the Social Security Act. Nothing in this
section shall be construed as permitting such memorandum to
modify or vitiate any requirement of a State Medicaid plan.
(f) Effective Culturally and Linguistically Appropriate
Communication.--In carrying out this section, the
Commissioner shall establish effective methods for
communicating in plain language and a culturally and
linguistically appropriate manner.
(g) Role for Enrollment Agents and Brokers.--Nothing in
this division shall be construed to affect the role of
enrollment agents and brokers under State law, including with
regard to the enrollment of individuals and employers in
qualified health benefits plans including the public health
insurance option.
(h) Assistance for Small Employers.--
(1) In general.--The Commissioner, in consultation with the
Small Business Administration, shall establish and carry out
a program to provide to small employers counseling and
technical assistance with respect to the provision of health
insurance to employees of such employers through the Health
Insurance Exchange.
(2) Duties.--The program established under paragraph (1)
shall include the following services:
(A) Educational activities to increase awareness of the
Health Insurance Exchange and available small employer health
plan options.
(B) Distribution of information to small employers with
respect to the enrollment and selection process for health
plans available under the Health Insurance Exchange,
including standardized comparative information on the health
plans available under the Health Insurance Exchange.
(C) Distribution of information to small employers with
respect to available affordability credits or other financial
assistance.
(D) Referrals to appropriate entities of complaints and
questions relating to the Health Insurance Exchange.
(E) Enrollment and plan selection assistance for employers
with respect to the Health Insurance Exchange.
(F) Responses to questions relating to the Health Insurance
Exchange and the program established under paragraph (1).
(3) Authority to provide services directly or by
contract.--The Commissioner may provide services under
paragraph (2) directly or by contract with nonprofit entities
that the Commissioner determines capable of carrying out such
services.
(4) Small employer defined.--In this subsection, the term
``small employer'' means an employer with less than 100
employees.
(i) Participation of Small Employer Benefit Arrangements.--
(1) In general.--The Commissioner may enter into contracts
with small employer benefit arrangements to provide consumer
information, outreach, and assistance in the enrollment of
small employers (and their employees) who are members of such
an arrangement under Exchange participating health benefits
plans.
(2) Small employer benefit arrangement defined.--In this
subsection, the term ``small employer benefit arrangement''
means a not-for-profit agricultural or other cooperative
that--
(A) consists solely of its members and is operated for the
primary purpose of providing affordable employee benefits to
its members;
(B) only has as members small employers in the same
industry or line of business;
(C) has no member that has more than a 5 percent voting
interest in the cooperative; and
(D) is governed by a board of directors elected by its
members.

SEC. 306. OTHER FUNCTIONS.

(a) Coordination of Affordability Credits.--The
Commissioner shall coordinate the distribution of
affordability premium and cost-sharing credits under subtitle
C to QHBP offering entities offering Exchange-participating
health benefits plans.
(b) Coordination of Risk Pooling.--The Commissioner shall
establish a mechanism whereby there is an adjustment made of
the premium amounts payable among QHBP offering entities
offering Exchange-participating health benefits plans of
premiums collected for such plans that takes into account (in
a manner specified by the Commissioner) the differences in
the risk characteristics of individuals and employees
enrolled under the different Exchange-participating health
benefits plans offered by such entities so as to minimize the
impact of adverse selection of enrollees among the plans
offered by such entities. For purposes of the previous
sentence, the Commissioner may utilize data regarding
enrollee demographics, inpatient and outpatient diagnoses (in
a similar manner as such data are used under parts C and D of
title XVIII of the Social Security Act), and such other
information as the Secretary determines may be necessary,
such as the actual medical costs of enrollees during the
previous year.

[[Page H12646]]

SEC. 307. HEALTH INSURANCE EXCHANGE TRUST FUND.

(a) Establishment of Health Insurance Exchange Trust
Fund.--There is created within the Treasury of the United
States a trust fund to be known as the ``Health Insurance
Exchange Trust Fund'' (in this section referred to as the
``Trust Fund''), consisting of such amounts as may be
appropriated or credited to the Trust Fund under this section
or any other provision of law.
(b) Payments From Trust Fund.--The Commissioner shall pay
from time to time from the Trust Fund such amounts as the
Commissioner determines are necessary to make payments to
operate the Health Insurance Exchange, including payments
under subtitle C (relating to affordability credits).
(c) Transfers to Trust Fund.--
(1) Dedicated payments.--There are hereby appropriated to
the Trust Fund amounts equivalent to the following:
(A) Taxes on individuals not obtaining acceptable
coverage.--The amounts received in the Treasury under section
59B of the Internal Revenue Code of 1986 (relating to
requirement of health insurance coverage for individuals).
(B) Employment taxes on employers not providing acceptable
coverage.--The amounts received in the Treasury under
sections 3111(c) and 3221(c) of the Internal Revenue Code of
1986 (relating to employers electing to not provide health
benefits).
(C) Excise tax on failures to meet certain health coverage
requirements.--The amounts received in the Treasury under
section 4980H(b) (relating to excise tax with respect to
failure to meet health coverage participation requirements).
(2) Appropriations to cover government contributions.--
There are hereby appropriated, out of any moneys in the
Treasury not otherwise appropriated, to the Trust Fund, an
amount equivalent to the amount of payments made from the
Trust Fund under subsection (b) plus such amounts as are
necessary reduced by the amounts deposited under paragraph
(1).
(d) Application of Certain Rules.--Rules similar to the
rules of subchapter B of chapter 98 of the Internal Revenue
Code of 1986 shall apply with respect to the Trust Fund.

SEC. 308. OPTIONAL OPERATION OF STATE-BASED HEALTH INSURANCE
EXCHANGES.

(a) In General.--If--
(1) a State (or group of States, subject to the approval of
the Commissioner) applies to the Commissioner for approval of
a State-based Health Insurance Exchange to operate in the
State (or group of States); and
(2) the Commissioner approves such State-based Health
Insurance Exchange,
then, subject to subsections (c) and (d), the State-based
Health Insurance Exchange shall operate, instead of the
Health Insurance Exchange, with respect to such State (or
group of States). The Commissioner shall approve a State-
based Health Insurance Exchange if it meets the requirements
for approval under subsection (b).
(b) Requirements for Approval.--
(1) In general.--The Commissioner may not approve a State-
based Health Insurance Exchange under this section unless the
following requirements are met:
(A) The State-based Health Insurance Exchange must
demonstrate the capacity to and provide assurances
satisfactory to the Commissioner that the State-based Health
Insurance Exchange will carry out the functions specified for
the Health Insurance Exchange in the State (or States)
involved, including--
(i) negotiating and contracting with QHBP offering entities
for the offering of Exchange-participating health benefits
plans, which satisfy the standards and requirements of this
title and title II;
(ii) enrolling Exchange-eligible individuals and employers
in such State in such plans;
(iii) the establishment of sufficient local offices to meet
the needs of Exchange-eligible individuals and employers;
(iv) administering affordability credits under subtitle B
using the same methodologies (and at least the same income
verification methods) as would otherwise apply under such
subtitle and at a cost to the Federal Government which does
exceed the cost to the Federal Government if this section did
not apply; and
(v) enforcement activities consistent with Federal
requirements.
(B) There is no more than one Health Insurance Exchange
operating with respect to any one State.
(C) The State provides assurances satisfactory to the
Commissioner that approval of such an Exchange will not
result in any net increase in expenditures to the Federal
Government.
(D) The State provides for reporting of such information as
the Commissioner determines and assurances satisfactory to
the Commissioner that it will vigorously enforce violations
of applicable requirements.
(E) Such other requirements as the Commissioner may
specify.
(2) Presumption for certain state-operated exchanges.--
(A) In general.--In the case of a State operating an
Exchange prior to January 1, 2010, that seeks to operate the
State-based Health Insurance Exchange under this section, the
Commissioner shall presume that such Exchange meets the
standards under this section unless the Commissioner
determines, after completion of the process established under
subparagraph (B), that the Exchange does not comply with such
standards.
(B) Process.--The Commissioner shall establish a process to
work with a State described in subparagraph (A) to provide
assistance necessary to assure that the State's Exchange
comes into compliance with the standards for approval under
this section.
(c) Ceasing Operation.--
(1) In general.--A State-based Health Insurance Exchange
may, at the option of each State involved, and only after
providing timely and reasonable notice to the Commissioner,
cease operation as such an Exchange, in which case the Health
Insurance Exchange shall operate, instead of such State-based
Health Insurance Exchange, with respect to such State (or
States).
(2) Termination; health insurance exchange resumption of
functions.--The Commissioner may terminate the approval (for
some or all functions) of a State-based Health Insurance
Exchange under this section if the Commissioner determines
that such Exchange no longer meets the requirements of
subsection (b) or is no longer capable of carrying out such
functions in accordance with the requirements of this
subtitle. In lieu of terminating such approval, the
Commissioner may temporarily assume some or all functions of
the State-based Health Insurance Exchange until such time as
the Commissioner determines the State-based Health Insurance
Exchange meets such requirements of subsection (b) and is
capable of carrying out such functions in accordance with the
requirements of this subtitle.
(3) Effectiveness.--The ceasing or termination of a State-
based Health Insurance Exchange under this subsection shall
be effective in such time and manner as the Commissioner
shall specify.
(d) Retention of Authority.--
(1) Authority retained.--Enforcement authorities of the
Commissioner shall be retained by the Commissioner.
(2) Discretion to retain additional authority.--The
Commissioner may specify functions of the Health Insurance
Exchange that--
(A) may not be performed by a State-based Health Insurance
Exchange under this section; or
(B) may be performed by the Commissioner and by such a
State-based Health Insurance Exchange.
(e) References.--In the case of a State-based Health
Insurance Exchange, except as the Commissioner may otherwise
specify under subsection (d), any references in this subtitle
to the Health Insurance Exchange or to the Commissioner in
the area in which the State-based Health Insurance Exchange
operates shall be deemed a reference to the State-based
Health Insurance Exchange and the head of such Exchange,
respectively.
(f) Funding.--In the case of a State-based Health Insurance
Exchange, there shall be assistance provided for the
operation of such Exchange in the form of a matching grant
with a State share of expenditures required.

SEC. 309. INTERSTATE HEALTH INSURANCE COMPACTS.

(a) In General.--Effective January 1, 2015, 2 or more
States may form Health Care Choice Compacts (in this section
referred to as ``compacts'') to facilitate the purchase of
individual health insurance coverage across State lines.
(b) Model Guidelines.--The Secretary of Health and Human
Services (in this section referred to as the ``Secretary'')
shall consult with the National Association of Insurance
Commissioners (in this section referred to as ``NAIC'') to
develop not later than January 1, 2014 model guidelines for
the creation of compacts. In developing such guidelines, the
Secretary shall consult with consumers, health insurance
issuers, and other interested parties. Such guidelines
shall--
(1) provide for the sale of health insurance coverage to
residents of all compacting States subject to the laws and
regulations of a primary State designated by the compacting
States;
(2) require health insurance issuers issuing health
insurance coverage in secondary States to maintain licensure
in every such State;
(3) preserve the authority of the State of an individual's
residence to enforce law relating to--
(A) market conduct;
(B) unfair trade practices;
(C) network adequacy;
(D) consumer protection standards;
(E) grievance and appeals;
(F) fair claims payment requirements;
(G) prompt payment of claims;
(H) rate review; and
(I) fraud;
(4) permit State insurance commissioners and other State
agencies in secondary States access to the records of a
health insurance issuer to the same extent as if the policy
were written in that State; and
(5) provide for clear and conspicuous disclosure to
consumers that the policy may not be subject to all the laws
and regulations of the State in which the purchaser resides.
(c) No Requirement to Compact.--Nothing in this section
shall be construed to require a State to join a compact.
(d) State Authority.--A State may not enter into a compact
under this subsection unless the State enacts a law after the
date of enactment of this Act that specifically authorizes
the State to enter into such compact.
(e) Consumer Protections.--If a State enters into a compact
it must retain responsibility for the consumer protections of
its residents and its residents retain the right to bring a
claim in a State court in the State in which the resident
resides.

[[Page H12647]]

(f) Assistance to Compacting States.--
(1) In general.--Beginning January 1, 2015, the Secretary
shall make awards, from amounts appropriated under paragraph
(5), to States in the amount specified in paragraph (2) for
the uses described in paragraph (3).
(2) Amount specified.--
(A) In general.--For each fiscal year, the Secretary shall
determine the total amount that the Secretary will make
available for grants under this subsection.
(B) State amount.--For each State that is awarded a grant
under paragraph (1), the amount of such grants shall be based
on a formula established by the Secretary, not to exceed $1
million per State, under which States shall receive an award
in the amount that is based on the following two components:
(i) A minimum amount for each State.
(ii) An additional amount based on population of the State.
(3) Use of funds.--A State shall use amounts awarded under
this subsection for activities (including planning
activities) related regulating health insurance coverage sold
in secondary States.
(4) Renewability of grant.--The Secretary may renew a grant
award under paragraph (1) if the State receiving the grant
continues to be a member of a compact.
(5) Authorization of appropriations.--There are authorized
to be appropriated such sums as may be necessary to carry out
this subsection in each of fiscal years 2015 through 2020.

SEC. 310. HEALTH INSURANCE COOPERATIVES.

(a) Establishment.--Not later than 6 months after the date
of the enactment of this Act, the Commissioner, in
consultation with the Secretary of the Treasury, shall
establish a Consumer Operated and Oriented Plan program (in
this section referred to as the ``CO-OP program'') under
which the Commissioner may make grants and loans for the
establishment and initial operation of not-for-profit,
member-run health insurance cooperatives (in this section
individually referred to as a ``cooperative'') that provide
insurance through the Health Insurance Exchange or a State-
based Health Insurance Exchange under section 308. Nothing in
this section shall be construed as requiring a State to
establish such a cooperative.
(b) Start-up and Solvency Grants and Loans.--
(1) In general.--Not later than 36 months after the date of
the enactment of this Act, the Commissioner, acting through
the CO-OP program, may make--
(A) loans (of such period and with such terms as the
Secretary may specify) to cooperatives to assist such
cooperatives with start-up costs; and
(B) grants to cooperatives to assist such cooperatives in
meeting State solvency requirements in the States in which
such cooperative offers or issues insurance coverage.
(2)  Conditions.--A grant or loan may not be awarded under
this subsection with respect to a cooperative unless the
following conditions are met:
(A) The cooperative is structured as a not-for-profit,
member organization under the law of each State in which such
cooperative offers, intends to offer, or issues insurance
coverage, with the membership of the cooperative being made
up entirely of beneficiaries of the insurance coverage
offered by such cooperative.
(B) The cooperative did not offer insurance on or before
July 16, 2009, and the cooperative is not an affiliate or
successor to an insurance company offering insurance on or
before such date.
(C) The governing documents of the cooperative incorporate
ethical and conflict of interest standards designed to
protect against insurance industry involvement and
interference in the governance of the cooperative.
(D) The cooperative is not sponsored by a State government.
(E) Substantially all of the activities of the cooperative
consist of the issuance of qualified health benefits plans
through the Health Insurance Exchange or a State-based health
insurance exchange.
(F) The cooperative is licensed to offer insurance in each
State in which it offers insurance.
(G) The governance of the cooperative must be subject to a
majority vote of its members.
(H) As provided in guidance issued by the Secretary of
Health and Human Services, the cooperative operates with a
strong consumer focus, including timeliness, responsiveness,
and accountability to members.
(I) Any profits made by the cooperative are used to lower
premiums, improve benefits, or to otherwise improve the
quality of health care delivered to members.
(3) Priority.--The Commissioner, in making grants and loans
under this subsection, shall give priority to cooperatives
that--
(A) operate on a statewide basis;
(B) use an integrated delivery system; or
(C) have a significant level of financial support from
nongovernmental sources.
(4) Rules of construction.--Nothing in this section shall
be construed to prevent a cooperative established in one
State from integrating with a cooperative established in
another State the administration, issuance of coverage, or
other activities related to acting as a QHBP offering entity.
Nothing in this section shall be construed as preventing
State governments from taking actions to permit such
integration.
(5) Amortization of grants and loans.--The Secretary shall
provide for the repayment of grants or loans provided under
this subsection to the Treasury in an amortized manner over a
10-year period.
(6) Repayment for violations of terms of program.--If a
cooperative violates the terms of the CO-OP program and fails
to correct the violation within a reasonable period of time,
as determined by the Commissioner, the cooperative shall
repay the total amount of any loan or grant received by such
cooperative under this section, plus interest (at a rate
determined by the Secretary).
(7) Authorization of appropriations.--There is authorized
to be appropriated $5,000,000,000 for the period of fiscal
years 2010 through 2014 to provide for grants and loans under
this subsection.
(c) Definitions.--For purposes of this section:
(1) State.--The term ``State'' means each of the 50 States
and the District of Columbia.
(2) Member.--The term ``member'', with respect to a
cooperative, means an individual who, after the cooperative
offers health insurance coverage, is enrolled in such
coverage.

SEC. 311. RETENTION OF DOD AND VA AUTHORITY.

Nothing in this subtitle shall be construed as affecting
any authority under title 38, United States Code, or chapter
55 of title 10, United States Code.

Subtitle B--Public Health Insurance Option

SEC. 321. ESTABLISHMENT AND ADMINISTRATION OF A PUBLIC HEALTH
INSURANCE OPTION AS AN EXCHANGE-QUALIFIED
HEALTH BENEFITS PLAN.

(a) Establishment.--For years beginning with Y1, the
Secretary of Health and Human Services (in this subtitle
referred to as the ``Secretary'') shall provide for the
offering of an Exchange-participating health benefits plan
(in this division referred to as the ``public health
insurance option'') that ensures choice, competition, and
stability of affordable, high quality coverage throughout the
United States in accordance with this subtitle. In designing
the option, the Secretary's primary responsibility is to
create a low-cost plan without compromising quality or access
to care.
(b) Offering as an Exchange-participating Health Benefits
Plan.--
(1) Exclusive to the exchange.--The public health insurance
option shall only be made available through the Health
Insurance Exchange.
(2) Ensuring a level playing field.--Consistent with this
subtitle, the public health insurance option shall comply
with requirements that are applicable under this title to an
Exchange-participating health benefits plan, including
requirements related to benefits, benefit levels, provider
networks, notices, consumer protections, and cost-sharing.
(3) Provision of benefit levels.--The public health
insurance option--
(A) shall offer basic, enhanced, and premium plans; and
(B) may offer premium-plus plans.
(c) Administrative Contracting.--The Secretary may enter
into contracts for the purpose of performing administrative
functions (including functions described in subsection (a)(4)
of section 1874A of the Social Security Act) with respect to
the public health insurance option in the same manner as the
Secretary may enter into contracts under subsection (a)(1) of
such section. The Secretary has the same authority with
respect to the public health insurance option as the
Secretary has under subsections (a)(1) and (b) of section
1874A of the Social Security Act with respect to title XVIII
of such Act. Contracts under this subsection shall not
involve the transfer of insurance risk to such entity.
(d) Ombudsman.--The Secretary shall establish an office of
the ombudsman for the public health insurance option which
shall have duties with respect to the public health insurance
option similar to the duties of the Medicare Beneficiary
Ombudsman under section 1808(c)(2) of the Social Security
Act.
(e) Data Collection.--The Secretary shall collect such data
as may be required to establish premiums and payment rates
for the public health insurance option and for other purposes
under this subtitle, including to improve quality and to
reduce racial, ethnic, and other disparities in health and
health care. Nothing in this subtitle may be construed as
authorizing the Secretary (or any employee or contractor) to
create or maintain lists of non-medical personal property.
(f) Treatment of Public Health Insurance Option.--With
respect to the public health insurance option, the Secretary
shall be treated as a QHBP offering entity offering an
Exchange-participating health benefits plan.
(g) Access to Federal Courts.--The provisions of Medicare
(and related provisions of title II of the Social Security
Act) relating to access of Medicare beneficiaries to Federal
courts for the enforcement of rights under Medicare,
including with respect to amounts in controversy, shall apply
to the public health insurance option and individuals
enrolled under such option under this title in the same
manner as such provisions apply to Medicare and Medicare
beneficiaries.

SEC. 322. PREMIUMS AND FINANCING.

(a) Establishment of Premiums.--
(1) In general.--The Secretary shall establish
geographically adjusted premium rates for the public health
insurance option--

[[Page H12648]]

(A) in a manner that complies with the premium rules
established by the Commissioner under section 213 for
Exchange-participating health benefits plans; and
(B) at a level sufficient to fully finance the costs of--
(i) health benefits provided by the public health insurance
option; and
(ii) administrative costs related to operating the public
health insurance option.
(2) Contingency margin.--In establishing premium rates
under paragraph (1), the Secretary shall include an
appropriate amount for a contingency margin (which shall be
not less than 90 days of estimated claims). Before setting
such appropriate amount for years starting with Y3, the
Secretary shall solicit a recommendation on such amount from
the American Academy of Actuaries.
(b) Account.--
(1) Establishment.--There is established in the Treasury of
the United States an Account for the receipts and
disbursements attributable to the operation of the public
health insurance option, including the start-up funding under
paragraph (2). Section 1854(g) of the Social Security Act
shall apply to receipts described in the previous sentence in
the same manner as such section applies to payments or
premiums described in such section.
(2) Start-up funding.--
(A) In general.--In order to provide for the establishment
of the public health insurance option, there is hereby
appropriated to the Secretary, out of any funds in the
Treasury not otherwise appropriated, $2,000,000,000. In order
to provide for initial claims reserves before the collection
of premiums, there are hereby appropriated to the Secretary,
out of any funds in the Treasury not otherwise appropriated,
such sums as necessary to cover 90 days worth of claims
reserves based on projected enrollment.
(B) Amortization of start-up funding.--The Secretary shall
provide for the repayment of the startup funding provided
under subparagraph (A) to the Treasury in an amortized manner
over the 10-year period beginning with Y1.
(C) Limitation on funding.--Nothing in this section shall
be construed as authorizing any additional appropriations to
the Account, other than such amounts as are otherwise
provided with respect to other Exchange-participating health
benefits plans.
(3) No bailouts.--In no case shall the public health
insurance option receive any Federal funds for purposes of
insolvency in any manner similar to the manner in which
entities receive Federal funding under the Troubled Assets
Relief Program of the Secretary of the Treasury.

SEC. 323. PAYMENT RATES FOR ITEMS AND SERVICES.

(a) Negotiation of Payment Rates.--
(1) In general.--The Secretary shall negotiate payment for
the public health insurance option for health care providers
and items and services, including prescription drugs,
consistent with this section and section 324.
(2) Manner of negotiation.--The Secretary shall negotiate
such rates in a manner that results in payment rates that are
not lower, in the aggregate, than rates under title XVIII of
the Social Security Act, and not higher, in the aggregate,
than the average rates paid by other QHBP offering entities
for services and health care providers.
(3) Innovative payment methods.--Nothing in this subsection
shall be construed as preventing the use of innovative
payment methods such as those described in section 324 in
connection with the negotiation of payment rates under this
subsection.
(4) Treatment of certain state waivers.--In the case of any
State operating a cost-containment waiver for health care
providers in accordance with section 1814(b)(3) of the Social
Security Act, the Secretary shall provide for payment to such
providers under the public health insurance option consistent
with the provisions and requirements of that waiver.
(b) Establishment of a Provider Network.--
(1) In general.--Health care providers (including
physicians and hospitals) participating in Medicare are
participating providers in the public health insurance option
unless they opt out in a process established by the Secretary
consistent with this subsection.
(2) Requirements for opt-out process.--Under the process
established under paragraph (1)--
(A) providers described in such paragraph shall be provided
at least a 1-year period prior to the first day of Y1 to opt
out of participating in the public health insurance option;
(B) no provider shall be subject to a penalty for not
participating in the public health insurance option;
(C) the Secretary shall include information on how
providers participating in Medicare who chose to opt out of
participating in the public health insurance option may opt
back in; and
(D) there shall be an annual enrollment period in which
providers may decide whether to participate in the public
health insurance option.
(3) Rulemaking.--Not later than 18 months before the first
day of Y1, the Secretary shall promulgate rules (pursuant to
notice and comment) for the process described in paragraph
(1).
(c) Limitations on Review.--There shall be no
administrative or judicial review of a payment rate or
methodology established under this section or under section
324.

SEC. 324. MODERNIZED PAYMENT INITIATIVES AND DELIVERY SYSTEM
REFORM.

(a) In General.--For plan years beginning with Y1, the
Secretary may utilize innovative payment mechanisms and
policies to determine payments for items and services under
the public health insurance option. The payment mechanisms
and policies under this section may include patient-centered
medical home and other care management payments, accountable
care organizations, value-based purchasing, bundling of
services, differential payment rates, performance or
utilization based payments, partial capitation, and direct
contracting with providers.
(b) Requirements for Innovative Payments.--The Secretary
shall design and implement the payment mechanisms and
policies under this section in a manner that--
(1) seeks to--
(A) improve health outcomes;
(B) reduce health disparities (including racial, ethnic,
and other disparities);
(C) provide efficient and affordable care;
(D) address geographic variation in the provision of health
services; or
(E) prevent or manage chronic illness; and
(2) promotes care that is integrated, patient-centered,
quality, and efficient.
(c) Encouraging the Use of High Value Services.--To the
extent allowed by the benefit standards applied to all
Exchange-participating health benefits plans, the public
health insurance option may modify cost-sharing and payment
rates to encourage the use of services that promote health
and value.
(d) Promotion of Delivery System Reform.--The Secretary
shall monitor and evaluate the progress of payment and
delivery system reforms under this Act and shall seek to
implement such reforms subject to the following:
(1) To the extent that the Secretary finds a payment and
delivery system reform successful in improving quality and
reducing costs, the Secretary shall implement such reform on
as large a geographic scale as practical and economical.
(2) The Secretary may delay the implementation of such a
reform in geographic areas in which such implementation would
place the public health insurance option at a competitive
disadvantage.
(3) The Secretary may prioritize implementation of such a
reform in high cost geographic areas or otherwise in order to
reduce total program costs or to promote high value care.
(e) Non-uniformity Permitted.--Nothing in this subtitle
shall prevent the Secretary from varying payments based on
different payment structure models (such as accountable care
organizations and medical homes) under the public health
insurance option for different geographic areas.

SEC. 325. PROVIDER PARTICIPATION.

(a) In General.--The Secretary shall establish conditions
of participation for health care providers under the public
health insurance option.
(b) Licensure or Certification.--
(1) In general.--Except as provided in paragraph (2), the
Secretary shall not allow a health care provider to
participate in the public health insurance option unless such
provider is appropriately licensed, certified, or otherwise
permitted to practice under State law.
(2) Special rule for ihs facilities and providers.--The
requirements under paragraph (1) shall not apply to--
(A) a facility that is operated by the Indian Health
Service;
(B) a facility operated by an Indian Tribe or tribal
organization under the Indian Self-Determination Act (Public
Law 93-638);
(C) a health care professional employed by the Indian
Health Service; or
(D) a health care professional--
(i) who is employed to provide health care services in a
facility operated by an Indian Tribe or tribal organization
under the Indian Self-Determination Act; and
(ii) who is licensed or certified in any State.
(c) Payment Terms for Providers.--
(1) Physicians.--The Secretary shall provide for the annual
participation of physicians under the public health insurance
option, for which payment may be made for services furnished
during the year, in one of 2 classes:
(A) Preferred physicians.--Those physicians who agree to
accept the payment under section 323 (without regard to cost-
sharing) as the payment in full.
(B) Participating, non-preferred physicians.--Those
physicians who agree not to impose charges (in relation to
the payment described in section 323 for such physicians)
that exceed the sum of the in-network cost-sharing plus 15
percent of the total payment for each item and service. The
Secretary shall reduce the payment described in section 323
for such physicians.
(2) Other providers.--The Secretary shall provide for the
participation (on an annual or other basis specified by the
Secretary) of health care providers (other than physicians)
under the public health insurance option under which payment
shall only be available if the provider agrees to accept the
payment under section 323 (without regard to cost-sharing) as
the payment in full.
(d) Exclusion of Certain Providers.--The Secretary shall
exclude from participation under the public health insurance
option a health care provider that is excluded from

[[Page H12649]]

participation in a Federal health care program (as defined in
section 1128B(f) of the Social Security Act).

SEC. 326. APPLICATION OF FRAUD AND ABUSE PROVISIONS.

Provisions of civil law identified by the Secretary by
regulation, in consultation with the Inspector General of the
Department of Health and Human Services, that impose
sanctions with respect to waste, fraud, and abuse under
Medicare, such as sections 3729 through 3733 of title 31,
United States Code (commonly known as the False Claims Act),
shall also apply to the public health insurance option.

SEC. 327. APPLICATION OF HIPAA INSURANCE REQUIREMENTS.

The requirements of sections 2701 through 2792 of the
Public Health Service Act shall apply to the public health
insurance option in the same manner as they apply to health
insurance coverage offered by a health insurance issuer in
the individual market.

SEC. 328. APPLICATION OF HEALTH INFORMATION PRIVACY,
SECURITY, AND ELECTRONIC TRANSACTION
REQUIREMENTS.

Part C of title XI of the Social Security Act, relating to
standards for protections against the wrongful disclosure of
individually identifiable health information, health
information security, and the electronic exchange of health
care information, shall apply to the public health insurance
option in the same manner as such part applies to other
health plans (as defined in section 1171(5) of such Act).

SEC. 329. ENROLLMENT IN PUBLIC HEALTH INSURANCE OPTION IS
VOLUNTARY.

Nothing in this division shall be construed as requiring
anyone to enroll in the public health insurance option.
Enrollment in such option is voluntary.

SEC. 330. ENROLLMENT IN PUBLIC HEALTH INSURANCE OPTION BY
MEMBERS OF CONGRESS.

Notwithstanding any other provision of this Act, Members of
Congress may enroll in the public health insurance option.

SEC. 331. REIMBURSEMENT OF SECRETARY OF VETERANS AFFAIRS.

The Secretary of Health and Human Services shall seek to
enter into a memorandum of understanding with the Secretary
of Veterans Affairs regarding the recovery of costs related
to non-service-connected care or services provided by the
Secretary of Veterans Affairs to an individual covered under
the public health insurance option in a manner consistent
with recovery of costs related to non-service-connected care
from private health insurance plans.

Subtitle C--Individual Affordability Credits

SEC. 341. AVAILABILITY THROUGH HEALTH INSURANCE EXCHANGE.

(a) In General.--Subject to the succeeding provisions of
this subtitle, in the case of an affordable credit eligible
individual enrolled in an Exchange-participating health
benefits plan--
(1) the individual shall be eligible for, in accordance
with this subtitle, affordability credits consisting of--
(A) an affordability premium credit under section 343 to be
applied against the premium for the Exchange-participating
health benefits plan in which the individual is enrolled; and
(B) an affordability cost-sharing credit under section 344
to be applied as a reduction of the cost-sharing otherwise
applicable to such plan; and
(2) the Commissioner shall pay the QHBP offering entity
that offers such plan from the Health Insurance Exchange
Trust Fund the aggregate amount of affordability credits for
all affordable credit eligible individuals enrolled in such
plan.
(b) Application.--
(1) In general.--An Exchange eligible individual may apply
to the Commissioner through the Health Insurance Exchange or
through another entity under an arrangement made with the
Commissioner, in a form and manner specified by the
Commissioner. The Commissioner through the Health Insurance
Exchange or through another public entity under an
arrangement made with the Commissioner shall make a
determination as to eligibility of an individual for
affordability credits under this subtitle. The Commissioner
shall establish a process whereby, on the basis of
information otherwise available, individuals may be deemed to
be affordable credit eligible individuals. In carrying this
subtitle, the Commissioner shall establish effective methods
that ensure that individuals with limited English proficiency
are able to apply for affordability credits.
(2) Use of state medicaid agencies.--If the Commissioner
determines that a State Medicaid agency has the capacity to
make a determination of eligibility for affordability credits
under this subtitle and under the same standards as used by
the Commissioner, under the Medicaid memorandum of
understanding under section 305(e)(2)--
(A) the State Medicaid agency is authorized to conduct such
determinations for any Exchange-eligible individual who
requests such a determination; and
(B) the Commissioner shall reimburse the State Medicaid
agency for the costs of conducting such determinations.
(3) Medicaid screen and enroll obligation.--In the case of
an application made under paragraph (1), there shall be a
determination of whether the individual is a Medicaid-
eligible individual. If the individual is determined to be so
eligible, the Commissioner, through the Medicaid memorandum
of understanding under section 305(e)(2), shall provide for
the enrollment of the individual under the State Medicaid
plan in accordance with such Medicaid memorandum of
understanding. In the case of such an enrollment, the State
shall provide for the same periodic redetermination of
eligibility under Medicaid as would otherwise apply if the
individual had directly applied for medical assistance to the
State Medicaid agency.
(4) Application and verification of requirement of
citizenship or lawful presence in the united states.--
(A) Requirement.--No individual shall be an affordable
credit eligible individual (as defined in section 342(a)(1))
unless the individual is a citizen or national of the United
States or is lawfully present in a State in the United States
(other than as a nonimmigrant described in a subparagraph
(excluding subparagraphs (K), (T), (U), and (V)) of section
101(a)(15) of the Immigration and Nationality Act).
(B) Declaration of citizenship or lawful immigration
status.--No individual shall be an affordable credit eligible
individual unless there has been a declaration made, in a
form and manner specified by the Health Choices Commissioner
similar to the manner required under section 1137(d)(1) of
the Social Security Act and under penalty of perjury, that
the individual--
(i) is a citizen or national of the United States; or
(ii) is not such a citizen or national but is lawfully
present in a State in the United States (other than as a
nonimmigrant described in a subparagraph (excluding
subparagraphs (K), (T), (U), and (V)) of section 101(a)(15)
of the Immigration and Nationality Act).

Such declaration shall be verified in accordance with
subparagraph (C) or (D), as the case may be.
(C) Verification process for citizens.--
(i) In general.--In the case of an individual making the
declaration described in subparagraph (B)(i), subject to
clause (ii), section 1902(ee) of the Social Security Act
shall apply to such declaration in the same manner as such
section applies to a declaration described in paragraph (1)
of such section.
(ii) Special rules.--In applying section 1902(ee) of such
Act under clause (i)--

(I) any reference in such section to a State is deemed a
reference to the Commissioner (or other public entity making
the eligibility determination);
(II) any reference to medical assistance or enrollment
under a State plan is deemed a reference to provision of
affordability credits under this subtitle;
(III) a reference to a newly enrolled individual under
paragraph (2)(A) of such section is deemed a reference to an
individual newly in receipt of an affordability credit under
this subtitle;
(IV) approval by the Secretary shall not be required in
applying paragraph (2)(B)(ii) of such section;
(V) paragraph (3) of such section shall not apply; and
(VI) before the end of Y2, the Health Choices Commissioner,
in consultation with the Commissioner of Social Security, may
extend the periods specified in paragraph (1)(B)(ii) of such
section.

(D) Verification process for noncitizens.--
(i) In general.--In the case of an individual making the
declaration described in subparagraph (B)(ii), subject to
clause (ii), the verification procedures of paragraphs (2)
through (5) of section 1137(d) of the Social Security Act
shall apply to such declaration in the same manner as such
procedures apply to a declaration described in paragraph (1)
of such section.
(ii) Special rules.--In applying such paragraphs of section
1137(d) of such Act under clause (i)--

(I) any reference in such paragraphs to a State is deemed a
reference to the Health Choices Commissioner; and
(II) any reference to benefits under a program is deemed a
reference to affordability credits under this subtitle.

(iii) Application to state-based exchanges.--In the case of
the application of the verification process under this
subparagraph to a State-based Health Insurance Exchange
approved under section 308, section 1137(e) of such Act shall
apply to the Health Choices Commissioner in relation to the
State.
(E) Annual reports.--The Health Choices Commissioner shall
report to Congress annually on the number of applicants for
affordability credits under this subtitle, their citizenship
or immigration status, and the disposition of their
applications. Such report shall be made publicly available
and shall include information on--
(i) the number of applicants whose declaration of
citizenship or immigration status, name, or social security
account number was not consistent with records maintained by
the Commissioner of Social Security or the Department of
Homeland Security and, of such applicants, the number who
contested the inconsistency and sought to document their
citizenship or immigration status, name, or social security
account number or to correct the information maintained in
such records and, of those, the results of such
contestations; and
(ii) the administrative costs of conducting the status
verification under this paragraph.
(F) GAO report.--Not later than the end of Y2, the
Comptroller General of the United States shall submit to the
Committee on

[[Page H12650]]

Ways and Means, the Committee on Energy and Commerce, the
Committee on Education and Labor, and the Committee on the
Judiciary of the House of Representatives and the Committee
on Finance, the Committee on Health, Education, Labor, and
Pensions, and the Committee on the Judiciary of the Senate a
report examining the effectiveness of the citizenship and
immigration verification systems applied under this
paragraph. Such report shall include an analysis of the
following:
(i) The causes of erroneous determinations under such
systems.
(ii) The effectiveness of the processes used in remedying
such erroneous determinations.
(iii) The impact of such systems on individuals, health
care providers, and Federal and State agencies, including the
effect of erroneous determinations under such systems.
(iv) The effectiveness of such systems in preventing
ineligible individuals from receiving for affordability
credits.
(v) The characteristics of applicants described in
subparagraph (E)(i).
(G) Prohibition of database.--Nothing in this paragraph or
the amendments made by paragraph (6) shall be construed as
authorizing the Health Choices Commissioner or the
Commissioner of Social Security to establish a database of
information on citizenship or immigration status.
(H) Initial funding.--
(i) In general.--Out of any funds in the Treasury not
otherwise appropriated, there is appropriated to the
Commissioner of Social Security $30,000,000, to be available
without fiscal year limit to carry out this paragraph and
section 205(v) of the Social Security Act.
(ii) Funding limitation.--In no case shall funds from the
Social Security Administration's Limitation on Administrative
Expenses be used to carry out activities related to this
paragraph or section 205(v) of the Social Security Act.
(5) Agreement with social security commissioner.--
(A) In general.--The Health Choices Commissioner shall
enter into and maintain an agreement described in section
205(v)(2) of the Social Security Act with the Commissioner of
Social Security.
(B) Funding.--The agreement entered into under subparagraph
(A) shall, for each fiscal year (beginning with fiscal year
2013)--
(i) provide funds to the Commissioner of Social Security
for the full costs of the responsibilities of the
Commissioner of Social Security under paragraph (4),
including--

(I) acquiring, installing, and maintaining technological
equipment and systems necessary for the fulfillment of the
responsibilities of the Commissioner of Social Security under
paragraph (4), but only that portion of such costs that are
attributable to such responsibilities; and
(II) responding to individuals who contest with the
Commissioner of Social Security a reported inconsistency with
records maintained by the Commissioner of Social Security or
the Department of Homeland Security relating to citizenship
or immigration status, name, or social security account
number under paragraph (4);

(ii) based on an estimating methodology agreed to by the
Commissioner of Social Security and the Health Choices
Commissioner, provide such funds, within 10 calendar days of
the beginning of the fiscal year for the first quarter and in
advance for all subsequent quarters in that fiscal year; and
(iii) provide for an annual accounting and reconciliation
of the actual costs incurred and the funds provided under the
agreement.
(C) Review of accounting.--The annual accounting and
reconciliation conducted pursuant to subparagraph (B)(iii)
shall be reviewed by the Inspectors General of the Social
Security Administration and the Health Choices
Administration, including an analysis of consistency with the
requirements of paragraph (4).
(D) Contingency.--In any case in which agreement with
respect to the provisions required under subparagraph (B) for
any fiscal year has not been reached as of the first day of
such fiscal year, the latest agreement with respect to such
provisions shall be deemed in effect on an interim basis for
such fiscal year until such time as an agreement relating to
such provisions is subsequently reached. In any case in which
an interim agreement applies for any fiscal year under this
subparagraph, the Commissioner of Social Security shall, not
later than the first day of such fiscal year, notify the
appropriate Committees of the Congress of the failure to
reach the agreement with respect to such provisions for such
fiscal year. Until such time as the agreement with respect to
such provisions has been reached for such fiscal year, the
Commissioner of Social Security shall, not later than the end
of each 90-day period after October 1 of such fiscal year,
notify such Committees of the status of negotiations between
such Commissioner and the Health Choices Commissioner in
order to reach such an agreement.
(E) Application to public entities administering
affordability credits.--If the Health Choices Commissioner
provides for the conduct of verifications under paragraph (4)
through a public entity, the Health Choices Commissioner
shall require the public entity to enter into an agreement
with the Commissioner of Social Security which provides the
same terms as the agreement described in this paragraph (and
section 205(v) of the Social Security Act) between the Health
Choices Commissioner and the Commissioner of Social Security,
except that the Health Choices Commissioner shall be
responsible for providing funds for the Commissioner of
Social Security in accordance with subparagraphs (B) through
(D).
(6) Amendments to social security act.--
(A) Coordination of information between social security
administration and health choices administration.--
(i) In general.--Section 205 of the Social Security Act (42
U.S.C. 405) is amended by adding at the end the following new
subsection:

``Coordination of Information With Health Choices Administration

``(v)(1) The Health Choices Commissioner may collect and
use the names and social security account numbers of
individuals as required to provide for verification of
citizenship under subsection (b)(4)(C) of section 341 of the
Affordable Health Care for America Act in connection with
determinations of eligibility for affordability credits under
such section.
``(2)(A) The Commissioner of Social Security shall enter
into and maintain an agreement with the Health Choices
Commissioner for the purpose of establishing, in compliance
with the requirements of section 1902(ee) as applied pursuant
to section 341(b)(4)(C) of the Affordable Health Care for
America Act, a program for verifying information required to
be collected by the Health Choices Commissioner under such
section 341(b)(4)(C).
``(B) The agreement entered into pursuant to subparagraph
(A) shall include such safeguards as are necessary to ensure
the maintenance of confidentiality of any information
disclosed for purposes of verifying information described in
subparagraph (A) and to provide procedures for permitting the
Health Choices Commissioner to use the information for
purposes of maintaining the records of the Health Choices
Administration.
``(C) The agreement entered into pursuant to subparagraph
(A) shall provide that information provided by the
Commissioner of Social Security to the Health Choices
Commissioner pursuant to the agreement shall be provided at
such time, at such place, and in such manner as the
Commissioner of Social Security determines appropriate.
``(D) Information provided by the Commissioner of Social
Security to the Health Choices Commissioner pursuant to an
agreement entered into pursuant to subparagraph (A) shall be
considered as strictly confidential and shall be used only
for the purposes described in this paragraph and for carrying
out such agreement. Any officer or employee or former officer
or employee of the Health Choices Commissioner, or any
officer or employee or former officer or employee of a
contractor of the Health Choices Commissioner, who, without
the written authority of the Commissioner of Social Security,
publishes or communicates any information in such
individual's possession by reason of such employment or
position as such an officer shall be guilty of a felony and,
upon conviction thereof, shall be fined or imprisoned, or
both, as described in section 208.
``(3) The agreement entered into under paragraph (2) shall
provide for funding to the Commissioner of Social Security
consistent with section 341(b)(5) of Affordable Health Care
for America Act.
``(4) This subsection shall apply in the case of a public
entity that conducts verifications under section 341(b)(4) of
the Affordable Health Care for America Act and the
obligations of this subsection shall apply to such an entity
in the same manner as such obligations apply to the Health
Choices Commissioner when such Commissioner is conducting
such verifications.''.
(ii) Conforming amendment.--Section 205(c)(2)(C) of such
Act (42 U.S.C. 405(c)(2)(C)) is amended by adding at the end
the following new clause:
``(x) For purposes of the administration of the
verification procedures described in section 341(b)(4) of the
Affordable Health Care for America Act, the Health Choices
Commissioner may collect and use social security account
numbers as provided for in section 205(v)(1).''.
(B) Improving the integrity of data and effectiveness of
save program.--Section 1137(d) of the Social Security Act (42
U.S.C. 1320b-7(d)) is amended by adding at the end the
following new paragraphs:
``(6)(A) With respect to the use by any agency of the
system described in subsection (b) by programs specified in
subsection (b) or any other use of such system, the U.S.
Citizenship and Immigration Services and any other agency
charged with the management of the system shall establish
appropriate safeguards necessary to protect and improve the
integrity and accuracy of data relating to individuals by--
``(i) establishing a process through which such individuals
are provided access to, and the ability to amend, correct,
and update, their own personally identifiable information
contained within the system;
``(ii) providing a written response, without undue delay,
to any individual who has made such a request to amend,
correct, or update such individual's own personally
identifiable information contained within the system; and
``(iii) developing a written notice for user agencies to
provide to individuals who are denied a benefit due to a
determination of ineligibility based on a final verification
determination under the system.
``(B) The notice described in subparagraph (A)(ii) shall
include--

[[Page H12651]]

``(i) information about the reason for such notice;
``(ii) a description of the right of the recipient of the
notice under subparagraph (A)(i) to contest such notice;
``(iii) a description of the right of the recipient under
subparagraph (A)(i) to access and attempt to amend, correct,
and update the recipient's own personally identifiable
information contained within records of the system described
in paragraph (3); and
``(iv) instructions on how to contest such notice and
attempt to correct records of such system relating to the
recipient, including contact information for relevant
agencies.''.
(C) Streamlining administration of verification process for
united states citizens.--Section 1902(ee)(2) of the Social
Security Act (42 U.S.C. 1396a(ee)(2)) is amended by adding at
the end the following:
``(D) In carrying out the verification procedures under
this subsection with respect to a State, if the Commissioner
of Social Security determines that the records maintained by
such Commissioner are not consistent with an individual's
allegation of United States citizenship, pursuant to
procedures which shall be established by the State in
coordination with the Commissioner of Social Security, the
Secretary of Homeland Security, and the Secretary of Health
and Human Services--
``(i) the Commissioner of Social Security shall inform the
State of the inconsistency;
``(ii) upon being so informed of the inconsistency, the
State shall submit the information on the individual to the
Secretary of Homeland Security for a determination of whether
the records of the Department of Homeland Security indicate
that the individual is a citizen;
``(iii) upon making such determination, the Department of
Homeland Security shall inform the State of such
determination; and
``(iv) information provided by the Commissioner of Social
Security shall be considered as strictly confidential and
shall only be used by the State and the Secretary of Homeland
Security for the purposes of such verification procedures.
``(E) Verification of status eligibility pursuant to the
procedures established under this subsection shall be deemed
a verification of status eligibility for purposes of this
title, title XXI, and affordability credits under section
341(b)(4) of the Affordable Health Care for America Act,
regardless of the program in which the individual is applying
for benefits.''.
(c) Use of Affordability Credits.--
(1) In general.--In Y1 and Y2 an affordable credit eligible
individual may use an affordability credit only with respect
to a basic plan.
(2) Flexibility in plan enrollment authorized.--Beginning
with Y3, the Commissioner shall establish a process to allow
an affordability premium credit under section 343, but not
the affordability cost-sharing credit under section 344, to
be used for enrollees in enhanced or premium plans. In the
case of an affordable credit eligible individual who enrolls
in an enhanced or premium plan, the individual shall be
responsible for any difference between the premium for such
plan and the affordability credit amount otherwise applicable
if the individual had enrolled in a basic plan.
(3) Prohibition of use of public funds for abortion
coverage.--An affordability credit may not be used for
payment for services described in section 222(e)(4)(A).
(d) Access to Data.--In carrying out this subtitle, the
Commissioner shall request from the Secretary of the Treasury
consistent with section 6103 of the Internal Revenue Code of
1986 such information as may be required to carry out this
subtitle.
(e) No Cash Rebates.--In no case shall an affordable credit
eligible individual receive any cash payment as a result of
the application of this subtitle.

SEC. 342. AFFORDABLE CREDIT ELIGIBLE INDIVIDUAL.

(a) Definition.--
(1) In general.--For purposes of this division, the term
``affordable credit eligible individual'' means, subject to
subsection (b) and section 346, an individual who is lawfully
present in a State in the United States (other than as a
nonimmigrant described in a subparagraph (excluding
subparagraphs (K), (T), (U), and (V)) of section 101(a)(15)
of the Immigration and Nationality Act)--
(A) who is enrolled under an Exchange-participating health
benefits plan and is not enrolled under such plan as an
employee (or dependent of an employee) through an employer
qualified health benefits plan that meets the requirements of
section 412;
(B) with modified adjusted gross income below 400 percent
of the Federal poverty level for a family of the size
involved;
(C) who is not a Medicaid eligible individual, other than
an individual during a transition period under section
302(d)(3)(B)(ii); and
(D) subject to paragraph (3), who is not enrolled in
acceptable coverage (other than an Exchange-participating
health benefits plan).
(2) Treatment of family.--Except as the Commissioner may
otherwise provide, members of the same family who are
affordable credit eligible individuals shall be treated as a
single affordable credit individual eligible for the
applicable credit for such a family under this subtitle.
(3) Special rule for indians.--Subparagraph (D) of
paragraph (1) shall not apply to an individual who has
coverage that is treated as acceptable coverage for purposes
of section 59B(d)(2) of the Internal Revenue Code of 1986 but
is not treated as acceptable coverage for purposes of this
division.
(b) Limitations on Employee and Dependent
Disqualification.--
(1) In general.--Subject to paragraph (2), the term
``affordable credit eligible individual'' does not include a
full-time employee of an employer if the employer offers the
employee coverage (for the employee and dependents) as a
full-time employee under a group health plan if the coverage
and employer contribution under the plan meet the
requirements of section 412.
(2) Exceptions.--
(A) For certain family circumstances.--The Commissioner
shall establish such exceptions and special rules in the case
described in paragraph (1) as may be appropriate in the case
of a divorced or separated individual or such a dependent of
an employee who would otherwise be an affordable credit
eligible individual.
(B) For unaffordable employer coverage.--Beginning in Y2,
in the case of full-time employees for which the cost of the
employee premium for coverage under a group health plan would
exceed 12 percent of current modified adjusted gross income
(determined by the Commissioner on the basis of verifiable
documentation), paragraph (1) shall not apply.
(c) Income Defined.--
(1) In general.--In this title, the term ``income'' means
modified adjusted gross income (as defined in section 59B of
the Internal Revenue Code of 1986).
(2) Study of income disregards.--The Commissioner shall
conduct a study that examines the application of income
disregards for purposes of this subtitle. Not later than the
first day of Y2, the Commissioner shall submit to Congress a
report on such study and shall include such recommendations
as the Commissioner determines appropriate.
(d) Clarification of Treatment of Affordability Credits.--
Affordability credits under this subtitle shall not be
treated, for purposes of title IV of the Personal
Responsibility and Work Opportunity Reconciliation Act of
1996, to be a benefit provided under section 403 of such
title.

SEC. 343. AFFORDABILITY PREMIUM CREDIT.

(a) In General.--The affordability premium credit under
this section for an affordable credit eligible individual
enrolled in an Exchange-participating health benefits plan is
in an amount equal to the amount (if any) by which the
reference premium amount specified in subsection (c), exceeds
the affordable premium amount specified in subsection (b) for
the individual, except that in no case shall the affordable
premium credit exceed the premium for the plan.
(b) Affordable Premium Amount.--
(1) In general.--The affordable premium amount specified in
this subsection for an individual for the annual premium in a
plan year shall be equal to the product of--
(A) the premium percentage limit specified in paragraph (2)
for the individual based upon the individual's modified
adjusted gross income for the plan year; and
(B) the individual's modified adjusted gross income for
such plan year.
(2) Premium percentage limits based on table.--The
Commissioner shall establish premium percentage limits so
that for individuals whose modified adjusted gross income is
within an income tier specified in the table in subsection
(d) such percentage limits shall increase, on a sliding scale
in a linear manner, from the initial premium percentage to
the final premium percentage specified in such table for such
income tier.
(c) Reference Premium Amount.--The reference premium amount
specified in this subsection for a plan year for an
individual in a premium rating area is equal to the average
premium for the 3 basic plans in the area for the plan year
with the lowest premium levels. In computing such amount the
Commissioner may exclude plans with extremely limited
enrollments.
(d) Table of Premium Percentage Limits, Actuarial Value
Percentages, and Out-of-pocket Limits for Y1 Based on Income
Tier.--
(1) In general.--For purposes of this subtitle, subject to
paragraph (3) and section 346, the table specified in this
subsection is as follows:

In the case of modified
adjusted gross income
(expressed as a percent of   The initial premium   The final premium   The actuarial value   The out-of-pocket
FPL) within the following     percentage is--      percentage is--      percentage is--     limit for Y1 is--
income tier:

133% through 150%             1.5%                 3.0%                 97%                  $500
150% through 200%             3.0%                 5.5%                 93%                  $1,000
200% through 250%             5.5%                 8.0%                 85%                  $2,000
250% through 300%             8.0%                 10.0%                78%                  $4,000
300% through 350%             10.0%                11.0%                72%                  $4,500
350% through 400%             11.0%                12.0%                70%                  $5,000

[[Page H12652]]

(2) Special rules.--For purposes of applying the table
under paragraph (1):
(A) For lowest level of income.--In the case of an
individual with income that does not exceed 133 percent of
FPL, the individual shall be considered to have income that
is 133 percent of FPL.
(B) Application of higher actuarial value percentage at
tier transition points.--If two actuarial value percentages
may be determined with respect to an individual, the
actuarial value percentage shall be the higher of such
percentages.
(3) Indexing.--For years after Y1, the Commissioner shall
adjust the initial and final premium percentages to maintain
the ratio of governmental to enrollee shares of premiums over
time, for each income tier identified in the table in
paragraph (1).

SEC. 344. AFFORDABILITY COST-SHARING CREDIT.

(a) In General.--The affordability cost-sharing credit
under this section for an affordable credit eligible
individual enrolled in an Exchange-participating health
benefits plan is in the form of the cost-sharing reduction
described in subsection (b) provided under this section for
the income tier in which the individual is classified based
on the individual's modified adjusted gross income.
(b) Cost-sharing Reductions.--The Commissioner shall
specify a reduction in cost-sharing amounts and the annual
limitation on cost-sharing specified in section 222(c)(2)(B)
under a basic plan for each income tier specified in the
table under section 343(d), with respect to a year, in a
manner so that, as estimated by the Commissioner--
(1) the actuarial value of the coverage with such reduced
cost-sharing amounts (and the reduced annual cost-sharing
limit) is equal to the actuarial value percentage (specified
in the table under section 343(d) for the income tier
involved) of the full actuarial value if there were no cost-
sharing imposed under the plan; and
(2) the annual limitation on cost-sharing specified in
section 222(c)(2)(B) is reduced to a level that does not
exceed the maximum out-of-pocket limit specified in
subsection (c).
(c) Maximum Out-of-pocket Limit.--
(1) In general.--Subject to paragraph (2), the maximum out-
of-pocket limit specified in this subsection for an
individual within an income tier--
(A) for individual coverage--
(i) for Y1 is the out-of-pocket limit for Y1 specified in
subsection (c) in the table under section 343(d) for the
income tier involved; or
(ii) for a subsequent year is such out-of-pocket limit for
the previous year under this subparagraph increased (rounded
to the nearest $10) for each subsequent year by the
percentage increase in the enrollment-weighted average of
premium increases for basic plans applicable to such year; or
(B) for family coverage is twice the maximum out-of-pocket
limit under subparagraph (A) for the year involved.
(2) Adjustment.--The Commissioner shall adjust the maximum
out-of-pocket limits under paragraph (1) to ensure that such
limits meet the actuarial value percentage specified in the
table under section 343(d) for the income tier involved.
(d) Determination and Payment of Cost-sharing Affordability
Credit.--In the case of an affordable credit eligible
individual in a tier enrolled in an Exchange-participating
health benefits plan offered by a QHBP offering entity, the
Commissioner shall provide for payment to the offering entity
of an amount equivalent to the increased actuarial value of
the benefits under the plan provided under section
303(c)(2)(B) resulting from the reduction in cost-sharing
described in subsections (b) and (c).

SEC. 345. INCOME DETERMINATIONS.

(a) In General.--In applying this subtitle for an
affordability credit for an individual for a plan year, the
individual's income shall be the income (as defined in
section 342(c)) for the individual for the most recent
taxable year (as determined in accordance with rules of the
Commissioner). The Federal poverty level applied shall be
such level in effect as of the date of the application.
(b) Program Integrity; Income Verification Procedures.--
(1) Program integrity.--The Commissioner shall take such
steps as may be appropriate to ensure the accuracy of
determinations and redeterminations under this subtitle.
(2) Income verification.--
(A) In general.--Upon an initial application of an
individual for an affordability credit under this subtitle
(or in applying section 342(b)) or upon an application for a
change in the affordability credit based upon a significant
change in modified adjusted gross income described in
subsection (c)(1)--
(i) the Commissioner shall request from the Secretary of
the Treasury the disclosure to the Commissioner of such
information as may be permitted to verify the information
contained in such application; and
(ii) the Commissioner shall use the information so
disclosed to verify such information.
(B) Alternative procedures.--The Commissioner shall
establish procedures for the verification of income for
purposes of this subtitle if no income tax return is
available for the most recent completed tax year.
(c) Special Rules.--
(1) Changes in income as a percent of fpl.--In the case
that an individual's income (expressed as a percentage of the
Federal poverty level for a family of the size involved) for
a plan year is expected (in a manner specified by the
Commissioner) to be significantly different from the income
(as so expressed) used under subsection (a), the Commissioner
shall establish rules requiring an individual to report,
consistent with the mechanism established under paragraph
(2), significant changes in such income (including a
significant change in family composition) to the Commissioner
and requiring the substitution of such income for the income
otherwise applicable.
(2) Reporting of significant changes in income.--The
Commissioner shall establish rules under which an individual
determined to be an affordable credit eligible individual
would be required to inform the Commissioner when there is a
significant change in the modified adjusted gross income of
the individual (expressed as a percentage of the FPL for a
family of the size involved) and of the information regarding
such change. Such mechanism shall provide for guidelines that
specify the circumstances that qualify as a significant
change, the verifiable information required to document such
a change, and the process for submission of such information.
If the Commissioner receives new information from an
individual regarding the modified adjusted gross income of
the individual, the Commissioner shall provide for a
redetermination of the individual's eligibility to be an
affordable credit eligible individual.
(3) Transition for chip.--In the case of a child described
in section 302(d)(4), the Commissioner shall establish rules
under which the modified adjusted gross income of the child
is deemed to be no greater than the family income of the
child as most recently determined before Y1 by the State
under title XXI of the Social Security Act.
(4) Study of geographic variation in application of fpl.--
(A) In general.--The Secretary of Health and Human Services
shall conduct a study to examine the feasibility and
implication of adjusting the application of the Federal
poverty level under this subtitle for different geographic
areas so as to reflect the variations in cost-of-living among
different areas within the United States. If the Secretary
determines that an adjustment is feasible, the study should
include a methodology to make such an adjustment. Not later
than the first day of Y1, the Secretary shall submit to
Congress a report on such study and shall include such
recommendations as the Secretary determines appropriate.
(B) Inclusion of territories.--
(i) In general.--The Secretary shall ensure that the study
under subparagraph (A) covers the territories of the United
States and that special attention is paid to the disparity
that exists among poverty levels and the cost of living in
such territories and to the impact of such disparity on
efforts to expand health coverage and ensure health care.
(ii) Territories defined.--In this subparagraph, the term
``territories of the United States'' includes the
Commonwealth of Puerto Rico, the United States Virgin
Islands, Guam, the Northern Mariana Islands, and any other
territory or possession of the United States.
(d) Penalties for Misrepresentation.--In the case of an
individual who intentionally misrepresents modified adjusted
gross income or the individual fails (without regard to
intent) to disclose to the Commissioner a significant change
in modified adjusted gross income under subsection (c) in a
manner that results in the individual becoming an affordable
credit eligible individual when the individual is not or in
the amount of the affordability credit exceeding the correct
amount--
(1) the individual is liable for repayment of the amount of
the improper affordability credit; and
(2) in the case of such an intentional misrepresentation or
other egregious circumstances specified by the Commissioner,
the Commissioner may impose an additional penalty.

SEC. 346. SPECIAL RULES FOR APPLICATION TO TERRITORIES.

(a) One-time Election for Treatment and Application of
Funding.--
(1) In general.--A territory may elect, in a form and
manner specified by the Commissioner in consultation with the
Secretary of Health and Human Services and the Secretary of
the Treasury and not later than October 1, 2012, either--
(A) to be treated as a State for purposes of applying this
title and title II; or
(B) not to be so treated but instead, to have the dollar
limitation otherwise applicable to the territory under
subsections (f) and (g) of section 1108 of the Social
Security Act (42 U.S.C. 1308) for a fiscal year increased by
a dollar amount equivalent to the cap amount determined under
subsection (c)(2) for the territory as applied by the
Secretary for the fiscal year involved.
(2) Conditions for acceptance.--The Commissioner has the
nonreviewable authority to accept or reject an election
described in paragraph (1)(A). Any such acceptance is--
(A) contingent upon entering into an agreement described in
subsection (b) between the Commissioner and the territory and
subsection (c); and
(B) subject to the approval of the Secretary of Health and
Human Services and the Secretary of the Treasury and subject
to such other terms and conditions as the Commissioner, in
consultation with such Secretaries, may specify.
(3) Default rule.--A territory failing to make such an
election (or having an election

[[Page H12653]]

under paragraph (1)(A) not accepted under paragraph (2))
shall be treated as having made the election described in
paragraph (1)(B).
(b) Agreement for Substitution of Percentages for
Affordability Credits.--
(1) Negotiation.--In the case of a territory making an
election under subsection (a)(1)(A) (in this section referred
to as an ``electing territory'') , the Commissioner, in
consultation with the Secretaries of Health and Human
Services and the Treasury, shall enter into negotiations with
the government of such territory so that, before Y1, there is
an agreement reached between the parties on the percentages
that shall be applied under paragraph (2) for that territory.
The Commissioner shall not enter into such an agreement
unless--
(A) payments made under this subtitle with respect to
residents of the territory are consistent with the cap
established under subsection (c) for such territory and with
subsection (d); and
(B) the requirements of paragraphs (3) and (4) are met.
(2) Application of substitute percentages and dollar
amounts.--In the case of an electing territory, there shall
be substituted in section 342(a)(1)(B) and in the table in
section 341(d)(1) for 400 percent, 133 percent, and other
percentages and dollar amounts specified in such table, such
respective percentages and dollar amounts as are established
under the agreement under paragraph (1) consistent with the
following:
(A) No income gap between medicaid and affordability
credits.--The substituted percentages shall be specified in a
manner so as to prevent any gap in coverage for individuals
between income level at which medical assistance is available
through Medicaid and the income level at which affordability
credits are available.
(B) Adjustment for out-of-pocket responsibility for
premiums and cost-sharing in relation to income.--The
substituted percentages of FPL for income tiers under such
table shall be specified in a manner so that--
(i) affordable credit eligible individuals residing in the
territory bear the same out-of-pocket responsibility for
premiums and cost-sharing in relation to average income for
residents in that territory, as
(ii) the out-of-pocket responsibility for premiums and
cost-sharing for affordable credit eligible individuals
residing in the 50 States or the District of Columbia in
relation to average income for such residents.
(3) Special rules with respect to application of tax and
penalty provisions.--The electing territory shall enact one
or more laws under which provisions similar to the following
provisions apply with respect to such territory:
(A) Section 59B of the Internal Revenue Code of 1986,
except that any resident of the territory who is not an
affordable credit eligible individual but who would be an
affordable credit eligible individual if such resident were a
resident of one of the 50 States (and any qualifying child
residing with such individual) may be treated as covered by
acceptable coverage.
(B) Section 4980H of the Internal Revenue Code of 1986 and
section 502(c)(11) of the Employee Retirement Income Security
Act of 1974.
(C) Section 3121(c) of the Internal Revenue Code of 1986.
(4) Implementation of insurance reform and consumer
protection requirements.--The electing territory shall enact
and implement such laws and regulations as may be required to
apply the requirements of title II with respect to health
insurance coverage offered in the territory.
(c) Cap on Additional Expenditures.--
(1) In general.--In entering into an agreement with an
electing territory under subsection (b), the Commissioner
shall ensure that the aggregate expenditures under this
subtitle with respect to residents of such territory during
the period beginning with Y1 and ending with 2019 will not
exceed the cap amount specified in paragraph (2) for such
territory. The Commissioner shall adjust from time to time
the percentages applicable under such agreement as needed in
order to carry out the previous sentence.
(2) Cap amount.--
(A) In general.--The cap amount specified in this
paragraph--
(i) for Puerto Rico is $3,700,000,000 increased by the
amount (if any) elected under subparagraph (C); or
(ii) for another territory is the portion of $300,000,000
negotiated for such territory under subparagraph (B).
(B) Negotiation for certain territories.--The Commissioner
in consultation with the Secretary of Health and Human
Services shall negotiate with the governments of the
territories (other than Puerto Rico) to allocate the amount
specified in subparagraph (A)(ii) among such territories.
(C) Optional supplementation for puerto rico.--
(i) In general.--Puerto Rico may elect, in a form and
manner specified by the Secretary of Health and Human
Services in consultation with the Commissioner to increase
the dollar amount specified in subparagraph (A)(i) by up to
$1,000,000,000.
(ii) Offset in medicaid cap.--If Puerto Rico makes the
election described in clause (i), the Secretary shall
decrease the dollar limitation otherwise applicable to Puerto
Rico under subsections (f) and (g) of section 1108 of the
Social Security Act (42 U.S.C. 1308) for a fiscal year by the
additional aggregate payments the Secretary estimates will be
payable under this section for the fiscal year because of
such election.
(d) Limitation on Funding.--In no case shall this section
(including the agreement under subsection (b)) permit--
(1) the obligation of funds for expenditures under this
subtitle for periods beginning on or after January 1, 2020;
or
(2) any increase in the dollar limitation described in
subsection (a)(1)(B) for any portion of any fiscal year
occurring on or after such date.

SEC. 347. NO FEDERAL PAYMENT FOR UNDOCUMENTED ALIENS.

Nothing in this subtitle shall allow Federal payments for
affordability credits on behalf of individuals who are not
lawfully present in the United States.

TITLE IV--SHARED RESPONSIBILITY

Subtitle A--Individual Responsibility

SEC. 401. INDIVIDUAL RESPONSIBILITY.

For an individual's responsibility to obtain acceptable
coverage, see section 59B of the Internal Revenue Code of
1986 (as added by section 501 of this Act).

Subtitle B--Employer Responsibility

PART 1--HEALTH COVERAGE PARTICIPATION REQUIREMENTS

SEC. 411. HEALTH COVERAGE PARTICIPATION REQUIREMENTS.

An employer meets the requirements of this section if such
employer does all of the following:
(1) Offer of coverage.--The employer offers each employee
individual and family coverage under a qualified health
benefits plan (or under a current employment-based health
plan (within the meaning of section 202(b))) in accordance
with section 412.
(2) Contribution towards coverage.--If an employee accepts
such offer of coverage, the employer makes timely
contributions towards such coverage in accordance with
section 412.
(3) Contribution in lieu of coverage.--Beginning with Y2,
if an employee declines such offer but otherwise obtains
coverage in an Exchange-participating health benefits plan
(other than by reason of being covered by family coverage as
a spouse or dependent of the primary insured), the employer
shall make a timely contribution to the Health Insurance
Exchange with respect to each such employee in accordance
with section 413.

SEC. 412. EMPLOYER RESPONSIBILITY TO CONTRIBUTE TOWARD
EMPLOYEE AND DEPENDENT COVERAGE.

(a) In General.--An employer meets the requirements of this
section with respect to an employee if the following
requirements are met:
(1) Offering of coverage.--The employer offers the coverage
described in section 411(1). In the case of an Exchange-
eligible employer, the employer may offer such coverage
either through an Exchange-participating health benefits plan
or other than through such a plan.
(2) Employer required contribution.--The employer timely
pays to the issuer of such coverage an amount not less than
the employer required contribution specified in subsection
(b) for such coverage.
(3) Provision of information.--The employer provides the
Health Choices Commissioner, the Secretary of Labor, the
Secretary of Health and Human Services, and the Secretary of
the Treasury, as applicable, with such information as the
Commissioner may require to ascertain compliance with the
requirements of this section, including the following:
(A) The name, date, and employer identification number of
the employer.
(B) A certification as to whether the employer offers to
its full-time employees (and their dependents) the
opportunity to enroll in a qualified health benefits plan or
a current employment-based health plan (within the meaning of
section 202(b)).
(C) If the employer certifies that the employer did offer
to its full-time employees (and their dependents) the
opportunity to so enroll--
(i) the months during the calendar year for which such
coverage was available; and
(ii) the monthly premium for the lowest cost option in each
of the enrollment categories under each such plan offered to
employees.
(D) The name, address, and TIN of each full-time employee
during the calendar year and the months (if any) during which
such employee (and any dependents) were covered under any
such plans.
(4) Autoenrollment of employees.--The employer provides for
autoenrollment of the employee in accordance with subsection
(c).
This subsection shall supersede any law of a State which
would prevent automatic payroll deduction of employee
contributions to an employment-based health plan.
(b) Reduction of Employee Premiums Through Minimum Employer
Contribution.--
(1) Full-time employees.--The minimum employer contribution
described in this subsection for coverage of a full-time
employee (and, if any, the employee's spouse and qualifying
children (as defined in section 152(c) of the Internal
Revenue Code of 1986)) under a qualified health benefits plan
(or current employment-based health plan) is equal to--
(A) in case of individual coverage, not less than 72.5
percent of the applicable premium (as defined in section
4980B(f)(4) of such Code, subject to paragraph (2)) of the
lowest cost plan offered by the employer that is a

[[Page H12654]]

qualified health benefits plan (or is such current
employment-based health plan); and
(B) in the case of family coverage which includes coverage
of such spouse and children, not less 65 percent of such
applicable premium of such lowest cost plan.
(2) Applicable premium for exchange coverage.--In this
subtitle, the amount of the applicable premium of the lowest
cost plan with respect to coverage of an employee under an
Exchange-participating health benefits plan is the reference
premium amount under section 343(c) for individual coverage
(or, if elected, family coverage) for the premium rating area
in which the individual or family resides.
(3) Minimum employer contribution for employees other than
full-time employees.--In the case of coverage for an employee
who is not a full-time employee, the amount of the minimum
employer contribution under this subsection shall be a
proportion (as determined in accordance with rules of the
Health Choices Commissioner, the Secretary of Labor, the
Secretary of Health and Human Services, and the Secretary of
the Treasury, as applicable) of the minimum employer
contribution under this subsection with respect to a full-
time employee that reflects the proportion of--
(A) the average weekly hours of employment of the employee
by the employer, to
(B) the minimum weekly hours specified by the Commissioner
for an employee to be a full-time employee.
(4) Salary reductions not treated as employer
contributions.--For purposes of this section, any
contribution on behalf of an employee with respect to which
there is a corresponding reduction in the compensation of the
employee shall not be treated as an amount paid by the
employer.
(c) Automatic Enrollment for Employer Sponsored Health
Benefits.--
(1) In general.--The requirement of this subsection with
respect to an employer and an employee is that the employer
automatically enroll such employee into the employment-based
health benefits plan for individual coverage under the plan
option with the lowest applicable employee premium.
(2) Opt-out.--In no case may an employer automatically
enroll an employee in a plan under paragraph (1) if such
employee makes an affirmative election to opt out of such
plan or to elect coverage under an employment-based health
benefits plan offered by such employer. An employer shall
provide an employee with a 30-day period to make such an
affirmative election before the employer may automatically
enroll the employee in such a plan.
(3) Notice requirements.--
(A) In general.--Each employer described in paragraph (1)
who automatically enrolls an employee into a plan as
described in such paragraph shall provide the employees,
within a reasonable period before the beginning of each plan
year (or, in the case of new employees, within a reasonable
period before the end of the enrollment period for such a new
employee), written notice of the employees' rights and
obligations relating to the automatic enrollment requirement
under such paragraph. Such notice must be comprehensive and
understood by the average employee to whom the automatic
enrollment requirement applies.
(B) Inclusion of specific information.--The written notice
under subparagraph (A) must explain an employee's right to
opt out of being automatically enrolled in a plan and in the
case that more than one level of benefits or employee premium
level is offered by the employer involved, the notice must
explain which level of benefits and employee premium level
the employee will be automatically enrolled in the absence of
an affirmative election by the employee.

SEC. 413. EMPLOYER CONTRIBUTIONS IN LIEU OF COVERAGE.

(a) In General.--A contribution is made in accordance with
this section with respect to an employee if such contribution
is equal to an amount equal to 8 percent of the average wages
paid by the employer during the period of enrollment
(determined by taking into account all employees of the
employer and in such manner as the Commissioner provides,
including rules providing for the appropriate aggregation of
related employers) but not to exceed the minimum employer
contribution described in section 412(b)(1)(A). Any such
contribution--
(1) shall be paid to the Health Choices Commissioner for
deposit into the Health Insurance Exchange Trust Fund; and
(2) shall not be applied against the premium of the
employee under the Exchange-participating health benefits
plan in which the employee is enrolled.
(b) Special Rules for Small Employers.--
(1) In general.--In the case of any employer who is a small
employer for any calendar year, subsection (a) shall be
applied by substituting the applicable percentage determined
in accordance with the following table for ``8 percent'':

If the annual payroll of such employer   The applicable percentage is:
for the preceding calendar year:
Does not exceed $500,000.............  0 percent
Exceeds $500,000, but does not exceed  2 percent
$585,000.
Exceeds $585,000, but does not exceed  4 percent
$670,000.
Exceeds $670,000, but does not exceed  6 percent
$750,000.

(2) Small employer.--For purposes of this subsection, the
term ``small employer'' means any employer for any calendar
year if the annual payroll of such employer for the preceding
calendar year does not exceed $750,000.
(3) Annual payroll.--For purposes of this paragraph, the
term ``annual payroll'' means, with respect to any employer
for any calendar year, the aggregate wages paid by the
employer during such calendar year.
(4) Aggregation rules.--Related employers and predecessors
shall be treated as a single employer for purposes of this
subsection.

SEC. 414. AUTHORITY RELATED TO IMPROPER STEERING.

The Health Choices Commissioner (in coordination with the
Secretary of Labor, the Secretary of Health and Human
Services, and the Secretary of the Treasury) shall have
authority to set standards for determining whether employers
or insurers are undertaking any actions to affect the risk
pool within the Health Insurance Exchange by inducing
individuals to decline coverage under a qualified health
benefits plan (or current employment-based health plan
(within the meaning of section 202(b)) offered by the
employer and instead to enroll in an Exchange-participating
health benefits plan. An employer violating such standards
shall be treated as not meeting the requirements of this
section.

SEC. 415. IMPACT STUDY ON EMPLOYER RESPONSIBILITY
REQUIREMENTS.

(a) In General.--The Secretary of Labor shall conduct a
study to examine the effect of the exemptions under section
512(a) and coverage thresholds under this division (in this
section referred to collectively as ``employer responsibility
requirements'' on employment-based health plan sponsorship,
generally and within specific industries, and the effect of
such requirements and thresholds on employers, employment-
based health plans, and employees in each industry.
(b) Annual Report.--The Secretary of Labor annually shall
submit to Congress a report on findings on how employer
responsibility requirements have impacted and are likely to
impact employers, plans, and employees during the previous
year and projected trends.
(c) Legislative Recommendations.--No later than January 1,
2012 and on an annual basis thereafter, the Secretary of
Labor shall submit legislative recommendations to Congress to
modify the employer responsibility requirements if the
Secretary determines that the requirements are detrimentally
affecting or will detrimentally affect employer plan
sponsorship or otherwise creating inequities among employers,
health plans, and employees. The Secretary may also submit
such recommendations as the Secretary determines necessary to
improve and strengthen employment-based health plan
sponsorship, employer responsibility, and related proposals
that would enhance the delivery of health care benefits
between employers and employees.

SEC. 416. STUDY ON EMPLOYER HARDSHIP EXEMPTION.

(a) In General.--The Secretary of Labor together with the
Secretary of Treasury, the Secretary of Health and Human
Services, and the Commissioner, shall conduct a study to
examine the impact of the employer responsibility
requirements described in section 415(a) and make a
recommendation to Congress about whether an employer hardship
exemption would be appropriate.
(b) Items Included in Study.--Within such study the
Secretaries and Commissioner shall examine cases where such
employer responsibility requirements may pose a particular
hardship, and specifically look at employers by industry,
profit margin, length of time in business, and size. In this
examination, the economic conditions shall be considered,
including the rate of increase in business costs, the
availability of short-term credit lines, and abilities to
restructure debt. In addition, the study shall examine the
impact an employer hardship waiver could have on employees.
(c) Report.--Not later than January 1, 2012, the
Secretaries and Commissioner shall report to Congress on
their findings and make a recommendation regarding the need
or lack of need for a partial or complete employer hardship
waiver. The Secretaries and Commissioner may also submit
recommendations about the criteria Congress should include
when developing eligibility requirements for the employer
hardship waiver and what safeguards are necessary to protect
the employees of that employer.

PART 2--SATISFACTION OF HEALTH COVERAGE PARTICIPATION REQUIREMENTS

SEC. 421. SATISFACTION OF HEALTH COVERAGE PARTICIPATION
REQUIREMENTS UNDER THE EMPLOYEE RETIREMENT
INCOME SECURITY ACT OF 1974.

(a) In General.--Subtitle B of title I of the Employee
Retirement Income Security Act of 1974 is amended by adding
at the end the following new part:

[[Page H12655]]

``PART 8--NATIONAL HEALTH COVERAGE PARTICIPATION REQUIREMENTS

``SEC. 801. ELECTION OF EMPLOYER TO BE SUBJECT TO NATIONAL
HEALTH COVERAGE PARTICIPATION REQUIREMENTS.

``(a) In General.--An employer may make an election with
the Secretary to be subject to the health coverage
participation requirements.
``(b) Time and Manner.--An election under subsection (a)
may be made at such time and in such form and manner as the
Secretary may prescribe.

``SEC. 802. TREATMENT OF COVERAGE RESULTING FROM ELECTION.

``(a) In General.--If an employer makes an election to the
Secretary under section 801--
``(1) such election shall be treated as the establishment
and maintenance of a group health plan (as defined in section
733(a)) for purposes of this title, subject to section 251 of
the Affordable Health Care for America Act; and
``(2) the health coverage participation requirements shall
be deemed to be included as terms and conditions of such
plan.
``(b) Periodic Investigations To Discover Noncompliance.--
The Secretary shall regularly audit a representative sampling
of employers and group health plans and conduct
investigations and other activities under section 504 with
respect to such sampling of plans so as to discover
noncompliance with the health coverage participation
requirements in connection with such plans. The Secretary
shall communicate findings of noncompliance made by the
Secretary under this subsection to the Secretary of the
Treasury and the Health Choices Commissioner. The Secretary
shall take such timely enforcement action as appropriate to
achieve compliance.
``(c) Recordkeeping.--To facilitate the audits described in
subsection (b), the Secretary shall promulgate recordkeeping
requirements for employers to account for both employees of
the employer and individuals whom the employer has not
treated as employees of the employer but with whom the
employer, in the course of its trade or business, has engaged
for the performance of labor or services. The scope and
content of such recordkeeping requirements shall be
determined by the Secretary and shall be designed to ensure
that employees who are not properly treated as such may be
identified and properly treated.

``SEC. 803. HEALTH COVERAGE PARTICIPATION REQUIREMENTS.

``For purposes of this part, the term `health coverage
participation requirements' means the requirements of part 1
of subtitle B of title IV of division A of (as in effect on
the date of the enactment of such Act).

``SEC. 804. RULES FOR APPLYING REQUIREMENTS.

``(a) Affiliated Groups.--In the case of any employer which
is part of a group of employers who are treated as a single
employer under subsection (b), (c), (m), or (o) of section
414 of the Internal Revenue Code of 1986, the election under
section 801 shall be made by such employer as the Secretary
may provide. Any such election, once made, shall apply to all
members of such group.
``(b) Separate Elections.--Under regulations prescribed by
the Secretary, separate elections may be made under section
801 with respect to--
``(1) separate lines of business, and
``(2) full-time employees and employees who are not full-
time employees.

``SEC. 805. TERMINATION OF ELECTION IN CASES OF SUBSTANTIAL
NONCOMPLIANCE.

``The Secretary may terminate the election of any employer
under section 801 if the Secretary (in coordination with the
Health Choices Commissioner) determines that such employer is
in substantial noncompliance with the health coverage
participation requirements and shall refer any such
determination to the Secretary of the Treasury as
appropriate.

``SEC. 806. REGULATIONS.

``The Secretary may promulgate such regulations as may be
necessary or appropriate to carry out the provisions of this
part, in accordance with section 424(a) of the . The
Secretary may promulgate any interim final rules as the
Secretary determines are appropriate to carry out this
part.''.
(b) Enforcement of Health Coverage Participation
Requirements.--Section 502 of such Act (29 U.S.C. 1132) is
amended--
(1) in subsection (a)(6), by striking ``paragraph'' and all
that follows through ``subsection (c)'' and inserting
``paragraph (2), (4), (5), (6), (7), (8), (9), (10), or (11)
of subsection (c)''; and
(2) in subsection (c), by redesignating the second
paragraph (10) as paragraph (12) and by inserting after the
first paragraph (10) the following new paragraph:
``(11) Health coverage participation requirements.--
``(A) Civil penalties.--In the case of any employer who
fails (during any period with respect to which an election
under section 801(a) is in effect) to satisfy the health
coverage participation requirements with respect to any
employee, the Secretary may assess a civil penalty against
the employer of $100 for each day in the period beginning on
the date such failure first occurs and ending on the date
such failure is corrected.
``(B) Health coverage participation requirements.--For
purposes of this paragraph, the term `health coverage
participation requirements' has the meaning provided in
section 803.
``(C) Limitations on amount of penalty.--
``(i) Penalty not to apply where failure not discovered
exercising reasonable diligence.--No penalty shall be
assessed under subparagraph (A) with respect to any failure
during any period for which it is established to the
satisfaction of the Secretary that the employer did not know,
or exercising reasonable diligence would not have known, that
such failure existed.
``(ii) Penalty not to apply to failures corrected within 30
days.--No penalty shall be assessed under subparagraph (A)
with respect to any failure if--

``(I) such failure was due to reasonable cause and not to
willful neglect, and
``(II) such failure is corrected during the 30-day period
beginning on the 1st date that the employer knew, or
exercising reasonable diligence would have known, that such
failure existed.

``(iii) Overall limitation for unintentional failures.--In
the case of failures which are due to reasonable cause and
not to willful neglect, the penalty assessed under
subparagraph (A) for failures during any 1-year period shall
not exceed the amount equal to the lesser of--

``(I) 10 percent of the aggregate amount paid or incurred
by the employer (or predecessor employer) during the
preceding 1-year period for group health plans, or
``(II) $500,000.

``(D) Advance notification of failure prior to
assessment.--Before a reasonable time prior to the assessment
of any penalty under this paragraph with respect to any
failure by an employer, the Secretary shall inform the
employer in writing of such failure and shall provide the
employer information regarding efforts and procedures which
may be undertaken by the employer to correct such failure.
``(E) Coordination with excise tax.--Under regulations
prescribed in accordance with section 424 of the Affordable
Health Care for America Act, the Secretary and the Secretary
of the Treasury shall coordinate the assessment of penalties
under this section in connection with failures to satisfy
health coverage participation requirements with the
imposition of excise taxes on such failures under section
4980H(b) of the Internal Revenue Code of 1986 so as to avoid
duplication of penalties with respect to such failures.
``(F) Deposit of penalty collected.--Any amount of penalty
collected under this paragraph shall be deposited as
miscellaneous receipts in the Treasury of the United
States.''.
(c) Clerical Amendments.--The table of contents in section
1 of such Act is amended by inserting after the item relating
to section 734 the following new items:

``Part 8--National Health Coverage Participation Requirements

``Sec. 801. Election of employer to be subject to national health
coverage participation requirements.
``Sec. 802. Treatment of coverage resulting from election.
``Sec. 803. Health coverage participation requirements.
``Sec. 804. Rules for applying requirements.
``Sec. 805. Termination of election in cases of substantial
noncompliance.
``Sec. 806. Regulations.''.
(d) Effective Date.--The amendments made by this section
shall apply to periods beginning after December 31, 2012.

SEC. 422. SATISFACTION OF HEALTH COVERAGE PARTICIPATION
REQUIREMENTS UNDER THE INTERNAL REVENUE CODE OF
1986.

(a) Failure To Elect, or Substantially Comply With, Health
Coverage Participation Requirements.--For employment tax on
employers who fail to elect, or substantially comply with,
the health coverage participation requirements described in
part 1, see section 3111(c) of the Internal Revenue Code of
1986 (as added by section 512 of this Act).
(b) Other Failures.--For excise tax on other failures of
electing employers to comply with such requirements, see
section 4980H of the Internal Revenue Code of 1986 (as added
by section 511 of this Act).

SEC. 423. SATISFACTION OF HEALTH COVERAGE PARTICIPATION
REQUIREMENTS UNDER THE PUBLIC HEALTH SERVICE
ACT.

(a) In General.--Part C of title XXVII of the Public Health
Service Act is amended by adding at the end the following new
section:

``SEC. 2793. NATIONAL HEALTH COVERAGE PARTICIPATION
REQUIREMENTS.

``(a) Election of Employer To Be Subject to National Health
Coverage Participation Requirements.--
``(1) In general.--An employer may make an election with
the Secretary to be subject to the health coverage
participation requirements.
``(2) Time and manner.--An election under paragraph (1) may
be made at such time and in such form and manner as the
Secretary may prescribe.
``(b) Treatment of Coverage Resulting From Election.--
``(1) In general.--If an employer makes an election to the
Secretary under subsection (a)--
``(A) such election shall be treated as the establishment
and maintenance of a group health plan for purposes of this
title, subject to section 251 of the Affordable Health Care
for America Act; and
``(B) the health coverage participation requirements shall
be deemed to be included as terms and conditions of such
plan.

[[Page H12656]]

``(2) Periodic investigations to determine compliance with
health coverage participation requirements.--The Secretary
shall regularly audit a representative sampling of employers
and conduct investigations and other activities with respect
to such sampling of employers so as to discover noncompliance
with the health coverage participation requirements in
connection with such employers (during any period with
respect to which an election under subsection (a) is in
effect). The Secretary shall communicate findings of
noncompliance made by the Secretary under this subsection to
the Secretary of the Treasury and the Health Choices
Commissioner. The Secretary shall take such timely
enforcement action as appropriate to achieve compliance.
``(3) Recordkeeping.--To facilitate the audits described in
subsection (b), the Secretary shall promulgate recordkeeping
requirements for employers to account for both employees of
the employer and individuals whom the employer has not
treated as employees of the employer but with whom the
employer, in the course of its trade or business, has engaged
for the performance of labor or services. The scope and
content of such recordkeeping requirements shall be
determined by the Secretary and shall be designed to ensure
that employees who are not properly treated as such may be
identified and properly treated.
``(c) Health Coverage Participation Requirements.--For
purposes of this section, the term `health coverage
participation requirements' means the requirements of part 1
of subtitle B of title IV of division A of the (as in effect
on the date of the enactment of this section).
``(d) Separate Elections.--Under regulations prescribed by
the Secretary, separate elections may be made under
subsection (a) with respect to full-time employees and
employees who are not full-time employees.
``(e) Termination of Election in Cases of Substantial
Noncompliance.--The Secretary may terminate the election of
any employer under subsection (a) if the Secretary (in
coordination with the Health Choices Commissioner) determines
that such employer is in substantial noncompliance with the
health coverage participation requirements and shall refer
any such determination to the Secretary of the Treasury as
appropriate.
``(f) Enforcement of Health Coverage Participation
Requirements.--
``(1) Civil penalties.--In the case of any employer who
fails (during any period with respect to which the election
under subsection (a) is in effect) to satisfy the health
coverage participation requirements with respect to any
employee, the Secretary may assess a civil penalty against
the employer of $100 for each day in the period beginning on
the date such failure first occurs and ending on the date
such failure is corrected.
``(2) Limitations on amount of penalty.--
``(A) Penalty not to apply where failure not discovered
exercising reasonable diligence.--No penalty shall be
assessed under paragraph (1) with respect to any failure
during any period for which it is established to the
satisfaction of the Secretary that the employer did not know,
or exercising reasonable diligence would not have known, that
such failure existed.
``(B) Penalty not to apply to failures corrected within 30
days.--No penalty shall be assessed under paragraph (1) with
respect to any failure if--
``(i) such failure was due to reasonable cause and not to
willful neglect, and
``(ii) such failure is corrected during the 30-day period
beginning on the 1st date that the employer knew, or
exercising reasonable diligence would have known, that such
failure existed.
``(C) Overall limitation for unintentional failures.--In
the case of failures which are due to reasonable cause and
not to willful neglect, the penalty assessed under paragraph
(1) for failures during any 1-year period shall not exceed
the amount equal to the lesser of--
``(i) 10 percent of the aggregate amount paid or incurred
by the employer (or predecessor employer) during the
preceding taxable year for group health plans, or
``(ii) $500,000.
``(3) Advance notification of failure prior to
assessment.--Before a reasonable time prior to the assessment
of any penalty under paragraph (1) with respect to any
failure by an employer, the Secretary shall inform the
employer in writing of such failure and shall provide the
employer information regarding efforts and procedures which
may be undertaken by the employer to correct such failure.
``(4) Actions to enforce assessments.--The Secretary may
bring a civil action in any District Court of the United
States to collect any civil penalty under this subsection.
``(5) Coordination with excise tax.--Under regulations
prescribed in accordance with section 424 of the Affordable
Health Care for America Act, the Secretary and the Secretary
of the Treasury shall coordinate the assessment of penalties
under paragraph (1) in connection with failures to satisfy
health coverage participation requirements with the
imposition of excise taxes on such failures under section
4980H(b) of the Internal Revenue Code of 1986 so as to avoid
duplication of penalties with respect to such failures.
``(6) Deposit of penalty collected.--Any amount of penalty
collected under this subsection shall be deposited as
miscellaneous receipts in the Treasury of the United States.
``(g) Regulations.--The Secretary may promulgate such
regulations as may be necessary or appropriate to carry out
the provisions of this section, in accordance with section
424(a) of the . The Secretary may promulgate any interim
final rules as the Secretary determines are appropriate to
carry out this section.''.
(b) Effective Date.--The amendments made by subsection (a)
shall apply to periods beginning after December 31, 2012.

SEC. 424. ADDITIONAL RULES RELATING TO HEALTH COVERAGE
PARTICIPATION REQUIREMENTS.

(a) Assuring Coordination.--The officers consisting of the
Secretary of Labor, the Secretary of the Treasury, the
Secretary of Health and Human Services, and the Health
Choices Commissioner shall ensure, through the execution of
an interagency memorandum of understanding among such
officers, that--
(1) regulations, rulings, and interpretations issued by
such officers relating to the same matter over which two or
more of such officers have responsibility under subpart B of
part 8 of subtitle B of title I of the Employee Retirement
Income Security Act of 1974, section 4980H of the Internal
Revenue Code of 1986, and section 2793 of the Public Health
Service Act are administered so as to have the same effect at
all times; and
(2) coordination of policies relating to enforcing the same
requirements through such officers in order to have a
coordinated enforcement strategy that avoids duplication of
enforcement efforts and assigns priorities in enforcement.
(b) Multiemployer Plans.--In the case of a group health
plan that is a multiemployer plan (as defined in section
3(37) of the Employee Retirement Income Security Act of
1974), the regulations prescribed in accordance with
subsection (a) by the officers referred to in subsection (a)
shall provide for the application of the health coverage
participation requirements to the plan sponsor and
contributing employers of such plan. For purposes of this
division, contributions made pursuant to a collective
bargaining agreement or other agreement to such a group
health plan shall be treated as amounts paid by the employer.

TITLE V--AMENDMENTS TO INTERNAL REVENUE CODE OF 1986

Subtitle A--Provisions Relating to Health Care Reform

PART 1--SHARED RESPONSIBILITY

Subpart A--Individual Responsibility

SEC. 501. TAX ON INDIVIDUALS WITHOUT ACCEPTABLE HEALTH CARE
COVERAGE.

(a) In General.--Subchapter A of chapter 1 of the Internal
Revenue Code of 1986 is amended by adding at the end the
following new part:

``PART VIII--HEALTH CARE RELATED TAXES

``subpart a. tax on individuals without acceptable health care
coverage.

``Subpart A--Tax on Individuals Without Acceptable Health Care Coverage

``Sec. 59B. Tax on individuals without acceptable health care coverage.

``SEC. 59B. TAX ON INDIVIDUALS WITHOUT ACCEPTABLE HEALTH CARE
COVERAGE.

``(a) Tax Imposed.--In the case of any individual who does
not meet the requirements of subsection (d) at any time
during the taxable year, there is hereby imposed a tax equal
to 2.5 percent of the excess of--
``(1) the taxpayer's modified adjusted gross income for the
taxable year, over
``(2) the amount of gross income specified in section
6012(a)(1) with respect to the taxpayer.
``(b) Limitations.--
``(1) Tax limited to average premium.--
``(A) In general.--The tax imposed under subsection (a)
with respect to any taxpayer for any taxable year shall not
exceed the applicable national average premium for such
taxable year.
``(B) Applicable national average premium.--
``(i) In general.--For purposes of subparagraph (A), the
`applicable national average premium' means, with respect to
any taxable year, the average premium (as determined by the
Secretary, in coordination with the Health Choices
Commissioner) for self-only coverage under a basic plan which
is offered in a Health Insurance Exchange for the calendar
year in which such taxable year begins.
``(ii) Failure to provide coverage for more than one
individual.--In the case of any taxpayer who fails to meet
the requirements of subsection (d) with respect to more than
one individual during the taxable year, clause (i) shall be
applied by substituting `family coverage' for `self-only
coverage'.
``(2) Proration for part year failures.--The tax imposed
under subsection (a) with respect to any taxpayer for any
taxable year shall not exceed the amount which bears the same
ratio to the amount of tax so imposed (determined without
regard to this paragraph and after application of paragraph
(1)) as--
``(A) the aggregate periods during such taxable year for
which such individual failed to meet the requirements of
subsection (d), bears to
``(B) the entire taxable year.
``(c) Exceptions.--

[[Page H12657]]

``(1) Dependents.--Subsection (a) shall not apply to any
individual for any taxable year if a deduction is allowable
under section 151 with respect to such individual to another
taxpayer for any taxable year beginning in the same calendar
year as such taxable year.
``(2) Nonresident aliens.--Subsection (a) shall not apply
to any individual who is a nonresident alien.
``(3) Individuals residing outside united states.--Any
qualified individual (as defined in section 911(d)) (and any
qualifying child residing with such individual) shall be
treated for purposes of this section as covered by acceptable
coverage during the period described in subparagraph (A) or
(B) of section 911(d)(1), whichever is applicable.
``(4) Individuals residing in possessions of the united
states.--Any individual who is a bona fide resident of any
possession of the United States (as determined under section
937(a)) for any taxable year (and any qualifying child
residing with such individual) shall be treated for purposes
of this section as covered by acceptable coverage during such
taxable year.
``(5) Religious conscience exemption.--
``(A) In general.--Subsection (a) shall not apply to any
individual (and any qualifying child residing with such
individual) for any period if such individual has in effect
an exemption which certifies that such individual is a member
of a recognized religious sect or division thereof described
in section 1402(g)(1) and an adherent of established tenets
or teachings of such sect or division as described in such
section.
``(B) Exemption.--An application for the exemption
described in subparagraph (A) shall be filed with the
Secretary at such time and in such form and manner as the
Secretary may prescribe. The Secretary may treat an
application for exemption under section 1402(g)(1) as an
application for exemption under this section, or may
otherwise coordinate applications under such sections, as the
Secretary determines appropriate. Any such exemption granted
by the Secretary shall be effective for such period as the
Secretary determines appropriate.
``(d) Acceptable Coverage Requirement.--
``(1) In general.--The requirements of this subsection are
met with respect to any individual for any period if such
individual (and each qualifying child of such individual) is
covered by acceptable coverage at all times during such
period.
``(2) Acceptable coverage.--For purposes of this section,
the term `acceptable coverage' means any of the following:
``(A) Qualified health benefits plan coverage.--Coverage
under a qualified health benefits plan (as defined in section
100(c) of the ).
``(B) Grandfathered health insurance coverage; coverage
under grandfathered employment-based health plan.--Coverage
under a grandfathered health insurance coverage (as defined
in subsection (a) of section 202 of the Affordable Health
Care for America Act) or under a current employment-based
health plan (within the meaning of subsection (b) of such
section).
``(C) Medicare.--Coverage under part A of title XVIII of
the Social Security Act.
``(D) Medicaid.--Coverage for medical assistance under
title XIX of the Social Security Act.
``(E) Members of the armed forces and dependents (including
tricare).--Coverage under chapter 55 of title 10, United
States Code, including similar coverage furnished under
section 1781 of title 38 of such Code.
``(F) VA.--Coverage under the veteran's health care program
under chapter 17 of title 38, United States Code.
``(G) Members of indian tribes.--Health care services made
available through the Indian Health Service, a tribal
organization (as defined in section 4 of the Indian Health
Care Improvement Act), or an urban Indian organization (as
defined in such section) to members of an Indian tribe (as
defined in such section).
``(H) Other coverage.--Such other health benefits coverage
as the Secretary, in coordination with the Health Choices
Commissioner, recognizes for purposes of this subsection.
``(e) Other Definitions and Special Rules.--
``(1) Qualifying child.--For purposes of this section, the
term `qualifying child' has the meaning given such term by
section 152(c). With respect to any period during which
health coverage for a child must be provided by an individual
pursuant to a child support order, such child shall be
treated as a qualifying child of such individual (and not as
a qualifying child of any other individual).
``(2) Basic plan.--For purposes of this section, the term
`basic plan' has the meaning given such term under section
100(c) of the Affordable Health Care for America Act.
``(3) Health insurance exchange.--For purposes of this
section, the term `Health Insurance Exchange' has the meaning
given such term under section 100(c) of the Affordable Health
Care for America Act, including any State-based health
insurance exchange approved for operation under section 308
of such Act.
``(4) Family coverage.--For purposes of this section, the
term `family coverage' means any coverage other than self-
only coverage.
``(5) Modified adjusted gross income.--For purposes of this
section, the term `modified adjusted gross income' means
adjusted gross income increased by--
``(A) any amount excluded from gross income under section
911, and
``(B) any amount of interest received or accrued by the
taxpayer during the taxable year which is exempt from tax.
``(6) Not treated as tax imposed by this chapter for
certain purposes.--The tax imposed under this section shall
not be treated as tax imposed by this chapter for purposes of
determining the amount of any credit under this chapter or
for purposes of section 55.
``(f) Regulations.--The Secretary shall prescribe such
regulations or other guidance as may be necessary or
appropriate to carry out the purposes of this section,
including regulations or other guidance (developed in
coordination with the Health Choices Commissioner) which
provide--
``(1) exemption from the tax imposed under subsection (a)
in cases of de minimis lapses of acceptable coverage, and
``(2) a waiver of the application of subsection (a) in
cases of hardship, including a process for applying for such
a waiver.''.
(b) Information Reporting.--
(1) In general.--Subpart B of part III of subchapter A of
chapter 61 of such Code is amended by inserting after section
6050W the following new section:

``SEC. 6050X. RETURNS RELATING TO HEALTH INSURANCE COVERAGE.

``(a) Requirement of Reporting.--Every person who provides
acceptable coverage (as defined in section 59B(d)) to any
individual during any calendar year shall, at such time as
the Secretary may prescribe, make the return described in
subsection (b) with respect to such individual.
``(b) Form and Manner of Returns.--A return is described in
this subsection if such return--
``(1) is in such form as the Secretary may prescribe, and
``(2) contains--
``(A) the name, address, and TIN of the primary insured and
the name of each other individual obtaining coverage under
the policy,
``(B) the period for which each such individual was
provided with the coverage referred to in subsection (a), and
``(C) such other information as the Secretary may require.
``(c) Statements to Be Furnished to Individuals With
Respect to Whom Information Is Required.--Every person
required to make a return under subsection (a) shall furnish
to each primary insured whose name is required to be set
forth in such return a written statement showing--
``(1) the name and address of the person required to make
such return and the phone number of the information contact
for such person, and
``(2) the information required to be shown on the return
with respect to such individual.
The written statement required under the preceding sentence
shall be furnished on or before January 31 of the year
following the calendar year for which the return under
subsection (a) is required to be made.
``(d) Coverage Provided by Governmental Units.--In the case
of coverage provided by any governmental unit or any agency
or instrumentality thereof, the officer or employee who
enters into the agreement to provide such coverage (or the
person appropriately designated for purposes of this section)
shall make the returns and statements required by this
section.''.
(2) Penalty for failure to file.--
(A) Return.--Subparagraph (B) of section 6724(d)(1) of such
Code is amended by striking ``or'' at the end of clause
(xxii), by striking ``and'' at the end of clause (xxiii) and
inserting ``or'', and by adding at the end the following new
clause:
``(xxiv) section 6050X (relating to returns relating to
health insurance coverage), and''.
(B) Statement.--Paragraph (2) of section 6724(d) of such
Code is amended by striking ``or'' at the end of subparagraph
(EE), by striking the period at the end of subparagraph (FF)
and inserting ``, or'', and by inserting after subparagraph
(FF) the following new subparagraph:
``(GG) section 6050X (relating to returns relating to
health insurance coverage).''.
(c) Return Requirement.--Subsection (a) of section 6012 of
such Code is amended by inserting after paragraph (9) the
following new paragraph:
``(10) Every individual to whom section 59B(a) applies and
who fails to meet the requirements of section 59B(d) with
respect to such individual or any qualifying child (as
defined in section 152(c)) of such individual.''.
(d) Clerical Amendments.--
(1) The table of parts for subchapter A of chapter 1 of the
Internal Revenue Code of 1986 is amended by adding at the end
the following new item:

``Part VIII. Health Care Related Taxes.''.

(2) The table of sections for subpart B of part III of
subchapter A of chapter 61 is amended by adding at the end
the following new item:

``Sec. 6050X. Returns relating to health insurance coverage.''.
(e) Section 15 Not to Apply.--The amendment made by
subsection (a) shall not be treated as a change in a rate of
tax for purposes of section 15 of the Internal Revenue Code
of 1986.
(f) Effective Date.--
(1) In general.--The amendments made by this section shall
apply to taxable years beginning after December 31, 2012.

[[Page H12658]]

(2) Returns.--The amendments made by subsection (b) shall
apply to calendar years beginning after December 31, 2012.

Subpart B--Employer Responsibility

SEC. 511. ELECTION TO SATISFY HEALTH COVERAGE PARTICIPATION
REQUIREMENTS.

(a) In General.--Chapter 43 of the Internal Revenue Code of
1986 is amended by adding at the end the following new
section:

``SEC. 4980H. ELECTION WITH RESPECT TO HEALTH COVERAGE
PARTICIPATION REQUIREMENTS.

``(a) Election of Employer Responsibility to Provide Health
Coverage.--
``(1) In general.--Subsection (b) shall apply to any
employer with respect to whom an election under paragraph (2)
is in effect.
``(2) Time and manner.--An employer may make an election
under this paragraph at such time and in such form and manner
as the Secretary may prescribe.
``(3) Affiliated groups.--In the case of any employer which
is part of a group of employers who are treated as a single
employer under subsection (b), (c), (m), or (o) of section
414, the election under paragraph (2) shall be made by such
person as the Secretary may provide. Any such election, once
made, shall apply to all members of such group.
``(4) Separate elections.--Under regulations prescribed by
the Secretary, separate elections may be made under paragraph
(2) with respect to--
``(A) separate lines of business, and
``(B) full-time employees and employees who are not full-
time employees.
``(5) Termination of election in cases of substantial
noncompliance.--The Secretary may terminate the election of
any employer under paragraph (2) if the Secretary (in
coordination with the Health Choices Commissioner) determines
that such employer is in substantial noncompliance with the
health coverage participation requirements.
``(b) Excise Tax With Respect to Failure to Meet Health
Coverage Participation Requirements.--
``(1) In general.--In the case of any employer who fails
(during any period with respect to which the election under
subsection (a) is in effect) to satisfy the health coverage
participation requirements with respect to any employee to
whom such election applies, there is hereby imposed on each
such failure with respect to each such employee a tax of $100
for each day in the period beginning on the date such failure
first occurs and ending on the date such failure is
corrected.
``(2) Limitations on amount of tax.--
``(A) Tax not to apply where failure not discovered
exercising reasonable diligence.--No tax shall be imposed by
paragraph (1) on any failure during any period for which it
is established to the satisfaction of the Secretary that the
employer neither knew, nor exercising reasonable diligence
would have known, that such failure existed.
``(B) Tax not to apply to failures corrected within 30
days.--No tax shall be imposed by paragraph (1) on any
failure if--
``(i) such failure was due to reasonable cause and not to
willful neglect, and
``(ii) such failure is corrected during the 30-day period
beginning on the 1st date that the employer knew, or
exercising reasonable diligence would have known, that such
failure existed.
``(C) Overall limitation for unintentional failures.--In
the case of failures which are due to reasonable cause and
not to willful neglect, the tax imposed by subsection (a) for
failures during the taxable year of the employer shall not
exceed the amount equal to the lesser of--
``(i) 10 percent of the aggregate amount paid or incurred
by the employer (or predecessor employer) during the
preceding taxable year for employment-based health plans, or
``(ii) $500,000.
``(D) Coordination with other enforcement provisions.--The
tax imposed under paragraph (1) with respect to any failure
shall be reduced (but not below zero) by the amount of any
civil penalty collected under section 502(c)(11) of the
Employee Retirement Income Security Act of 1974 or section
2793(g) of the Public Health Service Act with respect to such
failure.
``(c) Health Coverage Participation Requirements.--For
purposes of this section, the term `health coverage
participation requirements' means the requirements of part I
of subtitle B of title IV of the (as in effect on the date of
the enactment of this section).''.
(b) Clerical Amendment.--The table of sections for chapter
43 of such Code is amended by adding at the end the following
new item:

``Sec. 4980H. Election with respect to health coverage participation
requirements.''.
(c) Effective Date.--The amendments made by this section
shall apply to periods beginning after December 31, 2012.

SEC. 512. HEALTH CARE CONTRIBUTIONS OF NONELECTING EMPLOYERS.

(a) In General.--Section 3111 of the Internal Revenue Code
of 1986 is amended by redesignating subsection (c) as
subsection (d) and by inserting after subsection (b) the
following new subsection:
``(c) Employers Electing Not to Provide Health Benefits.--
``(1) In general.--In addition to other taxes, there is
hereby imposed on every nonelecting employer an excise tax,
with respect to having individuals in his employ, equal to 8
percent of the wages (as defined in section 3121(a)) paid by
him with respect to employment (as defined in section
3121(b)).
``(2) Special rules for small employers.--
``(A) In general.--In the case of any employer who is small
employer for any calendar year, paragraph (1) shall be
applied by substituting the applicable percentage determined
in accordance with the following table for `8 percent':

``If the annual payroll of such          The applicable percentage is:
employer for the preceding calendar
year:
Does not exceed $500,000.............  0 percent
Exceeds $500,000, but does not exceed  2 percent
$585,000.
Exceeds $585,000, but does not exceed  4 percent
$670,000.
Exceeds $670,000, but does not exceed  6 percent
$750,000.

``(B) Small employer.--For purposes of this paragraph, the
term `small employer' means any employer for any calendar
year if the annual payroll of such employer for the preceding
calendar year does not exceed $750,000.
``(C) Annual payroll.--For purposes of this paragraph, the
term `annual payroll' means, with respect to any employer for
any calendar year, the aggregate wages (as defined in section
3121(a)) paid by him with respect to employment (as defined
in section 3121(b)) during such calendar year.
``(3) Nonelecting employer.--For purposes of paragraph (1),
the term `nonelecting employer' means any employer for any
period with respect to which such employer does not have an
election under section 4980H(a) in effect.
``(4) Special rule for separate elections.--In the case of
an employer who makes a separate election described in
section 4980H(a)(4) for any period, paragraph (1) shall be
applied for such period by taking into account only the wages
paid to employees who are not subject to such election.
``(5) Aggregation; predecessors.--For purposes of this
subsection--
``(A) all persons treated as a single employer under
subsection (b), (c), (m), or (o) of section 414 shall be
treated as 1 employer, and
``(B) any reference to any person shall be treated as
including a reference to any predecessor of such person.''.
(b) Definitions.--Section 3121 of such Code is amended by
adding at the end the following new subsection:
``(aa) Special Rules for Tax on Employers Electing Not to
Provide Health Benefits.--For purposes of section 3111(c)--
``(1) Paragraphs (1), (5), and (19) of subsection (b) shall
not apply.
``(2) Paragraph (7) of subsection (b) shall apply by
treating all services as not covered by the retirement
systems referred to in subparagraphs (C) and (F) thereof.
``(3) Subsection (e) shall not apply and the term `State'
shall include the District of Columbia.''.
(c) Conforming Amendment.--Subsection (d) of section 3111
of such Code, as redesignated by this section, is amended by
striking ``this section'' and inserting ``subsections (a) and
(b)''.
(d) Application to Railroads.--
(1) In general.--Section 3221 of such Code is amended by
redesignating subsection (c) as subsection (d) and by
inserting after subsection (b) the following new subsection:
``(c) Employers Electing Not to Provide Health Benefits.--
``(1) In general.--In addition to other taxes, there is
hereby imposed on every nonelecting employer an excise tax,
with respect to having individuals in his employ, equal to 8
percent of the compensation paid during any calendar year by
such employer for services rendered to such employer.
``(2) Exception for small employers.--Rules similar to the
rules of section 3111(c)(2) shall apply for purposes of this
subsection.
``(3) Nonelecting employer.--For purposes of paragraph (1),
the term `nonelecting employer' means any employer for any
period with respect to which such employer does not have an
election under section 4980H(a) in effect.
``(4) Special rule for separate elections.--In the case of
an employer who makes a separate election described in
section 4980H(a)(4) for any period, subsection (a) shall be
applied for such period by taking into account only the
compensation paid to employees who are not subject to such
election.''.
(2) Definitions.--Subsection (e) of section 3231 of such
Code is amended by adding at the end the following new
paragraph:

[[Page H12659]]

``(13) Special rules for tax on employers electing not to
provide health benefits.--For purposes of section 3221(c)--
``(A) Paragraph (1) shall be applied without regard to the
third sentence thereof.
``(B) Paragraph (2) shall not apply.''.
(3) Conforming amendment.--Subsection (d) of section 3221
of such Code, as redesignated by this section, is amended by
striking ``subsections (a) and (b), see section 3231(e)(2)''
and inserting ``this section, see paragraphs (2) and (13)(B)
of section 3231(e)''.
(e) Effective Date.--The amendments made by this section
shall apply to periods beginning after December 31, 2012.

PART 2--CREDIT FOR SMALL BUSINESS EMPLOYEE HEALTH COVERAGE EXPENSES

SEC. 521. CREDIT FOR SMALL BUSINESS EMPLOYEE HEALTH COVERAGE
EXPENSES.

(a) In General.--Subpart D of part IV of subchapter A of
chapter 1 of the Internal Revenue Code of 1986 (relating to
business-related credits) is amended by adding at the end the
following new section:

``SEC. 45R. SMALL BUSINESS EMPLOYEE HEALTH COVERAGE CREDIT.

``(a) In General.--For purposes of section 38, in the case
of a qualified small employer, the small business employee
health coverage credit determined under this section for the
taxable year is an amount equal to the applicable percentage
of the qualified employee health coverage expenses of such
employer for such taxable year.
``(b) Applicable Percentage.--
``(1) In general.--For purposes of this section, the
applicable percentage is 50 percent.
``(2) Phaseout based on average compensation of
employees.--In the case of an employer whose average annual
employee compensation for the taxable year exceeds $20,000,
the percentage specified in paragraph (1) shall be reduced by
a number of percentage points which bears the same ratio to
50 as such excess bears to $20,000.
``(c) Limitations.--
``(1) Phaseout based on employer size.--In the case of an
employer who employs more than 10 qualified employees during
the taxable year, the credit determined under subsection (a)
shall be reduced by an amount which bears the same ratio to
the amount of such credit (determined without regard to this
paragraph and after the application of the other provisions
of this section) as--
``(A) the excess of--
``(i) the number of qualified employees employed by the
employer during the taxable year, over
``(ii) 10, bears to
``(B) 15.
``(2) Credit not allowed with respect to certain highly
compensated employees.--No credit shall be determined under
subsection (a) with respect to qualified employee health
coverage expenses paid or incurred with respect to any
employee for any taxable year if the aggregate compensation
paid by the employer to such employee during such taxable
year exceeds $80,000.
``(3) Credit allowed for only 2 taxable years.--No credit
shall be determined under subsection (a) with respect to any
employer for any taxable year unless the employer elects to
have this section apply for such taxable year. An employer
may elect the application of this section with respect to not
more than 2 taxable years.
``(d) Qualified Employee Health Coverage Expenses.--For
purposes of this section--
``(1) In general.--The term `qualified employee health
coverage expenses' means, with respect to any employer for
any taxable year, the aggregate amount paid or incurred by
such employer during such taxable year for coverage of any
qualified employee of the employer (including any family
coverage which covers such employee) under qualified health
coverage.
``(2) Qualified health coverage.--The term `qualified
health coverage' means acceptable coverage (as defined in
section 59B(d)) which--
``(A) is provided pursuant to an election under section
4980H(a), and
``(B) satisfies the requirements referred to in section
4980H(c).
``(e) Other Definitions.--For purposes of this section--
``(1) Qualified small employer.--For purposes of this
section, the term `qualified small employer' means any
employer for any taxable year if--
``(A) the number of qualified employees employed by such
employer during the taxable year does not exceed 25, and
``(B) the average annual employee compensation of such
employer for such taxable year does not exceed the sum of the
dollar amounts in effect under subsection (b)(2).
``(2) Qualified employee.--The term `qualified employee'
means any employee of an employer for any taxable year of the
employer if such employee received at least $5,000 of
compensation from such employer for services performed in the
trade or business of such employer during such taxable year.
``(3) Average annual employee compensation.--The term
`average annual employee compensation' means, with respect to
any employer for any taxable year, the average amount of
compensation paid by such employer to qualified employees of
such employer during such taxable year.
``(4) Compensation.--The term `compensation' has the
meaning given such term in section 408(p)(6)(A).
``(5) Family coverage.--The term `family coverage' means
any coverage other than self-only coverage.
``(f) Special Rules.--For purposes of this section--
``(1) Special rule for partnerships and self-employed.--In
the case of a partnership (or a trade or business carried on
by an individual) which has one or more qualified employees
(determined without regard to this paragraph) with respect to
whom the election under section 4980H(a) applies, each
partner (or, in the case of a trade or business carried on by
an individual, such individual) shall be treated as an
employee.
``(2) Aggregation rule.--All persons treated as a single
employer under subsection (b), (c), (m), or (o) of section
414 shall be treated as 1 employer.
``(3) Predecessors.--Any reference in this section to an
employer shall include a reference to any predecessor of such
employer.
``(4) Denial of double benefit.--Any deduction otherwise
allowable with respect to amounts paid or incurred for health
insurance coverage to which subsection (a) applies shall be
reduced by the amount of the credit determined under this
section.
``(5) Inflation adjustment.--In the case of any taxable
year beginning after 2013, each of the dollar amounts in
subsections (b)(2), (c)(2), and (e)(2) shall be increased by
an amount equal to--
``(A) such dollar amount, multiplied by
``(B) the cost of living adjustment determined under
section 1(f)(3) for the calendar year in which the taxable
year begins determined by substituting `calendar year 2012'
for `calendar year 1992' in subparagraph (B) thereof.
If any increase determined under this paragraph is not a
multiple of $50, such increase shall be rounded to the next
lowest multiple of $50.''.
(b) Credit to Be Part of General Business Credit.--
Subsection (b) of section 38 of such Code (relating to
general business credit) is amended by striking ``plus'' at
the end of paragraph (34), by striking the period at the end
of paragraph (35) and inserting ``, plus'' , and by adding at
the end the following new paragraph:
``(36) in the case of a qualified small employer (as
defined in section 45R(e)), the small business employee
health coverage credit determined under section 45R(a).''.
(c) Clerical Amendment.--The table of sections for subpart
D of part IV of subchapter A of chapter 1 of such Code is
amended by inserting after the item relating to section 45Q
the following new item:

``Sec. 45R. Small business employee health coverage credit.''.
(d) Effective Date.--The amendments made by this section
shall apply to taxable years beginning after December 31,
2012.

PART 3--LIMITATIONS ON HEALTH CARE RELATED EXPENDITURES

SEC. 531. DISTRIBUTIONS FOR MEDICINE QUALIFIED ONLY IF FOR
PRESCRIBED DRUG OR INSULIN.

(a) HSAs.--Subparagraph (A) of section 223(d)(2) of the
Internal Revenue Code of 1986 is amended by adding at the end
the following: ``Such term shall include an amount paid for
medicine or a drug only if such medicine or drug is a
prescribed drug or is insulin.''.
(b) Archer MSAs.--Subparagraph (A) of section 220(d)(2) of
such Code is amended by adding at the end the following:
``Such term shall include an amount paid for medicine or a
drug only if such medicine or drug is a prescribed drug or is
insulin.''.
(c) Health Flexible Spending Arrangements and Health
Reimbursement Arrangements.--Section 106 of such Code is
amended by adding at the end the following new subsection:
``(f) Reimbursements for Medicine Restricted to Prescribed
Drugs and Insulin.--For purposes of this section and section
105, reimbursement for expenses incurred for a medicine or a
drug shall be treated as a reimbursement for medical expenses
only if such medicine or drug is a prescribed drug or is
insulin.''.
(d) Effective Dates.--The amendment made by this section
shall apply to expenses incurred after December 31, 2010.

SEC. 532. LIMITATION ON HEALTH FLEXIBLE SPENDING ARRANGEMENTS
UNDER CAFETERIA PLANS.

(a) In General.--Section 125 of the Internal Revenue Code
of 1986 is amended--
(1) by redesignating subsections (i) and (j) as subsections
(j) and (k), respectively, and
(2) by inserting after subsection (h) the following new
subsection:
``(i) Limitation on Health Flexible Spending
Arrangements.--
``(1) In general.--For purposes of this section, if a
benefit is provided under a cafeteria plan through employer
contributions to a health flexible spending arrangement, such
benefit shall not be treated as a qualified benefit unless
the cafeteria plan provides that an employee may not elect
for any taxable year to have salary reduction contributions
in excess of $2,500 made to such arrangement.
``(2) Inflation adjustment.--In the case of any taxable
year beginning after 2013, the dollar amount in paragraph (1)
shall be increased by an amount equal to--
``(A) such dollar amount, multiplied by
``(B) the cost of living adjustment determined under
section 1(f)(3) for the calendar year in which the taxable
year begins determined by substituting `calendar year 2012'
for `calendar year 1992' in subparagraph (B) thereof.

[[Page H12660]]

If any increase determined under this paragraph is not a
multiple of $50, such increase shall be rounded to the next
lowest multiple of $50.''.
(b) Effective Date.--The amendments made by this section
shall apply to taxable years beginning after December 31,
2012.

SEC. 533. INCREASE IN PENALTY FOR NONQUALIFIED DISTRIBUTIONS
FROM HEALTH SAVINGS ACCOUNTS.

(a) In General.--Subparagraph (A) of section 223(f)(4) of
the Internal Revenue Code of 1986 is amended by striking ``10
percent'' and inserting ``20 percent''.
(b) Effective Date.--The amendment made by this section
shall apply to taxable years beginning after December 31,
2010.

SEC. 534. DENIAL OF DEDUCTION FOR FEDERAL SUBSIDIES FOR
PRESCRIPTION DRUG PLANS WHICH HAVE BEEN
EXCLUDED FROM GROSS INCOME.

(a) In General.--Section 139A of the Internal Revenue Code
of 1986 is amended by striking the second sentence.
(b) Effective Date.--The amendment made by this section
shall apply to taxable years beginning after December 31,
2012.

PART 4--OTHER PROVISIONS TO CARRY OUT HEALTH INSURANCE REFORM

SEC. 541. DISCLOSURES TO CARRY OUT HEALTH INSURANCE EXCHANGE
SUBSIDIES.

(a) In General.--Subsection (l) of section 6103 of the
Internal Revenue Code of 1986 is amended by adding at the end
the following new paragraph:
``(21) Disclosure of return information to carry out health
insurance exchange subsidies.--
``(A) In general.--The Secretary, upon written request from
the Health Choices Commissioner or the head of a State-based
health insurance exchange approved for operation under
section 308 of the Affordable Health Care for America Act,
shall disclose to officers and employees of the Health
Choices Administration or such State-based health insurance
exchange, as the case may be, return information of any
taxpayer whose income is relevant in determining any
affordability credit described in subtitle C of title III of
the Affordable Health Care for America Act. Such return
information shall be limited to--
``(i) taxpayer identity information with respect to such
taxpayer,
``(ii) the filing status of such taxpayer,
``(iii) the modified adjusted gross income of such taxpayer
(as defined in section 59B(e)(5)),
``(iv) the number of dependents of the taxpayer,
``(v) such other information as is prescribed by the
Secretary by regulation as might indicate whether the
taxpayer is eligible for such affordability credits (and the
amount thereof), and
``(vi) the taxable year with respect to which the preceding
information relates or, if applicable, the fact that such
information is not available.
``(B) Restriction on use of disclosed information.--Return
information disclosed under subparagraph (A) may be used by
officers and employees of the Health Choices Administration
or such State-based health insurance exchange, as the case
may be, only for the purposes of, and to the extent necessary
in, establishing and verifying the appropriate amount of any
affordability credit described in subtitle C of title III of
the Affordable Health Care for America Act and providing for
the repayment of any such credit which was in excess of such
appropriate amount.''.
(b) Procedures and Recordkeeping Related to Disclosures.--
Paragraph (4) of section 6103(p) of such Code is amended--
(1) by inserting ``, or any entity described in subsection
(l)(21),'' after ``or (20)'' in the matter preceding
subparagraph (A),
(2) by inserting ``or any entity described in subsection
(l)(21),'' after ``or (o)(1)(A),'' in subparagraph (F)(ii),
and
(3) by inserting ``or any entity described in subsection
(l)(21),'' after ``or (20),'' both places it appears in the
matter after subparagraph (F).
(c) Unauthorized Disclosure or Inspection.--Paragraph (2)
of section 7213(a) of such Code is amended by striking ``or
(20)'' and inserting ``(20), or (21)''.

SEC. 542. OFFERING OF EXCHANGE-PARTICIPATING HEALTH BENEFITS
PLANS THROUGH CAFETERIA PLANS.

(a) In General.--Subsection (f) of section 125 of the
Internal Revenue Code of 1986 is amended by adding at the end
the following new paragraph:
``(3) Certain exchange-participating health benefits plans
not qualified.--
``(A) In general.--The term `qualified benefit' shall not
include any exchange-participating health benefits plan (as
defined in section 101(c) of the Affordable Health Care for
America Act).
``(B) Exception for exchange-eligible employers.--
Subparagraph (A) shall not apply with respect to any employee
if such employee's employer is an exchange-eligible employer
(as defined in section 302 of the Affordable Health Care for
America Act).''.
(b) Conforming Amendments.--Subsection (f) of section 125
of such Code is amended--
(1) by striking ``For purposes of this section, the term''
and inserting ``For purposes of this section--
``(1) In General.--The term'', and
(2) by striking ``Such term shall not include'' and
inserting the following:
``(2) Long-term care insurance not qualified.--The term
`qualified benefit' shall not include''.
(c) Effective Date.--The amendments made by this section
shall apply to taxable years beginning after December 31,
2012.

SEC. 543. EXCLUSION FROM GROSS INCOME OF PAYMENTS MADE UNDER
REINSURANCE PROGRAM FOR RETIREES.

(a) In General.--Section 139A of the Internal Revenue Code
of 1986 is amended--
(1) by striking ``Gross income'' and inserting the
following:
``(a) Federal Subsidies for Prescription Drug Plans.--Gross
income'', and
(2) by adding at the end the following new subsection:
``(b) Federal Reinsurance Program for Retirees.--A rule
similar to the rule of subsection (a) shall apply with
respect to payments made under section 111 of the Affordable
Health Care for America Act.''.
(b) Conforming Amendment.--The heading of section 139A of
such Code (and the item relating to such section in the table
of sections for part III of subchapter B of chapter 1 of such
Code) is amended by inserting ``AND RETIREE HEALTH PLANS''
after ``PRESCRIPTION DRUG PLANS''.
(c) Effective Date.--The amendments made by this section
shall apply to taxable years ending after the date of the
enactment of this Act.

SEC. 544. CLASS PROGRAM TREATED IN SAME MANNER AS LONG-TERM
CARE INSURANCE.

(a) In General.--Subsection (f) of section 7702B of the
Internal Revenue Code of 1986 is amended--
(1) by striking ``State long-term care plan'' in paragraph
(1)(A) and inserting ``government long-term care plan'',
(2) by redesignating paragraph (2) as paragraph (3), and
(3) by inserting after paragraph (2) the following new
paragraph:
``(2) Government long-term care plan.--For purposes of this
subsection, the term `government long-term care plan' means--
``(A) the CLASS program established under title XXXII of
the Public Health Service Act, and
``(B) any State long-term care plan.''.
(b) Conforming Amendments.--
(1) Paragraph (3) of section 7702B(f) of such Code, as
redesignated by subsection (a), is amended by striking
``paragraph (1)'' and inserting ``this subsection''.
(2) Subsection (f) of section 7702(B) of such Code is
amended by striking ``State-maintained'' in the heading
thereof and inserting ``Government''.
(c) Effective Date.--The amendments made by this section
shall apply to taxable years ending after December 31, 2010.

SEC. 545. EXCLUSION FROM GROSS INCOME FOR MEDICAL CARE
PROVIDED FOR INDIANS.

(a) In General.--Part III of subchapter B of chapter 1 of
the Internal Revenue Code of 1986 (relating to items
specifically excluded from gross income) is amended by
inserting after section 139C the following new section:

``SEC. 139D. MEDICAL CARE PROVIDED FOR INDIANS.

``(a) In General.--Gross income does not include--
``(1) health services or benefits provided or purchased by
the Indian Health Service, either directly or indirectly,
through a grant to or a contract or compact with an Indian
tribe or tribal organization or through programs of third
parties funded by the Indian Health Service,
``(2) medical care provided by an Indian tribe or tribal
organization to a member of an Indian tribe (including for
this purpose, to the member's spouse or dependents) through
any one of the following: provided or purchased medical care
services; accident or health insurance (or an arrangement
having the effect of accident or health insurance); or
amounts paid, directly or indirectly, to reimburse the member
for expenses incurred for medical care,
``(3) the value of accident or health plan coverage
provided by an Indian tribe or tribal organization for
medical care to a member of an Indian tribe (including for
this purpose, coverage that extends to such member's spouse
or dependents) under an accident or health plan (or through
an arrangement having the effect of accident or health
insurance), and
``(4) any other medical care provided by an Indian tribe
that supplements, replaces, or substitutes for the programs
and services provided by the Federal Government to Indian
tribes or Indians.
``(b) Definitions.--For purposes of this section--
``(1) In general.--The terms `accident or health insurance'
and `accident or health plan' have the same meaning as when
used in sections 104 and 106.
``(2) Medical care.--The term `medical care' has the
meaning given such term in section 213.
``(3) Dependent.--The term `dependent' has the meaning
given such term in section 152, determined without regard to
subsections (b)(1), (b)(2), and (d)(1)(B).
``(4) Indian tribe.--The term `Indian tribe' means any
Indian tribe, band, nation, pueblo, or other organized group
or community, including any Alaska Native village, or
regional or village corporation, as defined in, or
established pursuant to, the Alaska Native Claims Settlement
Act (43 U.S.C. 1601 et seq.), which is recognized as eligible
for the special programs and services provided by the United
States to Indians because of their status as Indians.

[[Page H12661]]

``(5) Tribal organization.--The term `tribal organization'
has the meaning given such term in section 4(l) of the Indian
Self-Determination and Education Assistance Act (25 U.S.C.
450b(l)).''.
(b) Clerical Amendment.--The table of sections for such
part III is amended by inserting after the item relating to
section 139C the following new item:

``Sec. 139D. Medical care provided for Indians.''.
(c) Effective Date.--The amendments made by this section
shall apply to health benefits and coverage provided after
the date of enactment of this Act.
(d) No Inference.--Nothing in the amendments made by this
section shall be construed to create an inference with
respect to the exclusion from gross income of--
(1) benefits provided by Indian tribes that are not within
the scope of this section, and
(2) health benefits or coverage provided by Indian tribes
prior to the effective date of this section.

Subtitle B--Other Revenue Provisions

PART 1--GENERAL PROVISIONS

SEC. 551. SURCHARGE ON HIGH INCOME INDIVIDUALS.

(a) In General.--Part VIII of subchapter A of chapter 1 of
the Internal Revenue Code of 1986, as added by this title, is
amended by adding at the end the following new subpart:

``Subpart B--Surcharge on High Income Individuals

``Sec. 59C. Surcharge on high income individuals.

``SEC. 59C. SURCHARGE ON HIGH INCOME INDIVIDUALS.

``(a) General Rule.--In the case of a taxpayer other than a
corporation, there is hereby imposed (in addition to any
other tax imposed by this subtitle) a tax equal to 5.4
percent of so much of the modified adjusted gross income of
the taxpayer as exceeds $1,000,000.
``(b) Taxpayers Not Making a Joint Return.--In the case of
any taxpayer other than a taxpayer making a joint return
under section 6013 or a surviving spouse (as defined in
section 2(a)), subsection (a) shall be applied by
substituting `$500,000' for `$1,000,000'.
``(c) Modified Adjusted Gross Income.--For purposes of this
section, the term `modified adjusted gross income' means
adjusted gross income reduced by any deduction (not taken
into account in determining adjusted gross income) allowed
for investment interest (as defined in section 163(d)). In
the case of an estate or trust, adjusted gross income shall
be determined as provided in section 67(e).
``(d) Special Rules.--
``(1) Nonresident alien.--In the case of a nonresident
alien individual, only amounts taken into account in
connection with the tax imposed under section 871(b) shall be
taken into account under this section.
``(2) Citizens and residents living abroad.--The dollar
amount in effect under subsection (a) (after the application
of subsection (b)) shall be decreased by the excess of--
``(A) the amounts excluded from the taxpayer's gross income
under section 911, over
``(B) the amounts of any deductions or exclusions
disallowed under section 911(d)(6) with respect to the
amounts described in subparagraph (A).
``(3) Charitable trusts.--Subsection (a) shall not apply to
a trust all the unexpired interests in which are devoted to
one or more of the purposes described in section
170(c)(2)(B).
``(4) Not treated as tax imposed by this chapter for
certain purposes.--The tax imposed under this section shall
not be treated as tax imposed by this chapter for purposes of
determining the amount of any credit under this chapter or
for purposes of section 55.''.
(b) Clerical Amendment.--The table of subparts for part
VIII of subchapter A of chapter 1 of such Code, as added by
this title, is amended by inserting after the item relating
to subpart A the following new item:

``subpart b. surcharge on high income individuals.''.

(c) Section 15 Not to Apply.--The amendment made by
subsection (a) shall not be treated as a change in a rate of
tax for purposes of section 15 of the Internal Revenue Code
of 1986.
(d) Effective Date.--The amendments made by this section
shall apply to taxable years beginning after December 31,
2010.

SEC. 552. EXCISE TAX ON MEDICAL DEVICES.

(a) In General.--Chapter 31 of the Internal Revenue Code of
1986 is amended by adding at the end the following new
subchapter:

``Subchapter D--Medical Devices

``Sec. 4061. Medical devices.

``SEC. 4061. MEDICAL DEVICES.

``(a) In General.--There is hereby imposed on the first
taxable sale of any medical device a tax equal to 2.5 percent
of the price for which so sold.
``(b) First Taxable Sale.--For purposes of this section--
``(1) In general.--The term `first taxable sale' means the
first sale, for a purpose other than for resale, after
production, manufacture, or importation.
``(2) Exception for sales at retail establishments.--Such
term shall not include the sale of any medical device if--
``(A) such sale is made at a retail establishment on terms
which are available to the general public, and
``(B) such medical device is of a type (and purchased in a
quantity) which is purchased by the general public.
``(3) Exception for exports, etc.--Rules similar to the
rules of sections 4221 (other than paragraphs (3), (4), (5),
and (6) of subsection (a) thereof) and 4222 shall apply for
purposes of this section. To the extent provided by the
Secretary, section 4222 may be extended to, and made
applicable with respect to, the exemption provided by
paragraph (2).
``(4) Sales to patients not treated as resales.--If a
medical device is sold for use in connection with providing
any health care service to an individual, such sale shall not
be treated as being for the purpose of resale (even if such
device is sold to such individual).
``(c) Other Definitions and Special Rules.--For purposes of
this section--
``(1) Medical device.--The term `medical device' means any
device (as defined in section 201(h) of the Federal Food,
Drug, and Cosmetic Act) intended for humans.
``(2) Lease treated as sale.--Rules similar to the rules of
section 4217 shall apply.
``(3) Use treated as sale.--
``(A) In general.--If any person uses a medical device
before the first taxable sale of such device, then such
person shall be liable for tax under such subsection in the
same manner as if such use were the first taxable sale of
such device.
``(B) Exceptions.--The preceding sentence shall not apply
to--
``(i) use of a medical device as material in the
manufacture or production of, or as a component part of,
another medical device to be manufactured or produced by such
person, or
``(ii) use of a medical device after a sale described in
subsection (b)(2).
``(4) Determination of price.--
``(A) In general.--Rules similar to the rules of
subsections (a), (c), and (d) of section 4216 shall apply for
purposes of this section.
``(B) Constructive sale price.--If--
``(i) a medical device is sold (otherwise than through an
arm's length transaction) at less than the fair market price,
or
``(ii) a person is liable for tax for a use described in
paragraph (3),
the tax under this section shall be computed on the price for
which such or similar devices are sold in the ordinary course
of trade as determined by the Secretary.
``(5) Resales pursuant to certain contract arrangements.--
``(A) In general.--In the case of a specified contract sale
of a medical device, the seller referred to in subparagraph
(B)(i) shall be entitled to recover from the producer,
manufacturer, or importer referred to in subparagraph (B)(ii)
the amount of the tax paid by such seller under this section
with respect to such sale.
``(B) Specified contract sale.--For purposes of this
paragraph, the term `specified contract sale' means, with
respect to any medical device, the first taxable sale of such
device if--
``(i) the seller is not the producer, manufacturer, or
importer of such device, and
``(ii) the price at which such device is so sold is
determined in accordance with a contract between the
producer, manufacturer, or importer of such device and the
person to whom such device is so sold.
``(C) Special rules related to credits and refunds.--In the
case of any credit or refund under section 6416 of the tax
imposed under this section on a specified contract sale of a
medical device--
``(i) such credit or refund shall be allowed or made only
if the seller has filed with the Secretary the written
consent of the producer, manufacturer, or importer referred
to in subparagraph (B)(ii) to the allowance of such credit or
the making of such refund, and
``(ii) the amount of tax taken into account under
subparagraph (A) shall be reduced by the amount of such
credit or refund.''.
(b) Conforming Amendments.--
(1) Paragraph (2) of section 6416(b) of such Code is
amended--
(A) by inserting ``or 4061'' after ``under section 4051'',
and
(B) by adding at the end the following: ``In the case of
the tax imposed by section 4061, subparagraphs (B), (C), (D),
and (E) shall not apply.''.
(2) The table of subchapters for chapter 31 of such Code is
amended by adding at the end the following new item:

``subchapter d. medical devices.''.

(c) Effective Date.--The amendments made by this section
shall apply to sales (and leases and uses treated as sales)
after December 31, 2012.

SEC. 553. EXPANSION OF INFORMATION REPORTING REQUIREMENTS.

(a) In General.--Section 6041 of the Internal Revenue Code
of 1986 is amended by adding at the end the following new
subsections:
``(h) Application to Corporations.--Notwithstanding any
regulation prescribed by the Secretary before the date of the
enactment of this subsection, for purposes of this section
the term `person' includes any corporation that is not an
organization exempt from tax under section 501(a).
``(i) Regulations.--The Secretary may prescribe such
regulations and other guidance as may be appropriate or
necessary to carry out the purposes of this section,
including rules to prevent duplicative reporting of
transactions.''.
(b) Payments for Property and Other Gross Proceeds.--
Subsection (a) of section

[[Page H12662]]

6041 of the Internal Revenue Code of 1986 is amended--
(1) by inserting ``amounts in consideration for property,''
after ``wages,'',
(2) by inserting ``gross proceeds,'' after ``emoluments, or
other'', and
(3) by inserting ``gross proceeds,'' after ``setting forth
the amount of such''.
(c) Effective Date.--The amendments made by this section
shall apply to payments made after December 31, 2011.

SEC. 554. REPEAL OF WORLDWIDE ALLOCATION OF INTEREST.

(a) In General.--Section 864 of the Internal Revenue Code
of 1986 is amended by striking subsection (f) and by
redesignating subsection (g) as subsection (f).
(b) Effective Date.--The amendments made by this section
shall apply to taxable years beginning after December 31,
2010.

SEC. 555. EXCLUSION OF UNPROCESSED FUELS FROM THE CELLULOSIC
BIOFUEL PRODUCER CREDIT.

(a) In General.--Subparagraph (E) of section 40(b)(6) of
the Internal Revenue Code of 1986 is amended by adding at the
end the following new clause:
``(iii) Exclusion of unprocessed fuels.--The term
`cellulosic biofuel' shall not include any fuel if--
``(I) more than 4 percent of such fuel (determined by
weight) is any combination of water and sediment, or
``(II) the ash content of such fuel is more than 1 percent
(determined by weight).''.
(b) Effective Date.--The amendment made by this section
shall apply to fuels sold or used after the date of the
enactment of this Act.

PART 2--PREVENTION OF TAX AVOIDANCE

SEC. 561. LIMITATION ON TREATY BENEFITS FOR CERTAIN
DEDUCTIBLE PAYMENTS.

(a) In General.--Section 894 of the Internal Revenue Code
of 1986 (relating to income affected by treaty) is amended by
adding at the end the following new subsection:
``(d) Limitation on Treaty Benefits for Certain Deductible
Payments.--
``(1) In general.--In the case of any deductible related-
party payment, any withholding tax imposed under chapter 3
(and any tax imposed under subpart A or B of this part) with
respect to such payment may not be reduced under any treaty
of the United States unless any such withholding tax would be
reduced under a treaty of the United States if such payment
were made directly to the foreign parent corporation.
``(2) Deductible related-party payment.--For purposes of
this subsection, the term `deductible related-party payment'
means any payment made, directly or indirectly, by any person
to any other person if the payment is allowable as a
deduction under this chapter and both persons are members of
the same foreign controlled group of entities.
``(3) Foreign controlled group of entities.--For purposes
of this subsection--
``(A) In general.--The term `foreign controlled group of
entities' means a controlled group of entities the common
parent of which is a foreign corporation.
``(B) Controlled group of entities.--The term `controlled
group of entities' means a controlled group of corporations
as defined in section 1563(a)(1), except that--
``(i) `more than 50 percent' shall be substituted for `at
least 80 percent' each place it appears therein, and
``(ii) the determination shall be made without regard to
subsections (a)(4) and (b)(2) of section 1563.
A partnership or any other entity (other than a corporation)
shall be treated as a member of a controlled group of
entities if such entity is controlled (within the meaning of
section 954(d)(3)) by members of such group (including any
entity treated as a member of such group by reason of this
sentence).
``(4) Foreign parent corporation.--For purposes of this
subsection, the term `foreign parent corporation' means, with
respect to any deductible related-party payment, the common
parent of the foreign controlled group of entities referred
to in paragraph (3)(A).
``(5) Regulations.--The Secretary may prescribe such
regulations or other guidance as are necessary or appropriate
to carry out the purposes of this subsection, including
regulations or other guidance which provide for--
``(A) the treatment of two or more persons as members of a
foreign controlled group of entities if such persons would be
the common parent of such group if treated as one
corporation, and
``(B) the treatment of any member of a foreign controlled
group of entities as the common parent of such group if such
treatment is appropriate taking into account the economic
relationships among such entities.''.
(b) Effective Date.--The amendment made by this section
shall apply to payments made after the date of the enactment
of this Act.

SEC. 562. CODIFICATION OF ECONOMIC SUBSTANCE DOCTRINE;
PENALTIES.

(a) In General.--Section 7701 of the Internal Revenue Code
of 1986 is amended by redesignating subsection (o) as
subsection (p) and by inserting after subsection (n) the
following new subsection:
``(o) Clarification of Economic Substance Doctrine.--
``(1) Application of doctrine.--In the case of any
transaction to which the economic substance doctrine is
relevant, such transaction shall be treated as having
economic substance only if--
``(A) the transaction changes in a meaningful way (apart
from Federal income tax effects) the taxpayer's economic
position, and
``(B) the taxpayer has a substantial purpose (apart from
Federal income tax effects) for entering into such
transaction.
``(2) Special rule where taxpayer relies on profit
potential.--
``(A) In general.--The potential for profit of a
transaction shall be taken into account in determining
whether the requirements of subparagraphs (A) and (B) of
paragraph (1) are met with respect to the transaction only if
the present value of the reasonably expected pre-tax profit
from the transaction is substantial in relation to the
present value of the expected net tax benefits that would be
allowed if the transaction were respected.
``(B) Treatment of fees and foreign taxes.--Fees and other
transaction expenses and foreign taxes shall be taken into
account as expenses in determining pre-tax profit under
subparagraph (A).
``(3) State and local tax benefits.--For purposes of
paragraph (1), any State or local income tax effect which is
related to a Federal income tax effect shall be treated in
the same manner as a Federal income tax effect.
``(4) Financial accounting benefits.--For purposes of
paragraph (1)(B), achieving a financial accounting benefit
shall not be taken into account as a purpose for entering
into a transaction if the origin of such financial accounting
benefit is a reduction of Federal income tax.
``(5) Definitions and special rules.--For purposes of this
subsection--
``(A) Economic substance doctrine.--The term `economic
substance doctrine' means the common law doctrine under which
tax benefits under subtitle A with respect to a transaction
are not allowable if the transaction does not have economic
substance or lacks a business purpose.
``(B) Exception for personal transactions of individuals.--
In the case of an individual, paragraph (1) shall apply only
to transactions entered into in connection with a trade or
business or an activity engaged in for the production of
income.
``(C) Other common law doctrines not affected.--Except as
specifically provided in this subsection, the provisions of
this subsection shall not be construed as altering or
supplanting any other rule of law, and the requirements of
this subsection shall be construed as being in addition to
any such other rule of law.
``(D) Determination of application of doctrine not
affected.--The determination of whether the economic
substance doctrine is relevant to a transaction (or series of
transactions) shall be made in the same manner as if this
subsection had never been enacted.
``(6) Regulations.--The Secretary shall prescribe such
regulations as may be necessary or appropriate to carry out
the purposes of this subsection.''.
(b) Penalty for Underpayments Attributable to Transactions
Lacking Economic Substance.--
(1) In general.--Subsection (b) of section 6662 of such
Code is amended by inserting after paragraph (5) the
following new paragraph:
``(6) Any disallowance of claimed tax benefits by reason of
a transaction lacking economic substance (within the meaning
of section 7701(o)) or failing to meet the requirements of
any similar rule of law.''.
(2) Increased penalty for nondisclosed transactions.--
Section 6662 of such Code is amended by adding at the end the
following new subsection:
``(i) Increase in Penalty in Case of Nondisclosed
Noneconomic Substance Transactions.--
``(1) In general.--In the case of any portion of an
underpayment which is attributable to one or more
nondisclosed noneconomic substance transactions, subsection
(a) shall be applied with respect to such portion by
substituting `40 percent' for `20 percent'.
``(2) Nondisclosed noneconomic substance transactions.--For
purposes of this subsection, the term `nondisclosed
noneconomic substance transaction' means any portion of a
transaction described in subsection (b)(6) with respect to
which the relevant facts affecting the tax treatment are not
adequately disclosed in the return nor in a statement
attached to the return.
``(3) Special rule for amended returns.--Except as provided
in regulations, in no event shall any amendment or supplement
to a return of tax be taken into account for purposes of this
subsection if the amendment or supplement is filed after the
earlier of the date the taxpayer is first contacted by the
Secretary regarding the examination of the return or such
other date as is specified by the Secretary.''.
(3) Conforming amendment.--Subparagraph (B) of section
6662A(e)(2) of such Code is amended--
(A) by striking ``section 6662(h)'' and inserting
``subsections (h) or (i) of section 6662'', and
(B) by striking ``gross valuation misstatement penalty'' in
the heading and inserting ``certain increased underpayment
penalties''.
(c) Reasonable Cause Exception Not Applicable to
Noneconomic Substance Transactions and Tax Shelters.--
(1) Reasonable cause exception for underpayments.--
Subsection (c) of section 6664 of such Code is amended--

[[Page H12663]]

(A) by redesignating paragraphs (2) and (3) as paragraphs
(3) and (4), respectively,
(B) by striking ``paragraph (2)'' in paragraph (4)(A), as
so redesignated, and inserting ``paragraph (3)'', and
(C) by inserting after paragraph (1) the following new
paragraph:
``(2) Exception.--Paragraph (1) shall not apply to any
portion of an underpayment which is attributable to one or
more tax shelters (as defined in section 6662(d)(2)(C)) or
transactions described in section 6662(b)(6).''.
(2) Reasonable cause exception for reportable transaction
understatements.--Subsection (d) of section 6664 of such Code
is amended--
(A) by redesignating paragraphs (2) and (3) as paragraphs
(3) and (4), respectively,
(B) by striking ``paragraph (2)(C)'' in paragraph (4), as
so redesignated, and inserting ``paragraph (3)(C)'', and
(C) by inserting after paragraph (1) the following new
paragraph:
``(2) Exception.--Paragraph (1) shall not apply to any
portion of a reportable transaction understatement which is
attributable to one or more tax shelters (as defined in
section 6662(d)(2)(C)) or transactions described in section
6662(b)(6).''.
(d) Application of Penalty for Erroneous Claim for Refund
or Credit to Noneconomic Substance Transactions.--Section
6676 of such Code is amended by redesignating subsection (c)
as subsection (d) and inserting after subsection (b) the
following new subsection:
``(c) Noneconomic Substance Transactions Treated as Lacking
Reasonable Basis.--For purposes of this section, any
excessive amount which is attributable to any transaction
described in section 6662(b)(6) shall not be treated as
having a reasonable basis.''.
(e) Effective Date.--
(1) In general.--Except as otherwise provided in this
subsection, the amendments made by this section shall apply
to transactions entered into after the date of the enactment
of this Act.
(2) Underpayments.--The amendments made by subsections (b)
and (c)(1) shall apply to underpayments attributable to
transactions entered into after the date of the enactment of
this Act.
(3) Understatements.--The amendments made by subsection
(c)(2) shall apply to understatements attributable to
transactions entered into after the date of the enactment of
this Act.
(4) Refunds and credits.--The amendment made by subsection
(d) shall apply to refunds and credits attributable to
transactions entered into after the date of the enactment of
this Act.

SEC. 563. CERTAIN LARGE OR PUBLICLY TRADED PERSONS MADE
SUBJECT TO A MORE LIKELY THAN NOT STANDARD FOR
AVOIDING PENALTIES ON UNDERPAYMENTS.

(a) In General.--Subsection (c) of section 6664 of the
Internal Revenue Code of 1986, as amended by section 562, is
amended--
(1) by redesignating paragraphs (3) and (4) as paragraphs
(4) and (5), respectively,
(2) by striking ``paragraph (3)'' in paragraph (4)(A), as
so redesignated, and inserting ``paragraph (4)'', and
(3) by inserting after paragraph (2) the following new
paragraph:
``(3) Special rule for certain large or publicly traded
persons.--
``(A) In general.--In the case of any specified person,
paragraph (1) shall apply to the portion of an underpayment
which is attributable to any item only if such person has a
reasonable belief that the tax treatment of such item by such
person is more likely than not the proper tax treatment of
such item.
``(B) Specified person.--For purposes of this paragraph,
the term `specified person' means--
``(i) any person required to file periodic or other reports
under section 13 of the Securities Exchange Act of 1934, and
``(ii) any corporation with gross receipts in excess of
$100,000,000 for the taxable year involved.

All persons treated as a single employer under section 52(a)
shall be treated as one person for purposes of clause
(ii).''.
(b) Nonapplication of Substantial Authority and Reasonable
Basis Standards for Reducing Understatements.--Paragraph (2)
of section 6662(d) of such Code is amended by adding at the
end the following new subparagraph:
``(D) Reduction not to apply to certain large or publicly
traded persons.--Subparagraph (B) shall not apply to any
specified person (as defined in section 6664(c)(3)(B)).''.
(c) Effective Date.--
(1) In general.--Except as provided in paragraph (2), the
amendments made by this section shall apply to underpayments
attributable to transactions entered into after the date of
the enactment of this Act.
(2) Nonapplication of understatement reduction.--The
amendment made by subsection (b) shall apply to
understatements attributable to transactions entered into
after the date of the enactment of this Act.

PART 3--PARITY IN HEALTH BENEFITS

SEC. 571. CERTAIN HEALTH RELATED BENEFITS APPLICABLE TO
SPOUSES AND DEPENDENTS EXTENDED TO ELIGIBLE
BENEFICIARIES.

(a) Application of Accident and Health Plans to Eligible
Beneficiaries.--
(1) Exclusion of contributions.--Section 106 of the
Internal Revenue Code of 1986 (relating to contributions by
employer to accident and health plans), as amended by section
531, is amended by adding at the end the following new
subsection:
``(g) Coverage Provided for Eligible Beneficiaries of
Employees.--
``(1) In general.--Subsection (a) shall apply with respect
to any eligible beneficiary of the employee.
``(2) Eligible beneficiary.--For purposes of this
subsection, the term `eligible beneficiary' means any
individual who is eligible to receive benefits or coverage
under an accident or health plan.''.
(2) Exclusion of amounts expended for medical care.--The
first sentence of section 105(b) of such Code (relating to
amounts expended for medical care) is amended--
(A) by striking ``and his dependents'' and inserting ``his
dependents'', and
(B) by inserting before the period the following: ``and any
eligible beneficiary (within the meaning of section 106(g))
with respect to the taxpayer''.
(3) Payroll taxes.--
(A) Section 3121(a)(2) of such Code is amended--
(i) by striking ``or any of his dependents'' in the matter
preceding subparagraph (A) and inserting ``, any of his
dependents, or any eligible beneficiary (within the meaning
of section 106(g)) with respect to the employee'',
(ii) by striking ``or any of his dependents,'' in
subparagraph (A) and inserting ``, any of his dependents, or
any eligible beneficiary (within the meaning of section
106(g)) with respect to the employee,'', and
(iii) by striking ``and their dependents'' both places it
appears and inserting ``and such employees' dependents and
eligible beneficiaries (within the meaning of section
106(g))''.
(B) Section 3231(e)(1) of such Code is amended--
(i) by striking ``or any of his dependents'' and inserting
``, any of his dependents, or any eligible beneficiary
(within the meaning of section 106(g)) with respect to the
employee,'', and
(ii) by striking ``and their dependents'' both places it
appears and inserting ``and such employees' dependents and
eligible beneficiaries (within the meaning of section
106(g))''.
(C) Section 3306(b)(2) of such Code is amended--
(i) by striking ``or any of his dependents'' in the matter
preceding subparagraph (A) and inserting ``, any of his
dependents, or any eligible beneficiary (within the meaning
of section 106(g)) with respect to the employee,'',
(ii) by striking ``or any of his dependents'' in
subparagraph (A) and inserting ``, any of his dependents, or
any eligible beneficiary (within the meaning of section
106(g)) with respect to the employee'', and
(iii) by striking ``and their dependents'' both places it
appears and inserting ``and such employees' dependents and
eligible beneficiaries (within the meaning of section
106(g))''.
(D) Section 3401(a) of such Code is amended by striking
``or'' at the end of paragraph (22), by striking the period
at the end of paragraph (23) and inserting ``; or'', and by
inserting after paragraph (23) the following new paragraph:
``(24) for any payment made to or for the benefit of an
employee or any eligible beneficiary (within the meaning of
section 106(g)) if at the time of such payment it is
reasonable to believe that the employee will be able to
exclude such payment from income under section 106 or under
section 105 by reference in section 105(b) to section
106(g).''.
(b) Expansion of Dependency for Purposes of Deduction for
Health Insurance Costs of Self-employed Individuals.--
(1) In general.--Paragraph (1) of section 162(l) of the
Internal Revenue Code of 1986 (relating to special rules for
health insurance costs of self-employed individuals) is
amended to read as follows:
``(1) Allowance of deduction.--In the case of a taxpayer
who is an employee within the meaning of section 401(c)(1),
there shall be allowed as a deduction under this section an
amount equal to the amount paid during the taxable year for
insurance which constitutes medical care for--
``(A) the taxpayer,
``(B) the taxpayer's spouse,
``(C) the taxpayer's dependents,
``(D) any individual who--
``(i) satisfies the age requirements of section
152(c)(3)(A),
``(ii) bears a relationship to the taxpayer described in
section 152(d)(2)(H), and
``(iii) meets the requirements of section 152(d)(1)(C), and
``(E) one individual who--
``(i) does not satisfy the age requirements of section
152(c)(3)(A),
``(ii) bears a relationship to the taxpayer described in
section 152(d)(2)(H),
``(iii) meets the requirements of section 152(d)(1)(D), and
``(iv) is not the spouse of the taxpayer and does not bear
any relationship to the taxpayer described in subparagraphs
(A) through (G) of section 152(d)(2).''.
(2) Conforming amendment.--Subparagraph (B) of section
162(l)(2) of such Code is amended by inserting ``, any
dependent, or individual described in subparagraph (D) or (E)
of paragraph (1) with respect to'' after ``spouse''.
(c) Extension to Eligible Beneficiaries of Sick and
Accident Benefits Provided to

[[Page H12664]]

Members of a Voluntary Employees' Beneficiary Association and
Their Dependents.--Section 501(c)(9) of the Internal Revenue
Code of 1986 (relating to list of exempt organizations) is
amended by adding at the end the following new sentence:
``For purposes of providing for the payment of sick and
accident benefits to members of such an association and their
dependents, the term `dependents' shall include any
individual who is an eligible beneficiary (within the meaning
of section 106(g)), as determined under the terms of a
medical benefit, health insurance, or other program under
which members and their dependents are entitled to sick and
accident benefits.''.
(d) Flexible Spending Arrangements and Health Reimbursement
Arrangements.--The Secretary of Treasury shall issue guidance
of general applicability providing that medical expenses that
otherwise qualify--
(1) for reimbursement from a flexible spending arrangement
under regulations in effect on the date of the enactment of
this Act may be reimbursed from an employee's flexible
spending arrangement, notwithstanding the fact that such
expenses are attributable to any individual who is not the
employee's spouse or dependent (within the meaning of section
105(b) of the Internal Revenue Code of 1986) but is an
eligible beneficiary (within the meaning of section 106(g) of
such Code) under the flexible spending arrangement with
respect to the employee, and
(2) for reimbursement from a health reimbursement
arrangement under regulations in effect on the date of the
enactment of this Act may be reimbursed from an employee's
health reimbursement arrangement, notwithstanding the fact
that such expenses are attributable to an individual who is
not a spouse or dependent (within the meaning of section
105(b) of such Code) but is an eligible beneficiary (within
the meaning of section 106(g) of such Code) under the health
reimbursement arrangement with respect to the employee.
(e) Effective Date.--The amendments made by this section
shall apply to taxable years beginning after December 31,
2009.

DIVISION B--MEDICARE AND MEDICAID IMPROVEMENTS

SEC. 1001. TABLE OF CONTENTS OF DIVISION.

The table of contents of this division is as follows:

Sec. 1001. Table of contents of division.

TITLE I--IMPROVING HEALTH CARE VALUE

Subtitle A--Provisions Related to Medicare Part A

Part 1--Market Basket Updates

Sec. 1101. Skilled nursing facility payment update.
Sec. 1102. Inpatient rehabilitation facility payment update.
Sec. 1103. Incorporating productivity improvements into market basket
updates that do not already incorporate such
improvements.

Part 2--Other Medicare Part A Provisions

Sec. 1111. Payments to skilled nursing facilities.
Sec. 1112. Medicare DSH report and payment adjustments in response to
coverage expansion.
Sec. 1113. Extension of hospice regulation moratorium.
Sec. 1114. Permitting physician assistants to order post-hospital
extended care services and to provide for recognition of
attending physician assistants as attending physicians to
serve hospice patients.

Subtitle B--Provisions Related to Part B

Part 1--Physicians' Services

Sec. 1121. Resource-based feedback program for physicians in Medicare.
Sec. 1122. Misvalued codes under the physician fee schedule.
Sec. 1123. Payments for efficient areas.
Sec. 1124. Modifications to the Physician Quality Reporting Initiative
(PQRI).
Sec. 1125. Adjustment to Medicare payment localities.

Part 2--Market Basket Updates

Sec. 1131. Incorporating productivity improvements into market basket
updates that do not already incorporate such
improvements.

Part 3--Other Provisions

Sec. 1141. Rental and purchase of power-driven wheelchairs.
Sec. 1141A. Election to take ownership, or to decline ownership, of a
certain item of complex durable medical equipment after
the 13-month capped rental period ends.
Sec. 1142. Extension of payment rule for brachytherapy.
Sec. 1143. Home infusion therapy report to Congress.
Sec. 1144. Require ambulatory surgical centers (ASCs) to submit cost
data and other data.
Sec. 1145. Treatment of certain cancer hospitals.
Sec. 1146. Payment for imaging services.
Sec. 1147. Durable medical equipment program improvements.
Sec. 1148. MedPAC study and report on bone mass measurement.
Sec. 1149. Timely access to post-mastectomy items.
Sec. 1149A. Payment for biosimilar biological products.
Sec. 1149B. Study and report on DME competitive bidding process.

Subtitle C--Provisions Related to Medicare Parts A and B

Sec. 1151. Reducing potentially preventable hospital readmissions.
Sec. 1152. Post acute care services payment reform plan and bundling
pilot program.
Sec. 1153. Home health payment update for 2010.
Sec. 1154. Payment adjustments for home health care.
Sec. 1155. Incorporating productivity improvements into market basket
update for home health services.
Sec. 1155A. MedPAC study on variation in home health margins.
Sec. 1155B. Permitting home health agencies to assign the most
appropriate skilled service to make the initial
assessment visit under a Medicare home health plan of
care for rehabilitation cases.
Sec. 1156. Limitation on Medicare exceptions to the prohibition on
certain physician referrals made to hospitals.
Sec. 1157. Institute of Medicine study of geographic adjustment factors
under Medicare.
Sec. 1158. Revision of medicare payment systems to address geographic
inequities.
Sec. 1159. Institute of Medicine study of geographic variation in
health care spending and promoting high-value health
care.
Sec. 1160. Implementation, and Congressional review, of proposal to
revise Medicare payments to promote high value health
care.

Subtitle D--Medicare Advantage Reforms

Part 1--Payment and Administration

Sec. 1161. Phase-in of payment based on fee-for-service costs; quality
bonus payments.
Sec. 1162. Authority for Secretarial coding intensity adjustment
authority.
Sec. 1163. Simplification of annual beneficiary election periods.
Sec. 1164. Extension of reasonable cost contracts.
Sec. 1165. Limitation of waiver authority for employer group plans.
Sec. 1166. Improving risk adjustment for payments.
Sec. 1167. Elimination of MA Regional Plan Stabilization Fund.
Sec. 1168. Study regarding the effects of calculating Medicare
Advantage payment rates on a regional average of Medicare
fee for service rates.

Part 2--Beneficiary Protections and Anti-Fraud

Sec. 1171. Limitation on cost-sharing for individual health services.
Sec. 1172. Continuous open enrollment for enrollees in plans with
enrollment suspension.
Sec. 1173. Information for beneficiaries on MA plan administrative
costs.
Sec. 1174. Strengthening audit authority.
Sec. 1175. Authority to deny plan bids.
Sec. 1175A. State authority to enforce standardized marketing
requirements.

Part 3--Treatment of Special Needs Plans

Sec. 1176. Limitation on enrollment outside open enrollment period of
individuals into chronic care specialized MA plans for
special needs individuals.
Sec. 1177. Extension of authority of special needs plans to restrict
enrollment; service area moratorium for certain SNPs.
Sec. 1178. Extension of Medicare senior housing plans.

Subtitle E--Improvements to Medicare Part D

Sec. 1181. Elimination of coverage gap.
Sec. 1182. Discounts for certain part D drugs in original coverage gap.
Sec. 1183. Repeal of provision relating to submission of claims by
pharmacies located in or contracting with long-term care
facilities.
Sec. 1184. Including costs incurred by AIDS drug assistance programs
and Indian Health Service in providing prescription drugs
toward the annual out-of-pocket threshold under part D.
Sec. 1185. No mid-year formulary changes permitted.
Sec. 1186. Negotiation of lower covered part D drug prices on behalf of
Medicare beneficiaries.
Sec. 1187. Accurate dispensing in long-term care facilities.
Sec. 1188. Free generic fill.
Sec. 1189. State certification prior to waiver of licensure
requirements under Medicare prescription drug program.

Subtitle F--Medicare Rural Access Protections

Sec. 1191. Telehealth expansion and enhancements.
Sec. 1192. Extension of outpatient hold harmless provision.
Sec. 1193. Extension of section 508 hospital reclassifications.

[[Page H12665]]

Sec. 1194. Extension of geographic floor for work.
Sec. 1195. Extension of payment for technical component of certain
physician pathology services.
Sec. 1196. Extension of ambulance add-ons.

TITLE II--MEDICARE BENEFICIARY IMPROVEMENTS

Subtitle A--Improving and Simplifying Financial Assistance for Low
Income Medicare Beneficiaries

Sec. 1201. Improving assets tests for Medicare Savings Program and low-
income subsidy program.
Sec. 1202. Elimination of part D cost-sharing for certain non-
institutionalized full-benefit dual eligible individuals.
Sec. 1203. Eliminating barriers to enrollment.
Sec. 1204. Enhanced oversight relating to reimbursements for
retroactive low income subsidy enrollment.
Sec. 1205. Intelligent assignment in enrollment.
Sec. 1206. Special enrollment period and automatic enrollment process
for certain subsidy eligible individuals.
Sec. 1207. Application of MA premiums prior to rebate and quality bonus
payments in calculation of low income subsidy benchmark.

Subtitle B--Reducing Health Disparities

Sec. 1221. Ensuring effective communication in Medicare.
Sec. 1222. Demonstration to promote access for Medicare beneficiaries
with limited English proficiency by providing
reimbursement for culturally and linguistically
appropriate services.
Sec. 1223. IOM report on impact of language access services.
Sec. 1224. Definitions.

Subtitle C--Miscellaneous Improvements

Sec. 1231. Extension of therapy caps exceptions process.
Sec. 1232. Extended months of coverage of immunosuppressive drugs for
kidney transplant patients and other renal dialysis
provisions.
Sec. 1233. Voluntary advance care planning consultation.
Sec. 1234. Part B special enrollment period and waiver of limited
enrollment penalty for TRICARE beneficiaries.
Sec. 1235. Exception for use of more recent tax year in case of gains
from sale of primary residence in computing part B
income-related premium.
Sec. 1236. Demonstration program on use of patient decisions aids.

TITLE III--PROMOTING PRIMARY CARE, MENTAL HEALTH SERVICES, AND
COORDINATED CARE

Sec. 1301. Accountable Care Organization pilot program.
Sec. 1302. Medical home pilot program.
Sec. 1303. Payment incentive for selected primary care services.
Sec. 1304. Increased reimbursement rate for certified nurse-midwives.
Sec. 1305. Coverage and waiver of cost-sharing for preventive services.
Sec. 1306. Waiver of deductible for colorectal cancer screening tests
regardless of coding, subsequent diagnosis, or ancillary
tissue removal.
Sec. 1307. Excluding clinical social worker services from coverage
under the medicare skilled nursing facility prospective
payment system and consolidated payment.
Sec. 1308. Coverage of marriage and family therapist services and
mental health counselor services.
Sec. 1309. Extension of physician fee schedule mental health add-on.
Sec. 1310. Expanding access to vaccines.
Sec. 1311. Expansion of Medicare-Covered Preventive Services at
Federally Qualified Health Centers.
Sec. 1312. Independence at home demonstration program.
Sec. 1313. Recognition of certified diabetes educators as certified
providers for purposes of Medicare diabetes outpatient
self-management training services.

TITLE IV--QUALITY

Subtitle A--Comparative Effectiveness Research

Sec. 1401. Comparative effectiveness research.

Subtitle B--Nursing Home Transparency

Part 1--Improving Transparency of Information on Skilled Nursing
Facilities, Nursing Facilities, and Other Long-term Care Facilities

Sec. 1411. Required disclosure of ownership and additional disclosable
parties information.
Sec. 1412. Accountability requirements.
Sec. 1413. Nursing home compare Medicare website.
Sec. 1414. Reporting of expenditures.
Sec. 1415. Standardized complaint form.
Sec. 1416. Ensuring staffing accountability.
Sec. 1417. Nationwide program for national and State background checks
on direct patient access employees of long-term care
facilities and providers.

Part 2--Targeting Enforcement

Sec. 1421. Civil money penalties.
Sec. 1422. National independent monitor pilot program.
Sec. 1423. Notification of facility closure.

Part 3--Improving Staff Training

Sec. 1431. Dementia and abuse prevention training.
Sec. 1432. Study and report on training required for certified nurse
aides and supervisory staff.
Sec. 1433. Qualification of director of food services of a skilled
nursing facility or nursing facility.

Subtitle C--Quality Measurements

Sec. 1441. Establishment of national priorities for quality
improvement.
Sec. 1442. Development of new quality measures; GAO evaluation of data
collection process for quality measurement.
Sec. 1443. Multi-stakeholder pre-rulemaking input into selection of
quality measures.
Sec. 1444. Application of quality measures.
Sec. 1445. Consensus-based entity funding.
Sec. 1446. Quality Indicators for care of people with Alzheimers
disease.

Subtitle D--Physician Payments Sunshine Provision

Sec. 1451. Reports on financial relationships between manufacturers and
distributors of covered drugs, devices, biologicals, or
medical supplies under Medicare, Medicaid, or CHIP and
physicians and other health care entities and between
physicians and other health care entities.

Subtitle E--Public Reporting on Health Care-Associated Infections

Sec. 1461. Requirement for public reporting by hospitals and ambulatory
surgical centers on health care-associated infections.

TITLE V--MEDICARE GRADUATE MEDICAL EDUCATION

Sec. 1501. Distribution of unused residency positions.
Sec. 1502. Increasing training in nonprovider settings.
Sec. 1503. Rules for counting resident time for didactic and scholarly
activities and other activities.
Sec. 1504. Preservation of resident cap positions from closed
hospitals.
Sec. 1505. Improving accountability for approved medical residency
training.

TITLE VI--PROGRAM INTEGRITY

Subtitle A--Increased Funding to Fight Waste, Fraud, and Abuse

Sec. 1601. Increased funding and flexibility to fight fraud and abuse.

Subtitle B--Enhanced Penalties for Fraud and Abuse

Sec. 1611. Enhanced penalties for false statements on provider or
supplier enrollment applications.
Sec. 1612. Enhanced penalties for submission of false statements
material to a false claim.
Sec. 1613. Enhanced penalties for delaying inspections.
Sec. 1614. Enhanced hospice program safeguards.
Sec. 1615. Enhanced penalties for individuals excluded from program
participation.
Sec. 1616. Enhanced penalties for provision of false information by
Medicare Advantage and part D plans.
Sec. 1617. Enhanced penalties for Medicare Advantage and part D
marketing violations.
Sec. 1618. Enhanced penalties for obstruction of program audits.
Sec. 1619. Exclusion of certain individuals and entities from
participation in Medicare and State health care programs.
Sec. 1620.  OIG authority to exclude from Federal health care programs
officers and owners of entities convicted of fraud.
Sec. 1621. Self-referral disclosure protocol.

Subtitle C--Enhanced Program and Provider Protections

Sec. 1631. Enhanced CMS program protection authority.
Sec. 1632. Enhanced Medicare, Medicaid, and CHIP program disclosure
requirements relating to previous affiliations.
Sec. 1633. Required inclusion of payment modifier for certain
evaluation and management services.
Sec. 1634. Evaluations and reports required under Medicare Integrity
Program.
Sec. 1635. Require providers and suppliers to adopt programs to reduce
waste, fraud, and abuse.
Sec. 1636. Maximum period for submission of Medicare claims reduced to
not more than 12 months.
Sec. 1637. Physicians who order durable medical equipment or home
health services required to be Medicare enrolled
physicians or eligible professionals.
Sec. 1638. Requirement for physicians to provide documentation on
referrals to programs at high risk of waste and abuse.
Sec. 1639. Face-to-face encounter with patient required before
eligibility certifications for home health services or
durable medical equipment.

[[Page H12666]]

Sec. 1640. Extension of testimonial subpoena authority to program
exclusion investigations.
Sec. 1641. Required repayments of Medicare and Medicaid overpayments.
Sec. 1642. Expanded application of hardship waivers for OIG exclusions
to beneficiaries of any Federal health care program.
Sec. 1643. Access to certain information on renal dialysis facilities.
Sec. 1644. Billing agents, clearinghouses, or other alternate payees
required to register under Medicare.
Sec. 1645. Conforming civil monetary penalties to False Claims Act
amendments.
Sec. 1646. Requiring provider and supplier payments under Medicare to
be made through direct deposit or electronic funds
transfer (EFT) at insured depository institutions.
Sec. 1647. Inspector General for the Health Choices Administration.

Subtitle D--Access to Information Needed to Prevent Fraud, Waste, and
Abuse

Sec. 1651. Access to Information Necessary to Identify Fraud, Waste,
and Abuse.
Sec. 1652. Elimination of duplication between the Healthcare Integrity
and Protection Data Bank and the National Practitioner
Data Bank.
Sec. 1653. Compliance with HIPAA privacy and security standards.
Sec. 1654. Disclosure of Medicare Fraud and Abuse Hotline Number on
Explanation of Benefits.

TITLE VII--MEDICAID AND CHIP

Subtitle A--Medicaid and Health Reform

Sec. 1701. Eligibility for individuals with income below 150 percent of
the Federal poverty level.
Sec. 1702.  Requirements and special rules for certain Medicaid
eligible individuals.
Sec. 1703. CHIP and Medicaid maintenance of eligibility.
Sec. 1704. Reduction in Medicaid DSH.
Sec. 1705. Expanded outstationing.

Subtitle B--Prevention

Sec. 1711. Required coverage of preventive services.
Sec. 1712. Tobacco cessation.
Sec. 1713. Optional coverage of nurse home visitation services.
Sec. 1714. State eligibility option for family planning services.

Subtitle C--Access

Sec. 1721. Payments to primary care practitioners.
Sec. 1722. Medical home pilot program.
Sec. 1723. Translation or interpretation services.
Sec. 1724. Optional coverage for freestanding birth center services.
Sec. 1725. Inclusion of public health clinics under the vaccines for
children program.
Sec. 1726. Requiring coverage of services of podiatrists.
Sec. 1726A. Requiring coverage of services of optometrists.
Sec. 1727. Therapeutic foster care.
Sec. 1728. Assuring adequate payment levels for services.
Sec. 1729. Preserving Medicaid coverage for youths upon release from
public institutions.
Sec. 1730. Quality measures for maternity and adult health services
under Medicaid and CHIP.
Sec. 1730A. Accountable care organization pilot program.
Sec. 1730B. FQHC coverage.

Subtitle D--Coverage

Sec. 1731. Optional Medicaid coverage of low-income HIV-infected
individuals.
Sec. 1732. Extending transitional Medicaid Assistance (TMA).
Sec. 1733. Requirement of 12-month continuous coverage under certain
CHIP programs.
Sec. 1734. Preventing the application under CHIP of coverage waiting
periods for certain children.
Sec. 1735. Adult day health care services.
Sec. 1736. Medicaid coverage for citizens of Freely Associated States.
Sec. 1737. Continuing requirement of Medicaid coverage of nonemergency
transportation to medically necessary services.
Sec. 1738. State option to disregard certain income in providing
continued Medicaid coverage for certain individuals with
extremely high prescription costs.
Sec. 1739. Provisions relating to community living assistance services
and supports (CLASS).
Sec. 1739A. Sense of Congress regarding Community First Choice Option
to provide Medicaid Coverage of Community-Based Attendant
Services and Supports.

Subtitle E--Financing

Sec. 1741. Payments to pharmacists.
Sec. 1742. Prescription drug rebates.
Sec. 1743. Extension of prescription drug discounts to enrollees of
Medicaid managed care organizations.
Sec. 1744. Payments for graduate medical education.
Sec. 1745. Nursing Facility Supplemental Payment Program.
Sec. 1746. Report on Medicaid payments.
Sec. 1747. Reviews of Medicaid.
Sec. 1748. Extension of delay in managed care organization provider tax
elimination.
Sec. 1749. Extension of ARRA increase in FMAP.

Subtitle F--Waste, Fraud, and Abuse

Sec. 1751. Health care acquired conditions.
Sec. 1752. Evaluations and reports required under Medicaid Integrity
Program.
Sec. 1753. Require providers and suppliers to adopt programs to reduce
waste, fraud, and abuse.
Sec. 1754. Overpayments.
Sec. 1755. Managed care organizations.
Sec. 1756. Termination of provider participation under Medicaid and
CHIP if terminated under Medicare or other State plan or
child health plan.
Sec. 1757. Medicaid and CHIP exclusion from participation relating to
certain ownership, control, and management affiliations.
Sec. 1758. Requirement to report expanded set of data elements under
MMIS to detect fraud and abuse.
Sec. 1759. Billing agents, clearinghouses, or other alternate payees
required to register under Medicaid.
Sec. 1760. Denial of payments for litigation-related misconduct.
Sec. 1761. Mandatory State use of national correct coding initiative.

Subtitle G--Payments to the Territories

Sec. 1771. Payment to territories.

Subtitle H--Miscellaneous

Sec. 1781. Technical corrections.
Sec. 1782. Extension of QI program.
Sec. 1783. Assuring transparency of information.
Sec. 1784. Medicaid and CHIP Payment and Access Commission.
Sec. 1785. Outreach and enrollment of Medicaid and CHIP eligible
individuals.
Sec. 1786. Prohibitions on Federal Medicaid and CHIP payment for
undocumented aliens.
Sec. 1787. Demonstration project for stabilization of emergency medical
conditions by institutions for mental diseases.
Sec. 1788. Application of Medicaid Improvement Fund.
Sec. 1789. Treatment of certain Medicaid brokers.
Sec. 1790. Rule for changes requiring State legislation.

TITLE VIII--REVENUE-RELATED PROVISIONS

Sec. 1801. Disclosures to facilitate identification of individuals
likely to be ineligible for the low-income assistance
under the Medicare prescription drug program to assist
Social Security Administration's outreach to eligible
individuals.
Sec. 1802. Comparative Effectiveness Research Trust Fund; financing for
Trust Fund.

TITLE IX--MISCELLANEOUS PROVISIONS

Sec. 1901. Repeal of trigger provision.
Sec. 1902. Repeal of comparative cost adjustment (CCA) program.
Sec. 1903. Extension of gainsharing demonstration.
Sec. 1904. Grants to States for quality home visitation programs for
families with young children and families expecting
children.
Sec. 1905. Improved coordination and protection for dual eligibles.
Sec. 1906. Assessment of medicare cost-intensive diseases and
conditions.
Sec. 1907. Establishment of Center for Medicare and Medicaid Innovation
within CMS.
Sec. 1908. Application of emergency services laws.
Sec. 1909. Disregard under the Supplemental Security Income program of
compensation for participation in clinical trials for
rare diseases or conditions.

TITLE I--IMPROVING HEALTH CARE VALUE

Subtitle A--Provisions Related to Medicare Part A

PART 1--MARKET BASKET UPDATES

SEC. 1101. SKILLED NURSING FACILITY PAYMENT UPDATE.

(a) In General.--Section 1888(e)(4)(E)(ii) of the Social
Security Act (42 U.S.C. 1395yy(e)(4)(E)(ii)) is amended--
(1) in subclause (III), by striking ``and'' at the end;
(2) by redesignating subclause (IV) as subclause (VI); and
(3) by inserting after subclause (III) the following new
subclauses:

``(IV) for each of fiscal years 2004 through 2009, the rate
computed for the previous fiscal year increased by the
skilled nursing facility market basket percentage change for
the fiscal year involved;
``(V) for fiscal year 2010, the rate computed for the
previous fiscal year; and''.

(b) Delayed Effective Date.--Section 1888(e)(4)(E)(ii)(V)
of the Social Security Act, as inserted by subsection (a)(3),
shall not apply to payment for days before January 1, 2010.

SEC. 1102. INPATIENT REHABILITATION FACILITY PAYMENT UPDATE.

(a) In General.--Section 1886(j)(3)(C) of the Social
Security Act (42 U.S.C.

[[Page H12667]]

1395ww(j)(3)(C)) is amended by striking ``and 2009'' and
inserting ``through 2010''.
(b) Delayed Effective Date.--The amendment made by
subsection (a) shall not apply to payment units occurring
before January 1, 2010.

SEC. 1103. INCORPORATING PRODUCTIVITY IMPROVEMENTS INTO
MARKET BASKET UPDATES THAT DO NOT ALREADY
INCORPORATE SUCH IMPROVEMENTS.

(a) Inpatient Acute Hospitals.--Section 1886(b)(3)(B) of
the Social Security Act (42 U.S.C. 1395ww(b)(3)(B)) is
amended--
(1) in clause (iii)--
(A) by striking ``(iii) For purposes of this
subparagraph,'' and inserting ``(iii)(I) For purposes of this
subparagraph, subject to the productivity adjustment
described in subclause (II),''; and
(B) by adding at the end the following new subclause:
``(II) The productivity adjustment described in this
subclause, with respect to an increase or change for a fiscal
year or year or cost reporting period, or other annual
period, is a productivity offset in the form of a reduction
in such increase or change equal to the percentage change in
the 10-year moving average of annual economy-wide private
nonfarm business multi-factor productivity (as recently
published in final form before the promulgation or
publication of such increase for the year or period
involved). Except as otherwise provided, any reference to the
increase described in this clause shall be a reference to the
percentage increase described in subclause (I) minus the
percentage change under this subclause.'';
(2) in the first sentence of clause (viii)(I), by inserting
``(but not below zero)'' after ``shall be reduced''; and
(3) in the first sentence of clause (ix)(I)--
(A) by inserting ``(determined without regard to clause
(iii)(II))'' after ``clause (i)'' the second time it appears;
and
(B) by inserting ``(but not below zero)'' after
``reduced''.
(b) Skilled Nursing Facilities.--Section 1888(e)(5)(B) of
such Act (42 U.S.C. 1395yy(e)(5)(B)) is amended by inserting
``subject to the productivity adjustment described in section
1886(b)(3)(B)(iii)(II)'' after ``as calculated by the
Secretary''.
(c) Long Term Care Hospitals.--Section 1886(m) of the
Social Security Act (42 U.S.C. 1395ww(m)) is amended by
adding at the end the following new paragraph:
``(3) Productivity adjustment.--In implementing the system
described in paragraph (1) for discharges occurring on or
after January 1, 2010, during the rate year ending in 2010 or
any subsequent rate year for a hospital, to the extent that
an annual percentage increase factor applies to a standard
Federal rate for such discharges for the hospital, such
factor shall be subject to the productivity adjustment
described in subsection (b)(3)(B)(iii)(II).''.
(d) Inpatient Rehabilitation Facilities.--The second
sentence of section 1886(j)(3)(C) of the Social Security Act
(42 U.S.C. 1395ww(j)(3)(C)) is amended by inserting
``(subject to the productivity adjustment described in
subsection (b)(3)(B)(iii)(II))'' after ``appropriate
percentage increase''.
(e) Psychiatric Hospitals.--Section 1886 of the Social
Security Act (42 U.S.C. 1395ww) is amended by adding at the
end the following new subsection:
``(o) Prospective Payment for Psychiatric Hospitals.--
``(1) Reference to establishment and implementation of
system.--For provisions related to the establishment and
implementation of a prospective payment system for payments
under this title for inpatient hospital services furnished by
psychiatric hospitals (as described in clause (i) of
subsection (d)(1)(B) and psychiatric units (as described in
the matter following clause (v) of such subsection), see
section 124 of the Medicare, Medicaid, and SCHIP Balanced
Budget Refinement Act of 1999.
``(2) Productivity adjustment.--In implementing the system
described in paragraph (1) for days occurring during the rate
year ending in 2011 or any subsequent rate year for a
psychiatric hospital or unit described in such paragraph, to
the extent that an annual percentage increase factor applies
to a base rate for such days for the hospital or unit,
respectively, such factor shall be subject to the
productivity adjustment described in subsection
(b)(3)(B)(iii)(II).''.
(f) Hospice Care.--Subclause (VII) of section
1814(i)(1)(C)(ii) of the Social Security Act (42 U.S.C.
1395f(i)(1)(C)(ii)) is amended by inserting after ``the
market basket percentage increase'' the following: ``(which
is subject to the productivity adjustment described in
section 1886(b)(3)(B)(iii)(II))''.
(g) Effective Dates.--
(1) IPPS.--The amendments made by subsection (a) shall
apply to annual increases effected for fiscal years beginning
with fiscal year 2010, but only with respect to discharges
occurring on or after January 1, 2010.
(2) SNF and irf.--The amendments made by subsections (b)
and (d) shall apply to annual increases effected for fiscal
years beginning with fiscal year 2011.
(3) Hospice care.--The amendment made by subsection (f)
shall apply to annual increases effected for fiscal years
beginning with fiscal year 2010, but only with respect to
days of care occurring on or after January 1, 2010.

PART 2--OTHER MEDICARE PART A PROVISIONS

SEC. 1111. PAYMENTS TO SKILLED NURSING FACILITIES.

(a) Change in Recalibration Factor.--
(1) Analysis.--The Secretary of Health and Human Services
shall conduct, using calendar year 2006 claims data, an
initial analysis comparing total payments under title XVIII
of the Social Security Act for skilled nursing facility
services under the RUG-53 and under the RUG-44 classification
systems.
(2) Adjustment in recalibration factor.--Based on the
initial analysis under paragraph (1), the Secretary shall
adjust the case mix indexes under section 1888(e)(4)(G)(i) of
the Social Security Act (42 U.S.C. 1395yy(e)(4)(G)(i)) for
fiscal year 2010 by the appropriate recalibration factor as
proposed in the final rule for Medicare skilled nursing
facilities issued by such Secretary on August 11, 2009 (74
Federal Register 40287 et seq.).
(b) Change in Payment for Nontherapy Ancillary (NTA)
Services and Therapy Services.--
(1) Changes under current snf classification system.--
(A) In general.--Subject to subparagraph (B), the Secretary
of Health and Human Services shall, under the system for
payment of skilled nursing facility services under section
1888(e) of the Social Security Act (42 U.S.C. 1395yy(e)),
increase payment by 10 percent for non-therapy ancillary
services (as specified by the Secretary in the notice issued
on November 27, 1998 (63 Federal Register 65561 et seq.)) and
shall decrease payment for the therapy case mix component of
such rates by 5.5 percent.
(B) Effective date.--The changes in payment described in
subparagraph (A) shall apply for days on or after April 1,
2010, and until the Secretary implements an alternative case
mix classification system for payment of skilled nursing
facility services under section 1888(e) of the Social
Security Act (42 U.S.C. 1395yy(e)).
(C) Implementation.--Notwithstanding any other provision of
law, the Secretary may implement by program instruction or
otherwise the provisions of this paragraph.
(2) Changes under a future snf case mix classification
system.--
(A) Analysis.--
(i) In general.--The Secretary of Health and Human Services
shall analyze payments for non-therapy ancillary services
under a future skilled nursing facility classification system
to ensure the accuracy of payment for non-therapy ancillary
services. Such analysis shall consider use of appropriate
predictors which may include age, physical and mental status,
ability to perform activities of daily living, prior nursing
home stay, diagnoses, broad RUG category, and a proxy for
length of stay.
(ii) Application.--Such analysis shall be conducted in a
manner such that the future skilled nursing facility
classification system is implemented to apply to services
furnished during a fiscal year beginning with fiscal year
2011.
(B) Consultation.--In conducting the analysis under
subparagraph (A), the Secretary shall consult with interested
parties, including the Medicare Payment Advisory Commission
and other interested stakeholders, to identify appropriate
predictors of nontherapy ancillary costs.
(C) Rulemaking.--The Secretary shall include the result of
the analysis under subparagraph (A) in the fiscal year 2011
rulemaking cycle for purposes of implementation beginning for
such fiscal year.
(D) Implementation.--Subject to subparagraph (E) and
consistent with subparagraph (A)(ii), the Secretary shall
implement changes to payments for non-therapy ancillary
services (which shall include a separate rate component for
non-therapy ancillary services and may include use of a model
that predicts payment amounts applicable for non-therapy
ancillary services) under such future skilled nursing
facility services classification system as the Secretary
determines appropriate based on the analysis conducted
pursuant to subparagraph (A).
(E) Budget neutrality.--The Secretary shall implement
changes described in subparagraph (D) in a manner such that
the estimated expenditures under such future skilled nursing
facility services classification system for a fiscal year
beginning with fiscal year 2011 with such changes would be
equal to the estimated expenditures that would otherwise
occur under title XVIII of the Social Security Act under such
future skilled nursing facility services classification
system for such year without such changes.
(c) Outlier Policy for NTA and Therapy.--Section 1888(e) of
the Social Security Act (42 U.S.C. 1395yy(e)) is amended by
adding at the end the following new paragraph:
``(13) Outliers for nta and therapy.--
``(A) In general.--With respect to outliers because of
unusual variations in the type or amount of medically
necessary care, beginning with October 1, 2010, the
Secretary--
``(i) shall provide for an addition or adjustment to the
payment amount otherwise made under this section with respect
to non-therapy ancillary services in the case of such
outliers; and
``(ii) may provide for such an addition or adjustment to
the payment amount otherwise made under this section with
respect to therapy services in the case of such outliers.
``(B) Outliers based on aggregate costs.--Outlier
adjustments or additional payments described in subparagraph
(A) shall be based on aggregate costs during a stay in a
skilled nursing facility and not on the number of days in
such stay.

[[Page H12668]]

``(C) Budget neutrality.--The Secretary shall reduce
estimated payments that would otherwise be made under the
prospective payment system under this subsection with respect
to a fiscal year by 2 percent. The total amount of the
additional payments or payment adjustments for outliers made
under this paragraph with respect to a fiscal year may not
exceed 2 percent of the total payments projected or estimated
to be made based on the prospective payment system under this
subsection for the fiscal year.''.
(d) Conforming Amendments.--Section 1888(e)(8) of such Act
(42 U.S.C. 1395yy(e)(8)) is amended--
(1) in subparagraph (A)--
(A) by striking ``and'' before ``adjustments''; and
(B) by inserting ``, and adjustment under section 1111(b)
of the Affordable Health Care for America Act'' before the
semicolon at the end;
(2) in subparagraph (B), by striking ``and'';
(3) in subparagraph (C), by striking the period and
inserting ``; and''; and
(4) by adding at the end the following new subparagraph:
``(D) the establishment of outliers under paragraph
(13).''.

SEC. 1112. MEDICARE DSH REPORT AND PAYMENT ADJUSTMENTS IN
RESPONSE TO COVERAGE EXPANSION.

(a) DSH Report.--
(1) In general.--Not later than January 1, 2016, the
Secretary of Health and Human Services shall submit to
Congress a report on Medicare DSH taking into account the
impact of the health care reforms carried out under division
A in reducing the number of uninsured individuals. The report
shall include recommendations relating to the following:
(A) The appropriate amount, targeting, and distribution of
Medicare DSH to compensate for higher Medicare costs
associated with serving low-income beneficiaries (taking into
account variations in the empirical justification for
Medicare DSH attributable to hospital characteristics,
including bed size), consistent with the original intent of
Medicare DSH.
(B) The appropriate amount, targeting, and distribution of
Medicare DSH to hospitals given their continued uncompensated
care costs, to the extent such costs remain.
(2) Coordination with medicaid dsh report.--The Secretary
shall coordinate the report under this subsection with the
report on Medicaid DSH under section 1704(a).
(b) Payment Adjustments in Response to Coverage
Expansion.--
(1) In general.--If there is a significant decrease in the
national rate of uninsurance as a result of this Act (as
determined under paragraph (2)(A)), then the Secretary of
Health and Human Services shall, beginning in fiscal year
2017, implement the following adjustments to Medicare DSH:
(A) In lieu of the amount of Medicare DSH payment that
would otherwise be made under section 1886(d)(5)(F) of the
Social Security Act, the amount of Medicare DSH payment shall
be an amount based on the recommendations of the report under
subsection (a)(1)(A) and shall take into account variations
in the empirical justification for Medicare DSH attributable
to hospital characteristics, including bed size.
(B) Subject to paragraph (3), make an additional payment to
a hospital by an amount that is estimated based on the amount
of uncompensated care provided by the hospital based on
criteria for uncompensated care as determined by the
Secretary, which shall exclude bad debt.
(2) Significant decrease in national rate of uninsurance as
a result of this act.--For purposes of this subsection--
(A) In general.--There is a ``significant decrease in the
national rate of uninsurance as a result of this Act'' if
there is a decrease in the national rate of uninsurance (as
defined in subparagraph (B)) from 2012 to 2014 that exceeds 8
percentage points.
(B) National rate of uninsurance defined.--The term
``national rate of uninsurance'' means, for a year, such rate
for the under-65 population for the year as determined and
published by the Bureau of the Census in its Current
Population Survey in or about September of the succeeding
year.
(3) Uncompensated care increase.--
(A) Computation of dsh savings.--For each fiscal year
(beginning with fiscal year 2017), the Secretary shall
estimate the aggregate reduction in the amount of Medicare
DSH payment that would be expected to result from the
adjustment under paragraph (1)(A).
(B) Structure of payment increase.--The Secretary shall
compute the additional payment to a hospital as described in
paragraph (1)(B) for a fiscal year in accordance with a
formula established by the Secretary that provides that--
(i) the estimated aggregate amount of such increase for the
fiscal year does not exceed 50 percent of the aggregate
reduction in Medicare DSH estimated by the Secretary for such
fiscal year; and
(ii) hospitals with higher levels of uncompensated care
receive a greater increase.
(c) Medicare DSH.--In this section, the term ``Medicare
DSH'' means adjustments in payments under section
1886(d)(5)(F) of the Social Security Act (42 U.S.C.
1395ww(d)(5)(F)) for inpatient hospital services furnished by
disproportionate share hospitals.

SEC. 1113. EXTENSION OF HOSPICE REGULATION MORATORIUM.

Section 4301(a) of division B of the American Recovery and
Reinvestment Act of 2009 (Public Law 111-5) is amended--
(1) by striking ``October 1, 2009'' and inserting ``October
1, 2010''; and
(2) by striking ``for fiscal year 2009'' and inserting
``for fiscal years 2009 and 2010''.

SEC. 1114. PERMITTING PHYSICIAN ASSISTANTS TO ORDER POST-
HOSPITAL EXTENDED CARE SERVICES AND TO PROVIDE
FOR RECOGNITION OF ATTENDING PHYSICIAN
ASSISTANTS AS ATTENDING PHYSICIANS TO SERVE
HOSPICE PATIENTS.

(a) Ordering Post-hospital Extended Care Services.--Section
1814(a) of the Social Security Act (42 U.S.C. 1395f(a)) is
amended--
(1) in paragraph (2) in the matter preceding subparagraph
(A), is amended by striking ``nurse practitioner or clinical
nurse specialist'' and inserting ``nurse practitioner, a
clinical nurse specialist, or a physician assistant''.
(2) in the second sentence, by striking ``or clinical nurse
specialist'' and inserting ``clinical nurse specialist, or
physician assistant''.
(b) Recognition of Attending Physician Assistants as
Attending Physicians to Serve Hospice Patients.--
(1) In general.--Section 1861(dd)(3)(B) of such Act (42
U.S.C. 1395x(dd)(3)(B)) is amended--
(A) by striking ``or nurse'' and inserting ``, the nurse'';
and
(B) by inserting ``or the physician assistant (as defined
in such subsection),'' after ``subsection (aa)(5)),''.
(2) Conforming amendment.--Section 1814(a)(7)(A)(i)(I) of
such Act (42 U.S.C. 1395f(a)(7)(A)(i)(I)) is amended by
inserting ``or a physician assistant'' after ``a nurse
practitioner''.
(3) Construction.--Nothing in the amendments made by this
subsection shall be construed as changing the requirements of
section 1842(b)(6)(C) of the Social Security Act (42 U.S.C.
1395u(b)(6)(C)) with respect to payment for services of
physician assistants under part B of title XVIII of such Act.
(c) Effective Date.--The amendments made by this section
shall apply to items and services furnished on or after
January 1, 2010.

Subtitle B--Provisions Related to Part B

PART 1--PHYSICIANS' SERVICES

SEC. 1121. RESOURCE-BASED FEEDBACK PROGRAM FOR PHYSICIANS IN
MEDICARE.

Section 1848(n) of the Social Security Act (42 U.S.C.
1395w-4(n)) is amended by adding at the end the following new
paragraph:
``(9) Feedback implementation plan.--
``(A) Timeline for feedback program.--
``(i) Evaluation.--During 2011 the Secretary shall conduct
the evaluation specified in subparagraph (E)(i).
``(ii) Expansion.--The Secretary shall expand the Program
under this subsection as specified in subparagraph (E)(ii).
``(B) Establishment of nature of reports.--
``(i) In general.--The Secretary shall develop and specify
the nature of the reports that will be disseminated under
this subsection, based on results and findings from the
Program under this subsection as in existence before the date
of the enactment of this paragraph. Such reports may be based
on a per capita basis, an episode basis that combines
separate but clinically related physicians' services and
other items and services furnished or ordered by a physician
into an episode of care, as appropriate, or both.
``(ii) Timeline for development.--The nature of the reports
described in clause (i) shall be developed by not later than
January 1, 2012.
``(iii) Public availability.--The Secretary shall make the
details of the nature of the reports developed under clause
(i) available to the public.
``(C) Analysis of data.--The Secretary shall, for purposes
of preparing reports under this subsection, establish
methodologies as appropriate such as to--
``(i) attribute items and services, in whole or in part, to
physicians;
``(ii) identify appropriate physicians for purposes of
comparison under subparagraph (B)(i); and
``(iii) aggregate items and services attributed to a
physician under clause (i) into a composite measure per
individual.
``(D) Feedback program.--The Secretary shall engage in
efforts to disseminate reports under this subsection. In
disseminating such reports, the Secretary shall consider the
following:
``(i) Direct meetings between contracted physicians,
facilitated by the Secretary, to discuss the contents of
reports under this subsection, including any reasons for
divergence from local or national averages.
``(ii) Contract with local, non-profit entities engaged in
quality improvement efforts at the community level. Such
entities shall use the reports under this subsection, or such
equivalent tool as specified by the Secretary. Any exchange
of data under this paragraph shall be protected by
appropriate privacy safeguards.
``(iii) Mailings or other methods of communication that
facilitate large-scale dissemination.
``(iv) Other methods specified by the Secretary.
``(E) Evaluation and expansion.--
``(i) Evaluation.--The Secretary shall evaluate the methods
specified in subparagraph (D) with regard to their efficacy
in changing practice patterns to improve quality and decrease
costs.

[[Page H12669]]

``(ii) Expansion.--Taking into account the cost of each
method specified in subparagraph (D), the Secretary shall
develop a plan to disseminate reports under this subsection
in a significant manner in the regions and cities of the
country with the highest utilization of services under this
title. To the extent practicable, reports under this
subsection shall be disseminated to increasing numbers of
physicians each year, such that during 2014 and subsequent
years, reports are disseminated at least to physicians with
utilization rates among the highest 5 percent of the nation,
subject the authority to focus under paragraph (4).
``(F) Administration.--
``(i) Chapter 35 of title 44, United States Code shall not
apply to this paragraph.
``(ii) Notwithstanding any other provision of law, the
Secretary may implement the provisions of this paragraph by
program instruction or otherwise.''.

SEC. 1122. MISVALUED CODES UNDER THE PHYSICIAN FEE SCHEDULE.

(a) In General.--Section 1848(c)(2) of the Social Security
Act (42 U.S.C. 1395w-4(c)(2)) is amended by adding at the end
the following new subparagraphs:
``(K) Potentially misvalued codes.--
``(i) In general.--The Secretary shall--

``(I) periodically identify services as being potentially
misvalued using criteria specified in clause (ii); and
``(II) review and make appropriate adjustments to the
relative values established under this paragraph for services
identified as being potentially misvalued under subclause
(I).

``(ii) Identification of potentially misvalued codes.--For
purposes of identifying potentially misvalued services
pursuant to clause (i)(I), the Secretary shall examine (as
the Secretary determines to be appropriate) codes (and
families of codes as appropriate) for which there has been
the fastest growth; codes (and families of codes as
appropriate) that have experienced substantial changes in
practice expenses; codes for new technologies or services
within an appropriate period (such as three years) after the
relative values are initially established for such codes;
multiple codes that are frequently billed in conjunction with
furnishing a single service; codes with low relative values,
particularly those that are often billed multiple times for a
single treatment; codes which have not been subject to review
since the implementation of the RBRVS (the so-called
`Harvard-valued codes'); and such other codes determined to
be appropriate by the Secretary.
``(iii) Review and adjustments.--

``(I) The Secretary may use existing processes to receive
recommendations on the review and appropriate adjustment of
potentially misvalued services described clause (i)(II).
``(II) The Secretary may conduct surveys, other data
collection activities, studies, or other analyses as the
Secretary determines to be appropriate to facilitate the
review and appropriate adjustment described in clause
(i)(II).
``(III) The Secretary may use analytic contractors to
identify and analyze services identified under clause (i)(I),
conduct surveys or collect data, and make recommendations on
the review and appropriate adjustment of services described
in clause (i)(II).
``(IV) The Secretary may coordinate the review and
appropriate adjustment described in clause (i)(II) with the
periodic review described in subparagraph (B).
``(V) As part of the review and adjustment described in
clause (i)(II), including with respect to codes with low
relative values described in clause (ii), the Secretary may
make appropriate coding revisions (including using existing
processes for consideration of coding changes) which may
include consolidation of individual services into bundled
codes for payment under the fee schedule under subsection
(b).
``(VI) The provisions of subparagraph (B)(ii)(II) shall
apply to adjustments to relative value units made pursuant to
this subparagraph in the same manner as such provisions apply
to adjustments under subparagraph (B)(ii)(II).

``(L) Validating relative value units.--
``(i) In general.--The Secretary shall establish a process
to validate relative value units under the fee schedule under
subsection (b).
``(ii) Components and elements of work.--The process
described in clause (i) may include validation of work
elements (such as time, mental effort and professional
judgment, technical skill and physical effort, and stress due
to risk) involved with furnishing a service and may include
validation of the pre, post, and intra-service components of
work.
``(iii) Scope of codes.--The validation of work relative
value units shall include a sampling of codes for services
that is the same as the codes listed under subparagraph
(K)(ii)
``(iv) Methods.--The Secretary may conduct the validation
under this subparagraph using methods described in subclauses
(I) through (V) of subparagraph (K)(iii) as the Secretary
determines to be appropriate.
``(v) Adjustments.--The Secretary shall make appropriate
adjustments to the work relative value units under the fee
schedule under subsection (b). The provisions of subparagraph
(B)(ii)(II) shall apply to adjustments to relative value
units made pursuant to this subparagraph in the same manner
as such provisions apply to adjustments under subparagraph
(B)(ii)(II).''.
(b) Implementation.--
(1) Funding.--For purposes of carrying out the provisions
of subparagraphs (K) and (L) of 1848(c)(2) of the Social
Security Act, as added by subsection (a), in addition to
funds otherwise available, out of any funds in the Treasury
not otherwise appropriated, there are appropriated to the
Secretary of Health and Human Services for the Center for
Medicare & Medicaid Services Program Management Account
$20,000,000 for fiscal year 2010 and each subsequent fiscal
year. Amounts appropriated under this paragraph for a fiscal
year shall be available until expended.
(2) Administration.--
(A) Chapter 35 of title 44, United States Code and the
provisions of the Federal Advisory Committee Act (5 U.S.C.
App.) shall not apply to this section or the amendment made
by this section.
(B) Notwithstanding any other provision of law, the
Secretary may implement subparagraphs (K) and (L) of
1848(c)(2) of the Social Security Act, as added by subsection
(a), by program instruction or otherwise.
(C) Section 4505(d) of the Balanced Budget Act of 1997 is
repealed.
(D) Except for provisions related to confidentiality of
information, the provisions of the Federal Acquisition
Regulation shall not apply to this section or the amendment
made by this section.
(3) Focusing cms resources on potentially overvalued
codes.--Section 1868(a) of the Social Security Act (42
1395ee(a)) is repealed.

SEC. 1123. PAYMENTS FOR EFFICIENT AREAS.

Section 1833 of the Social Security Act (42 U.S.C. 1395l)
is amended by adding at the end the following new subsection:
``(x) Incentive Payments for Efficient Areas.--
``(1) In general.--In the case of services furnished under
the physician fee schedule under section 1848 on or after
January 1, 2011, and before January 1, 2013, by a supplier
that is paid under such fee schedule in an efficient area (as
identified under paragraph (2)), in addition to the amount of
payment that would otherwise be made for such services under
this part, there also shall be paid (on a monthly or
quarterly basis) an amount equal to 5 percent of the payment
amount for the services under this part.
``(2) Identification of efficient areas.--
``(A) In general.--Based upon available data, the Secretary
shall identify those counties or equivalent areas in the
United States in the lowest fifth percentile of utilization
based on per capita spending under this part and part A for
services provided in the most recent year for which data are
available as of the date of the enactment of this subsection,
as standardized to eliminate the effect of geographic
adjustments in payment rates.
``(B) Identification of counties where service is
furnished..--For purposes of paying the additional amount
specified in paragraph (1), if the Secretary uses the 5-digit
postal ZIP Code where the service is furnished, the dominant
county of the postal ZIP Code (as determined by the United
States Postal Service, or otherwise) shall be used to
determine whether the postal ZIP Code is in a county
described in subparagraph (A).
``(C) Limitation on review.--There shall be no
administrative or judicial review under section 1869, 1878,
or otherwise, respecting--
``(i) the identification of a county or other area under
subparagraph (A); or
``(ii) the assignment of a postal ZIP Code to a county or
other area under subparagraph (B).
``(D) Publication of list of counties; posting on
website.--With respect to a year for which a county or area
is identified under this paragraph, the Secretary shall
identify such counties or areas as part of the proposed and
final rule to implement the physician fee schedule under
section 1848 for the applicable year. The Secretary shall
post the list of counties identified under this paragraph on
the Internet website of the Centers for Medicare & Medicaid
Services.''.

SEC. 1124. MODIFICATIONS TO THE PHYSICIAN QUALITY REPORTING
INITIATIVE (PQRI).

(a) Feedback.--Section 1848(m)(5) of the Social Security
Act (42 U.S.C. 1395w-4(m)(5)) is amended by adding at the end
the following new subparagraph:
``(H) Feedback.--The Secretary shall provide timely
feedback to eligible professionals on the performance of the
eligible professional with respect to satisfactorily
submitting data on quality measures under this subsection.''.
(b) Appeals.--Such section is further amended--
(1) in subparagraph (E), by striking ``There shall be'' and
inserting ``Except as provided in subparagraph (I), there
shall be''; and
(2) by adding at the end the following new subparagraph:
``(I) Informal appeals process.--By not later than January
1, 2011, the Secretary shall establish and have in place an
informal process for eligible professionals to seek a review
of the determination that an eligible professional did not
satisfactorily submit data on quality measures under this
subsection.''.
(c) Integration of Physician Quality Reporting and EHR
Reporting.--Section 1848(m) of such Act is amended by adding
at the end the following new paragraph:
``(7) Integration of physician quality reporting and ehr
reporting.--Not later than January 1, 2012, the Secretary
shall develop a plan to integrate clinical reporting on

[[Page H12670]]

quality measures under this subsection with reporting
requirements under subsection (o) relating to the meaningful
use of electronic health records. Such integration shall
consist of the following:
``(A) The development of measures, the reporting of which
would both demonstrate--
``(i) meaningful use of an electronic health record for
purposes of subsection (o); and
``(ii) clinical quality of care furnished to an individual.
``(B) The collection of health data to identify
deficiencies in the quality and coordination of care for
individuals eligible for benefits under this part.
``(C) Such other activities as specified by the
Secretary.''.
(d) Extension of Incentive Payments.--Section 1848(m)(1) of
such Act (42 U.S.C. 1395w-4(m)(1)) is amended--
(1) in subparagraph (A), by striking ``2010'' and inserting
``2012''; and
(2) in subparagraph (B)(ii), by striking ``2009 and 2010''
and inserting ``for each of the years 2009 through 2012''.

SEC. 1125. ADJUSTMENT TO MEDICARE PAYMENT LOCALITIES.

(a) In General.--Section 1848(e) of the Social Security Act
(42 U.S.C.1395w-4(e)) is amended by adding at the end the
following new paragraph:
``(6) Transition to use of msas as fee schedule areas in
california.--
``(A) In general.--
``(i) Revision.--Subject to clause (ii) and notwithstanding
the previous provisions of this subsection, for services
furnished on or after January 1, 2011, the Secretary shall
revise the fee schedule areas used for payment under this
section applicable to the State of California using the
Metropolitan Statistical Area (MSA) iterative Geographic
Adjustment Factor methodology as follows:

``(I) The Secretary shall configure the physician fee
schedule areas using the Metropolitan Statistical Areas (each
in this paragraph referred to as an `MSA'), as defined by the
Director of the Office of Management and Budget and published
in the Federal Register, using the most recent available
decennial population data as of the date of the enactment of
the Affordable Health Care for America Act, as the basis for
the fee schedule areas.
``(II) For purposes of this clause, the Secretary shall
treat all areas not included in an MSA as a single rest of
the State MSA.
``(III) The Secretary shall list all MSAs within the State
by Geographic Adjustment Factor described in paragraph (2)
(in this paragraph referred to as a `GAF') in descending
order.
``(IV) In the first iteration, the Secretary shall compare
the GAF of the highest cost MSA in the State to the weighted-
average GAF of all the remaining MSAs in the State (including
the rest of State MSA described in subclause (II)). If the
ratio of the GAF of the highest cost MSA to the weighted-
average of the GAF of remaining lower cost MSAs is 1.05 or
greater, the highest cost MSA shall be a separate fee
schedule area.
``(V) In the next iteration, the Secretary shall compare
the GAF of the MSA with the second-highest GAF to the
weighted-average GAF of the all the remaining MSAs (excluding
MSAs that become separate fee schedule areas). If the ratio
of the second-highest MSA's GAF to the weighted-average of
the remaining lower cost MSAs is 1.05 or greater, the second-
highest MSA shall be a separate fee schedule area. ``(VI) The
iterative process shall continue until the ratio of the GAF
of the MSA with highest remaining GAF to the weighted-average
of the remaining MSAs with lower GAFS is less than 1.05, and
the remaining group of MSAs with lower GAFS shall be treated
as a single fee schedule area.
``(VI) For purposes of the iterative process described in
this clause, if two MSAs have identical GAFs, they shall be
combined.

``(ii) Transition.--For services furnished on or after
January 1, 2011, and before January 1, 2016, in the State of
California, after calculating the work, practice expense, and
malpractice geographic indices that would otherwise be
determined under clauses (i), (ii), and (iii) of paragraph
(1)(A) for a fee schedule area determined under clause (i),
if the index for a county within a fee schedule area is less
than the index in effect for such county on December 31,
2010, the Secretary shall instead apply the index in effect
for such county on such date.
``(B) Subsequent revisions.--After the transition described
in subparagraph (A)(ii), not less than every 3 years the
Secretary shall review and update the fee schedule areas
using the methodology described in subparagraph (A)(i) and
any updated MSAs as defined by the Director of the Office of
Management and Budget and published in the Federal Register.
The Secretary shall review and make any changes pursuant to
such reviews concurrent with the application of the periodic
review of the adjustment factors required under paragraph
(1)(C) for California.
``(C) References to fee schedule areas.--Effective for
services furnished on or after January 1, 2011, for the State
of California, any reference in this section to a fee
schedule area shall be deemed a reference to an MSA in the
State (including the single rest of state MSA described in
subparagraph (A)(i)(II)).''.
(b) Conforming Amendment to Definition of Fee Schedule
Area.--Section 1848(j)(2) of the Social Security Act (42
U.S.C. 1395w(j)(2)) is amended by striking ``The term'' and
inserting ``Except as provided in subsection (e)(6)(C), the
term''.

PART 2--MARKET BASKET UPDATES

SEC. 1131. INCORPORATING PRODUCTIVITY IMPROVEMENTS INTO
MARKET BASKET UPDATES THAT DO NOT ALREADY
INCORPORATE SUCH IMPROVEMENTS.

(a) Outpatient Hospitals.--
(1) In general.--Section 1833(t)(3)(C)(iv) of the Social
Security Act (42 U.S.C. 1395l(t)(3)(C)(iv)) is amended----
(A) in the first sentence--
(i) by inserting ``(which is subject to the productivity
adjustment described in subclause (II) of such section)''
after ``1886(b)(3)(B)(iii)''; and
(ii) by inserting ``(but not below 0)'' after ``reduced'';
and
(B) in the second sentence, by inserting ``and which is
subject, beginning with 2010, to the productivity adjustment
described in section 1886(b)(3)(B)(iii)(II)''.
(2) Effective date.--The amendments made by this subsection
shall apply to increase factors for services furnished in
years beginning with 2010.
(b) Ambulance Services.--Section 1834(l)(3)(B) of such Act
(42 U.S.C. 1395m(l)(3)(B))) is amended by inserting before
the period at the end the following: ``and, in the case of
years beginning with 2010, subject to the productivity
adjustment described in section 1886(b)(3)(B)(iii)(II)''.
(c) Ambulatory Surgical Center Services.--Section
1833(i)(2)(D) of such Act (42 U.S.C. 1395l(i)(2)(D)) is
amended--
(1) by redesignating clause (v) as clause (vi); and
(2) by inserting after clause (iv) the following new
clause:
``(v) In implementing the system described in clause (i),
for services furnished during 2010 or any subsequent year, to
the extent that an annual percentage change factor applies,
such factor shall be subject to the productivity adjustment
described in section 1886(b)(3)(B)(iii)(II).''.
(d) Laboratory Services.--Section 1833(h)(2)(A) of such Act
(42 U.S.C. 1395l(h)(2)(A)) is amended--
(1) in clause (i), by striking ``for each of the years 2009
through 2013'' and inserting ``for 2009''; and
(2) clause (ii)--
(A) by striking ``and'' at the end of subclause (III);
(B) by striking the period at the end of subclause (IV) and
inserting ``; and''; and
(C) by adding at the end the following new subclause:
``(V) the annual adjustment in the fee schedules determined
under clause (i) for years beginning with 2010 shall be
subject to the productivity adjustment described in section
1886(b)(3)(B)(iii)(II).''.
(e) Certain Durable Medical Equipment.--Section 1834(a)(14)
of such Act (42 U.S.C. 1395m(a)(14)) is amended--
(1) in subparagraph (K), by inserting before the semicolon
at the end the following: ``, subject to the productivity
adjustment described in section 1886(b)(3)(B)(iii)(II)'';
(2) in subparagraph (L)(i), by inserting after ``June
2013,'' the following: ``subject to the productivity
adjustment described in section 1886(b)(3)(B)(iii)(II),'';
(3) in subparagraph (L)(ii), by inserting after ``June
2013'' the following: ``, subject to the productivity
adjustment described in section 1886(b)(3)(B)(iii)(II)''; and
(4) in subparagraph (M), by inserting before the period at
the end the following: ``, subject to the productivity
adjustment described in section 1886(b)(3)(B)(iii)(II)''.

PART 3--OTHER PROVISIONS

SEC. 1141. RENTAL AND PURCHASE OF POWER-DRIVEN WHEELCHAIRS.

(a) In General.--Section 1834(a)(7)(A)(iii) of the Social
Security Act (42 U.S.C. 1395m(a)(7)(A)(iii)) is amended--
(1) in the heading, by inserting ``certain complex
rehabilitative'' after ``option for''; and
(2) by striking ``power-driven wheelchair'' and inserting
``complex rehabilitative power-driven wheelchair recognized
by the Secretary as classified within group 3 or higher''.
(b) Effective Date.--The amendments made by subsection (a)
shall take effect on January 1, 2011, and shall apply to
power-driven wheelchairs furnished on or after such date.
Such amendments shall not apply to contracts entered into
under section 1847 of the Social Security Act (42 U.S.C.
1395w-3) pursuant to a bid submitted under such section
before October 1, 2010, under subsection (a)(1)(B)(i)(I) of
such section.

SEC. 1141A. ELECTION TO TAKE OWNERSHIP, OR TO DECLINE
OWNERSHIP, OF A CERTAIN ITEM OF COMPLEX DURABLE
MEDICAL EQUIPMENT AFTER THE 13-MONTH CAPPED
RENTAL PERIOD ENDS.

(a) In General.--Section 1834(a)(7)(A) of the Social
Security Act (42 U.S.C. 1395m(a)(7)(A)) is amended--
(1) in clause (ii)--
(A) by striking ``rental.--On'' and inserting ``rental.--

``(I) In general.--Except as provided in subclause (II),
on''; and

(B) by adding at the end the following new subclause:

``(II) Option to accept or reject transfer of title to
group 3 support surface.--

``(aa) In general.--During the 10th continuous month during
which payment is made for the rental of a Group 3 Support
Surface under clause (i), the supplier of such item shall
offer the individual the option to accept or reject transfer
of title to a Group 3 Support Surface after the 13th
continuous

[[Page H12671]]

month during which payment is made for the rental of the
Group 3 Support Surface under clause (i). Such title shall be
transferred to the individual only if the individual notifies
the supplier not later than 1 month after the supplier makes
such offer that the individual agrees to accept transfer of
the title to the Group 3 Support Surface. Unless the
individual accepts transfer of title to the Group 3 Support
Surface in the manner set forth in this subclause, the
individual shall be deemed to have rejected transfer of
title. If the individual agrees to accept the transfer of the
title to the Group 3 Support Surface, the supplier shall
transfer such title to the individual on the first day that
begins after the 13th continuous month during which payment
is made for the rental of the Group 3 Support Surface under
clause (i).
``(bb) Special rule.--If, on the effective date of this
subclause, an individual's rental period for a Group 3
Support Surface has exceeded 10 continuous months, but the
first day that begins after the 13th continuous month during
which payment is made for the rental under clause (i) has not
been reached, the supplier shall, within 1 month following
such effective date, offer the individual the option to
accept or reject transfer of title to a Group 3 Support
Surface. Such title shall be transferred to the individual
only if the individual notifies the supplier not later than 1
month after the supplier makes such offer that the individual
agrees to accept transfer of title to the Group 3 Support
Surface. Unless the individual accepts transfer of title to
the Group 3 Support Surface in the manner set forth in this
subclause, the individual shall be deemed to have rejected
transfer of title. If the individual agrees to accept the
transfer of the title to the Group 3 Support Surface, the
supplier shall transfer such title to the individual on the
first day that begins after the 13th continuous month during
which payment is made for the rental of the Group 3 Support
Surface under clause (i) unless that day has passed, in which
case the supplier shall transfer such title to the individual
not later than 1 month after notification that the individual
accepts transfer of title.
``(cc) Treatment of subsequent resupply within period of
reasonable useful lifetime of group 3 support surface in case
of need.--If an individual rejects transfer of title to a
Group 3 Support Surface under this subclause and the
individual requires such Support Surface at any subsequent
time during the period of the reasonable useful lifetime of
such equipment (as defined by the Secretary) beginning with
the first month for which payment is made for the rental of
such equipment under clause (i), the supplier shall supply
the equipment without charge to the individual or the program
under this title during the remainder of such period, other
than payment for maintenance and servicing during such period
which would otherwise have been paid if the individual had
accepted title to such equipment. The previous sentence shall
not affect the payment of amounts under this part for such
equipment after the end of such period of the reasonable
useful lifetime of the equipment.
``(dd) Payments.--Maintenance and servicing payments shall
be made in accordance with clause (iv), in the case of a
supplier that transfers title to the Group 3 Support Surface
under this subclause, after such transfer and, in the case of
an individual who rejects transfer of title under this
subclause, after the end of the period of medical need during
which payment is made under clause (i).''; and
(2) in clause (iv), by inserting ``or, in the case of an
individual who rejects transfer of title to a Group 3 Support
Surface under clause (ii), after the end of the period of
medical need during which payment is made under clause (i),''
after ``under clause (ii)''.
(b) Effective Date.--The amendments made by this section
shall apply with respect to durable medical equipment not
later than January 1, 2011.

SEC. 1142. EXTENSION OF PAYMENT RULE FOR BRACHYTHERAPY.

Section 1833(t)(16)(C) of the Social Security Act (42
U.S.C. 1395l(t)(16)(C)), as amended by section 142 of the
Medicare Improvements for Patients and Providers Act of 2008
(Public Law 110-275), is amended by striking, the first place
it appears, ``January 1, 2010'' and inserting ``January 1,
2012''.

SEC. 1143. HOME INFUSION THERAPY REPORT TO CONGRESS.

Not later than July 1, 2011, the Medicare Payment Advisory
Commission shall submit to Congress a report on the
following:
(1) The scope of coverage for home infusion therapy in the
fee-for-service Medicare program under title XVIII of the
Social Security Act, Medicare Advantage under part C of such
title, the veteran's health care program under chapter 17 of
title 38, United States Code, and among private payers,
including an analysis of the scope of services provided by
home infusion therapy providers to their patients in such
programs.
(2) The benefits and costs of providing such coverage under
the Medicare program, including a calculation of the
potential savings achieved through avoided or shortened
hospital and nursing home stays as a result of Medicare
coverage of home infusion therapy.
(3) An assessment of sources of data on the costs of home
infusion therapy that might be used to construct payment
mechanisms in the Medicare program.
(4) Recommendations, if any, on the structure of a payment
system under the Medicare program for home infusion therapy,
including an analysis of the payment methodologies used under
Medicare Advantage plans and private health plans for the
provision of home infusion therapy and their applicability to
the Medicare program.

SEC. 1144. REQUIRE AMBULATORY SURGICAL CENTERS (ASCS) TO
SUBMIT COST DATA AND OTHER DATA.

(a) Cost Reporting.--
(1) In general.--Section 1833(i) of the Social Security Act
(42 U.S.C. 1395l(i)) is amended by adding at the end the
following new paragraph:
``(8) The Secretary shall require, as a condition of the
agreement described in section 1832(a)(2)(F)(i), the
submission of such cost report as the Secretary may specify,
taking into account the requirements for such reports under
section 1815 in the case of a hospital.''.
(2) Development of cost report.--Not later than 3 years
after the date of the enactment of this Act, the Secretary of
Health and Human Services shall develop a cost report form
for use under section 1833(i)(8) of the Social Security Act,
as added by paragraph (1).
(3) Audit requirement.--The Secretary shall provide for
periodic auditing of cost reports submitted under section
1833(i)(8) of the Social Security Act, as added by paragraph
(1).
(4) Effective date.--The amendment made by paragraph (1)
shall apply to agreements applicable to cost reporting
periods beginning 18 months after the date the Secretary
develops the cost report form under paragraph (2).
(b) Additional Data on Quality.--
(1) In general.--Section 1833(i)(7) of such Act (42 U.S.C.
1395l(i)(7)) is amended--
(A) in subparagraph (B), by inserting ``subject to
subparagraph (C),'' after ``may otherwise provide,''; and
(B) by adding at the end the following new subparagraph:
``(C) Under subparagraph (B) the Secretary shall require
the reporting of such additional data relating to quality of
services furnished in an ambulatory surgical facility,
including data on health care associated infections, as the
Secretary may specify.''.
(2) Effective date.--The amendment made by paragraph (1)
shall to reporting for years beginning with 2012.

SEC. 1145. TREATMENT OF CERTAIN CANCER HOSPITALS.

Section 1833(t) of the Social Security Act (42 U.S.C.
1395l(t)) is amended by adding at the end the following new
paragraph:
``(18) Authorization of adjustment for cancer hospitals.--
``(A) Study.--The Secretary shall conduct a study to
determine if, under the system under this subsection, costs
incurred by hospitals described in section 1886(d)(1)(B)(v)
with respect to ambulatory payment classification groups
exceed those costs incurred by other hospitals furnishing
services under this subsection (as determined appropriate by
the Secretary).
``(B) Authorization of adjustment.--Insofar as the
Secretary determines under subparagraph (A) that costs
incurred by hospitals described in section 1886(d)(1)(B)(v)
exceed those costs incurred by other hospitals furnishing
services under this subsection, the Secretary shall provide
for an appropriate adjustment under paragraph (2)(E) to
reflect those higher costs effective for services furnished
on or after January 1, 2011.''.

SEC. 1146. PAYMENT FOR IMAGING SERVICES.

(a) Adjustment in Practice Expense to Reflect a Presumed
Level of Utilization.--Section 1848 of the Social Security
Act (42 U.S.C. 1395w-4) is amended--
(1) in subsection (b)(4)--
(A) in subparagraph (B), by striking ``subparagraph (A)''
and inserting ``this paragraph''; and
(B) by adding at the end the following new subparagraph:
``(C) Adjustment in practice expense to reflect a presumed
level of utilization.--Consistent with the methodology for
computing the number of practice expense relative value units
under subsection (c)(2)(C)(ii) with respect to advanced
diagnostic imaging services (as defined in section
1834(e)(1)(B)) furnished on or after January 1, 2011, the
Secretary shall adjust such number of units so it reflects a
presumed rate of utilization of imaging equipment of 75
percent.''; and
(2) in subsection (c)(2)(B)(v)), by adding at the end the
following new subclause:

``(III) Change in presumed utilization level of certain
advanced diagnostic imaging services.--Effective for fee
schedules established beginning with 2011, reduced
expenditures attributable to the presumed utilization of 75
percent under subsection (b)(4)(C) instead of a presumed
utilization of imaging equipment of 50 percent.''.

(b) Adjustment in Technical Component ``discount'' on
Single-session Imaging to Consecutive Body Parts.--Section
1848 of such Act (42 U.S.C. 1395w-4) is further amended--
(1) in subsection (b)(4), by adding at the end the
following new subparagraph:
``(D) Adjustment in technical component discount on single-
session imaging involving consecutive body parts.--For
services furnished on or after January 1, 2011, the Secretary
shall increase the reduction in expenditures attributable to
the multiple procedure payment reduction applicable to the
technical component for imaging under the final rule
published by the Secretary in the Federal Register on
November 21, 2005 (part

[[Page H12672]]

405 of title 42, Code of Federal Regulations) from 25 percent
to 50 percent.''; and
(2) in subsection (c)(2)(B)(v), by adding at the end the
following new subclause:

``(III) Additional reduced payment for multiple imaging
procedures.--Effective for fee schedules established
beginning with 2011, reduced expenditures attributable to the
increase in the multiple procedure payment reduction from 25
percent to 50 percent as described in subsection
(b)(4)(D).''.

SEC. 1147. DURABLE MEDICAL EQUIPMENT PROGRAM IMPROVEMENTS.

(a) Waiver of Surety Bond Requirement.--Section 1834(a)(16)
of the Social Security Act (42 U.S.C. 1395m(a)(16)) is
amended by adding at the end the following sentence: ``The
requirement for a surety bond described in subparagraph (B)
shall not apply in the case of a pharmacy or supplier that
exclusively furnishes eyeglasses or contact lenses described
in section 1861(s)(8) if the pharmacy or supply has been
enrolled under section 1866(j) as a supplier of durable
medical equipment, prosthetics, orthotics, and supplies and
has been issued (which may include renewal of) a supplier
number (as described in the first sentence of this paragraph)
for at least 5 years, and if a final adverse action (as
defined in section 424.57(a) of title 42, Code of Federal
Regulations) has never been imposed for such pharmacy or
supplier.''.
(b) Ensuring Supply of Oxygen Equipment.--
(1) In general.--Section 1834(a)(5)(F) of the Social
Security Act (42 U.S.C. 1395m(a)(5)(F)) is amended--
(A) in clause (ii), by striking ``After the'' and inserting
``Except as provided in clause (iii), after the''; and
(B) by adding at the end the following new clause:
``(iii) Continuation of supply.--In the case of a supplier
furnishing such equipment to an individual under this
subsection as of the 27th month of the 36 months described in
clause (i), the supplier furnishing such equipment as of such
month shall continue to furnish such equipment to such
individual (either directly or though arrangements with other
suppliers of such equipment) during any subsequent period of
medical need for the remainder of the reasonable useful
lifetime of the equipment, as determined by the Secretary,
regardless of the location of the individual, unless another
supplier has accepted responsibility for continuing to
furnish such equipment during the remainder of such
period.''.
(2) Effective date.--The amendments made by paragraph (1)
shall take effect as of the date of the enactment of this Act
and shall apply to the furnishing of equipment to individuals
for whom the 27th month of a continuous period of use of
oxygen equipment described in section 1834(a)(5)(F) of the
Social Security Act occurs on or after July 1, 2010.
(c) Treatment of Current Accreditation Applications.--
Section 1834(a)(20)(F) of such Act (42 U.S.C.
1395m(a)(20)(F)) is amended--
(1) in clause (i)--
(A) by striking ``clause (ii)'' and inserting ``clauses
(ii) and (iii)''; and
(B) by striking ``and'' at the end;
(2) by striking the period at the end of clause (ii)(II)
and by inserting a semicolon;
(3) by inserting after clause (ii) the following new
clauses:
``(iii) the requirement for accreditation described in
clause (i) shall not apply for purposes of supplying diabetic
testing supplies, canes, and crutches in the case of a
pharmacy that is enrolled under section 1866(j) as a supplier
of durable medical equipment, prosthetics, orthotics, and
supplies; and
``(iv) a supplier that has submitted an application for
accreditation before August 1, 2009, shall retain the
supplier's provider or supplier number until an independent
accreditation organization determines if such supplier
complies with requirements under this paragraph.''; and
(4) by adding at the end the following new sentence:
``Nothing in clauses (iii) and (iv) shall be construed as
affecting the application of an accreditation requirement for
suppliers to qualify for bidding in a competitive acquisition
area under section 1847,''.
(d) Restoring 36-month Oxygen Rental Period in Case of
Supplier Bankruptcy for Certain Individuals.--Section
1834(a)(5)(F) of such Act (42 U.S.C. 1395m(a)(5)(F)), as
amended by subsection (b), is further amended by adding at
the end the following new clause:
``(iv) Exception for bankruptcy.--If a supplier who
furnishes oxygen and oxygen equipment to an individual is
declared bankrupt and its assets are liquidated and at the
time of such declaration and liquidation more than 24 months
of rental payments have been made, such individual may begin
a new 36-month rental period under this subparagraph with
another supplier of oxygen.''.

SEC. 1148. MEDPAC STUDY AND REPORT ON BONE MASS MEASUREMENT.

(a) In General.--The Medicare Payment Advisory Commission
shall conduct a study regarding bone mass measurement,
including computed tomography, duel-energy x-ray
absorptriometry, and vertebral fracture assessment. The study
shall focus on the following:
(1) An assessment of the adequacy of Medicare payment rates
for such services, taking into account costs of acquiring the
necessary equipment, professional work time, and practice
expense costs.
(2) The impact of Medicare payment changes since 2006 on
beneficiary access to bone mass measurement benefits in
general and in rural and minority communities specifically.
(3) A review of the clinically appropriate and recommended
use among Medicare beneficiaries and how usage rates among
such beneficiaries compares to such recommendations.
(4) In conjunction with the findings under (3),
recommendations, if necessary, regarding methods for reaching
appropriate use of bone mass measurement studies among
Medicare beneficiaries.
(b) Report.--The Commission shall submit a report to the
Congress, not later than 9 months after the date of the
enactment of this Act, containing a description of the
results of the study conducted under subsection (a) and the
conclusions and recommendations, if any, regarding each of
the issues described in paragraphs (1), (2) (3) and (4) of
such subsection.

SEC. 1149. TIMELY ACCESS TO POST-MASTECTOMY ITEMS.

(a) In General.--Section 1834(h)(1) of the Social Security
Act (42 U.S.C. 1395m) is amended--
(1) by redesignating subparagraph (H) as subparagraph (I);
and
(2) by inserting after subparagraph (G) the following new
subparagraph:
``(H) Special payment rule for post-mastectomy external
breast prosthesis garments.--Payment for post-mastectomy
external breast prosthesis garments shall be made regardless
of whether such items are supplied to the beneficiary prior
to or after the mastectomy procedure or other breast cancer
surgical procedure. The Secretary shall develop policies to
ensure appropriate beneficiary access and utilization
safeguards for such items supplied to a beneficiary prior to
the mastectomy or other breast cancer surgical procedure.''
(b) Effective Date.--This amendment shall apply not later
than January 1, 2011.

SEC. 1149A. PAYMENT FOR BIOSIMILAR BIOLOGICAL PRODUCTS.

(a) In General.--Section 1847A of the Social Security Act
(42 U.S.C. 1395w-3a) is amended--
(1) in subsection (b)(1)--
(A) in subparagraph (A), by striking ``or'' at the end;
(B) in subparagraph (B), by striking the period at the end
and inserting ``; or''; and
(C) by adding at the end the following new subparagraph:
``(C) in the case of one or more interchangeable biological
products (as defined in subsection (c)(6)(I)) and their
reference biological product (as defined in subsection
(c)(6)(J)), which shall be included in the same billing and
payment code, the sum of--
``(i) the average sales price as determined using the
methodology described in paragraph (6) applied to such
interchangeable and reference products for all National Drug
Codes assigned to such products in the same manner as such
paragraph (6) is applied to multiple source drugs; and
``(ii) 6 percent of the amount determined under clause (i);
``(D) in the case of a biosimilar biological product (as
defined in subsection (c)(6)(H)), the sum of--
``(i) the average sales price as determined using the
methodology described in paragraph (4) applied to such
biosimilar biological product for all National Drug Codes
assigned to such product in the same manner as such paragraph
(4) is applied to a single source drug; and
``(ii) 6 percent of the amount determined under paragraph
(4) or the amount determined under subparagraph (C)(ii), as
the case may be, for the reference biological product (as
defined in subsection (c)(6)(J)); or
``(E) in the case of a reference biological product for
both an interchangeable biological product and a biosimilar
product, the amount determined in subparagraph (C).''; and
(2) in subsection (c)(6)--
(A) by amending subparagraph (D)(i) to read as follows:
``(i) a biological, including a reference biological
product for a biosimilar product, but excluding--

``(I) a biosimilar biological product;
``(II) an interchangeable biological product;
``(III) a reference biological product for an
interchangeable biological product; and
``(IV) a reference biological product for both an
interchangeable biological product and a biosimilar product;
or''; and

(B) by adding at the end the following new subparagraphs:
``(H) Biosimilar biological product.--The term `biosimilar
biological product' means a biological product licensed as a
biosimilar biological product under section 351(k) of the
Public Health Service Act.
``(I) Interchangeable biological product.--The term
`interchangeable biological product' means a biological
product licensed as an interchangeable biological product
under section 351(k) of the Public Health Service Act
``(J) Reference biological product.--The term `reference
biological product' means the biological product that is
referred to in the application for a biosimilar or
interchangeable biological product licensed under section
351(k) of the Public Health Service Act.''.
(b) Effective Date.--The amendments made by subsection (a)
shall apply to payments for biosimilar biological products,

[[Page H12673]]

interchangeable biological products, and reference biological
products beginning with the first day of the second calendar
quarter after the date of the enactment of this Act.

SEC. 1149B. STUDY AND REPORT ON DME COMPETITIVE BIDDING
PROCESS.

(a) Study.--The Comptroller General of the United States
shall conduct a study to evaluate the potential establishment
of a program under Medicare under title XVIII of the Social
Security Act to acquire durable medical equipment and
supplies through a competitive bidding process among
manufacturers of such equipment and supplies. Such study
shall address the following:
(1) Identification of types of durable medical equipment
and supplies that would be appropriate for bidding under such
a program.
(2) Recommendations on how to structure such an acquisition
program in order to promote fiscal responsibility while also
ensuring beneficiary access to high quality equipment and
supplies.
(3) Recommendations on how such a program could be phased-
in and on what geographic level would bidding be most
appropriate.
(4) In addition to price, recommendations on criteria that
could be factored into the bidding process.
(5) Recommendations on how suppliers could be compensated
for furnishing and servicing equipment and supplies acquired
under such a program.
(6) Comparison of such a program to the current competitive
bidding program under Medicare for durable medical equipment,
as well as any other similar Federal acquisition programs,
such as the General Services Administration's vehicle
purchasing program.
(7) Any other consideration relevant to the acquisition,
supply, and service of durable medical equipment and supplies
that is deemed appropriate by the Comptroller General.
(b) Report.--Not later than 12 months after the date of the
enactment of this Act, the Comptroller General of the United
States shall submit to Congress a report on the findings of
the study under subsection (a).

Subtitle C--Provisions Related to Medicare Parts A and B

SEC. 1151. REDUCING POTENTIALLY PREVENTABLE HOSPITAL
READMISSIONS.

(a) Hospitals.--
(1) In general.--Section 1886 of the Social Security Act
(42 U.S.C. 1395ww), as amended by section 1103(a), is amended
by adding at the end the following new subsection:
``(p) Adjustment to Hospital Payments for Excess
Readmissions.--
``(1) In general.--With respect to payment for discharges
from an applicable hospital (as defined in paragraph (5)(C))
occurring during a fiscal year beginning on or after October
1, 2011, in order to account for excess readmissions in the
hospital, the Secretary shall reduce the payments that would
otherwise be made to such hospital under subsection (d) (or
section 1814(b)(3), as the case may be) for such a discharge
by an amount equal to the product of--
``(A) the base operating DRG payment amount (as defined in
paragraph (2)) for the discharge; and
``(B) the adjustment factor (described in paragraph (3)(A))
for the hospital for the fiscal year.
``(2) Base operating drg payment amount.--
``(A) In general.--Except as provided in subparagraph (B),
for purposes of this subsection, the term `base operating DRG
payment amount' means, with respect to a hospital for a
fiscal year, the payment amount that would otherwise be made
under subsection (d) for a discharge if this subsection did
not apply, reduced by any portion of such amount that is
attributable to payments under subparagraphs (B) and (F) of
paragraph (5).
``(B) Adjustments.--For purposes of subparagraph (A), in
the case of a hospital that is paid under section 1814(b)(3),
the term `base operating DRG payment amount' means the
payment amount under such section.
``(3) Adjustment factor.--
``(A) In general.--For purposes of paragraph (1), the
adjustment factor under this paragraph for an applicable
hospital for a fiscal year is equal to the greater of--
``(i) the ratio described in subparagraph (B) for the
hospital for the applicable period (as defined in paragraph
(5)(D)) for such fiscal year; or
``(ii) the floor adjustment factor specified in
subparagraph (C).
``(B) Ratio.--The ratio described in this subparagraph for
a hospital for an applicable period is equal to 1 minus the
ratio of--
``(i) the aggregate payments for excess readmissions (as
defined in paragraph (4)(A)) with respect to an applicable
hospital for the applicable period; and
``(ii) the aggregate payments for all discharges (as
defined in paragraph (4)(B)) with respect to such applicable
hospital for such applicable period.
``(C) Floor adjustment factor.--For purposes of
subparagraph (A), the floor adjustment factor specified in
this subparagraph for--
``(i) fiscal year 2012 is 0.99;
``(ii) fiscal year 2013 is 0.98;
``(iii) fiscal year 2014 is 0.97; or
``(iv) a subsequent fiscal year is 0.95.
``(4) Aggregate payments, excess readmission ratio
defined.--For purposes of this subsection:
``(A) Aggregate payments for excess readmissions.--The term
`aggregate payments for excess readmissions' means, for a
hospital for a fiscal year, the sum, for applicable
conditions (as defined in paragraph (5)(A)), of the product,
for each applicable condition, of--
``(i) the base operating DRG payment amount for such
hospital for such fiscal year for such condition;
``(ii) the number of admissions for such condition for such
hospital for such fiscal year; and
``(iii) the excess readmissions ratio (as defined in
subparagraph (C)) for such hospital for the applicable period
for such fiscal year minus 1.
``(B) Aggregate payments for all discharges.--The term
`aggregate payments for all discharges' means, for a hospital
for a fiscal year, the sum of the base operating DRG payment
amounts for all discharges for all conditions from such
hospital for such fiscal year.
``(C) Excess readmission ratio.--
``(i) In general.--Subject to clauses (ii) and (iii), the
term `excess readmissions ratio' means, with respect to an
applicable condition for a hospital for an applicable period,
the ratio (but not less than 1.0) of--

``(I) the risk adjusted readmissions based on actual
readmissions, as determined consistent with a readmission
measure methodology that has been endorsed under paragraph
(5)(A)(ii)(I), for an applicable hospital for such condition
with respect to the applicable period; to
``(II) the risk adjusted expected readmissions (as
determined consistent with such a methodology) for such
hospital for such condition with respect to such applicable
period.

``(ii) Exclusion of certain readmissions.--For purposes of
clause (i), with respect to a hospital, excess readmissions
shall not include readmissions for an applicable condition
for which there are fewer than a minimum number (as
determined by the Secretary) of discharges for such
applicable condition for the applicable period and such
hospital.
``(iii) Adjustment.--In order to promote a reduction over
time in the overall rate of readmissions for applicable
conditions, the Secretary may provide, beginning with
discharges for fiscal year 2014, for the determination of the
excess readmissions ratio under subparagraph (C) to be based
on a ranking of hospitals by readmission ratios (from lower
to higher readmission ratios) normalized to a benchmark that
is lower than the 50th percentile.
``(5) Definitions.--For purposes of this subsection:
``(A) Applicable condition.--The term `applicable
condition' means, subject to subparagraph (B), a condition or
procedure selected by the Secretary among conditions and
procedures for which--
``(i) readmissions (as defined in subparagraph (E)) that
represent conditions or procedures that are high volume or
high expenditures under this title (or other criteria
specified by the Secretary); and
``(ii) measures of such readmissions--

``(I) have been endorsed by the entity with a contract
under section 1890(a); and
``(II) such endorsed measures have appropriate exclusions
for readmissions that are unrelated to the prior discharge
(such as a planned readmission or transfer to another
applicable hospital).

``(B) Expansion of applicable conditions.--Beginning with
fiscal year 2013, the Secretary shall expand the applicable
conditions beyond the 3 conditions for which measures have
been endorsed as described in subparagraph (A)(ii)(I) as of
the date of the enactment of this subsection to the
additional 4 conditions that have been so identified by the
Medicare Payment Advisory Commission in its report to
Congress in June 2007 and to other conditions and procedures
which may include an all-condition measure of readmissions,
as determined appropriate by the Secretary. In expanding such
applicable conditions, the Secretary shall seek the
endorsement described in subparagraph (A)(ii)(I) but may
apply such measures without such an endorsement.
``(C) Applicable hospital.--The term `applicable hospital'
means a subsection (d) hospital or a hospital that is paid
under section 1814(b)(3).
``(D) Applicable period.--The term `applicable period'
means, with respect to a fiscal year, such period as the
Secretary shall specify for purposes of determining excess
readmissions.
``(E) Readmission.--The term `readmission' means, in the
case of an individual who is discharged from an applicable
hospital, the admission of the individual to the same or
another applicable hospital within a time period specified by
the Secretary from the date of such discharge. Insofar as the
discharge relates to an applicable condition for which there
is an endorsed measure described in subparagraph (A)(ii)(I),
such time period (such as 30 days) shall be consistent with
the time period specified for such measure.
``(6) Limitations on review.--There shall be no
administrative or judicial review under section 1869, section
1878, or otherwise of--
``(A) the determination of base operating DRG payment
amounts;
``(B) the methodology for determining the adjustment factor
under paragraph (3), including excess readmissions ratio
under paragraph (4)(C), aggregate payments for excess
readmissions under paragraph (4)(A), and aggregate payments
for all discharges

[[Page H12674]]

under paragraph (4)(B), and applicable periods and applicable
conditions under paragraph (5);
``(C) the measures of readmissions as described in
paragraph (5)(A)(ii); and
``(D) the determination of a targeted hospital under
paragraph (8)(B)(i), the increase in payment under paragraph
(8)(B)(ii), the aggregate cap under paragraph (8)(C)(i), the
hospital-specific limit under paragraph (8)(C)(ii), and the
form of payment made by the Secretary under paragraph (8)(D).
``(7) Monitoring inappropriate changes in admissions
practices.--The Secretary shall monitor the activities of
applicable hospitals to determine if such hospitals have
taken steps to avoid patients at risk in order to reduce the
likelihood of increasing readmissions for applicable
conditions or taken other inappropriate steps involving
readmissions or transfers. If the Secretary determines that
such a hospital has taken such a step, after notice to the
hospital and opportunity for the hospital to undertake action
to alleviate such steps, the Secretary may impose an
appropriate sanction.
``(8) Assistance to certain hospitals.--
``(A) In general.--For purposes of providing funds to
applicable hospitals to take steps described in subparagraph
(E) to address factors that may impact readmissions of
individuals who are discharged from such a hospital, for
fiscal years beginning on or after October 1, 2011, the
Secretary shall make a payment adjustment for a hospital
described in subparagraph (B), with respect to each such
fiscal year, by a percent estimated by the Secretary to be
consistent with subparagraph (C). The Secretary shall provide
priority to hospitals that serve Medicare beneficiaries at
highest risk for readmission or for a poor transition from
such a hospital to a post-hospital site of care.
``(B) Targeted hospitals.--Subparagraph (A) shall apply to
an applicable hospital that--
``(i) had (or, in the case of an 1814(b)(3) hospital,
otherwise would have had) a disproportionate patient
percentage (as defined in section 1886(d)(5)(F)) of at least
30 percent, using the latest available data as estimated by
the Secretary; and
``(ii) provides assurances satisfactory to the Secretary
that the increase in payment under this paragraph shall be
used for purposes described in subparagraph (E).
``(C) Caps.--
``(i) Aggregate cap.--The aggregate amount of the payment
adjustment under this paragraph for a fiscal year shall not
exceed 5 percent of the estimated difference in the spending
that would occur for such fiscal year with and without
application of the adjustment factor described in paragraph
(3) and applied pursuant to paragraph (1).
``(ii) Hospital-specific limit.--The aggregate amount of
the payment adjustment for a hospital under this paragraph
shall not exceed the estimated difference in spending that
would occur for such fiscal year for such hospital with and
without application of the adjustment factor described in
paragraph (3) and applied pursuant to paragraph (1).
``(D) Form of payment.--The Secretary may make the
additional payments under this paragraph on a lump sum basis,
a periodic basis, a claim by claim basis, or otherwise.
``(E) Use of additional payment.--
``(i) In general.--Funding under this paragraph shall be
used by targeted hospitals for activities designed to address
the patient noncompliance issues that result in higher than
normal readmission rates, including transitional care
services described in clause (ii) and any or all of the other
activities described in clause (iii).
``(ii) Transitional care services.--The transitional care
services described in this clause are transitional care
services furnished by a qualified transitional care provider,
such as a nurse or other health professional, who meets
relevant experience and training requirements as specified by
the Secretary that support a beneficiary under this section
beginning on the date of an individual's admission to a
hospital for inpatient hospital services and ending at the
latest on the last day of the 90-day period beginning on the
date of the individual's discharge from the applicable
hospital. The Secretary shall determine and update services
to be included in transitional care services under this
clause as appropriate, based on evidence of their
effectiveness in reducing hospital readmissions and improving
health outcomes. Such services shall include the following:

``(I) Conduct of an assessment prior to discharge, which
assessment may include an assessment of the individual's
physical and mental condition, cognitive and functional
capacities, medication regimen and adherence, social and
environmental needs, and primary caregiver needs and
resources.
``(II) Development of a evidence-based plan of transitional
care for the individual developed after consultation with the
individual and the individual's primary caregiver and other
health team members, as appropriate. Such plan shall include
a list of current therapies prescribed, treatment goals and
may include other items or elements as determined by the
Secretary, such as identifying list of potential health risks
and future services for both the individual and any primary
caregiver.

``(iii) Other activities.--The other activities described
in this clause are the following:

``(I) Providing other care coordination services not
described under clause (ii).
``(II) Hiring translators and interpreters.
``(III) Increasing services offered by discharge planners.
``(IV) Ensuring that individuals receive a summary of care
and medication orders upon discharge.
``(V) Developing a quality improvement plan to assess and
remedy preventable readmission rates.
``(VI) Assigning appropriate follow-up care for discharged
individuals.
``(VII) Doing other activities as determined appropriate by
the Secretary.

``(F) GAO report on use of funds.--Not later than 3 years
after the date on which funds are first made available under
this paragraph, the Comptroller General of the United States
shall submit to Congress a report on the use of such funds.
Such report shall consider information on the effective uses
of such funds, how the uses of such funds affected hospital
readmission rates (including at 6 months post-discharge),
health outcomes and quality, reductions in expenditures under
this title and the experiences of beneficiaries, primary
caregivers, and providers, as well as any appropriate
recommendations.''.
(b) Application to Critical Access Hospitals.--Section
1814(l) of the Social Security Act (42 U.S.C. 1395f(l)) is
amended--
(1) in paragraph (5)--
(A) by striking ``and'' at the end of subparagraph (C);
(B) by striking the period at the end of subparagraph (D)
and inserting ``; and'';
(C) by inserting at the end the following new subparagraph:
``(E) the methodology for determining the adjustment factor
under paragraph (5), including the determination of aggregate
payments for actual and expected readmissions, applicable
periods, applicable conditions and measures of
readmissions.''; and
(D) by redesignating such paragraph as paragraph (6); and
(2) by inserting after paragraph (4) the following new
paragraph:
``(5) The adjustment factor described in section 1886(p)(3)
shall apply to payments with respect to a critical access
hospital with respect to a cost reporting period beginning in
fiscal year 2012 and each subsequent fiscal year (after
application of paragraph (4) of this subsection) in a manner
similar to the manner in which such section applies with
respect to a fiscal year to an applicable hospital as
described in section 1886(p)(2).''.
(c) Post Acute Care Providers.--
(1) Interim policy.--
(A) In general.--With respect to a readmission to an
applicable hospital or a critical access hospital (as
described in section 1814(l) of the Social Security Act) from
a post acute care provider (as defined in paragraph (3)) and
such a readmission is not governed by section 412.531 of
title 42, Code of Federal Regulations, if the claim submitted
by such a post-acute care provider under title XVIII of the
Social Security Act indicates that the individual was
readmitted to a hospital from such a post-acute care provider
or admitted from home and under the care of a home health
agency within 30 days of an initial discharge from an
applicable hospital or critical access hospital, the payment
under such title on such claim shall be the applicable
percent specified in subparagraph (B) of the payment that
would otherwise be made under the respective payment system
under such title for such post-acute care provider if this
subsection did not apply. In applying the previous sentence,
the Secretary shall exclude a period of 1 day from the date
the individual is first admitted to or under the care of the
post-acute care provider.
(B) Applicable percent defined.--For purposes of
subparagraph (A), the applicable percent is--
(i) for fiscal or rate year 2012 is 0.996;
(ii) for fiscal or rate year 2013 is 0.993; and
(iii) for fiscal or rate year 2014 is 0.99.
(C) Effective date.--Subparagraph (1) shall apply to
discharges or services furnished (as the case may be with
respect to the applicable post acute care provider) on or
after the first day of the fiscal year or rate year,
beginning on or after October 1, 2011, with respect to the
applicable post acute care provider.
(2) Development and application of performance measures.--
(A) In general.--The Secretary of Health and Human Services
shall develop appropriate measures of readmission rates for
post acute care providers. The Secretary shall seek
endorsement of such measures by the entity with a contract
under section 1890(a) of the Social Security Act but may
adopt and apply such measures under this paragraph without
such an endorsement. The Secretary shall expand such measures
in a manner similar to the manner in which applicable
conditions are expanded under paragraph (5)(B) of section
1886(p) of the Social Security Act, as added by subsection
(a).
(B) Implementation.--The Secretary shall apply, on or after
October 1, 2014, with respect to post acute care providers,
policies similar to the policies applied with respect to
applicable hospitals and critical access hospitals under the
amendments made by subsection (a). The provisions of
paragraph (1) shall apply with respect to any period on or
after October 1, 2014, and before such application date
described in the previous sentence in the same manner as such
provisions apply with respect to fiscal or rate year 2014.
(C) Monitoring and penalties.--The provisions of paragraph
(7) of such section 1886(p) shall apply to providers under
this paragraph

[[Page H12675]]

in the same manner as they apply to hospitals under such
section.
(3) Definitions.--For purposes of this subsection:
(A) Post acute care provider.--The term ``post acute care
provider'' means--
(i) a skilled nursing facility (as defined in section
1819(a) of the Social Security Act);
(ii) an inpatient rehabilitation facility (described in
section 1886(h)(1)(A) of such Act);
(iii) a home health agency (as defined in section 1861(o)
of such Act); and
(iv) a long term care hospital (as defined in section
1861(ccc) of such Act).
(B) Other terms.--The terms ``applicable condition'',
``applicable hospital'', and ``readmission'' have the
meanings given such terms in section 1886(p)(5) of the Social
Security Act, as added by subsection (a)(1).
(d) Physicians.--
(1) Study.--The Secretary of Health and Human Services
shall conduct a study to determine how the readmissions
policy described in the previous subsections could be applied
to physicians.
(2) Considerations.--In conducting the study, the Secretary
shall consider approaches such as--
(A) creating a new code (or codes) and payment amount (or
amounts) under the fee schedule in section 1848 of the Social
Security Act (in a budget neutral manner) for services
furnished by an appropriate physician who sees an individual
within the first week after discharge from a hospital or
critical access hospital;
(B) developing measures of rates of readmission for
individuals treated by physicians;
(C) applying a payment reduction for physicians who treat
the patient during the initial admission that results in a
readmission; and
(D) methods for attributing payments or payment reductions
to the appropriate physician or physicians.
(3) Report.--The Secretary shall issue a public report on
such study not later than the date that is one year after the
date of the enactment of this Act.
(e) Funding.--For purposes of carrying out the provisions
of this section, in addition to funds otherwise available,
out of any funds in the Treasury not otherwise appropriated,
there are appropriated to the Secretary of Health and Human
Services for the Center for Medicare & Medicaid Services
Program Management Account $25,000,000 for each fiscal year
beginning with 2010. Amounts appropriated under this
subsection for a fiscal year shall be available until
expended.

SEC. 1152. POST ACUTE CARE SERVICES PAYMENT REFORM PLAN AND
BUNDLING PILOT PROGRAM.

(a) Plan.--
(1) In general.--The Secretary of Health and Human Services
(in this section referred to as the ``Secretary'') shall
develop a detailed plan to reform payment for post acute care
(PAC) services under the Medicare program under title XVIII
of the Social Security Act (in this section referred to as
the ``Medicare program)''. The goals of such payment reform
are to--
(A) improve the coordination, quality, and efficiency of
such services; and
(B) improve outcomes for individuals such as reducing the
need for readmission to hospitals from providers of such
services.
(2) Bundling post acute services.--The plan described in
paragraph (1) shall include detailed specifications for a
bundled payment for post acute services (in this section
referred to as the ``post acute care bundle''), and may
include other approaches determined appropriate by the
Secretary.
(3) Post acute services.--For purposes of this section, the
term ``post acute services'' means services for which payment
may be made under the Medicare program that are furnished by
skilled nursing facilities, inpatient rehabilitation
facilities, long term care hospitals, hospital based
outpatient rehabilitation facilities and home health agencies
to an individual after discharge of such individual from a
hospital, and such other services determined appropriate by
the Secretary.
(b) Details.--The plan described in subsection (a)(1) shall
include consideration of the following issues:
(1) The nature of payments under a post acute care bundle,
including the type of provider or entity to whom payment
should be made, the scope of activities and services included
in the bundle, whether payment for physicians' services
should be included in the bundle, and the period covered by
the bundle.
(2) Whether the payment should be consolidated with the
payment under the inpatient prospective system under section
1886 of the Social Security Act (in this section referred to
as MS-DRGs) or a separate payment should be established for
such bundle, and if a separate payment is established,
whether it should be made only upon use of post acute care
services or for every discharge.
(3) Whether the bundle should be applied across all
categories of providers of inpatient services (including
critical access hospitals) and post acute care services or
whether it should be limited to certain categories of
providers, services, or discharges, such as high volume or
high cost MS-DRGs.
(4) The extent to which payment rates could be established
to achieve offsets for efficiencies that could be expected to
be achieved with a bundle payment, whether such rates should
be established on a national basis or for different
geographic areas, should vary according to discharge, case
mix, outliers, and geographic differences in wages or other
appropriate adjustments, and how to update such rates.
(5) The nature of protections needed for individuals under
a system of bundled payments to ensure that individuals
receive quality care, are furnished the level and amount of
services needed as determined by an appropriate assessment
instrument, are offered choice of provider, and the extent to
which transitional care services would improve quality of
care for individuals and the functioning of a bundled post-
acute system.
(6) The nature of relationships that may be required
between hospitals and providers of post acute care services
to facilitate bundled payments, including the application of
gainsharing, anti-referral, anti-kickback, and anti-trust
laws.
(7) Quality measures that would be appropriate for
reporting by hospitals and post acute providers (such as
measures that assess changes in functional status and quality
measures appropriate for each type of post acute services
provider including how the reporting of such quality measures
could be coordinated with other reporting of such quality
measures by such providers otherwise required).
(8) How cost-sharing for a post acute care bundle should be
treated relative to current rules for cost-sharing for
inpatient hospital, home health, skilled nursing facility,
and other services.
(9) How other programmatic issues should be treated in a
post acute care bundle, including rules specific to various
types of post-acute providers such as the post-acute transfer
policy, three-day hospital stay to qualify for services
furnished by skilled nursing facilities, and the coordination
of payments and care under the Medicare program and the
Medicaid program.
(10) Such other issues as the Secretary deems appropriate.
(c) Consultations and Analysis.--
(1) Consultation with stakeholders.--In developing the plan
under subsection (a)(1), the Secretary shall consult with
relevant stakeholders and shall consider experience with such
research studies and demonstrations that the Secretary
determines appropriate.
(2) Analysis and data collection.--In developing such plan,
the Secretary shall--
(A) analyze the issues described in subsection (b) and
other issues that the Secretary determines appropriate;
(B) analyze the impacts (including geographic impacts) of
post acute service reform approaches, including bundling of
such services on individuals, hospitals, post acute care
providers, and physicians;
(C) use existing data (such as data submitted on claims)
and collect such data as the Secretary determines are
appropriate to develop such plan required in this section;
and
(D) if patient functional status measures are appropriate
for the analysis, to the extent practical, build upon the
CARE tool being developed pursuant to section 5008 of the
Deficit Reduction Act of 2005.
(d) Administration.--
(1) Funding.--For purposes of carrying out the provisions
of this section, in addition to funds otherwise available,
out of any funds in the Treasury not otherwise appropriated,
there are appropriated to the Secretary for the Center for
Medicare & Medicaid Services Program Management Account
$15,000,000 for each of the fiscal years 2010 through 2012.
Amounts appropriated under this paragraph for a fiscal year
shall be available until expended.
(2) Expedited data collection.--Chapter 35 of title 44,
United States Code shall not apply to this section.
(e) Public Reports.--
(1) Interim reports.--The Secretary shall issue interim
public reports on a periodic basis on the plan described in
subsection (a)(1), the issues described in subsection (b),
and impact analyses as the Secretary determines appropriate.
(2) Final report.--Not later than the date that is 3 years
after the date of the enactment of this Act, the Secretary
shall issue a final public report on such plan, including
analysis of issues described in subsection (b) and impact
analyses.
(f) Conversion of Acute Care Episode Demonstration to Pilot
Program and Expansion to Include Post Acute Services.--
(1) In general.--Part E of title XVIII of the Social
Security Act is amended by inserting after section 1866C the
following new section:

``conversion of acute care episode demonstration to pilot program and
expansion to include post acute services

``Sec. 1866D.  (a) Conversion and Expansion.--
``(1) In general.--By not later than January 1, 2011, the
Secretary shall, for the purpose of promoting the use of
bundled payments to promote efficient, coordinated, and high
quality delivery of care--
``(A) convert the acute care episode demonstration program
conducted under section 1866C to a pilot program; and
``(B) subject to subsection (c), expand such program as so
converted to include post acute services and such other
services the Secretary determines to be appropriate, which
may include transitional services.
``(2) Bundled payment structures.--
``(A) In general.--In carrying out paragraph (1), the
Secretary may apply bundled payments with respect to--
``(i) hospitals and physicians;
``(ii) hospitals and post-acute care providers;

[[Page H12676]]

``(iii) hospitals, physicians, and post-acute care
providers; or
``(iv) combinations of post-acute providers.
``(B) Further application.--
``(i) In general.--In carrying out paragraph (1), the
Secretary shall apply bundled payments in a manner so as to
include collaborative care networks and continuing care
hospitals.
``(ii) Collaborative care network defined.--For purposes of
this subparagraph, the term `collaborative care network'
means a consortium of health care providers that provides a
comprehensive range of coordinated and integrated health care
services to low-income patient populations (including the
uninsured) which may include coordinated and comprehensive
care by safety net providers to reduce any unnecessary use of
items and services furnished in emergency departments, manage
chronic conditions, improve quality and efficiency of care,
increase preventive services, and promote adherence to post-
acute and follow-up care plans.
``(iii) Continuing care hospital defined.--For purposes of
this subparagraph, the term `continuing care hospital' means
an entity that has demonstrated the ability to meet patient
care and patient safety standards and that provides under
common management the medical and rehabilitation services
provided in inpatient rehabilitation hospitals and units (as
defined in section 1886(d)(1)(B)(ii)), long-term care
hospitals (as defined in section 1886(d)(1)(B)(iv)(I)), and
skilled nursing facilities (as defined in section 1819(a))
that are located in a hospital described in section 1886(d).
``(b) Scope.--The Secretary shall set specific goals for
the number of acute and post-acute bundling test sites under
the pilot program to ensure that over time the pilot program
is of sufficient size and scope to--
``(1) test the approaches under the pilot program in a
variety of settings, including urban, rural, and underserved
areas;
``(2) include geographic areas and additional conditions
that account for significant program spending, as defined by
the Secretary; and
``(3) subject to subsection (d), disseminate the pilot
program rapidly on a national basis.
To the extent that the Secretary finds inpatient and post
acute care bundling to be successful in improving quality and
reducing costs, the Secretary shall implement such mechanisms
and reforms under the pilot program on as large a geographic
scale as practical and economical, consistent with subsection
(e). Nothing in this subsection shall be construed as
limiting the number of hospital and physician groups or the
number of hospital and post-acute provider groups that may
participate in the pilot program.
``(c) Limitation.--The Secretary shall only expand the
pilot program under subsection (a) if the Secretary finds
that--
``(1) the demonstration program under section 1866C and
pilot program under this section maintain or increase the
quality of care received by individuals enrolled under this
title; and
``(2) such demonstration program and pilot program reduce
program expenditures and, based on the certification under
subsection (d), that the expansion of such pilot program
would result in estimated spending that would be less than
what spending would otherwise be in the absence of this
section.
``(d) Certification.--For purposes of subsection (c), the
Chief Actuary of the Centers for Medicare & Medicaid Services
shall certify whether expansion of the pilot program under
this section would result in estimated spending that would be
less than what spending would otherwise be in the absence of
this section.
``(e) Voluntary Participation.--Nothing in this paragraph
shall be construed as requiring the participation of an
entity in the pilot program under this section.
``(f) Evaluation on Cost and Quality of Care.--The
Secretary shall conduct an evaluation of the pilot program
under subsection (a) to study the effect of such program on
costs and quality of care. The findings of such evaluation
shall be included in the final report required under section
1152(e)(2) of the Affordable Health Care for America Act.
``(g) Study of Additional Bundling and Episode-based
Payment for Physicians' Services.--
``(1) In general.--The Secretary shall provide for a study
of and development of a plan for testing additional ways to
increase bundling of payments for physicians in connection
with an episode of care, such as in connection with
outpatient hospital services or services rendered in
physicians' offices, other than those provided under the
pilot program.
``(2) Application.--The Secretary may implement such a plan
through a demonstration program.''.
(2) Conforming amendment.--Section 1866C(b) of the Social
Security Act (42 U.S.C. 1395cc-3(b)) is amended by striking
``The Secretary'' and inserting ``Subject to section 1866D,
the Secretary''.

SEC. 1153. HOME HEALTH PAYMENT UPDATE FOR 2010.

Section 1895(b)(3)(B)(ii) of the Social Security Act (42
U.S.C. 1395fff(b)(3)(B)(ii)) is amended--
(1) in subclause (IV), by striking ``and'';
(2) by redesignating subclause (V) as subclause (VII); and
(3) by inserting after subclause (IV) the following new
subclauses:

``(V) 2007, 2008, and 2009, subject to clause (v), the home
health market basket percentage increase;
``(VI) 2010, subject to clause (v), 0 percent; and''.

SEC. 1154. PAYMENT ADJUSTMENTS FOR HOME HEALTH CARE.

(a) Acceleration of Adjustment for Case Mix Changes.--
Section 1895(b)(3)(B) of the Social Security Act (42 U.S.C.
1395fff(b)(3)(B)) is amended--
(1) in clause (iv), by striking ``Insofar as'' and
inserting ``Subject to clause (vi), insofar as''; and
(2) by adding at the end the following new clause:
``(vi) Special rule for case mix changes for 2011.--

``(I) In general.--With respect to the case mix adjustments
established in section 484.220(a) of title 42, Code of
Federal Regulations, the Secretary shall apply, in 2010, the
adjustment established in paragraph (3) of such section for
2011, in addition to applying the adjustment established in
paragraph (2) for 2010.
``(II) Construction.--Nothing in this clause shall be
construed as limiting the amount of adjustment for case mix
for 2010 or 2011 if more recent data indicate an appropriate
adjustment that is greater than the amount established in the
section described in subclause (I).''.

(b) Rebasing Home Health Prospective Payment Amount.--
Section 1895(b)(3)(A) of the Social Security Act (42 U.S.C.
1395fff(b)(3)(A)) is amended--
(1) in clause (i)--
(A) in subclause (III), by inserting ``and before 2011''
after ``after the period described in subclause (II)''; and
(B) by inserting after subclause (III) the following new
subclauses:

``(IV) Subject to clause (iii)(I), for 2011, such amount
(or amounts) shall be adjusted by a uniform percentage
determined to be appropriate by the Secretary based on
analysis of factors such as changes in the average number and
types of visits in an episode, the change in intensity of
visits in an episode, growth in cost per episode, and other
factors that the Secretary considers to be relevant.
``(V) Subject to clause (iii)(II), for a year after 2011,
such a amount (or amounts) shall be equal to the amount (or
amounts) determined under this clause for the previous year,
updated under subparagraph (B).''; and

(2) by adding at the end the following new clause:
``(iii) Special rule in case of inability to effect timely
rebasing.--

``(I) Application of proxy amount for 2011.--If the
Secretary is not able to compute the amount (or amounts)
under clause (i)(IV) so as to permit, on a timely basis, the
application of such clause for 2011, the Secretary shall
substitute for such amount (or amounts) 95 percent of the
amount (or amounts) that would otherwise be specified under
clause (i)(III) if it applied for 2011.
``(II) Adjustment for subsequent years based on data.--If
the Secretary applies subclause (I), the Secretary before
July 1, 2011, shall compare the amount (or amounts) applied
under such subclause with the amount (or amounts) that should
have been applied under clause (i)(IV). The Secretary shall
decrease or increase the prospective payment amount (or
amounts) under clause (i)(V) for 2012 (or, at the Secretary's
discretion, over a period of several years beginning with
2012) by the amount (if any) by which the amount (or amounts)
applied under subclause (I) is greater or less, respectively,
than the amount (or amounts) that should have been applied
under clause (i)(IV).''.

SEC. 1155. INCORPORATING PRODUCTIVITY IMPROVEMENTS INTO
MARKET BASKET UPDATE FOR HOME HEALTH SERVICES.

(a) In General.--Section 1895(b)(3)(B) of the Social
Security Act (42 U.S.C. 1395fff(b)(3)(B)) is amended--
(1) in clause (iii), by inserting ``(including being
subject to the productivity adjustment described in section
1886(b)(3)(B)(iii)(II))'' after ``in the same manner''; and
(2) in clause (v)(I), by inserting ``(but not below 0)''
after ``reduced''.
(b) Effective Date.--The amendments made by subsection (a)
shall apply to home health market basket percentage increases
for years beginning with 2011.

SEC. 1155A. MEDPAC STUDY ON VARIATION IN HOME HEALTH MARGINS.

(a) In General.--The Medicare Payment Advisory Commission
shall conduct a study regarding variation in performance of
home health agencies in an effort to explain variation in
Medicare margins for such agencies. Such study shall include
an examination of at least the following issues:
(1) The demographic characteristics of individuals served
and the geographic distribution associated with
transportation costs.
(2) The characteristics of such agencies, such as whether
such agencies operate 24 hours each day, provide charity
care, or are part of an integrated health system.
(3) The socio-economic status of individuals served, such
as the proportion of such individuals who are dually eligible
for Medicare and Medicaid benefits.
(4) The presence of severe and or chronic disease or
disability in individuals served, as evidenced by multiple
discontinuous home health episodes with a high number of
visits per episode.
(5) The differences in services provided, such as therapy
and non-therapy services.
(b) Report.--Not later than June 1, 2011, the Commission
shall submit a report to the Congress on the results of the
study conducted under subsection (a) and shall include

[[Page H12677]]

in the report the Commission's conclusions and
recommendations, if appropriate, regarding each of the issues
described in paragraphs (1), (2) and (3) of such subsection.

SEC. 1155B. PERMITTING HOME HEALTH AGENCIES TO ASSIGN THE
MOST APPROPRIATE SKILLED SERVICE TO MAKE THE
INITIAL ASSESSMENT VISIT UNDER A MEDICARE HOME
HEALTH PLAN OF CARE FOR REHABILITATION CASES.

(a) In General.--Notwithstanding section 484.55(a)(2) of
title 42 of the Code of Federal Regulations or any other
provision of law, a home health agency may determine the most
appropriate skilled therapist to make the initial assessment
visit for an individual who is referred (and may be eligible)
for home health services under title XVIII of the Social
Security Act but who does not require skilled nursing care as
long as the skilled service (for which that therapist is
qualified to provide the service) is included as part of the
plan of care for home health services for such individual.
(b) Rule of Construction.--Nothing in subsection (a) shall
be construed to provide for initial eligibility for coverage
of home health services under title XVIII of the Social
Security Act on the basis of a need for occupational therapy.

SEC. 1156. LIMITATION ON MEDICARE EXCEPTIONS TO THE
PROHIBITION ON CERTAIN PHYSICIAN REFERRALS MADE
TO HOSPITALS.

(a) In General.--Section 1877 of the Social Security Act
(42 U.S.C. 1395nn) is amended--
(1) in subsection (d)(2)--
(A) in subparagraph (A), by striking ``and'' at the end;
(B) in subparagraph (B), by striking the period at the end
and inserting ``; and''; and
(C) by adding at the end the following new subparagraph:
``(C) in the case where the entity is a hospital, the
hospital meets the requirements of paragraph (3)(D).'';
(2) in subsection (d)(3)--
(A) in subparagraph (B), by striking ``and'' at the end;
(B) in subparagraph (C), by striking the period at the end
and inserting ``; and''; and
(C) by adding at the end the following new subparagraph:
``(D) the hospital meets the requirements described in
subsection (i)(1).'';
(3) by amending subsection (f) to read as follows:
``(f) Reporting and Disclosure Requirements.--
``(1) In general.--Each entity providing covered items or
services for which payment may be made under this title shall
provide the Secretary with the information concerning the
entity's ownership, investment, and compensation
arrangements, including--
``(A) the covered items and services provided by the
entity, and
``(B) the names and unique physician identification numbers
of all physicians with an ownership or investment interest
(as described in subsection (a)(2)(A)), or with a
compensation arrangement (as described in subsection
(a)(2)(B)), in the entity, or whose immediate relatives have
such an ownership or investment interest or who have such a
compensation relationship with the entity.
Such information shall be provided in such form, manner, and
at such times as the Secretary shall specify. The requirement
of this subsection shall not apply to designated health
services provided outside the United States or to entities
which the Secretary determines provide services for which
payment may be made under this title very infrequently.
``(2) Requirements for hospitals with physician ownership
or investment.--In the case of a hospital that meets the
requirements described in subsection (i)(1), the hospital
shall--
``(A) submit to the Secretary an initial report, and
periodic updates at a frequency determined by the Secretary,
containing a detailed description of the identity of each
physician owner and physician investor and any other owners
or investors of the hospital;
``(B) require that any referring physician owner or
investor discloses to the individual being referred, by a
time that permits the individual to make a meaningful
decision regarding the receipt of services, as determined by
the Secretary, the ownership or investment interest, as
applicable, of such referring physician in the hospital; and
``(C) disclose the fact that the hospital is partially or
wholly owned by one or more physicians or has one or more
physician investors--
``(i) on any public website for the hospital; and
``(ii) in any public advertising for the hospital.
The information to be reported or disclosed under this
paragraph shall be provided in such form, manner, and at such
times as the Secretary shall specify. The requirements of
this paragraph shall not apply to designated health services
furnished outside the United States or to entities which the
Secretary determines provide services for which payment may
be made under this title very infrequently.
``(3) Publication of information.--The Secretary shall
publish, and periodically update, the information submitted
by hospitals under paragraph (2)(A) on the public Internet
website of the Centers for Medicare & Medicaid Services.'';
(4) by amending subsection (g)(5) to read as follows:
``(5) Failure to report or disclose information.--
``(A) Reporting.--Any person who is required, but fails, to
meet a reporting requirement of paragraphs (1) and (2)(A) of
subsection (f) is subject to a civil money penalty of not
more than $10,000 for each day for which reporting is
required to have been made.
``(B) Disclosure.--Any physician who is required, but
fails, to meet a disclosure requirement of subsection
(f)(2)(B) or a hospital that is required, but fails, to meet
a disclosure requirement of subsection (f)(2)(C) is subject
to a civil money penalty of not more than $10,000 for each
case in which disclosure is required to have been made.
``(C) Application.--The provisions of section 1128A (other
than the first sentence of subsection (a) and other than
subsection (b)) shall apply to a civil money penalty under
subparagraphs (A) and (B) in the same manner as such
provisions apply to a penalty or proceeding under section
1128A(a).''; and
(5) by adding at the end the following new subsection:
``(i) Requirements To Qualify for Rural Provider and
Hospital Ownership Exceptions to Self-referral Prohibition.--
``(1) Requirements described.--For purposes of subsection
(d)(3)(D), the requirements described in this paragraph are
as follows:
``(A) Provider agreement.--The hospital had--
``(i) physician ownership or investment on January 1, 2009;
and
``(ii) a provider agreement under section 1866 in effect on
such date.
``(B) Prohibition on physician ownership or investment.--
The percentage of the total value of the ownership or
investment interests held in the hospital, or in an entity
whose assets include the hospital, by physician owners or
investors in the aggregate does not exceed such percentage as
of the date of enactment of this subsection.
``(C) Prohibition on expansion of facility capacity.--
Except as provided in paragraph (2), the number of operating
rooms, procedure rooms, or beds of the hospital at any time
on or after the date of the enactment of this subsection are
no greater than the number of operating rooms, procedure
rooms, or beds, respectively, as of such date.
``(D) Ensuring bona fide ownership and investment.--
``(i) Any ownership or investment interests that the
hospital offers to a physician are not offered on more
favorable terms than the terms offered to a person who is not
in a position to refer patients or otherwise generate
business for the hospital.
``(ii) The hospital (or any investors in the hospital) does
not directly or indirectly provide loans or financing for any
physician owner or investor in the hospital.
``(iii) The hospital (or any investors in the hospital)
does not directly or indirectly guarantee a loan, make a
payment toward a loan, or otherwise subsidize a loan, for any
physician owner or investor or group of physician owners or
investors that is related to acquiring any ownership or
investment interest in the hospital.
``(iv) Ownership or investment returns are distributed to
each owner or investor in the hospital in an amount that is
directly proportional to the ownership or investment interest
of such owner or investor in the hospital.
``(v) The investment interest of the owner or investor is
directly proportional to the owner's or investor's capital
contributions made at the time the ownership or investment
interest is obtained.
``(vi) Physician owners and investors do not receive,
directly or indirectly, any guaranteed receipt of or right to
purchase other business interests related to the hospital,
including the purchase or lease of any property under the
control of other owners or investors in the hospital or
located near the premises of the hospital.
``(vii) The hospital does not offer a physician owner or
investor the opportunity to purchase or lease any property
under the control of the hospital or any other owner or
investor in the hospital on more favorable terms than the
terms offered to a person that is not a physician owner or
investor.
``(viii) The hospital does not condition any physician
ownership or investment interests either directly or
indirectly on the physician owner or investor making or
influencing referrals to the hospital or otherwise generating
business for the hospital.
``(E) Patient safety.--In the case of a hospital that does
not offer emergency services, the hospital has the capacity
to--
``(i) provide assessment and initial treatment for medical
emergencies; and
``(ii) if the hospital lacks additional capabilities
required to treat the emergency involved, refer and transfer
the patient with the medical emergency to a hospital with the
required capability.
``(F) Limitation on application to certain converted
facilities.--The hospital was not converted from an
ambulatory surgical center to a hospital on or after the date
of enactment of this subsection.
``(2) Exception to prohibition on expansion of facility
capacity.--
``(A) Process.--
``(i) Establishment.--The Secretary shall establish and
implement a process under which a hospital may apply for an
exception from the requirement under paragraph (1)(C).
``(ii) Opportunity for community input.--The process under
clause (i) shall provide persons and entities in the
community in

[[Page H12678]]

which the hospital applying for an exception is located with
the opportunity to provide input with respect to the
application.
``(iii) Timing for implementation.--The Secretary shall
implement the process under clause (i) on the date that is
one month after the promulgation of regulations described in
clause (iv).
``(iv) Regulations.--Not later than the first day of the
month beginning 18 months after the date of the enactment of
this subsection, the Secretary shall promulgate regulations
to carry out the process under clause (i). The Secretary may
issue such regulations as interim final regulations.
``(B) Frequency.--The process described in subparagraph (A)
shall permit a hospital to apply for an exception up to once
every 2 years.
``(C) Permitted increase.--
``(i) In general.--Subject to clause (ii) and subparagraph
(D), a hospital granted an exception under the process
described in subparagraph (A) may increase the number of
operating rooms, procedure rooms, or beds of the hospital
above the baseline number of operating rooms, procedure
rooms, or beds, respectively, of the hospital (or, if the
hospital has been granted a previous exception under this
paragraph, above the number of operating rooms, procedure
rooms, or beds, respectively, of the hospital after the
application of the most recent increase under such an
exception).
``(ii) 100 percent increase limitation.--The Secretary
shall not permit an increase in the number of operating
rooms, procedure rooms, or beds of a hospital under clause
(i) to the extent such increase would result in the number of
operating rooms, procedure rooms, or beds of the hospital
exceeding 200 percent of the baseline number of operating
rooms, procedure rooms, or beds of the hospital.
``(iii) Baseline number of operating rooms, procedure
rooms, or beds.--In this paragraph, the term `baseline number
of operating rooms, procedure rooms, or beds' means the
number of operating rooms, procedure rooms, or beds of a
hospital as of the date of enactment of this subsection.
``(D) Increase limited to facilities on the main campus of
the hospital.--Any increase in the number of operating rooms,
procedure rooms, or beds of a hospital pursuant to this
paragraph may only occur in facilities on the main campus of
the hospital.
``(E) Conditions for approval of an increase in facility
capacity.--The Secretary may grant an exception under the
process described in subparagraph (A) only to a hospital
described in subparagraph (F) or a hospital--
``(i) that is located in a county in which the percentage
increase in the population during the most recent 5-year
period for which data are available is estimated to be at
least 150 percent of the percentage increase in the
population growth of the State in which the hospital is
located during that period, as estimated by Bureau of the
Census and available to the Secretary;
``(ii) whose annual percent of total inpatient admissions
that represent inpatient admissions under the program under
title XIX is estimated to be equal to or greater than the
average percent with respect to such admissions for all
hospitals located in the county in which the hospital is
located;
``(iii) that does not discriminate against beneficiaries of
Federal health care programs and does not permit physicians
practicing at the hospital to discriminate against such
beneficiaries;
``(iv) that is located in a State in which the average bed
capacity in the State is estimated to be less than the
national average bed capacity;
``(v) that has an average bed occupancy rate that is
estimated to be greater than the average bed occupancy rate
in the State in which the hospital is located; and
``(vi) that meets other conditions as determined by the
Secretary.
``(F) Special rule for a high medicaid facility.--A
hospital described in this subparagraph is a hospital that--
``(i) with respect to each of the 3 most recent cost
reporting periods for which data are available, has an annual
percent of total inpatient admissions that represent
inpatient admissions under the program under title XIX that
is determined by the Secretary to be greater than such
percent with respect to such admissions for any other
hospital located in the county in which the hospital is
located; and
``(ii) meets the conditions described in clauses (iii) and
(vi) of subparagraph (E).
``(G) Procedure rooms.--In this subsection, the term
`procedure rooms' includes rooms in which catheterizations,
angiographies, angiograms, and endoscopies are furnished, but
such term shall not include emergency rooms or departments
(except for rooms in which catheterizations, angiographies,
angiograms, and endoscopies are furnished).
``(H) Publication of final decisions.--Not later than 120
days after receiving a complete application under this
paragraph, the Secretary shall publish on the public Internet
website of the Centers for Medicare & Medicaid Services the
final decision with respect to such application.
``(I) Limitation on review.--There shall be no
administrative or judicial review under section 1869, section
1878, or otherwise of the exception process under this
paragraph, including the establishment of such process, and
any determination made under such process.
``(3) Physician owner or investor defined.--For purposes of
this subsection and subsection (f)(2), the term `physician
owner or investor' means a physician (or an immediate family
member of such physician) with a direct or an indirect
ownership or investment interest in the hospital.
``(4) Patient safety requirement.--In the case of a
hospital to which the requirements of paragraph (1) apply,
insofar as the hospital admits a patient and does not have
any physician available on the premises 24 hours per day, 7
days per week, before admitting the patient--
``(A) the hospital shall disclose such fact to the patient;
and
``(B) following such disclosure, the hospital shall receive
from the patient a signed acknowledgment that the patient
understands such fact.
``(5) Clarification.--Nothing in this subsection shall be
construed as preventing the Secretary from terminating a
hospital's provider agreement if the hospital is not in
compliance with regulations pursuant to section 1866.''.
(b) Verifying Compliance.--The Secretary of Health and
Human Services shall establish policies and procedures to
verify compliance with the requirements described in
subsections (i)(1) and (i)(4) of section 1877 of the Social
Security Act, as added by subsection (a)(5). The Secretary
may use unannounced site reviews of hospitals and audits to
verify compliance with such requirements.
(c) Implementation.--
(1) Funding.--For purposes of carrying out the amendments
made by subsection (a) and the provisions of subsection (b),
in addition to funds otherwise available, out of any funds in
the Treasury not otherwise appropriated there are
appropriated to the Secretary of Health and Human Services
for the Centers for Medicare & Medicaid Services Program
Management Account $5,000,000 for each fiscal year beginning
with fiscal year 2010. Amounts appropriated under this
paragraph for a fiscal year shall be available until
expended.
(2) Administration.--Chapter 35 of title 44, United States
Code, shall not apply to the amendments made by subsection
(a) and the provisions of subsection (b).

SEC. 1157. INSTITUTE OF MEDICINE STUDY OF GEOGRAPHIC
ADJUSTMENT FACTORS UNDER MEDICARE.

(a) In General.--The Secretary of Health and Human Services
shall enter into a contract with the Institute of Medicine of
the National Academy of Science to conduct a comprehensive
empirical study, and provide recommendations as appropriate,
on the accuracy of the geographic adjustment factors
established under sections 1848(e) and 1886(d)(3)(E) of the
Social Security Act (42 U.S.C. 1395w-4(e), 1395ww(d)(3)(E)).
(b) Matters Included.--Such study shall include an
evaluation and assessment of the following with respect to
such adjustment factors:
(1) Empirical validity of the adjustment factors.
(2) Methodology used to determine the adjustment factors.
(3) Measures used for the adjustment factors, taking into
account--
(A) timeliness of data and frequency of revisions to such
data;
(B) sources of data and the degree to which such data are
representative of costs; and
(C) operational costs of providers who participate in
Medicare.
(c) Evaluation.--Such study shall, within the context of
the United States health care marketplace, evaluate and
consider the following:
(1) The effect of the adjustment factors on the level and
distribution of the health care workforce and resources,
including--
(A) recruitment and retention that takes into account
workforce mobility between urban and rural areas;
(B) ability of hospitals and other facilities to maintain
an adequate and skilled workforce; and
(C) patient access to providers and needed medical
technologies.
(2) The effect of the adjustment factors on population
health and quality of care.
(3) The effect of the adjustment factors on the ability of
providers to furnish efficient, high value care.
(d) Report.--The contract under subsection (a) shall
provide for the Institute of Medicine to submit, not later
than 1 year after the date of the enactment of this Act, to
the Secretary and the Congress a report containing results
and recommendations of the study conducted under this
section.
(e) Funding.--There are authorized to be appropriated to
carry out this section such sums as may be necessary.

SEC. 1158. REVISION OF MEDICARE PAYMENT SYSTEMS TO ADDRESS
GEOGRAPHIC INEQUITIES.

(a) Revision of Medicare Payment Systems.--Taking into
account the recommendations described in the report under
section 1157, and notwithstanding the geographic adjustments
that would otherwise apply under section 1848(e) and section
1886(d)(3)(E) of the Social Security Act (42 U.S.C. 1395w-
4(e), 1395ww(d)(3)(E)), the Secretary of Health and Human
Services shall include in proposed rules applicable to the
rulemaking cycle for payment systems for physicians' services
and inpatient hospital services under sections 1848 and
section 1886(d) of such Act, respectively, proposals (as the
Secretary determines to be appropriate) to revise the
geographic adjustment factors used in such systems. Such
proposals'

[[Page H12679]]

rules shall be contained in the next rulemaking cycle
following the submission to the Secretary of the report
described in section 1157.
(b) Payment Adjustments.--
(1) Funding for improvements.--For years before 2014, the
Secretary shall ensure that the additional expenditures
resulting from the implementation of the provisions of this
section, as estimated by the Secretary, do not exceed
$8,000,000,000, and do not exceed half of such amount in any
payment year.
(2) Hold harmless.--In carrying out this subsection--
(A) for payment years before 2014, the Secretary shall not
reduce the geographic adjustment below the factor that
applied for such payment system in the payment year before
such changes; and
(B) for payment years beginning with 2014, the Secretary
shall implement the geographic adjustment in a manner that
does not result in any net change in aggregate expenditures
under title XVIII of the Social Security Act from the amount
of such expenditures that the Secretary estimates would have
occurred if no geographic adjustment had occurred under this
section.
(c) Medicare Improvement Fund.--
(1) Amounts in the Medicare Improvement Fund under section
1898 of the Social Security Act, as amended by paragraph (2),
shall be available to the Secretary to make changes to the
geographic adjustments factors as described in subsections
(a) and (b) with respect to services furnished before January
1, 2014. No more than one-half of such amounts shall be
available with respect to services furnished in any one
payment year.
(2) Section 1898(b) of the Social Security Act (42 U.S.C.
1395iii(b)) is amended--
(A) by amending paragraph (1)(A) to read as follows:
``(A) the period beginning with fiscal year 2011 and ending
with fiscal year 2019, $8,000,000,000; and''; and
(B) by adding at the end the following new paragraph:
``(5) Adjustment for underfunding.--For fiscal year 2014 or
a subsequent fiscal year specified by the Secretary, the
amount available to the fund under subsection (a) shall be
increased by the Secretary's estimate of the amount (based on
data on actual expenditures) by which--
``(A) the additional expenditures resulting from the
implementation of subsection (a) of section 1158 of the
Affordable Health Care for America Act for the period before
fiscal year 2014, is less than
``(B) the maximum amount of funds available under
subsection (a) of such section for funding for such
expenditures.''.

SEC. 1159. INSTITUTE OF MEDICINE STUDY OF GEOGRAPHIC
VARIATION IN HEALTH CARE SPENDING AND PROMOTING
HIGH-VALUE HEALTH CARE.

(a) In General.--The Secretary of Health and Human Services
(in this section and the succeeding section referred to as
the ``Secretary'') shall enter into an agreement with the
Institute of Medicine of the National Academies (referred to
in this section as the ``Institute'') to conduct a study on
geographic variation and growth in volume and intensity of
services in per capita health care spending among the
Medicare, Medicaid, privately insured and uninsured
populations. Such study may draw on recent relevant reports
of the Institute and shall include each of the following:
(1) An evaluation of the extent and range of such variation
using various units of geographic measurement, including
micro areas within larger areas.
(2) An evaluation of the extent to which geographic
variation can be attributed to differences in input prices;
health status; practice patterns; access to medical services;
supply of medical services; socio-economic factors, including
race, ethnicity, gender, age, income and educational status;
and provider and payer organizational models.
(3) An evaluation of the extent to which variations in
spending are correlated with patient access to care,
insurance status, distribution of health care resources,
health care outcomes, and consensus-based measures of health
care quality.
(4) An evaluation of the extent to which variation can be
attributed to physician and practitioner discretion in making
treatment decisions, and the degree to which discretionary
treatment decisions are made that could be characterized as
different from the best available medical evidence.
(5) An evaluation of the extent to which variation can be
attributed to patient preferences and patient compliance with
treatment protocols.
(6) An assessment of the degree to which variation cannot
be explained by empirical evidence.
(7) For Medicare beneficiaries, An evaluation of the extent
to which variations in spending are correlated with insurance
status prior to enrollment in the Medicare program under
title XVIII of the Social Security Act, and
institutionalization status; whether beneficiaries are dually
eligible for the Medicare program and Medicaid under title
XIX of such Act; and whether beneficiaries are enrolled in
fee-for-service Medicare or Medicare Advantage.
(8) An evaluation of such other factors as the Institute
deems appropriate.
The Institute shall conduct public hearings and provide an
opportunity for comments prior to completion of the reports
under subsection (e).
(b) Recommendations.--Taking into account the findings
under subsection (a) and the changes to the payment systems
made by this Act, the Institute shall recommend changes to
payment for items and services under parts A and B of title
XVIII of the Social Security Act, for addressing variation in
Medicare per capita spending for items and services (not
including add-ons for graduate medical education,
disproportionate share payments, and health information
technology, as specified in sections 1886(d)(5)(F),
1886(d)(5)(B), 1886(h), 1848(o), and 1886(n), respectively,
of such Act) by promoting high-value care (as defined in
subsection (f)), with particular attention to high-volume,
high-cost conditions. In making such recommendations, the
Institute shall consider each of the following:
(1) Measurement and reporting on quality and population
health.
(2) Reducing fragmented and duplicative care.
(3) Promoting the practice of evidence-based medicine.
(4) Empowering patients to make value-based care decisions.
(5) Leveraging the use of health information technology.
(6) The role of financial and other incentives affecting
provision of care.
(7) Variation in input costs.
(8) The characteristics of the patient population,
including socio-economic factors (including race, ethnicity,
gender, age, income and educational status), and whether the
beneficiaries are dually eligible for the Medicare program
under title XVIII of the Social Security Act and Medicaid
under title XIX of such Act.
(9) Other topics the Institute deems appropriate.
In making such recommendations, the Institute shall consider
an appropriate phase-in that takes into account the impact of
payment changes on providers and facilities and preserves
access to care for Medicare beneficiaries.
(c) Specific Considerations.--In making the recommendations
under subsection (b), the Institute shall specifically
address whether payment systems under title XVIII of the
Social Security Act for physicians and hospitals should be
further modified to incentivize high-value care. In so doing,
the Institute shall consider the adoption of a value index
based on a composite of appropriate measures of quality and
cost that would adjust provider payments on a regional or
provider-level basis. If the Institute finds that application
of such a value index would significantly incentivize
providers to furnish high-value care, it shall make specific
recommendations on how such an index would be designed and
implemented. In so doing, it should identify specific
measures of quality and cost appropriate for use in such an
index, and include a thorough analysis (including on a
geographic basis) of how payments and spending under such
title would be affected by such an index.
(d) Additional Considerations.--The Institute shall
consider the experience of governmental and community-based
programs that promote high-value care.
(e) Reports.--
(1) Not later than April 15, 2011, the Institute shall
submit to the Secretary and each House of Congress a report
containing findings and recommendations of the study
conducted under this section.
(2) Following submission of the report under paragraph (1),
the Institute shall use the data collected and analyzed in
this section to issue a subsequent report, or series of
reports, on how best to address geographic variation or
efforts to promote high-value care for items and services
reimbursed by private insurance or other programs. Such
reports shall include a comparison to the Institute's
findings and recommendations regarding the Medicare program.
Such reports, and any recommendations, would not be subject
to the procedures outlined in section 1160.
(f) High-value Care Defined.--For purposes of this section,
the term ``high-value care'' means the efficient delivery of
high quality, evidence-based, patient-centered care.
(g) Appropriations.--There is appropriated from amounts in
the general fund of the Treasury not otherwise appropriated
$10,000,000 to carry out this section. Such sums are
authorized to remain available until expended.

SEC. 1160. IMPLEMENTATION, AND CONGRESSIONAL REVIEW, OF
PROPOSAL TO REVISE MEDICARE PAYMENTS TO PROMOTE
HIGH VALUE HEALTH CARE.

(a) Preparation and Submission of Implementation Plans.--
(1) Final implementation plan.--Not later than 240 days
after the date of receipt by the Secretary and each House of
Congress of the report under section 1159(e)(1), the
Secretary shall submit to each House of Congress a final
implementation plan describing proposed changes to payment
for items and services under parts A and B of title XVIII of
the Social Security Act (which may include payment for
inpatient and outpatient hospital services for services
furnished in PPS and PPS-exempt hospitals, physicians'
services, dialysis facility services, skilled nursing
facility services, home health services, hospice care,
clinical laboratory services, durable medical equipment, and
other items and services, but which shall exclude add-on
payments for graduate medical education, disproportionate
share payments, and health

[[Page H12680]]

information technology, as specified in sections
1886(d)(5)(F), 1886(d)(5)(B), 1886(h), 1848(o), and 1886(n),
respectively, of the Social Security Act) taking into
consideration, as appropriate, the recommendations of the
report submitted under section 1159(e)(1) and the changes to
the payment systems made by this Act. To the extent such
implementation plan requires a substantial change to the
payment system, it shall include a transition phase-in that
takes into consideration possible disruption to provider
participation in the Medicare program under title XVIII of
the Social Security Act and preserves access to care for
Medicare beneficiaries.
(2) Preliminary implementation plan.--Not later than 90
days after the date the Institute of Medicine submits to each
House of Congress the report under section 1159(e)(1), the
Secretary shall submit to each House of Congress a
preliminary version of the implementation plan provided for
under paragraph (1)(A).
(3) No increase in budget expenditures.--The Secretary
shall include with the submission of the final implementation
plan under paragraph (1) a certification by the Chief Actuary
of the Centers for Medicare & Medicaid Services that over the
initial 10-year period in which the plan is implemented, the
aggregate level of net expenditures under the Medicare
program under title XVIII of the Social Security Act will not
exceed the aggregate level of such expenditures that would
have occurred if the plan were not implemented.
(4) Waivers required.--To the extent the final
implementation plan under paragraph (1) proposes changes that
are not otherwise permitted under title XVIII of the Social
Security Act, the Secretary shall specify in the plan the
specific waivers required under such title to implement such
changes. Except as provided in subsection (c), the Secretary
is authorized to waive the requirements so specified in order
to implement such changes.
(5) Assessment of impact.--In addition, both the
preliminary and final implementation plans under this
subsection shall include a detailed assessment of the effects
of the proposed payment changes by provider or supplier type
and State relative to the payments that would otherwise
apply.
(b) Review by MedPAC and GAO.--Not later than 45 days after
the date the preliminary implementation plan is received by
each House of Congress under subsection (a)(2), the Medicare
Payment Advisory Committee and the Comptroller General of the
United States shall each evaluate such plan and submit to
each House of Congress a report containing its analysis and
recommendations regarding implementation of the plan,
including an analysis of the effects of the proposed changes
in the plan on payments and projected spending.
(c) Implementation.--
(1) In general.--The Secretary shall include, in applicable
proposed rules for the next rulemaking cycle beginning after
the Congressional action deadline, appropriate proposals to
revise payments under title XVIII of the Social Security Act
in accordance with the final implementation plan submitted
under subsection (a)(1), and the waivers specified in
subsection (a)(4) to the extent required to carry out such
plan are effective, unless a joint resolution (described in
subsection (d)(5)(A)) with respect to such plan is enacted by
not later than such deadline. If such a joint resolution is
enacted, the Secretary is not authorized to implement such
plan and the waiver authority provided under subsection
(a)(4) shall no longer be effective.
(2) Congressional action deadline.--For purposes of this
section, the term ``Congressional action deadline'' means,
with respect to a final implementation plan under subsection
(a)(1), May 31, 2012, or, if later, the date that is 145 days
after the date of receipt of such plan by each House of
Congress under subsection (a).
(d) Congressional Procedures.--
(1) Introduction.--On the day on which the final
implementation plan is received by the House of
Representatives and the Senate under subsection (a), a joint
resolution specified in paragraph (5)(A) shall be introduced
in the House of Representatives by the majority leader and
minority leader of the House of Representatives and in the
Senate by the majority leader and minority leader of the
Senate. If either House is not in session on the day on which
such a plan is received, the joint resolution with respect to
such plan shall be introduced in that House, as provided in
the preceding sentence, on the first day thereafter on which
that House is in session.
(2) Consideration in the house of representatives.--
(A) Reporting and discharge.--Any committee of the House of
Representatives to which a joint resolution introduced under
paragraph (1) is referred shall report such joint resolution
to the House not later than 50 legislative days after the
applicable date of introduction of the joint resolution. If a
committee fails to report such joint resolution within that
period, a motion to discharge the committee from further
consideration of the joint resolution shall be in order. Such
a motion shall be in order only at a time designated by the
Speaker in the legislative schedule within two legislative
days after the day on which the proponent announces an
intention to offer the motion. Notice may not be given on an
anticipatory basis. Such a motion shall not be in order after
the last committee authorized to consider the joint
resolution reports it to the House or after the House has
disposed of a motion to discharge the joint resolution. The
previous question shall be considered as ordered on the
motion to its adoption without intervening motion except 20
minutes of debate equally divided and controlled by the
proponent and an opponent. A motion to reconsider the vote by
which the motion is disposed of shall not be in order.
(B) Proceeding to consideration.--After each committee
authorized to consider a joint resolution reports such joint
resolution to the House of Representatives or has been
discharged from its consideration, a motion to proceed to
consider such joint resolution shall be in order. Such a
motion shall be in order only at a time designated by the
Speaker in the legislative schedule within two legislative
days after the day on which the proponent announces an
intention to offer the motion. Notice may not be given on an
anticipatory basis. Such a motion shall not be in order after
the House of Representatives has disposed of a motion to
proceed on the joint resolution. The previous question shall
be considered as ordered on the motion to its adoption
without intervening motion. A motion to reconsider the vote
by which the motion is disposed of shall not be in order.
(C) Consideration.--The joint resolution shall be
considered in the House and shall be considered as read. All
points of order against a joint resolution and against its
consideration are waived. The previous question shall be
considered as ordered on the joint resolution to its passage
without intervening motion except two hours of debate equally
divided and controlled by the proponent and an opponent. A
motion to reconsider the vote on passage of a joint
resolution shall not be in order.
(3) Consideration in the senate.--
(A) Reporting and discharge.--Any committee of the Senate
to which a joint resolution introduced under paragraph (1) is
referred shall report such joint resolution to the Senate
within 50 legislative days. If a committee fails to report
such joint resolution at the close of the 15th legislative
day after its receipt by the Senate, such committee shall be
automatically discharged from further consideration of such
joint resolution and such joint resolution or joint
resolutions shall be placed on the calendar. A vote on final
passage of such joint resolution shall be taken in the Senate
on or before the close of the second legislative day after
such joint resolution is reported by the committee or
committees of the Senate to which it was referred, or after
such committee or committees have been discharged from
further consideration of such joint resolution.
(B) Proceeding to consideration.--A motion in the Senate to
proceed to the consideration of a joint resolution shall be
privileged and not debatable. An amendment to such a motion
shall not be in order, nor shall it be in order to move to
reconsider the vote by which such a motion is agreed to or
disagreed to.
(C) Consideration.--
(i) Debate in the Senate on a joint resolution, and all
debatable motions and appeals in connection therewith, shall
be limited to not more than 20 hours. The time shall be
equally divided between, and controlled by, the majority
leader and the minority leader or their designees.
(ii) Debate in the Senate on any debatable motion or appeal
in connection with a joint resolution shall be limited to not
more than 1 hour, to be equally divided between, and
controlled by, the mover and the manager of the resolution,
except that in the event the manager of the joint resolution
is in favor of any such motion or appeal, the time in
opposition thereto shall be controlled by the minority leader
or a designee. Such leaders, or either of them, may, from
time under their control on the passage of a joint
resolution, allot additional time to any Senator during the
consideration of any debatable motion or appeal.
(iii) A motion in the Senate to further limit debate is not
debatable. A motion to recommit a joint resolution is not in
order.
(4) Rules relating to senate and house of
representatives.--
(A) Coordination with action by other house.--If, before
the passage by one House of a joint resolution of that House,
that House receives from the other House a joint resolution,
then the following procedures shall apply:
(i) The joint resolution of the other House shall not be
referred to a committee.
(ii) With respect to the joint resolution of the House
receiving the resolution, the procedure in that House shall
be the same as if no such joint resolution had been received
from the other House; but the vote on passage shall be on the
joint resolution of the other House.
(B) Treatment of companion measures.--If, following passage
of a joint resolution in the Senate, the Senate then receives
the companion measure from the House of Representatives, the
companion measure shall not be debatable.
(C) Rules of house of representatives and senate.--This
paragraph and the preceding paragraphs are enacted by
Congress--
(i) as an exercise of the rulemaking power of the Senate
and House of Representatives, respectively, and as such it is
deemed a part of the rules of each House, respectively, but
applicable only with respect to the procedure to be followed
in that House in the case of a joint resolution, and it
supersedes other

[[Page H12681]]

rules only to the extent that it is inconsistent with such
rules; and
(ii) with full recognition of the constitutional right of
either House to change the rules (so far as relating to the
procedure of that House) at any time, in the same manner, and
to the same extent as in the case of any other rule of that
House.
(5) Definitions.--In this section:
(A) Joint resolution.--The term ``joint resolution'' means
only a joint resolution--
(i) which does not have a preamble;
(ii) the title of which is as follows: ``Joint resolution
disapproving a Medicare final implementation plan of the
Secretary of Health and Human Services submitted under
section 1160(a) of the Affordable Health Care for America
Act''; and
(iii) the sole matter after the resolving clause of which
is as follows: ``That the Congress disapproves the final
implementation plan of the Secretary of Health and Human
Services transmitted to the Congress on----------.'', the
blank space being filled with the appropriate date.
(B) Legislative day.--The term ``legislative day'' means
any calendar day excluding any day on which that House was
not in session.
(6) Budgetary treatment.--For the purposes of consideration
of a joint resolution, the Chairmen of the House of
Representatives and Senate Committees on the Budget shall
exclude from the evaluation of the budgetary effects of the
measure, any such effects that are directly attributable to
disapproving a Medicare final implementation plan of the
Secretary submitted under subsection (a).

Subtitle D--Medicare Advantage Reforms

PART 1--PAYMENT AND ADMINISTRATION

SEC. 1161. PHASE-IN OF PAYMENT BASED ON FEE-FOR-SERVICE
COSTS; QUALITY BONUS PAYMENTS.

(a) Phase-in of Payment Based on Fee-for-service Costs.--
Section 1853 of the Social Security Act (42 U.S.C. 1395w-23)
is amended--
(1) in subsection (j)(1)(A)--
(A) by striking ``beginning with 2007'' and inserting ``for
2007, 2008, 2009, and 2010''; and
(B) by inserting after ``(k)(1)'' the following: ``, or,
beginning with 2011, \1/12\ of the blended benchmark amount
determined under subsection (n)(1)''; and
(2) by adding at the end the following new subsection:
``(n) Determination of Blended Benchmark Amount.--
``(1) In general.--For purposes of subsection (j), subject
to paragraphs (3) and (4), the term `blended benchmark
amount' means for an area--
``(A) for 2011 the sum of--
``(i) \2/3\ of the applicable amount (as defined in
subsection (k)) for the area and year; and
``(ii) \1/3\ of the amount specified in paragraph (2) for
the area and year;
``(B) for 2012 the sum of--
``(i) \1/3\ of the applicable amount for the area and year;
and
``(ii) \2/3\ of the amount specified in paragraph (2) for
the area and year; and
``(C) for a subsequent year the amount specified in
paragraph (2) for the area and year.
``(2) Specified amount.--The amount specified in this
paragraph for an area and year is the amount specified in
subsection (c)(1)(D)(i) for the area and year adjusted (in a
manner specified by the Secretary) to take into account the
phase-out in the indirect costs of medical education from
capitation rates described in subsection (k)(4).
``(3) Fee-for-service payment floor.--In no case shall the
blended benchmark amount for an area and year be less than
the amount specified in paragraph (2).
``(4) Exception for pace plans.--This subsection shall not
apply to payments to a PACE program under section 1894.''.
(b) Quality Bonus Payments.--Section 1853 of the Social
Security Act (42 U.S.C. 1395w–23), as amended by
subsection (a), is amended--
(1) in subsection (j), by inserting ``subject to subsection
(o),'' after ``For purposes of this part,''; and
(2) by adding at the end the following new subsection:
``(o) Quality Based Payment Adjustment.--
``(1) In general.--In the case of a qualifying plan in a
qualifying county with respect to a year beginning with 2011,
the blended benchmark amount under subsection (n)(1) shall be
increased--
``(A) for 2011, by 1.5 percent;
``(B) for 2012, by 3.0 percent; and
``(C) for a subsequent year, by 5.0 percent.
``(2) Qualifying plan and qualifying county defined.--For
purposes of this subsection:
``(A) Qualifying plan.--The term `qualifying plan' means,
for a year and subject to paragraph (4), a plan that, in a
preceding year specified by the Secretary, had a quality
ranking (based on the quality ranking system established by
the Centers for Medicare & Medicaid Services for Medicare
Advantage plans) of 4 stars or higher.
``(B) Qualifying county.--The term `qualifying county'
means, for a year, a county--
``(i) that ranked within the lowest third of counties in
the amount specified in subsection (n)(2) for a year
specified by the Secretary; and
``(ii) for which, as of June of a year specified by the
Secretary, of the Medicare Advantage eligible individuals
residing in the county at least 20 percent of such
individuals were enrolled in Medicare Advantage plans.
``(3) Determinations of quality.--
``(A) Quality performance.--The Secretary shall provide for
the computation of a quality performance score for each
Medicare Advantage plan to be applied for each year.
``(B) Computation of score.--
``(i) Quality performance sore.--For years before a year
specified by the Secretary, the quality performance score for
a Medicare Advantage plan shall be computed based on a blend
(as designated by the Secretary) of the plan's performance
on--

``(I) HEDIS effectiveness of care quality measures;
``(II) CAHPS quality measures; and
``(III) such other measures of clinical quality as the
Secretary may specify.

Such measures shall be risk-adjusted as the Secretary deems
appropriate.
``(ii) Establishment of outcome-based measures.--By not
later than for a year specified by the Secretary, the
Secretary shall implement reporting requirements for quality
under this section on measures selected under clause (iii)
that reflect the outcomes of care experienced by individuals
enrolled in Medicare Advantage plans (in addition to measures
described in clause (i)). Such measures may include--

``(I) measures of rates of admission and readmission to a
hospital;
``(II) measures of prevention quality, such as those
established by the Agency for Healthcare Research and Quality
(that include hospital admission rates for specified
conditions);
``(III) measures of patient mortality and morbidity
following surgery;
``(IV) measures of health functioning (such as limitations
on activities of daily living) and survival for patients with
chronic diseases;
``(V) measures of patient safety; and
``(VI) other measure of outcomes and patient quality of
life as determined by the Secretary.

Such measures shall be risk-adjusted as the Secretary deems
appropriate. In determining the quality measures to be used
under this clause, the Secretary shall take into
consideration the recommendations of the Medicare Payment
Advisory Commission in its report to Congress under section
168 of the Medicare Improvements for Patients and Providers
Act of 2008 (Public Law 110-275) and shall provide preference
to measures collected on and comparable to measures used in
measuring quality under parts A and B.
``(iii) Rules for selection of measures.--The Secretary
shall select measures for purposes of clause (ii) consistent
with the following:

``(I) The Secretary shall provide preference to clinical
quality measures that have been endorsed by the entity with a
contract with the Secretary under section 1890(a).
``(II) Prior to any measure being selected under this
clause, the Secretary shall publish in the Federal Register
such measure and provide for a period of public comment on
such measure.

``(iv) Transitional use of blend.--For payments for years
specified by the Secretary, the Secretary may compute the
quality performance score for a Medicare Advantage plan based
on a blend of the measures specified in clause (i) and the
measures described in clause (ii) and selected under clause
(iii).
``(v) Use of quality outcomes measures.--For payments
beginning with a year specified by the Secretary (beginning
after the years specified for section (iv)), the
preponderance of measures used under this paragraph shall be
quality outcomes measures described in clause (ii) and
selected under clause (iii).
``(C) Reporting of data.--Each Medicare Advantage
organization shall provide for the reporting to the Secretary
of quality performance data described in this paragraph (in
order to determine a quality performance score under this
paragraph) in such time and manner as the Secretary shall
specify.
``(4) Notification.--The Secretary, in the annual
announcement required under subsection (b)(1)(B) in 2010 and
each succeeding year, shall notify the Medicare Advantage
organization that is offering a qualifying plan in a
qualifying county of such identification for the year. The
Secretary shall provide for publication on the website for
the Medicare program of the information described in the
previous sentence.
``(5) Authority to disqualify deficient plans.--The
Secretary may determine that a Medicare Advantage plan is not
a qualifying plan if the Secretary has identified
deficiencies in the plan's compliance with rules for Medicare
Advantage plans under this part.''.

SEC. 1162. AUTHORITY FOR SECRETARIAL CODING INTENSITY
ADJUSTMENT AUTHORITY.

Section 1853(a)(1)(C)(ii) of the Social Security Act (42
U.S.C. 1395w-23(a)(1)(C)(ii)) is amended--
(1) in the matter before subclause (I), by striking
``through 2010'' and inserting ``and each subsequent year'';
and
(2) in subclause (II)--
(A) by inserting ``periodically'' before ``conduct an
analysis'';
(B) by inserting ``on a timely basis'' after ``are
incorporated''; and
(C) by striking ``only for 2008, 2009, and 2010'' and
inserting ``for 2008 and subsequent years''.

[[Page H12682]]

SEC. 1163. SIMPLIFICATION OF ANNUAL BENEFICIARY ELECTION
PERIODS.

(a) 2-Week Processing Period for Annual Enrollment Period
(AEP).--Paragraph (3)(B) of section 1851(e) of the Social
Security Act (42 U.S.C. 1395w-21(e)) is amended--
(1) by striking ``and'' at the end of clause (iii);
(2) in clause (iv)--
(A) by striking ``and succeeding years'' and inserting ``,
2008, 2009, and 2010''; and
(B) by striking the period at the end and inserting ``;
and''; and
(3) by adding at the end the following new clause:
``(v) with respect to 2011 and succeeding years, the period
beginning on November 1 and ending on December 15 of the year
before such year.''.
(b) Elimination of 3-Month Additional Open Enrollment
Period (OEP).--Effective for plan years beginning with 2011,
paragraph (2) of such section is amended by striking
subparagraph (C).

SEC. 1164. EXTENSION OF REASONABLE COST CONTRACTS.

Section 1876(h)(5)(C) of the Social Security Act (42 U.S.C.
1395mm(h)(5)(C)) is amended--
(1) in clause (ii), by striking ``January 1, 2010'' and
inserting ``January 1, 2012''; and
(2) in clause (iii), by striking ``the service area for the
year'' and inserting ``the portion of the plan's service area
for the year that is within the service area of a reasonable
cost reimbursement contract''.

SEC. 1165. LIMITATION OF WAIVER AUTHORITY FOR EMPLOYER GROUP
PLANS.

(a) In General.--The first sentence of each of paragraphs
(1) and (2) of section 1857(i) of the Social Security Act (42
U.S.C. 1395w-27(i)) is amended by inserting before the period
at the end the following: ``, but only if 90 percent of the
Medicare Advantage eligible individuals enrolled under such
plan reside in a county in which the MA organization offers
an MA local plan''.
(b) Effective Date.--The amendment made by subsection (a)
shall apply for plan years beginning on or after January 1,
2011, and shall not apply to plans which were in effect as of
December 31, 2010.

SEC. 1166. IMPROVING RISK ADJUSTMENT FOR PAYMENTS.

(a) Report to Congress.--Not later than 1 year after the
date of the enactment of this Act, the Secretary of Health
and Human Services shall submit to Congress a report that
evaluates the adequacy of the risk adjustment system under
section 1853(a)(1)(C) of the Social Security Act (42 U.S.C.
1395-23(a)(1)(C)) in predicting costs for beneficiaries with
chronic or co-morbid conditions, beneficiaries dually-
eligible for Medicare and Medicaid, and non-Medicaid eligible
low-income beneficiaries; and the need and feasibility of
including further gradations of diseases or conditions and
multiple years of beneficiary data.
(b) Improvements to Risk Adjustment.--Not later than
January 1, 2012, the Secretary shall implement necessary
improvements to the risk adjustment system under section
1853(a)(1)(C) of the Social Security Act (42 U.S.C. 1395-
23(a)(1)(C)), taking into account the evaluation under
subsection (a).

SEC. 1167. ELIMINATION OF MA REGIONAL PLAN STABILIZATION
FUND.

(a) In General.--Section 1858 of the Social Security Act
(42 U.S.C. 1395w-27a) is amended by striking subsection (e).
(b) Transition.--Any amount contained in the MA Regional
Plan Stabilization Fund as of the date of the enactment of
this Act shall be transferred to the Federal Supplementary
Medical Insurance Trust Fund.

SEC. 1168. STUDY REGARDING THE EFFECTS OF CALCULATING
MEDICARE ADVANTAGE PAYMENT RATES ON A REGIONAL
AVERAGE OF MEDICARE FEE FOR SERVICE RATES.

(a) In General.--The Administrator of the Centers for
Medicare and Medicaid Services shall conduct a study to
determine the potential effects of calculating Medicare
Advantage payment rates on a more aggregated geographic basis
(such as metropolitan statistical areas or other regional
delineations) rather than using county boundaries. In
conducting such study, the Administrator shall consider the
effect of such alternative geographic basis on the following:
(1) The quality of care received by Medicare Advantage
enrollees.
(2) The networks of Medicare Advantage plans, including any
implications for providers contracting with Medicare
Advantage plans.
(3) The predictability of benchmark amounts for Medicare
advantage plans.
(b) Consultations.--In conducting the study, the
Administrator shall consult with the following:
(1) Experts in health care financing.
(2) Representatives of foundations and other nonprofit
entities that have conducted or supported research on
Medicare financing issues.
(3) Representatives from Medicare Advantage plans.
(4) Such other entities or people as determined by the
Secretary.
(c) Report.--Not later than one year after the date of the
enactment of this Act, the Administrator shall transmit a
report to the Congress on the study conducted under this
section. The report shall contain a detailed statement of
findings and conclusions of the study, together with its
recommendations for such legislation and administrative
actions as the Administrator considers appropriate.

PART 2--BENEFICIARY PROTECTIONS AND ANTI-FRAUD

SEC. 1171. LIMITATION ON COST-SHARING FOR INDIVIDUAL HEALTH
SERVICES.

(a) In General.--Section 1852(a)(1) of the Social Security
Act (42 U.S.C. 1395w-22(a)(1)) is amended--
(1) in subparagraph (A), by inserting before the period at
the end the following: ``with cost-sharing that is no greater
(and may be less) than the cost-sharing that would otherwise
be imposed under such program option'';
(2) in subparagraph (B)(i), by striking ``or an actuarially
equivalent level of cost-sharing as determined in this
part''; and
(3) by amending clause (ii) of subparagraph (B) to read as
follows:
``(ii) Permitting use of flat copayment or per diem rate.--
Nothing in clause (i) shall be construed as prohibiting a
Medicare Advantage plan from using a flat copayment or per
diem rate, in lieu of the cost-sharing that would be imposed
under part A or B, so long as the amount of the cost-sharing
imposed does not exceed the amount of the cost-sharing that
would be imposed under the respective part if the individual
were not enrolled in a plan under this part.''.
(b) Limitation for Dual Eligibles and Qualified Medicare
Beneficiaries.--Section 1852(a)(7) of such Act is amended to
read as follows:
``(7) Limitation on cost-sharing for dual eligibles and
qualified medicare beneficiaries.--In the case of a
individual who is a full-benefit dual eligible individual (as
defined in section 1935(c)(6)) or a qualified medicare
beneficiary (as defined in section 1905(p)(1)) who is
enrolled in a Medicare Advantage plan, the plan may not
impose cost-sharing that exceeds the amount of cost-sharing
that would be permitted with respect to the individual under
this title and title XIX if the individual were not enrolled
with such plan.''.
(c) Effective Dates.--
(1) The amendments made by subsection (a) shall apply to
plan years beginning on or after January 1, 2011.
(2) The amendments made by subsection (b) shall apply to
plan years beginning on or after January 1, 2011.

SEC. 1172. CONTINUOUS OPEN ENROLLMENT FOR ENROLLEES IN PLANS
WITH ENROLLMENT SUSPENSION.

Section 1851(e)(4) of the Social Security Act (42 U.S.C.
1395w(e)(4)) is amended--
(1) in subparagraph (C), by striking at the end ``or'';
(2) in subparagraph (D)--
(A) by inserting ``, taking into account the health or
well-being of the individual'' before the period; and
(B) by redesignating such subparagraph as subparagraph (E);
and
(3) by inserting after subparagraph (C) the following new
subparagraph:
``(D) the individual is enrolled in an MA plan and
enrollment in the plan is suspended under paragraph (2)(B) or
(3)(C) of section 1857(g) because of a failure of the plan to
meet applicable requirements; or''.

SEC. 1173. INFORMATION FOR BENEFICIARIES ON MA PLAN
ADMINISTRATIVE COSTS.

(a) Disclosure of Medical Loss Ratios and Other Expense
Data.--Section 1851 of the Social Security Act (42 U.S.C.
1395w-21), as previously amended by this subtitle, is amended
by adding at the end the following new subsection:
``(p) Publication of Medical Loss Ratios and Other Cost-
related Information.--
``(1) In general.--The Secretary shall publish, not later
than November 1 of each year (beginning with 2011), for each
MA plan contract, the medical loss ratio of the plan in the
previous year.
``(2) Submission of data.--
``(A) In general.--Each MA organization shall submit to the
Secretary, in a form and manner specified by the Secretary,
data necessary for the Secretary to publish the medical loss
ratio on a timely basis.
``(B) Data for 2010 and 2011.--The data submitted under
subparagraph (A) for 2010 and for 2011 shall be consistent in
content with the data reported as part of the MA plan bid in
June 2009 for 2010.
``(C) Use of standardized elements and definitions.--The
data to be submitted under subparagraph (A) relating to
medical loss ratio for a year, beginning with 2012, shall be
submitted based on the standardized elements and definitions
developed under paragraph (3).
``(3) Development of data reporting standards.--
``(A) In general.--The Secretary shall develop and
implement standardized data elements and definitions for
reporting under this subsection, for contract years beginning
with 2012, of data necessary for the calculation of the
medical loss ratio for MA plans. Not later than December 31,
2010, the Secretary shall publish a report describing the
elements and definitions so developed.
``(B) Consultation.--The Secretary shall consult with the
Health Choices Commissioner, representatives of MA
organizations, experts on health plan accounting systems, and
representatives of the National Association of Insurance
Commissioners, in the development of such data elements and
definitions.
``(4) Medical loss ratio to be defined.--For purposes of
this part, the term `medical loss ratio' has the meaning
given such term by the Secretary, taking into account the
meaning given such term by the Health

[[Page H12683]]

Choices Commissioner under section 116 of the Affordable
Health Care for America Act.''.
(b) Minimum Medical Loss Ratio.--Section 1857(e) of the
Social Security Act (42 U.S.C. 1395w-27(e)) is amended by
adding at the end the following new paragraph:
``(4) Requirement for minimum medical loss ratio.--If the
Secretary determines for a contract year (beginning with
2014) that an MA plan has failed to have a medical loss ratio
(as defined in section 1851(p)(4)) of at least .85--
``(A) the Secretary shall require the Medicare Advantage
organization offering the plan to give enrollees a rebate (in
the second succeeding contract year) of premiums under this
part (or part B or part D, if applicable) by such amount as
would provide for a benefits ratio of at least .85;
``(B) for 3 consecutive contract years, the Secretary shall
not permit the enrollment of new enrollees under the plan for
coverage during the second succeeding contract year; and
``(C) the Secretary shall terminate the plan contract if
the plan fails to have such a medical loss ratio for 5
consecutive contract years.''.

SEC. 1174. STRENGTHENING AUDIT AUTHORITY.

(a) For Part C Payments Risk Adjustment.--Section
1857(d)(1) of the Social Security Act (42 U.S.C. 1395w-
27(d)(1)) is amended by inserting after ``section 1858(c))''
the following: ``, and data submitted with respect to risk
adjustment under section 1853(a)(3)''.
(b) Enforcement of Audits and Deficiencies.--
(1) In general.--Section 1857(e) of such Act, as amended by
section 1173, is amended by adding at the end the following
new paragraph:
``(5) Enforcement of audits and deficiencies.--
``(A) Information in contract.--The Secretary shall require
that each contract with an MA organization under this section
shall include terms that inform the organization of the
provisions in subsection (d).
``(B) Enforcement authority.--The Secretary is authorized,
in connection with conducting audits and other activities
under subsection (d), to take such actions, including pursuit
of financial recoveries, necessary to address deficiencies
identified in such audits or other activities.''.
(2) Application under part d.--For provision applying the
amendment made by paragraph (1) to prescription drug plans
under part D, see section 1860D-12(b)(3)(D) of the Social
Security Act.
(c) Effective Date.--The amendments made by this section
shall take effect on the date of the enactment of this Act
and shall apply to audits and activities conducted for
contract years beginning on or after January 1, 2011.

SEC. 1175. AUTHORITY TO DENY PLAN BIDS.

(a) In General.--Section 1854(a)(5) of the Social Security
Act (42 U.S.C. 1395w-24(a)(5)) is amended by adding at the
end the following new subparagraph:
``(C) Rejection of bids.--Nothing in this section shall be
construed as requiring the Secretary to accept any or every
bid by an MA organization under this subsection.''.
(b) Application Under Part D.--Section 1860D-11(d) of such
Act (42 U.S.C. 1395w-111(d)) is amended by adding at the end
the following new paragraph:
``(3) Rejection of bids.--Paragraph (5)(C) of section
1854(a) shall apply with respect to bids under this section
in the same manner as it applies to bids by an MA
organization under such section.''.
(c) Effective Date.--The amendments made by this section
shall apply to bids for contract years beginning on or after
January 1, 2011.

SEC. 1175A. STATE AUTHORITY TO ENFORCE STANDARDIZED MARKETING
REQUIREMENTS.

Section 1856(b)(3) of the Social Security Act (42 U.S.C.
1395w-26(b)(3)) is amended--
(1) by striking ``The standards'' and inserting ``(A) in
general.--The standards'' with appropriate indentation that
is the same as for the subparagraph (B) added by paragraph
(2); and
(2) by adding at the end the following new subparagraph:
``(B) Enforcement of federal standards permitted.--
``(i) In general.--Subject to the subsequent provision of
this subparagraph, nothing in this title shall be construed
to prohibit a State from conducting a market conduct
examination or from imposing civil monetary penalties, in
accordance with laws and procedures of the State, against
Medicare Advantage organizations, PDP sponsors, or agents or
brokers of such organizations or sponsors for violations of
the marketing requirements under subsections (h)(4), (h)(6),
and (j) of section 1851 and section 1857(g)(1)(E).
``(ii) Additional remedies resulting from federal-state
cooperation.--

``(I) State recommendation.--A State may recommend to the
Secretary the imposition of an intermediate sanction not
described in clause (i) (such as those available under
section 1857(g)) against a Medicare Advantage organization,
PDP sponsor, or agent or broker of such an organization or
sponsor for a violation described in such clause.
``(II) Response to recommendation.--Not later than 30 days
after receipt of a recommendation under subclause (I) from a
State, with respect to a violation described in clause (i),
the Secretary shall respond in writing to the State
indicating the progress of any investigation involving such
violation, whether the Secretary intends to pursue the
recommendation from the State, and in the case the Secretary
does not intend to pursue such recommendation, the reason for
such decision.

``(iii) Non-duplication of penalties.--In the case that an
action has been initiated against a Medicare Advantage
organization, PDP sponsor, or agent or broker of such an
organization or sponsor for a violation of a marketing
requirement under subsection (h)(4), (h)(6), or (j) of
section 1851 or section 1857(g)(1)(E)--

``(I) in the case such action has been initiated by the
Secretary, no State may bring an action under such applicable
subsection or section against such organization, sponsor,
agent, or broker with respect to such violation during the
pendency period of the action initiated by the Secretary and,
if a penalty is imposed pursuant to such action, after such
period; and
``(II) in the case such action has been initiated by a
State, the Secretary may not bring an action under such
applicable subsection or section against such organization,
sponsor, agent, or broker with respect to such violation
during the pendency period of the action initiated by the
Secretary and, if a penalty is imposed pursuant to such
action, after such period.

Nothing in this clause shall be construed as limiting the
ability of the Secretary to impose any sanction other than a
civil monetary penalty under section 1857 against a Medicare
Advantage organization, PDP sponsor, or agent or broker of
such an organization or sponsor for a violation described in
clause (i).
``(iv) Construction.--Nothing in this subparagraph shall be
construed as affecting any State authority to regulate
brokers described in this paragraph or any other conduct of a
Medicare Advantage organization or PDP sponsor.''.

PART 3--TREATMENT OF SPECIAL NEEDS PLANS

SEC. 1176. LIMITATION ON ENROLLMENT OUTSIDE OPEN ENROLLMENT
PERIOD OF INDIVIDUALS INTO CHRONIC CARE
SPECIALIZED MA PLANS FOR SPECIAL NEEDS
INDIVIDUALS.

Section 1859(f)(4) of the Social Security Act (42 U.S.C.
1395w-28(f)(4)) is amended by adding at the end the following
new subparagraph:
``(C) The plan does not enroll an individual on or after
January 1, 2011, other than--
``(i) during an annual, coordinated open enrollment period;
or
``(ii) during a special election period consisting of the
period for which the individual has a chronic condition that
qualifies the individual as an individual described in
subsection (b)(6)(B)(iii) for such plan and ending on the
date on which the individual enrolls in such a plan on the
basis of such condition.

If an individual is enrolled in such a plan on the basis of a
chronic condition and becomes eligible for another such plan
on the basis of another chronic condition, the other plan may
enroll the individual on the basis of such other chronic
condition during a special enrollment period described in
clause (ii). An individual is eligible to apply such clause
only once on the basis of any specific chronic condition.''.

SEC. 1177. EXTENSION OF AUTHORITY OF SPECIAL NEEDS PLANS TO
RESTRICT ENROLLMENT; SERVICE AREA MORATORIUM
FOR CERTAIN SNPS.

(a) In General.--Section 1859(f)(1) of the Social Security
Act (42 U.S.C. 1395w-28(f)(1)) is amended by striking
``January 1, 2011'' and inserting ``January 1, 2013 (or
January 1, 2016, in the case of a plan described in section
1177(b)(1) of the Affordable Health Care for America Act)''.
(b) Extension of Certain Plans.--
(1) Plans described.--For purposes of Section 1859(f)(1) of
the Social Security Act (42 U.S.C. 1395w-28(f)(1)), a plan
described in this paragraph is a Medicare Advantage dual
eligible special needs plan that--
(A) whose sponsoring Medicare Advantage organization, as of
the date enactment of the Affordable Health Care for America
Act, has a contract with a State Medicaid Agency that
participated in the ``Demonstrations Serving Those Dually-
Eligible for Medicare and Medicaid'' under the Medicare
program; and
(B) that has been approved by the Centers for Medicare &
Medicaid Services as a dual eligible special needs plan and
that offers integrated Medicare and Medicaid services under a
contract with the State Medicaid agency.
(2) Analysis; report.--
(A) Analysis.--The Secretary of Health and Human Services
shall provide, through a contract with an independent health
services evaluation organization, for an analysis of the
plans described in paragraph (1) with regard to the impact of
such plans on cost, quality of care, patient satisfaction,
and other subjects specified by the Secretary. Such report
also will identify statutory changes needed to simplify
access to needed services, improve coordination of benefits
and services and ensure protection for dual eligibles as
appropriate.
(B) Report.--Not later than December 31, 2011, the
Secretary shall submit to the Congress a report on the
analysis under subparagraph (A) and shall include in such
report such recommendations with regard to the treatment of
such plans as the Secretary deems appropriate.

[[Page H12684]]

(c) Extension of Service Area Moratorium for Certain
SNPs.--Section 164(c)(2) of the Medicare Improvements for
Patients and Providers Act of 2008 is amended by striking
``December 31, 2010'' and inserting ``December 31, 2012''.

SEC. 1178. EXTENSION OF MEDICARE SENIOR HOUSING PLANS.

Section 1859 of the Social Security Act (42 U.S.C. 1395w-
28) is amended by adding at the end the following new
subsection:
``(g) Special Rules for Senior Housing Facility Plans.--
``(1) In general.--Notwithstanding any other provision of
this part, in the case of a Medicare Advantage senior housing
facility plan described in paragraph (2) and for periods
before January 1, 2013--
``(A) the service area of such plan may be limited to a
senior housing facility in a geographic area;
``(B) the service area of such plan may not be expanded;
and
``(C) additional senior housing facilities may not be
serviced by such plan.
``(2) Medicare advantage senior housing facility plan
described.--For purposes of this subsection, a Medicare
Advantage senior housing facility plan is a Medicare
Advantage plan that--
``(A)(i) restricts enrollment of individuals under this
part to individuals who reside in a continuing care
retirement community (as defined in section 1852(l)(4)(B));
``(ii) provides primary care services onsite and has a
ratio of accessible providers to beneficiaries that the
Secretary determines is adequate, taking into consideration
the number of residents onsite, the health needs of those
residents, and the accessibility of providers offsite; and
``(iii) provides transportation services for beneficiaries
to providers outside of the facility; and
``(B) is offered by a Medicare Advantage organization that
has offered at least 1 plan described in subparagraph (A) for
at least 1 year prior to January 1, 2010, under a
demonstration project established by the Secretary.''.

Subtitle E--Improvements to Medicare Part D

SEC. 1181. ELIMINATION OF COVERAGE GAP.

(a) Immediate Reduction in Coverage Gap in 2010.--Section
1860D-2(b) of the Social Security Act (42 U.S.C. 1395w-
102(b)) is amended--
(1) in paragraph (3)(A), by striking ``paragraph (4)'' and
inserting ``paragraphs (4) and (7)''; and
(2) by adding at the end the following new paragraph:
``(7) Increase in initial coverage limit in 2010.--
``(A) In general.--For plan years beginning during 2010,
the initial coverage limit described in paragraph (3)(B)
otherwise applicable shall be increased by $500.
``(B) Application.--In applying subparagraph (A)--
``(i) except as otherwise provided in this subparagraph,
there shall be no change in the premiums, bids, or any other
parameters under this part or part C;
``(ii) costs that would be treated as incurred costs for
purposes of applying paragraph (4) but for the application of
subparagraph (A) shall continue to be treated as incurred
costs;
``(iii) the Secretary shall establish procedures, which may
include a reconciliation process, to fully reimburse PDP
sponsors with respect to prescription drug plans and MA
organizations with respect to MA-PD plans for the reduction
in beneficiary cost sharing associated with the application
of subparagraph (A);
``(iv) the Secretary shall develop an estimate of the
additional increased costs attributable to the application of
this paragraph for increased drug utilization and financing
and administrative costs and shall use such estimate to
adjust payments to PDP sponsors with respect to prescription
drug plans under this part and MA organizations with respect
to MA-PD plans under part C; and
``(v) the Secretary shall establish procedures for
retroactive reimbursement of part D eligible individuals who
are covered under such a plan for costs which are incurred
before the date of initial implementation of subparagraph (A)
and which would be reimbursed under such a plan if such
implementation occurred as of January 1, 2010.''.
(b) Additional Closure in Gap Beginning in 2011.--Section
1860D-2(b) of such Act (42 U.S.C. 1395w-102(b)) as amended by
subsection (a), is further amended--
(1) in paragraph (3)(A), by striking ``and (7)'' and
inserting ``, (7), and (8)'' ;
(2) in paragraph (4)(B)(i), by inserting ``subject to
paragraph (8)'' after ``purposes of this part''; and
(3) by adding at the end the following new paragraph:
``(8) Phased-in elimination of coverage gap.--
``(A) In general.--For each year beginning with 2011, the
Secretary shall consistent with this paragraph progressively
increase the initial coverage limit (described in subsection
(b)(3)) and decrease the annual out-of-pocket threshold from
the amounts otherwise computed until, beginning in 2019,
there is a continuation of coverage from the initial coverage
limit for expenditures incurred through the total amount of
expenditures at which benefits are available under paragraph
(4).
``(B) Increase in initial coverage limit.--
``(i) In general.--For a year beginning with 2011, subject
to clause (ii), the initial coverage limit otherwise computed
without regard to this paragraph shall be increased by the
cumulative ICL phase-in percentage (as defined in clause
(iii) for the year) times the out-of-pocket gap amount (as
defined in subparagraph (D)) for the year.
``(ii) Maintenance of 2010 initial coverage limit level.--
If for a year the initial coverage limit otherwise computed
under this paragraph would be less than the initial coverage
limit applied during 2010, taking into account paragraph (7),
the initial coverage limit for that year shall be such
initial coverage limit as so applied during 2010.
``(iii) Cumulative phase-in percentage.--

``(I) In general.--For purposes of this paragraph, subject
to subclause (II), the term `cumulative ICL phase-in
percentage' means for a year the sum of the annual ICL phase-
in percentage (as defined in clause (iv)) for the year and
the annual ICL phase-in percentages for each previous year
beginning with 2011.
``(II) Limitation.--If the sum of the cumulative ICL phase-
in percentage and the cumulative OPT phase-in percentage (as
defined in subparagraph (C)(iii)) for a year would otherwise
exceed 100 percent, each such percentage shall be reduced in
a proportional amount so the sum does not exceed 100 percent.

``(iv) Annual icl phase-in percentage.--For purposes of
this paragraph, the term `annual ICL phase-in percentage'
means--

``(I) for 2011, 8.25 percent;
``(II) for 2012, 2013, and 2014, 4.5 percent;
``(III) for 2015 and 2016, 6 percent;
``(IV) for 2017, 7.5 percent;
``(V) for 2018, 8 percent; and
``(VI) for 2019, 8 percent, or such other percent as may be
necessary to provide for a full continuation of coverage as
described in subparagraph (A) in that year.

``(C) Decrease in annual out-of-pocket threshold.--
``(i) In general.--For a year beginning with 2011, subject
to clause (ii), the annual out-of-pocket threshold otherwise
computed without regard to this paragraph shall be decreased
by the cumulative OPT phase-in percentage (as defined in
clause (iii) for the year) of the out-of-pocket gap amount
for the year multiplied by 1.75.
``(ii) Maintenance.--The Secretary shall adjust the annual
out-of-pocket threshold for a year to the extent necessary to
ensure that the sum of the initial coverage limit described
in subparagraph (A) and the out-of-pocket gap amount (defined
in subparagraph (D)), as determined for the year pursuant to
the provisions of this paragraph for such year, does not
exceed such sum that would have applied if this paragraph did
not apply.
``(iii) Cumulative opt phase-in percentage.--For purposes
of this paragraph, subject to subparagraph (B)(iii)(II), the
term `cumulative OPT phase-in percentage' means for a year
the sum of the annual OPT phase-in percentage (as defined in
clause (iv)) for the year and the annual OPT phase-in
percentages for each previous year beginning with 2011.
``(iv) Annual opt phase-in percentage.--For purposes of
this paragraph, the term `annual OPT phase-in percentage'
means--

``(I) for 2011, 0 percent;
``(II) for 2012, 2013, and 2014, 4.5 percent;
``(III) for 2015 and 2016, 6 percent;
``(IV) for 2017, 7.5 percent; and
``(V) for 2018 and 2019, 8 percent.

``(D) Out-of-pocket gap amount.--For purposes of this
paragraph, the term `out-of-pocket gap amount' means for a
year the amount by which--
``(i) the annual out-of-pocket threshold specified in
paragraph (4)(B) for the year (as determined as if this
paragraph did not apply), exceeds
``(ii) the sum of--

``(I) the annual deductible under paragraph (1) for the
year; and
``(II) \1/4\ of the amount by which the initial coverage
limit under paragraph (3) for the year (as determined as if
this paragraph did not apply) exceeds such annual deductible.

``(E) Relation to aahca transitional increase.--Except as
otherwise specifically provided, this paragraph shall be
applied as if no increase had been made in the initial
coverage limit under paragraph (7).''.
(c) Requiring Drug Manufacturers to Provide Drug Rebates
for Rebate Eligible Individuals.--
(1) In general.--Section 1860D-2 of the Social Security Act
(42 U.S.C. 1395w-102) is amended--
(A) in subsection (e)(1), in the matter before subparagraph
(A), by inserting ``and subsection (f)'' after ``this
subsection''; and
(B) by adding at the end the following new subsection:
``(f) Prescription Drug Rebate Agreement for Rebate
Eligible Individuals.--
``(1) Requirement.--
``(A) In general.--For plan years beginning on or after
January 1, 2011, in this part, the term `covered part D drug'
does not include any drug or biological product that is
manufactured by a manufacturer that has not entered into and
have in effect a rebate agreement described in paragraph (2).
``(B) 2010 plan year requirement.--Any drug or biological
product manufactured by a manufacturer that declines to enter
into a rebate agreement described in paragraph (2) for the
period beginning on January 1, 2010, and ending on December
31, 2010, shall not be included as a `covered part D drug `
for the subsequent plan year.
``(2) Rebate agreement.--A rebate agreement under this
subsection shall require the

[[Page H12685]]

manufacturer to provide to the Secretary a rebate for each
rebate period (as defined in paragraph (6)(B)) ending after
December 31, 2009, in the amount specified in paragraph (3)
for any covered part D drug of the manufacturer dispensed
after December 31, 2009, to any rebate eligible individual
(as defined in paragraph (6)(A)) for which payment was made
by a PDP sponsor under part D or a MA organization under part
C for such period, including payments passed through the low-
income and reinsurance subsidies under sections 1860D-14 and
1860D-15(b), respectively. Such rebate shall be paid by the
manufacturer to the Secretary not later than 30 days after
the date of receipt of the information described in section
1860D-12(b)(7), including as such section is applied under
section 1857(f)(3), or 30 days after the receipt of
information under subparagraph (D) of paragraph (3), as
determined by the Secretary. Insofar as not inconsistent with
this subsection, the Secretary shall establish terms and
conditions of such agreement relating to compliance,
penalties, and program evaluations, investigations, and
audits that are similar to the terms and conditions for
rebate agreements under paragraphs (3) and (4) of section
1927(b).
``(3) Rebate for rebate eligible medicare drug plan
enrollees.--
``(A) In general.--The amount of the rebate specified under
this paragraph for a manufacturer for a rebate period, with
respect to each dosage form and strength of any covered part
D drug provided by such manufacturer and dispensed to a
rebate eligible individual, shall be equal to the product
of--
``(i) the total number of units of such dosage form and
strength of the drug so provided and dispensed for which
payment was made by a PDP sponsor under part D or a MA
organization under part C for the rebate period, including
payments passed through the low-income and reinsurance
subsidies under sections 1860D-14 and 1860D-15(b),
respectively; and
``(ii) the amount (if any) by which--

``(I) the Medicaid rebate amount (as defined in
subparagraph (B)) for such form, strength, and period,
exceeds
``(II) the average Medicare drug program rebate eligible
rebate amount (as defined in subparagraph (C)) for such form,
strength, and period.

``(B) Medicaid rebate amount.--For purposes of this
paragraph, the term `Medicaid rebate amount' means, with
respect to each dosage form and strength of a covered part D
drug provided by the manufacturer for a rebate period--
``(i) in the case of a single source drug or an innovator
multiple source drug, the amount specified in paragraph
(1)(A)(ii) of section 1927(c) plus the amount, if any,
specified in paragraph (2)(A)(ii) of such section, for such
form, strength, and period; or
``(ii) in the case of any other covered outpatient drug,
the amount specified in paragraph (3)(A)(i) of such section
for such form, strength, and period.
``(C) Average medicare drug program rebate eligible rebate
amount.--For purposes of this subsection, the term `average
Medicare drug program rebate eligible rebate amount' means,
with respect to each dosage form and strength of a covered
part D drug provided by a manufacturer for a rebate period,
the sum, for all PDP sponsors under part D and MA
organizations administering a MA-PD plan under part C, of--
``(i) the product, for each such sponsor or organization,
of--

``(I) the sum of all rebates, discounts, or other price
concessions (not taking into account any rebate provided
under paragraph (2) for such dosage form and strength of the
drug dispensed, calculated on a per-unit basis, but only to
the extent that any such rebate, discount, or other price
concession applies equally to drugs dispensed to rebate
eligible Medicare drug plan enrollees and drugs dispensed to
PDP and MA-PD enrollees who are not rebate eligible
individuals; and
``(II) the number of the units of such dosage and strength
of the drug dispensed during the rebate period to rebate
eligible individuals enrolled in the prescription drug plans
administered by the PDP sponsor or the MA-PD plans
administered by the MA organization; divided by

``(ii) the total number of units of such dosage and
strength of the drug dispensed during the rebate period to
rebate eligible individuals enrolled in all prescription drug
plans administered by PDP sponsors and all MA-PD plans
administered by MA organizations.
``(D) Use of estimates.--The Secretary may establish a
methodology for estimating the average Medicare drug program
rebate eligible rebate amounts for each rebate period based
on bid and utilization information under this part and may
use these estimates as the basis for determining the rebates
under this section. If the Secretary elects to estimate the
average Medicare drug program rebate eligible rebate amounts,
the Secretary shall establish a reconciliation process for
adjusting manufacturer rebate payments not later than 3
months after the date that manufacturers receive the
information collected under section 1860D-12(b)(7)(B).
``(4) Length of agreement.--The provisions of paragraph (4)
of section 1927(b) (other than clauses (iv) and (v) of
subparagraph (B)) shall apply to rebate agreements under this
subsection in the same manner as such paragraph applies to a
rebate agreement under such section.
``(5) Other terms and conditions.--The Secretary shall
establish other terms and conditions of the rebate agreement
under this subsection, including terms and conditions related
to compliance, that are consistent with this subsection.
``(6) Definitions.--In this subsection and section 1860D-
12(b)(7):
``(A) Rebate eligible individual.--The term `rebate
eligible individual'--
``(i) means a full-benefit dual eligible individual (as
defined in section 1935(c)(6)); and
``(ii) includes, for drugs dispensed after December 31,
2014, a subsidy eligible individual (as defined in section
1860D-14(a)(3)(A)).
``(B) Rebate period.--The term `rebate period' has the
meaning given such term in section 1927(k)(8).
``(7) Waiver.--Chapter 35 of title 44, United States Code,
shall not apply to the requirements under this subsection for
the period beginning on January 1, 2010, and ending on
December 31, 2010.''.
(2) Reporting requirement for the determination and payment
of rebates by manufactures related to rebate for rebate
eligible medicare drug plan enrollees.--
(A) Requirements for pdp sponsors.--Section 1860D-12(b) of
the Social Security Act (42 U.S.C. 1395w-112(b)) is amended
by adding at the end the following new paragraph:
``(7) Reporting requirement for the determination and
payment of rebates by manufacturers related to rebate for
rebate eligible medicare drug plan enrollees.--
``(A) In general.--For purposes of the rebate under section
1860D-2(f) for contract years beginning on or after January
1, 2011, each contract entered into with a PDP sponsor under
this part with respect to a prescription drug plan shall
require that the sponsor comply with subparagraphs (B) and
(C).
``(B) Report form and contents.--Not later than a date
specified by the Secretary, a PDP sponsor of a prescription
drug plan under this part shall report to each manufacturer--
``(i) information (by National Drug Code number) on the
total number of units of each dosage, form, and strength of
each drug of such manufacturer dispensed to rebate eligible
Medicare drug plan enrollees under any prescription drug plan
operated by the PDP sponsor during the rebate period;
``(ii) information on the price discounts, price
concessions, and rebates for such drugs for such form,
strength, and period;
``(iii) information on the extent to which such price
discounts, price concessions, and rebates apply equally to
rebate eligible Medicare drug plan enrollees and PDP
enrollees who are not rebate eligible Medicare drug plan
enrollees; and
``(iv) any additional information that the Secretary
determines is necessary to enable the Secretary to calculate
the average Medicare drug program rebate eligible rebate
amount (as defined in paragraph (3)(C) of such section), and
to determine the amount of the rebate required under this
section, for such form, strength, and period.

Such report shall be in a form consistent with a standard
reporting format established by the Secretary.
``(C) Submission to secretary.--Each PDP sponsor shall
promptly transmit a copy of the information reported under
subparagraph (B) to the Secretary for the purpose of audit
oversight and evaluation.
``(D) Confidentiality of information.--The provisions of
subparagraph (D) of section 1927(b)(3), relating to
confidentiality of information, shall apply to information
reported by PDP sponsors under this paragraph in the same
manner that such provisions apply to information disclosed by
manufacturers or wholesalers under such section, except--
``(i) that any reference to `this section' in clause (i) of
such subparagraph shall be treated as being a reference to
this section;
``(ii) the reference to the Director of the Congressional
Budget Office in clause (iii) of such subparagraph shall be
treated as including a reference to the Medicare Payment
Advisory Commission; and
``(iii) clause (iv) of such subparagraph shall not apply.
``(E) Oversight.--Information reported under this paragraph
may be used by the Inspector General of the Department of
Health and Human Services for the statutorily authorized
purposes of audit, investigation, and evaluations.
``(F) Penalties for failure to provide timely information
and provision of false information.--In the case of a PDP
sponsor--
``(i) that fails to provide information required under
subparagraph (B) on a timely basis, the sponsor is subject to
a civil money penalty in the amount of $10,000 for each day
in which such information has not been provided; or
``(ii) that knowingly (as defined in section 1128A(i))
provides false information under such subparagraph, the
sponsor is subject to a civil money penalty in an amount not
to exceed $100,000 for each item of false information.

Such civil money penalties are in addition to other penalties
as may be prescribed by law. The provisions of section 1128A
(other than subsections (a) and (b)) shall apply to a civil
money penalty under this subparagraph in the same manner as
such provisions apply to a penalty or proceeding under
section 1128A(a).''.

[[Page H12686]]

(B) Application to ma organizations.--Section 1857(f)(3) of
the Social Security Act (42 U.S.C. 1395w-27(f)(3)) is amended
by adding at the end the following:
``(D) Reporting requirement related to rebate for rebate
eligible medicare drug plan enrollees.--Section 1860D-
12(b)(7).''.
(3) Deposit of rebates into medicare prescription drug
account.--Section 1860D-16(c) of such Act (42 U.S.C. 1395w-
116(c)) is amended by adding at the end the following new
paragraph:
``(6) Rebate for rebate eligible medicare drug plan
enrollees.--Amounts paid under a rebate agreement under
section 1860D-2(f) shall be deposited into the Account and
shall be used to pay for all or part of the gradual
elimination of the coverage gap under section 1860D-
2(b)(7).''.

SEC. 1182. DISCOUNTS FOR CERTAIN PART D DRUGS IN ORIGINAL
COVERAGE GAP.

Section 1860D-2 of the Social Security Act (42 U.S.C.
1395w-102), as amended by section 1181, is amended--
(1) in subsection (b)(4)(C)(ii), by inserting ``subject to
subsection (g)(2)(C),'' after ``(ii)'';
(2) in subsection (e)(1), in the matter before subparagraph
(A), by striking ``subsection (f)'' and inserting
``subsections (f) and (g)'' after ``this subsection''; and
(3) by adding at the end the following new subsection:
``(g) Requirement for Manufacturer Discount Agreement for
Certain Qualifying Drugs.--
``(1) In general.--In this part, the term `covered part D
drug' does not include any drug or biological product that is
manufactured by a manufacturer that has not entered into and
have in effect for all qualifying drugs (as defined in
paragraph (5)(A)) a discount agreement described in paragraph
(2).
``(2) Discount agreement.--
``(A) Periodic discounts.--A discount agreement under this
paragraph shall require the manufacturer involved to provide,
to each PDP sponsor with respect to a prescription drug plan
or each MA organization with respect to each MA-PD plan, a
discount in an amount specified in paragraph (3) for
qualifying drugs (as defined in paragraph (5)(A)) of the
manufacturer dispensed to a qualifying enrollee after January
1, 2010, insofar as the individual is in the original gap in
coverage (as defined in paragraph (5)(E)).
``(B) Discount agreement.--Insofar as not inconsistent with
this subsection, the Secretary shall establish terms and
conditions of such agreement, including terms and conditions
relating to compliance, similar to the terms and conditions
for rebate agreements under paragraphs (2), (3), and (4) of
section 1927(b), except that--
``(i) discounts shall be applied under this subsection to
prescription drug plans and MA-PD plans instead of State
plans under title XIX;
``(ii) PDP sponsors and MA organizations shall be
responsible, instead of States, for provision of necessary
utilization information to drug manufacturers; and
``(iii) sponsors and MA organizations shall be responsible
for reporting information on drug-component negotiated price.
``(C) Counting discount toward true out-of-pocket costs.--
Under the discount agreement, in applying subsection (b)(4),
with regard to subparagraph (C)(i) of such subsection, if a
qualified enrollee purchases the qualified drug insofar as
the enrollee is in an actual gap of coverage (as defined in
paragraph (5)(D)), the amount of the discount under the
agreement shall be treated and counted as costs incurred by
the plan enrollee.
``(3) Discount amount.--The amount of the discount
specified in this paragraph for a discount period for a plan
is equal to 50 percent of the amount of the drug-component
negotiated price (as defined in paragraph (5)(C)) for
qualifying drugs for the period involved.
``(4) Additional terms.--In the case of a discount provided
under this subsection with respect to a prescription drug
plan offered by a PDP sponsor or an MA-PD plan offered by an
MA organization, if a qualified enrollee purchases the
qualified drug--
``(A) insofar as the enrollee is in an actual gap of
coverage (as defined in paragraph (5)(D)), the sponsor or
plan shall provide the discount to the enrollee at the time
the enrollee pays for the drug; and
``(B) insofar as the enrollee is in the portion of the
original gap in coverage (as defined in paragraph (5)(E))
that is not in the actual gap in coverage, the discount shall
not be applied against the negotiated price (as defined in
subsection (d)(1)(B)) for the purpose of calculating the
beneficiary payment.
``(5) Definitions.--In this subsection:
``(A) Qualifying drug.--The term `qualifying drug' means,
with respect to a prescription drug plan or MA-PD plan, a
drug or biological product that--
``(i)(I) is a drug produced or distributed under an
original new drug application approved by the Food and Drug
Administration, including a drug product marketed by any
cross-licensed producers or distributors operating under the
new drug application;
``(II) is a drug that was originally marketed under an
original new drug application approved by the Food and Drug
Administration; or
``(III) is a biological product as approved under Section
351(a) of the Public Health Services Act;
``(ii) is covered under the formulary of the plan or is
treated as covered under the formulary of the plan as a
result of a coverage determination or appeal under subsection
(g) or (h) of section 1860D-4; and
``(iii) is dispensed to an individual who is in the
original gap in coverage.
``(B) Qualifying enrollee.--The term `qualifying enrollee'
means an individual enrolled in a prescription drug plan or
MA-PD plan other than such an individual who is a subsidy-
eligible individual (as defined in section 1860D-14(a)(3)).
``(C) Drug-component negotiated price.--The term `drug-
component negotiated price' means, with respect to a
qualifying drug, the negotiated price (as defined in section
423.100 of title 42, Code of Federal Regulations, as in
effect on the date of enactment of this subsection), as
determined without regard to any dispensing fee, of the drug
under the prescription drug plan or MA-PD plan involved.
``(D) Actual gap in coverage.--The term `actual gap in
coverage' means the gap in prescription drug coverage that
occurs between the initial coverage limit (as modified under
paragraph (7) and subparagraph (B) of paragraph (8) of
subsection (b)) and the annual out-of-pocket threshold (as
modified under subparagraph (C) of such subsection).
``(E) Original gap in coverage.--The term `original in gap
coverage' means the gap in prescription drug coverage that
would occur between the initial coverage limit (described in
subsection (b)(3)) and the out-of-pocket threshold (as
defined in subsection (b)(4)(B)) if subsections (b)(7) and
(b)(8) did not apply.
``(6) Special rule for 2010.--For the period beginning
January 1, 2010, and ending December 31, 2010, the Secretary
may--
``(A) enter into agreements with manufacturers to directly
receive the discount amount described in paragraph (3);
``(B) collect the necessary information from prescription
drug plans and MA-PD plans to calculate the discount amount
described in such paragraph; and
``(C) provide the discount described in such paragraph to
beneficiaries as close as practicable after the point of
sale.
``(7) Waiver.--Chapter 35 of title 44, United States Code,
shall not apply to the requirements under this subsection for
the period beginning on January 1, 2010, and ending on
December 31, 2010.''.

SEC. 1183. REPEAL OF PROVISION RELATING TO SUBMISSION OF
CLAIMS BY PHARMACIES LOCATED IN OR CONTRACTING
WITH LONG-TERM CARE FACILITIES.

(a) Part D Submission.--Section 1860D-12(b) of the Social
Security Act (42 U.S.C. 1395w-112(b)), as amended by section
172(a)(1) of Public Law 110-275, is amended by striking
paragraph (5) and redesignating paragraph (6) and paragraph
(7), as added by section 1181(c)(2)(A), as paragraph (5) and
paragraph (6), respectively.
(b) Submission to MA-PD Plans.--Section 1857(f)(3) of the
Social Security Act (42 U.S.C. 1395w-27(f)(3)), as added by
section 171(b) of Public Law 110-275 and amended by section
172(a)(2) of such Public Law and section 1181 of this Act, is
amended by striking subparagraph (B) and redesignating
subparagraphs (C) and (D) as subparagraphs (B) and (C)
respectively.
(c) Effective Date.--The amendments made by this section
shall apply for contract years beginning with 2010.

SEC. 1184. INCLUDING COSTS INCURRED BY AIDS DRUG ASSISTANCE
PROGRAMS AND INDIAN HEALTH SERVICE IN PROVIDING
PRESCRIPTION DRUGS TOWARD THE ANNUAL OUT-OF-
POCKET THRESHOLD UNDER PART D.

(a) In General.--Section 1860D-2(b)(4)(C) of the Social
Security Act (42 U.S.C. 1395w-102(b)(4)(C)) is amended--
(1) in clause (i), by striking ``and'' at the end;
(2) in clause (ii)--
(A) by striking ``such costs shall be treated as incurred
only if'' and inserting ``and subject to clause (iii), such
costs shall be treated as incurred only if'';
(B) by striking ``, under section 1860D-14, or under a
State Pharmaceutical Assistance Program''; and
(C) by striking the period at the end and inserting ``;
and''; and
(3) by inserting after clause (ii) the following new
clause:
``(iii) such costs shall be treated as incurred and shall
not be considered to be reimbursed under clause (ii) if such
costs are borne or paid--

``(I) under section 1860D-14;
``(II) under a State Pharmaceutical Assistance Program;
``(III) by the Indian Health Service, an Indian tribe or
tribal organization, or an urban Indian organization (as
defined in section 4 of the Indian Health Care Improvement
Act); or
``(IV) under an AIDS Drug Assistance Program under part B
of title XXVI of the Public Health Service Act.''.

(b) Effective Date.--The amendments made by subsection (a)
shall apply to costs incurred on or after January 1, 2011.

SEC. 1185. NO MID-YEAR FORMULARY CHANGES PERMITTED.

(a) In General.--Section 1860D-4(b)(3)(E) of the Social
Security Act (42 U.S.C. 1395w-104(b)(3)(E)) is amended--
(1) in the heading, by inserting ``; certain formulary
changes only before initiating marketing for a plan year''
after ``status of drug'';
(2) by striking ``Any removal'' and inserting ``(i)
notice.--Any removal'' with the same indentation as the
clause added by paragraph (2);

[[Page H12687]]

(3) by adding at the end the following new clause:
``(ii) Certain changes in formulary only before initiating
marketing for a plan year.--Any removal of a covered part D
drug from a formulary used by a PDP sponsor of a prescription
drug plan (or MA organization of a MA-PD plan) or any other
material change to the formulary so as to reduce the coverage
(or increase the cost-sharing) of the drug under the plan for
a plan year shall take effect by a date specified by the
Secretary but no later than the start of plan marketing
activities for the plan year. In addition to any exceptions
to the previous sentence specified by the Secretary, the
previous sentence shall not apply in the case that a drug is
removed from the formulary of a plan because of a recall or
withdrawal of the drug issued by the Food and Drug
Administration, because the drug is replaced with a generic
drug that is a therapeutic equivalent, or because of
utilization management applied to--

``(I) a drug whose labeling includes a boxed warning
required by the Food and Drug Administration under section
201.57(c)(1) of title 21, Code of Federal Regulations (or a
successor regulation); or
``(II) a drug required under subsection (c)(2) of section
505-1 of the Federal Food, Drug, and Cosmetic Act to have a
Risk Evaluation and Management Strategy that includes
elements under subsection (f) of such section.''.

(b) Effective Date.--The amendments made by subsection (a)
shall apply to contract years beginning on or after January
1, 2011.

SEC. 1186. NEGOTIATION OF LOWER COVERED PART D DRUG PRICES ON
BEHALF OF MEDICARE BENEFICIARIES.

(a) Negotiation by Secretary.--Section 1860D-11 of the
Social Security Act (42 U.S.C. 1395w-111) is amended by
striking subsection (i) (relating to noninterference) and
inserting the following:
``(i) Negotiation of Lower Drug Prices.--
``(1) In general.--Notwithstanding any other provision of
law, the Secretary shall negotiate with pharmaceutical
manufacturers the prices (including discounts, rebates, and
other price concessions) that may be charged to PDP sponsors
and MA organizations for covered part D drugs for part D
eligible individuals who are enrolled under a prescription
drug plan or under an MA-PD plan.
``(2) No change in rules for formularies.--
``(A) In general.--Nothing in paragraph (1) shall be
construed to authorize the Secretary to establish or require
a particular formulary.
``(B) Construction.--Subparagraph (A) shall not be
construed as affecting the Secretary's authority to ensure
appropriate and adequate access to covered part D drugs under
prescription drug plans and under MA-PD plans, including
compliance of such plans with formulary requirements under
section 1860D-4(b)(3).
``(3) Construction.--Nothing in this subsection shall be
construed as preventing the sponsor of a prescription drug
plan, or an organization offering an MA-PD plan, from
obtaining a discount or reduction of the price for a covered
part D drug below the price negotiated under paragraph (1).
``(4) Annual reports to congress.--Not later than June 1,
2011, and annually thereafter, the Secretary shall submit to
the Committees on Ways and Means, Energy and Commerce, and
Oversight and Government Reform of the House of
Representatives and the Committee on Finance of the Senate a
report on negotiations conducted by the Secretary to achieve
lower prices for Medicare beneficiaries, and the prices and
price discounts achieved by the Secretary as a result of such
negotiations.''.
(b) Effective Date.--The amendment made by subsection (a)
shall take effect on the date of the enactment of this Act
and shall first apply to negotiations and prices for plan
years beginning on January 1, 2011.

SEC. 1187. ACCURATE DISPENSING IN LONG-TERM CARE FACILITIES.

Section 1860D-4(c) of the Social Security Act (42 U.S.C.
1395w-104(c)) is amended by adding at the end the following
new paragraph:
``(3) Reduction of wasteful dispensing.--
``(A) In general.--For plan years beginning on or after
January 1, 2012, a PDP sponsor offering a prescription drug
plan and MA organization offering a MA-PD plan under part C
shall have in place the utilization management techniques
established under subparagraph (B).
``(B) Requirements.--The Secretary shall establish
utilization management techniques, such as daily, weekly, or
automated dose dispensing, to apply to PDP sponsors and MA
organizations to reduce the quantities of covered part D
drugs dispensed to enrollees who are residing in long-term
care facilities in order to reduce waste associated with
unused medications.
``(C) Consultation.--In establishing the requirements under
subparagraph (A), the Secretary shall consult with the
Administrator of the Environmental Protection Agency,
Administrator of the Food and Drug Administration,
Administrator of the Drug Enforcement Administration, State
Boards of Pharmacy, pharmacy and physician organizations, and
other appropriate stakeholders to study and determine
additional methods for prescription drug plans to reduce
waste associated with unused prescription drugs.''.

SEC. 1188. FREE GENERIC FILL.

(a) In General.--Section 1128A(i)(6) of the Social Security
Act (42 U.S.C. 1320a-7a(i)(6)) is amended--
(1) in subparagraph (C), by striking ``of 1996'' and all
that follows and inserting ``of 1996;'';
(2) in the first subparagraph (D), by striking
``promulgated'' and all that follows and inserting
``promulgated;'';
(3) by redesignating the second subparagraph (D) as a
subparagraph (E) and by striking the period at the end of
such subparagraph and inserting ``; and''; and
(4) by adding at the end the following new subparagraph:
``(F) with regard to a prescription drug plan offered by a
PDP sponsor or an MA-PD plan offered by an MA organization, a
reduction in or waiver of the copayment amount under the plan
given to an individual to induce the individual to switch to
a generic, bioequivalent drug, or biosimilar.''.
(b) Effective Date.--The amendments made by this subsection
shall take effect on the date of the enactment of this Act
and shall first apply with respect to remuneration offered,
paid, solicited, or received on or after January 1, 2011.

SEC. 1189. STATE CERTIFICATION PRIOR TO WAIVER OF LICENSURE
REQUIREMENTS UNDER MEDICARE PRESCRIPTION DRUG
PROGRAM.

(a) In General.--Section 1860D-12(c) of the Social Security
Act (42 U.S.C. 1395w-112(c)) is amended--
(1) in paragraph (1)(A), by striking ``In the case'' and
inserting ``Subject to paragraph (5), in the case''; and
(2) by adding at the end the following new paragraph:
``(5) State certification required.--
``(A) In general.--Except as provided in section 1860D-
21(f)(4), the Secretary may only grant a waiver under
paragraph (1)(A) if the Secretary has received a
certification from the State insurance commissioner that the
prescription drug plan has a substantially complete
application pending in the State.
``(B) Revocation of waiver upon finding of fraud and
abuse.--The Secretary shall revoke a waiver granted under
paragraph (1)(A) if the State insurance commissioner submits
a certification to the Secretary that the recipient of such a
waiver--
``(i) has committed fraud or abuse with respect to such
waiver;
``(ii) has failed to make a good faith effort to satisfy
State licensing requirements; or
``(iii) was determined ineligible for licensure by the
State.''.
(b) Exception for PACE Programs.--Section 1860D-21(f) of
such Act (42 U.S.C. 1395w-131(f)) is amended--
(1) in paragraph (1), by striking ``paragraphs (2) and
(3)'' and inserting ``the succeeding paragraphs''; and
(2) by adding at the end the following new paragraph:
``(4) Inapplicability of certain licensure waiver
requirements.--The provisions of paragraph (1) of section
1860D-12(c) (relating to waiver of licensure under certain
circumstances) shall apply without regard to paragraph (5) of
such section in the case of a PACE program that elects to
provide qualified prescription drug coverage to a part D
eligible individual who is enrolled under such program.''.
(b) Effective Date.--The amendments made by this section
shall apply with respect to plan years beginning on or after
January 1, 2010.

Subtitle F--Medicare Rural Access Protections

SEC. 1191. TELEHEALTH EXPANSION AND ENHANCEMENTS.

(a) Additional Telehealth Site.--
(1) In general.--Paragraph (4)(C)(ii) of section 1834(m) of
the Social Security Act (42 U.S.C. 1395m(m)) is amended by
adding at the end the following new subclause:

``(IX) A renal dialysis facility.''

(2) Effective date.--The amendment made by paragraph (1)
shall apply to services furnished on or after January 1,
2011.
(b) Telehealth Advisory Committee.--
(1) Establishment.--Section 1868 of the Social Security Act
(42 U.S.C. 1395ee) is amended--
(A) in the heading, by adding at the end the following:
``telehealth advisory committee''; and
(B) by adding at the end the following new subsection:
``(c) Telehealth Advisory Committee.--
``(1) In general.--The Secretary shall appoint a Telehealth
Advisory Committee (in this subsection referred to as the
`Advisory Committee') to make recommendations to the
Secretary on policies of the Centers for Medicare & Medicaid
Services regarding telehealth services as established under
section 1834(m), including the appropriate addition or
deletion of services (and HCPCS codes) to those specified in
paragraphs (4)(F)(i) and (4)(F)(ii) of such section and for
authorized payment under paragraph (1) of such section.
``(2) Membership; terms.--
``(A) Membership.--
``(i) In general.--The Advisory Committee shall be composed
of 9 members, to be appointed by the Secretary, of whom--

``(I) 5 shall be practicing physicians;
``(II) 2 shall be practicing non-physician health care
practitioners; and
``(III) 2 shall be administrators of telehealth programs.

``(ii) Requirements for appointing members.--In appointing
members of the Advisory Committee, the Secretary shall--

[[Page H12688]]

``(I) ensure that each member has prior experience with the
practice of telemedicine or telehealth;
``(II) give preference to individuals who are currently
providing telemedicine or telehealth services or who are
involved in telemedicine or telehealth programs;
``(III) ensure that the membership of the Advisory
Committee represents a balance of specialties and geographic
regions; and
``(IV) take into account the recommendations of
stakeholders.

``(B) Terms.--The members of the Advisory Committee shall
serve for such term as the Secretary may specify.
``(C) Conflicts of interest.--An advisory committee member
may not participate with respect to a particular matter
considered in an advisory committee meeting if such member
(or an immediate family member of such member) has a
financial interest that could be affected by the advice given
to the Secretary with respect to such matter.
``(3) Meetings.--The Advisory Committee shall meet twice
each calendar year and at such other times as the Secretary
may provide.
``(4) Permanent committee.--Section 14 of the Federal
Advisory Committee Act (5 U.S.C. App.) shall not apply to the
Advisory Committee.''
(2) Following recommendations.--Section 1834(m)(4)(F) of
such Act (42 U.S.C. 1395m(m)(4)(F)) is amended by adding at
the end the following new clause:
``(iii) Recommendations of the telehealth advisory
committee.--In making determinations under clauses (i) and
(ii), the Secretary shall take into account the
recommendations of the Telehealth Advisory Committee
(established under section 1868(c)) when adding or deleting
services (and HCPCS codes) and in establishing policies of
the Centers for Medicare & Medicaid Services regarding the
delivery of telehealth services. If the Secretary does not
implement such a recommendation, the Secretary shall publish
in the Federal Register a statement regarding the reason such
recommendation was not implemented.''
(3) Waiver of administrative limitation.--The Secretary of
Health and Human Services shall establish the Telehealth
Advisory Committee under the amendment made by paragraph (1)
notwithstanding any limitation that may apply to the number
of advisory committees that may be established (within the
Department of Health and Human Services or otherwise).
(c) Hospital Credentialing of Telemedicine Physicians and
Practitioners.--
(1) In general.--Not later than 60 days after the date of
the enactment of this Act, the Secretary of Health and Human
Services shall issue guidance for hospitals (as defined in
paragraph (4)) to simplify requirements regarding compiling
practitioner credentials for the purpose of rendering a
medical staff privileging decision (under bylaws of the type
described in section 1861(e)(3) of the Social Security Act)
for physicians and practitioners (as defined in paragraph
(4)) delivering telehealth services that are furnished via a
telecommunications system.
(2) Flexibility in accepting credentialing by another
medicare participating hospital.--
(A) In general.--Such guidance shall permit a hospital to
accept credentialing packages compiled by another hospital
participating under Medicare with regard to physicians and
practitioners who seek medical staff privileges in the
hospital to provide telehealth services via a
telecommunications system from a site other than the hospital
where the patient is located.
(B) Construction.--Nothing in this subsection shall be
construed to require a hospital to accept the credentialing
package compiled by another facility.
(C) No oversight required.--If a hospital does accept the
credentialing materials prepared by another hospital, the
hospital shall not be required to exercise oversight over the
other hospital's process for compiling and verifying
credentials.
(D) Privileging.--This paragraph shall only apply to
credentialing and does not relieve a hospital from any
applicable privileging requirements.
(3) Construction.--This subsection shall not be construed
as limiting the ability of the Secretary to issue additional
guidance regarding the requirements for the compilation of
credentials for physicians and practitioners not described in
paragraph (1).
(4) Definitions.--In this subsection:
(A) The term ``hospital'' has the meaning given such term
in subsection (e) of section 1861 of the Social Security Act
(42 U.S.C. 1395x) and includes a critical access hospital (as
defined in subsection (mm)(1) of such section).
(B) The term ``physician'' has the meaning given such term
in subsection (r) of such section.
(C) The term ``practitioner'' means a practitioner
described in section 1842(b)(18)(C) of the Social Security
Act (42 U.S.C. 1395u(b)(18)(C)).

SEC. 1192. EXTENSION OF OUTPATIENT HOLD HARMLESS PROVISION.

Section 1833(t)(7)(D)(i) of the Social Security Act (42
U.S.C. 1395l(t)(7)(D)(i)) is amended--
(1) in subclause (II)--
(A) in the first sentence, by striking ```2010'' and
inserting ``2012''; and
(B) in the second sentence, by striking ``or 2009'' and
inserting ``, 2009, 2010, or 2011''; and
(2) in subclause (III), by striking ``January 1, 2010'' and
inserting ``January 1, 2012''.

SEC. 1193. EXTENSION OF SECTION 508 HOSPITAL
RECLASSIFICATIONS.

(a) In General.--Subsection (a) of section 106 of division
B of the Tax Relief and Health Care Act of 2006 (42 U.S.C.
1395 note), as amended by section 117 of the Medicare,
Medicaid, and SCHIP Extension Act of 2007 (Public Law 110-
173) and section 124 of the Medicare Improvements for
Patients and Providers Act of 2008 (Public Law 110-275), is
amended by striking ``September 30, 2009'' and inserting
``September 30, 2011''.
(b) Use of Particular Wage Index for Fiscal Year 2010.--For
purposes of implementation of the amendment made by
subsection (a) for fiscal year 2010, the Secretary shall use
the hospital wage index that was promulgated by the Secretary
in the Federal Register on August 27, 2009 (74 Fed. Reg.
43754), and any subsequent corrections.

SEC. 1194. EXTENSION OF GEOGRAPHIC FLOOR FOR WORK.

Section 1848(e)(1)(E) of the Social Security Act (42 U.S.C.
1395w-4(e)(1)(E)) is amended by striking ``before January 1,
2010'' and inserting ``before January 1, 2012''.

SEC. 1195. EXTENSION OF PAYMENT FOR TECHNICAL COMPONENT OF
CERTAIN PHYSICIAN PATHOLOGY SERVICES.

Section 542(c) of the Medicare, Medicaid, and SCHIP
Benefits Improvement and Protection Act of 2000 (as enacted
into law by section 1(a)(6) of Public Law 106-554), as
amended by section 732 of the Medicare Prescription Drug,
Improvement, and Modernization Act of 2003 (42 U.S.C. 1395w-4
note), section 104 of division B of the Tax Relief and Health
Care Act of 2006 (42 U.S.C. 1395w-4 note), section 104 of the
Medicare, Medicaid, and SCHIP Extension Act of 2007 (Public
Law 110-173), and section 136 of the Medicare Improvements
for Patients and Providers Act of 1008 (Public Law 110-275),
is amended by striking ``and 2009'' and inserting ``2009,
2010, and 2011''.

SEC. 1196. EXTENSION OF AMBULANCE ADD-ONS.

(a) In General.--Section 1834(l)(13) of the Social Security
Act (42 U.S.C. 1395m(l)(13)) is amended--
(1) in subparagraph (A)--
(A) in the matter preceding clause (i), by striking
``before January 1, 2010'' and inserting ``before January 1,
2012''; and
(B) in each of clauses (i) and (ii), by striking ``before
January 1, 2010'' and inserting ``before January 1, 2012''.
(b) Air Ambulance Improvements.--Section 146(b)(1) of the
Medicare Improvements for Patients and Providers Act of 2008
(Public Law 110-275) is amended by striking ``ending on
December 31, 2009'' and inserting ``ending on December 31,
2011''.

TITLE II--MEDICARE BENEFICIARY IMPROVEMENTS

Subtitle A--Improving and Simplifying Financial Assistance for Low
Income Medicare Beneficiaries

SEC. 1201. IMPROVING ASSETS TESTS FOR MEDICARE SAVINGS
PROGRAM AND LOW-INCOME SUBSIDY PROGRAM.

(a) Application of Highest Level Permitted Under LIS to All
Subsidy Eligible Individuals.--
(1) In general.--Section 1860D-14(a)(1) of the Social
Security Act (42 U.S.C. 1395w-114(a)(1)) is amended in the
matter before subparagraph (A), by inserting ``(or, beginning
with 2012, paragraph (3)(E))'' after ``paragraph (3)(D)''.
(2) Annual increase in lis resource test.--Section 1860D-
14(a)(3)(E)(i) of such Act (42 U.S.C. 1395w-114(a)(3)(E)(i))
is amended--
(A) by striking ``and'' at the end of subclause (I);
(B) in subclause (II), by inserting ``(before 2012)'' after
``subsequent year'';
(C) by striking the period at the end of subclause (II) and
inserting a semicolon;
(D) by inserting after subclause (II) the following new
subclauses:

``(III) for 2012, $17,000 (or $34,000 in the case of the
combined value of the individual's assets or resources and
the assets or resources of the individual's spouse); and
``(IV) for a subsequent year, the dollar amounts specified
in this subclause (or subclause (III)) for the previous year
increased by the annual percentage increase in the consumer
price index (all items; U.S. city average) as of September of
such previous year.''; and

(E) in the last sentence, by inserting ``or (IV)'' after
``subclause (II)''.
(3) Application of lis test under medicare savings
program.--Section 1905(p)(1)(C) of such Act (42 U.S.C.
1396d(p)(1)(C)) is amended--
(A) by striking ``effective beginning with January 1,
2010'' and inserting ``effective for the period beginning
with January 1, 2010, and ending with December 31, 2011'';
and
(B) by inserting before the period at the end the
following: ``or, effective beginning with January 1, 2012,
whose resources (as so determined) do not exceed the maximum
resource level applied for the year under subparagraph (E) of
section 1860D-14(a)(3) (determined without regard to the life
insurance policy exclusion provided under subparagraph (G) of
such section) applicable to an individual or to the
individual and the individual's spouse (as the case may
be)''.
(b) Effective Date.--The amendments made by subsection (a)
shall apply to eligibility determinations for income-related
subsidies and medicare cost-sharing furnished for periods
beginning on or after January 1, 2012.

[[Page H12689]]

SEC. 1202. ELIMINATION OF PART D COST-SHARING FOR CERTAIN
NON-INSTITUTIONALIZED FULL-BENEFIT DUAL
ELIGIBLE INDIVIDUALS.

(a) In General.--Section 1860D-14(a)(1)(D)(i) of the Social
Security Act (42 U.S.C. 1395w-114(a)(1)(D)(i)) is amended--
(1) by striking ``Institutionalized individuals.--In'' and
inserting ``Elimination of cost-sharing for certain full-
benefit dual eligible individuals.--

``(I) Institutionalized individuals.--In''; and

(2) by adding at the end the following new subclause:

``(II) Certain other individuals.--In the case of an
individual who is a full-benefit dual eligible individual and
with respect to whom there has been a determination that but
for the provision of home and community based care (whether
under section 1915, 1932, or under a waiver under section
1115) the individual would require the level of care provided
in a hospital or a nursing facility or intermediate care
facility for the mentally retarded the cost of which could be
reimbursed under the State plan under title XIX, the
elimination of any beneficiary coinsurance described in
section 1860D-2(b)(2) (for all amounts through the total
amount of expenditures at which benefits are available under
section 1860D-2(b)(4)).''.

(b) Effective Date.--The amendments made by subsection (a)
shall apply to drugs dispensed on or after January 1, 2011.

SEC. 1203. ELIMINATING BARRIERS TO ENROLLMENT.

(a) Administrative Verification of Income and Resources
Under the Low-income Subsidy Program.--
(1) In general.--Clause (iii) of section 1860D-14(a)(3)(E)
of the Social Security Act (42 U.S.C. 1395w-114(a)(3)(E)) is
amended to read as follows:
``(iii) Certification of income and resources.--For
purposes of applying this section--

``(I) an individual shall be permitted to apply on the
basis of self-certification of income and resources; and
``(II) matters attested to in the application shall be
subject to appropriate methods of verification without the
need of the individual to provide additional documentation,
except in extraordinary situations as determined by the
Commissioner.''.

(2) Effective date.--The amendment made by paragraph (1)
shall apply beginning January 1, 2010.
(b) Disclosures to Facilitate Identification of Individuals
Likely to Be Ineligible for the Low-income Assistance Under
the Medicare Prescription Drug Program to Assist Social
Security Administration's Outreach to Eligible Individuals.--
For provision authorizing disclosure of return information to
facilitate identification of individuals likely to be
ineligible for low-income subsidies under Medicare
prescription drug program, see section 1801.

SEC. 1204. ENHANCED OVERSIGHT RELATING TO REIMBURSEMENTS FOR
RETROACTIVE LOW INCOME SUBSIDY ENROLLMENT.

(a) In General.--In the case of a retroactive LIS
enrollment beneficiary who is enrolled under a prescription
drug plan under part D of title XVIII of the Social Security
Act (or an MA-PD plan under part C of such title), the
beneficiary (or any eligible third party) is entitled to
reimbursement by the plan for covered drug costs incurred by
the beneficiary during the retroactive coverage period of the
beneficiary in accordance with subsection (b) and in the case
of such a beneficiary described in subsection (c)(4)(A)(i),
such reimbursement shall be made automatically by the plan
upon receipt of appropriate notice the beneficiary is
eligible for assistance described in such subsection
(c)(4)(A)(i) without further information required to be filed
with the plan by the beneficiary.
(b) Administrative Requirements Relating to
Reimbursements.--
(1) Line-item description.--Each reimbursement made by a
prescription drug plan or MA-PD plan under subsection (a)
shall include a line-item description of the items for which
the reimbursement is made.
(2) Timing of reimbursements.--A prescription drug plan or
MA-PD plan must make a reimbursement under subsection (a) to
a retroactive LIS enrollment beneficiary, with respect to a
claim, not later than 45 days after--
(A) in the case of a beneficiary described in subsection
(c)(4)(A)(i), the date on which the plan receives notice from
the Secretary that the beneficiary is eligible for assistance
described in such subsection; or
(B) in the case of a beneficiary described in subsection
(c)(4)(A)(ii), the date on which the beneficiary files the
claim with the plan.
(3) Reporting requirement.--For each month beginning with
January 2011, each prescription drug plan and each MA-PD plan
shall report to the Secretary the following:
(A) The number of claims the plan has readjudicated during
the month due to a beneficiary becoming retroactively
eligible for subsidies available under section 1860D-14 of
the Social Security Act.
(B) The total value of the readjudicated claim amount for
the month.
(C) The Medicare Health Insurance Claims Number of
beneficiaries for whom claims were readjudicated.
(D) For the claims described in subparagraphs (A) and (B),
an attestation to the Administrator of the Centers for
Medicare & Medicaid Services of the total amount of
reimbursement the plan has provided to beneficiaries for
premiums and cost-sharing that the beneficiary overpaid for
which the plan received payment from the Centers for Medicare
& Medicaid Services.
(c) Definitions.--For purposes of this section:
(1) Covered drug costs.--The term ``covered drug costs''
means, with respect to a retroactive LIS enrollment
beneficiary enrolled under a prescription drug plan under
part D of title XVIII of the Social Security Act (or an MA-PD
plan under part C of such title), the amount by which--
(A) the costs incurred by such beneficiary during the
retroactive coverage period of the beneficiary for covered
part D drugs, premiums, and cost-sharing under such title;
exceeds
(B) such costs that would have been incurred by such
beneficiary during such period if the beneficiary had been
both enrolled in the plan and recognized by such plan as
qualified during such period for the low income subsidy under
section 1860D-14 of the Social Security Act to which the
individual is entitled.
(2) Eligible third party.--The term ``eligible third
party'' means, with respect to a retroactive LIS enrollment
beneficiary, an organization or other third party that is
owed payment on behalf of such beneficiary for covered drug
costs incurred by such beneficiary during the retroactive
coverage period of such beneficiary.
(3) Retroactive coverage period.--The term ``retroactive
coverage period'' means--
(A) with respect to a retroactive LIS enrollment
beneficiary described in paragraph (4)(A)(i), the period--
(i) beginning on the effective date of the assistance
described in such paragraph for which the individual is
eligible; and
(ii) ending on the date the plan effectuates the status of
such individual as so eligible; and
(B) with respect to a retroactive LIS enrollment
beneficiary described in paragraph (4)(A)(ii), the period--
(i) beginning on the date the individual is both entitled
to benefits under part A, or enrolled under part B, of title
XVIII of the Social Security Act and eligible for medical
assistance under a State plan under title XIX of such Act;
and
(ii) ending on the date the plan effectuates the status of
such individual as a full-benefit dual eligible individual
(as defined in section 1935(c)(6) of such Act).
(4) Retroactive lis enrollment beneficiary.--
(A) In general.--The term ``retroactive LIS enrollment
beneficiary'' means an individual who--
(i) is enrolled in a prescription drug plan under part D of
title XVIII of the Social Security Act (or an MA-PD plan
under part C of such title) and subsequently becomes eligible
as a full-benefit dual eligible individual (as defined in
section 1935(c)(6) of such Act), an individual receiving a
low-income subsidy under section 1860D-14 of such Act, an
individual receiving assistance under the Medicare Savings
Program implemented under clauses (i), (iii), and (iv) of
section 1902(a)(10)(E) of such Act, or an individual
receiving assistance under the supplemental security income
program under section 1611 of such Act; or
(ii) subject to subparagraph (B)(i), is a full-benefit dual
eligible individual (as defined in section 1935(c)(6) of such
Act) who is automatically enrolled in such a plan under
section 1860D-1(b)(1)(C) of such Act.
(B) Exception for beneficiaries enrolled in rfp plan.--
(i) In general.--In no case shall an individual described
in subparagraph (A)(ii) include an individual who is
enrolled, pursuant to a RFP contract described in clause
(ii), in a prescription drug plan offered by the sponsor of
such plan awarded such contract.
(ii) RFP contract described.--The RFP contract described in
this section is a contract entered into between the Secretary
and a sponsor of a prescription drug plan pursuant to the
Centers for Medicare & Medicaid Services' request for
proposals issued on February 17, 2009, relating to Medicare
part D retroactive coverage for certain low income
beneficiaries, or a similar subsequent request for proposals.

SEC. 1205. INTELLIGENT ASSIGNMENT IN ENROLLMENT.

(a) In General.--Section 1860D-1(b)(1)(C) of the Social
Security Act (42 U.S.C. 1395w-101(b)(1)(C)) is amended by
adding after ``PDP region'' the following: ``or through use
of an intelligent assignment process that is designed to
maximize the access of such individual to necessary
prescription drugs while minimizing costs to such individual
and to the program under this part to the greatest extent
possible. In the case the Secretary enrolls such individuals
through use of an intelligent assignment process, such
process shall take into account the extent to which
prescription drugs necessary for the individual are covered
in the case of a PDP sponsor of a prescription drug plan that
uses a formulary, the use of prior authorization or other
restrictions on access to coverage of such prescription drugs
by such a sponsor, and the overall quality of a prescription
drug plan as measured by quality ratings established by the
Secretary''
(b) Effective Date.--The amendment made by subsection (a)
shall take effect for contract years beginning with 2012.

[[Page H12690]]

SEC. 1206. SPECIAL ENROLLMENT PERIOD AND AUTOMATIC ENROLLMENT
PROCESS FOR CERTAIN SUBSIDY ELIGIBLE
INDIVIDUALS.

(a) Special Enrollment Period.--Section 1860D-1(b)(3)(D) of
the Social Security Act (42 U.S.C. 1395w-101(b)(3)(D)) is
amended to read as follows:
``(D) Subsidy eligible individuals.--In the case of an
individual (as determined by the Secretary) who is determined
under subparagraph (B) of section 1860D-14(a)(3) to be a
subsidy eligible individual.''.
(b) Automatic Enrollment.--Section 1860D-1(b)(1) of the
Social Security Act (42 U.S.C. 1395w-101(b)(1)) is amended by
adding at the end the following new subparagraph:
``(D) Special rule for subsidy eligible individuals.--The
process established under subparagraph (A) shall include, in
the case of an individual described in section 1860D-
1(b)(3)(D) who fails to enroll in a prescription drug plan or
an MA-PD plan during the special enrollment established under
such section applicable to such individual, the application
of the assignment process described in subparagraph (C) to
such individual in the same manner as such assignment process
applies to a part D eligible individual described in such
subparagraph (C). Nothing in the previous sentence shall
prevent an individual described in such sentence from
declining enrollment in a plan determined appropriate by the
Secretary (or in the program under this part) or from
changing such enrollment.''.
(c) Effective Date.--The amendments made by this section
shall apply to subsidy determinations made for months
beginning with January 2011.

SEC. 1207. APPLICATION OF MA PREMIUMS PRIOR TO REBATE AND
QUALITY BONUS PAYMENTS IN CALCULATION OF LOW
INCOME SUBSIDY BENCHMARK.

(a) In General.--Section 1860D-14(b)(2)(B)(iii) of the
Social Security Act (42 U.S.C. 1395w-114(b)(2)(B)(iii)) is
amended by inserting before the period the following:
``before the application of the monthly rebate computed under
section 1854(b)(1)(C)(i) for that plan and year involved and,
in the case of a qualifying plan in a qualifying county,
before the application of the increase under section 1853(o)
for that plan and year involved''.
(b) Effective Date.--The amendment made by subsection (a)
shall apply to subsidy determinations made for months
beginning with January 2011.

Subtitle B--Reducing Health Disparities

SEC. 1221. ENSURING EFFECTIVE COMMUNICATION IN MEDICARE.

(a) Ensuring Effective Communication by the Centers for
Medicare & Medicaid Services.--
(1) Study on medicare payments for language services.--The
Secretary of Health and Human Services shall conduct a study
that examines the extent to which Medicare service providers
utilize, offer, or make available language services for
beneficiaries who are limited English proficient and ways
that Medicare should develop payment systems for language
services.
(2) Analyses.--The study shall include an analysis of each
of the following:
(A) How to develop and structure appropriate payment
systems for language services for all Medicare service
providers.
(B) The feasibility of adopting a payment methodology for
on-site interpreters, including interpreters who work as
independent contractors and interpreters who work for
agencies that provide on-site interpretation, pursuant to
which such interpreters could directly bill Medicare for
services provided in support of physician office services for
an LEP Medicare patient.
(C) The feasibility of Medicare contracting directly with
agencies that provide off-site interpretation including
telephonic and video interpretation pursuant to which such
contractors could directly bill Medicare for the services
provided in support of physician office services for an LEP
Medicare patient.
(D) The feasibility of modifying the existing Medicare
resource-based relative value scale (RBRVS) by using
adjustments (such as multipliers or add-ons) when a patient
is LEP.
(E) How each of options described in a previous paragraph
would be funded and how such funding would affect physician
payments, a physician's practice, and beneficiary cost-
sharing.
(F) The extent to which providers under parts A and B of
title XVIII of the Social Security Act, MA organizations
offering Medicare Advantage plans under part C of such title
and PDP sponsors of a prescription drug plan under part D of
such title utilize, offer, or make available language
services for beneficiaries with limited English proficiency.
(G) The nature and type of language services provided by
States under title XIX of the Social Security Act and the
extent to which such services could be utilized by
beneficiaries and providers under title XVIII of such Act.
(H) The extent to which interpreters and translators
providing services to Medicare beneficiaries under title
XVIII of such Act are trained or accredited.
(3) Variation in payment system described.--The payment
systems described in paragraph (2)(A) may allow variations
based upon types of service providers, available delivery
methods, and costs for providing language services including
such factors as--
(A) the type of language services provided (such as
provision of health care or health care related services
directly in a non-English language by a bilingual provider or
use of an interpreter);
(B) type of interpretation services provided (such as in-
person, telephonic, video interpretation);
(C) the methods and costs of providing language services
(including the costs of providing language services with
internal staff or through contract with external independent
contractors or agencies, or both);
(D) providing services for languages not frequently
encountered in the United States; and
(E) providing services in rural areas.
(4) Report.--The Secretary shall submit a report on the
study conducted under subsection (a) to appropriate
committees of Congress not later than 12 months after the
date of the enactment of this Act.
(5) Exemption from paperwork reduction act.--Chapter 35 of
title 44, United States Code (commonly known as the
``Paperwork Reduction Act'' ), shall not apply for purposes
of carrying out this subsection.
(6) Authorization of appropriations.--The Secretary shall
provide for the transfer, from the Federal Supplementary
Medical Insurance Trust Fund under section 1841 of the Social
Security Act (42 U.S.C. 1395t) of $2,000,000 for purposes of
carrying out this subsection.
(b) Health Plans.--Section 1857(g)(1) of the Social
Security Act (42 U.S.C. 1395w-27(g)(1)) is amended--
(1) by striking ``or'' at the end of subparagraph (F);
(2) by adding ``or'' at the end of subparagraph (G); and
(3) by inserting after subparagraph (G) the following new
subparagraph:
``(H) fails substantially to provide language services to
limited English proficient beneficiaries enrolled in the plan
that are required under law;''.

SEC. 1222. DEMONSTRATION TO PROMOTE ACCESS FOR MEDICARE
BENEFICIARIES WITH LIMITED ENGLISH PROFICIENCY
BY PROVIDING REIMBURSEMENT FOR CULTURALLY AND
LINGUISTICALLY APPROPRIATE SERVICES.

(a) In General.--Not later than 6 months after the date of
the completion of the study described in section 1221(a) of
this Act, the Secretary, acting through the Centers for
Medicare & Medicaid Services and the Center for Medicare and
Medicaid Innovation established under section 1115A of the
Social Security Act (as added by section 1907) and consistent
with the applicable provisions of such section, shall carry
out a demonstration program under which the Secretary shall
award not fewer than 24 3-year grants to eligible Medicare
service providers (as described in subsection (b)(1)) to
improve effective communication between such providers and
Medicare beneficiaries who are living in communities where
racial and ethnic minorities, including populations that face
language barriers, are underserved with respect to such
services. In designing and carrying out the demonstration the
Secretary shall take into consideration the results of the
study conducted under section 1221(a) of this Act and adjust,
as appropriate, the distribution of grants so as to better
target Medicare beneficiaries who are in the greatest need of
language services. The Secretary shall not authorize a grant
larger than $500,000 over three years for any grantee.
(b) Eligibility; Priority.--
(1) Eligibility.--To be eligible to receive a grant under
subsection (a) an entity shall--
(A) be--
(i) a provider of services under part A of title XVIII of
the Social Security Act;
(ii) a service provider under part B of such title;
(iii) a part C organization offering a Medicare part C plan
under part C of such title; or
(iv) a PDP sponsor of a prescription drug plan under part D
of such title; and
(B) prepare and submit to the Secretary an application, at
such time, in such manner, and accompanied by such additional
information as the Secretary may require.
(2) Priority.--
(A) Distribution.--To the extent feasible, in awarding
grants under this section, the Secretary shall award--
(i) at least 6 grants to providers of services described in
paragraph (1)(A)(i);
(ii) at least 6 grants to service providers described in
paragraph (1)(A)(ii);
(iii) at least 6 grants to organizations described in
paragraph (1)(A)(iii); and
(iv) at least 6 grants to sponsors described in paragraph
(1)(A)(iv).
(B) For community organizations.--The Secretary shall give
priority to applicants that have developed partnerships with
community organizations or with agencies with experience in
language access.
(C) Variation in grantees.--The Secretary shall also ensure
that the grantees under this section represent, among other
factors--
(i) different types of language services provided and of
service providers and organizations under parts A through D
of title XVIII of the Social Security Act;
(ii) variations in languages needed and their frequency of
use;
(iii) urban and rural settings;
(iv) at least two geographic regions, as defined by the
Secretary; and
(v) at least two large metropolitan statistical areas with
diverse populations.
(c) Use of Funds.--
(1) In general.--A grantee shall use grant funds received
under this section to pay for

[[Page H12691]]

the provision of competent language services to Medicare
beneficiaries who are limited English proficient. Competent
interpreter services may be provided through on-site
interpretation, telephonic interpretation, or video
interpretation or direct provision of health care or health
care related services by a bilingual health care provider. A
grantee may use bilingual providers, staff, or contract
interpreters. A grantee may use grant funds to pay for
competent translation services. A grantee may use up to 10
percent of the grant funds to pay for administrative costs
associated with the provision of competent language services
and for reporting required under subsection (e).
(2) Organizations.--Grantees that are part C organizations
or PDP sponsors must ensure that their network providers
receive at least 50 percent of the grant funds to pay for the
provision of competent language services to Medicare
beneficiaries who are limited English proficient, including
physicians and pharmacies.
(3) Determination of payments for language services.--
Payments to grantees shall be calculated based on the
estimated numbers of limited English proficient Medicare
beneficiaries in a grantee's service area utilizing--
(A) data on the numbers of limited English proficient
individuals who speak English less than ``very well'' from
the most recently available data from the Bureau of the
Census or other State-based study the Secretary determines
likely to yield accurate data regarding the number of such
individuals served by the grantee; or
(B) the grantee's own data if the grantee routinely
collects data on Medicare beneficiaries' primary language in
a manner determined by the Secretary to yield accurate data
and such data shows greater numbers of limited English
proficient individuals than the data listed in subparagraph
(A).
(4) Limitations.--
(A) Reporting.--Payments shall only be provided under this
section to grantees that report their costs of providing
language services as required under subsection (e) and may be
modified annually at the discretion of the Secretary. If a
grantee fails to provide the reports under such section for
the first year of a grant, the Secretary may terminate the
grant and solicit applications from new grantees to
participate in the subsequent two years of the demonstration
program.
(B) Type of services.--
(i) In general.--Subject to clause (ii), payments shall be
provided under this section only to grantees that utilize
competent bilingual staff or competent interpreter or
translation services which--

(I) if the grantee operates in a State that has statewide
health care interpreter standards, meet the State standards
currently in effect; or
(II) if the grantee operates in a State that does not have
statewide health care interpreter standards, utilizes
competent interpreters who follow the National Council on
Interpreting in Health Care's Code of Ethics and Standards of
Practice.

(ii) Exemptions.--The requirements of clause (i) shall not
apply--

(I) in the case of a Medicare beneficiary who is limited
English proficient (who has been informed in the
beneficiary's primary language of the availability of free
interpreter and translation services) and who requests the
use of family, friends, or other persons untrained in
interpretation or translation and the grantee documents the
request in the beneficiary's record; and
(II) in the case of a medical emergency where the delay
directly associated with obtaining a competent interpreter or
translation services would jeopardize the health of the
patient.

Nothing in clause (ii)(II) shall be construed to exempt
emergency rooms or similar entities that regularly provide
health care services in medical emergencies from having in
place systems to provide competent interpreter and
translation services without undue delay.
(d) Assurances.--Grantees under this section shall--
(1) ensure that appropriate clinical and support staff
receive ongoing education and training in linguistically
appropriate service delivery;
(2) ensure the linguistic competence of bilingual
providers;
(3) offer and provide appropriate language services at no
additional charge to each patient with limited English
proficiency at all points of contact, in a timely manner
during all hours of operation;
(4) notify Medicare beneficiaries of their right to receive
language services in their primary language;
(5) post signage in the languages of the commonly
encountered group or groups present in the service area of
the organization; and
(6) ensure that--
(A) primary language data are collected for recipients of
language services and are consistent with standards developed
under section 1709(b)(3)(B)(iv) of the Public Health Service
Act, as added by section 2402 of this Act, to the extent such
standards are available upon the initiation of the
demonstration; and
(B) consistent with the privacy protections provided under
the regulations promulgated pursuant to section 264(c) of the
Health Insurance Portability and Accountability Act of 1996
(42 U.S.C. 1320d-2 note), if the recipient of language
services is a minor or is incapacitated, the primary language
of the parent or legal guardian is collected and utilized.
(e) Reporting Requirements.--Grantees under this section
shall provide the Secretary with reports at the conclusion of
the each year of a grant under this section. Each report
shall include at least the following information:
(1) The number of Medicare beneficiaries to whom language
services are provided.
(2) The languages of those Medicare beneficiaries.
(3) The types of language services provided (such as
provision of services directly in non-English language by a
bilingual health care provider or use of an interpreter).
(4) Type of interpretation (such as in-person, telephonic,
or video interpretation).
(5) The methods of providing language services (such as
staff or contract with external independent contractors or
agencies).
(6) The length of time for each interpretation encounter.
(7) The costs of providing language services (which may be
actual or estimated, as determined by the Secretary).
(8) An account of the training or accreditation of
bilingual staff, interpreters, or translators providing
services under this demonstration.
(f) No Cost Sharing.--Limited English proficient Medicare
beneficiaries shall not have to pay cost-sharing or co-pays
for language services provided through this demonstration
program.
(g) Evaluation and Report.--The Secretary shall conduct an
evaluation of the demonstration program under this section
and shall submit to the appropriate committees of Congress a
report not later than 1 year after the completion of the
program. The report shall include the following:
(1) An analysis of the patient outcomes and costs of
furnishing care to the limited English proficient Medicare
beneficiaries participating in the project as compared to
such outcomes and costs for limited English proficient
Medicare beneficiaries not participating.
(2) The effect of delivering culturally and linguistically
appropriate services on beneficiary access to care,
utilization of services, efficiency and cost-effectiveness of
health care delivery, patient satisfaction, and select health
outcomes.
(3) The extent to which bilingual staff, interpreters, and
translators providing services under such demonstration were
trained or accredited and the nature of accreditation or
training needed by type of provider, service, or other
category as determined by the Secretary to ensure the
provision of high-quality interpretation, translation, or
other language services to Medicare beneficiaries if such
services are expanded pursuant to subsection (c) of section
1907 of this Act.
(4) Recommendations, if any, regarding the extension of
such project to the entire Medicare program.
(h) Accreditation or Training for Providers of
Interpretation, Translation or Language Services in
Medicare.--
(1) In general.--
(A) Designation of standards.--If the Secretary, pursuant
to section 1907(c) of this Act, expands the model initially
developed through the demonstration program under this
section, the Secretary shall use the results of the study
under section 1221 and the demonstration under this section
to designate standards for training or accreditation. The
Secretary may designate one or more training or accreditation
organizations, as appropriate for the nature and type of
interpretation and translation services provided to Medicare
beneficiaries to ensure that payments are made only for
approved services by trained or accredited language services
providers.
(B) Alternatives to training or accreditation.--If the
Secretary designates one or more training or accreditation
organizations but determines that accreditation is not
available in all languages for which payments may be
initiated, the Secretary shall provide payments for and
accept alternatives to training or accreditation for certain
languages, including languages of lesser diffusion. The
Secretary must ensure that the alternatives to training or
accreditation provide, at a minimum--
(i) a determination that the interpreter is proficient and
able to communicate information accurately in both English
and in the language for which interpreting is needed;
(ii) an attestation from the interpreter to comply with and
adhere to the role of an interpreter as defined by the
National Code of Ethics and National Standards of Practice as
published by the National Council on Interpreting in Health
Care; and
(iii) an attestation to adhere to HIPAA privacy and
security law, as defined in section 3009(a)(2) of the Public
Health Service Act, to the same extent as the healthcare
provider for whom interpreting is provided.
(C) Modifiers, add-ons, and other forms of payment.--If the
Secretary decides that modifiers, add-ons, or other forms of
payment may be made for the provision of services directly by
bilingual providers, the Secretary shall designate standards
to ensure the competency of such providers delivering such
services in a non-English language.
(2) Consultation with stakeholders and considerations for
accreditation or training.--
(A) Consultation.--In designating accreditation or training
requirements under this subsection, the Secretary shall
consult with

[[Page H12692]]

patients, providers, organizations that advocate on behalf of
limited English proficient individuals, and other individuals
or entities determined appropriate by the Secretary.
(B) Considerations.--In designating accreditation or
training requirements under this section, the Secretary shall
consider, as appropriate--
(i) standards for qualifications of health care
interpreters who interpret infrequently encountered
languages;
(ii) standards for qualifications of health care
interpreters who interpret in languages of lesser diffusion;
(iii) standards for training of interpreters; and
(iv) standards for continuing education of interpreters.
(i) General Provisions.--Nothing in this section shall be
construed to limit otherwise existing obligations of
recipients of Federal financial assistance under title VI of
the Civil Rights Act of 1964 (42 U.S.C. 2000(d) et seq.) or
any other statute.
(j) Appropriations.--There are appropriated to carry out
this section, in equal parts from the Federal Hospital
Insurance Trust Fund and the Federal Supplementary Medical
Insurance Trust Fund, $16,000,000 for each fiscal year of the
demonstration program.

SEC. 1223. IOM REPORT ON IMPACT OF LANGUAGE ACCESS SERVICES.

(a) In General.--The Secretary of Health and Human Services
shall enter into an arrangement with the Institute of
Medicine under which the Institute will prepare and publish,
not later than 3 years after the date of the enactment of
this Act, a report on the impact of language access services
on the health and health care of limited English proficient
populations.
(b) Contents.--Such report shall include--
(1) recommendations on the development and implementation
of policies and practices by health care organizations and
providers for limited English proficient patient populations;
(2) a description of the effect of providing language
access services on quality of health care and access to care
and reduced medical error; and
(3) a description of the costs associated with or savings
related to provision of language access services.

SEC. 1224. DEFINITIONS.

In this subtitle:
(1) Bilingual.--The term ``bilingual'' with respect to an
individual means a person who has sufficient degree of
proficiency in two languages and can ensure effective
communication can occur in both languages.
(2) Competent interpreter services.--The term ``competent
interpreter services'' means a trans-language rendition of a
spoken message in which the interpreter comprehends the
source language and can speak comprehensively in the target
language to convey the meaning intended in the source
language. The interpreter knows health and health-related
terminology and provides accurate interpretations by choosing
equivalent expressions that convey the best matching and
meaning to the source language and captures, to the greatest
possible extent, all nuances intended in the source message.
(3) Competent translation services.--The term ``competent
translation services'' means a trans-language rendition of a
written document in which the translator comprehends the
source language and can write comprehensively in the target
language to convey the meaning intended in the source
language. The translator knows health and health-related
terminology and provides accurate translations by choosing
equivalent expressions that convey the best matching and
meaning to the source language and captures, to the greatest
possible extent, all nuances intended in the source document.
(4) Effective communication.--The term ``effective
communication'' means an exchange of information between the
provider of health care or health care-related services and
the limited English proficient recipient of such services
that enables limited English proficient individuals to
access, understand, and benefit from health care or health
care-related services.
(5) Interpreting/interpretation.--The terms
``interpreting'' and ``interpretation'' mean the transmission
of a spoken message from one language into another,
faithfully, accurately, and objectively.
(6) Health care services.--The term ``health care
services'' means services that address physical as well as
mental health conditions in all care settings.
(7) Health care-related services.--The term ``health care-
related services'' means human or social services programs or
activities that provide access, referrals or links to health
care.
(8) Language access.--The term ``language access'' means
the provision of language services to an LEP individual
designed to enhance that individual's access to,
understanding of or benefit from health care or health care-
related services.
(9) Language services.--The term ``language services''
means provision of health care services directly in a non-
English language, interpretation, translation, and non-
English signage.
(10) Limited english proficient.--The term ``limited
English proficient'' or ``LEP'' with respect to an individual
means an individual who speaks a primary language other than
English and who cannot speak, read, write or understand the
English language at a level that permits the individual to
effectively communicate with clinical or nonclinical staff at
an entity providing health care or health care related
services.
(11) Medicare beneficiary.--The term ``Medicare
beneficiary'' means an individual entitled to benefits under
part A of title XVIII of the Social Security Act or enrolled
under part B of such title.
(12) Medicare program.--The term ``Medicare program'' means
the programs under parts A through D of title XVIII of the
Social Security Act.
(13) Service provider.--The term ``service provider''
includes all suppliers, providers of services, or entities
under contract to provide coverage, items or services under
any part of title XVIII of the Social Security Act.

Subtitle C--Miscellaneous Improvements

SEC. 1231. EXTENSION OF THERAPY CAPS EXCEPTIONS PROCESS.

Section 1833(g)(5) of the Social Security Act (42 U.S.C.
1395l(g)(5)), as amended by section 141 of the Medicare
Improvements for Patients and Providers Act of 2008 (Public
Law 110-275), is amended by striking ``December 31, 2009''
and inserting ``December 31, 2011''.

SEC. 1232. EXTENDED MONTHS OF COVERAGE OF IMMUNOSUPPRESSIVE
DRUGS FOR KIDNEY TRANSPLANT PATIENTS AND OTHER
RENAL DIALYSIS PROVISIONS.

(a) Provision of Appropriate Coverage of Immunosuppressive
Drugs Under the Medicare Program for Kidney Transplant
Recipients.--
(1) Continued entitlement to immunosuppressive drugs.--
(A) Kidney transplant recipients.--Section 226A(b)(2) of
the Social Security Act (42 U.S.C. 426-1(b)(2)) is amended by
inserting ``(except for coverage of immunosuppressive drugs
under section 1861(s)(2)(J))'' before ``, with the thirty-
sixth month''.
(B) Application.--Section 1836 of such Act (42 U.S.C.
1395o) is amended--
(i) by striking ``Every individual who'' and inserting
``(a) In General.--Every individual who''; and
(ii) by adding at the end the following new subsection:
``(b) Special Rules Applicable to Individuals Only Eligible
for Coverage of Immunosuppressive Drugs.--
``(1) In general.--In the case of an individual whose
eligibility for benefits under this title has ended on or
after January 1, 2012, except for the coverage of
immunosuppressive drugs by reason of section 226A(b)(2), the
following rules shall apply:
``(A) The individual shall be deemed to be enrolled under
this part for purposes of receiving coverage of such drugs.
``(B) The individual shall be responsible for providing for
payment of the portion of the premium under section 1839
which is not covered under the Medicare savings program (as
defined in section 1144(c)(7)) in order to receive such
coverage.
``(C) The provision of such drugs shall be subject to the
application of--
``(i) the deductible under section 1833(b); and
``(ii) the coinsurance amount applicable for such drugs (as
determined under this part).
``(D) If the individual is an inpatient of a hospital or
other entity, the individual is entitled to receive coverage
of such drugs under this part.
``(2) Establishment of procedures in order to implement
coverage.--The Secretary shall establish procedures for--
``(A) identifying individuals that are entitled to coverage
of immunosuppressive drugs by reason of section 226A(b)(2);
and
``(B) distinguishing such individuals from individuals that
are enrolled under this part for the complete package of
benefits under this part.''.
(C) Technical amendment to correct duplicate subsection
designation.--Subsection (c) of section 226A of such Act (42
U.S.C. 426-1), as added by section 201(a)(3)(D)(ii) of the
Social Security Independence and Program Improvements Act of
1994 (Public Law 103-296; 108 Stat. 1497), is redesignated as
subsection (d).
(2) Extension of secondary payer requirements for esrd
beneficiaries.--Section 1862(b)(1)(C) of such Act (42 U.S.C.
1395y(b)(1)(C)) is amended by adding at the end the following
new sentence: ``With regard to immunosuppressive drugs
furnished on or after the date of the enactment of the
Affordable Health Care for America Act, this subparagraph
shall be applied without regard to any time limitation.''.
(b) Medicare Coverage for ESRD Patients.--Section 1881 of
such Act is further amended--
(1) in subsection (b)(14)(B)(iii), by inserting ``,
including oral drugs that are not the oral equivalent of an
intravenous drug (such as oral phosphate binders and
calcimimetics),'' after ``other drugs and biologicals'';
(2) in subsection (b)(14)(E)(ii)--
(A) in the first sentence--
(i) by striking ``a one-time election to be excluded from
the phase-in'' and inserting ``an election, with respect to
2011, 2012, or 2013, to be excluded from the phase-in (or the
remainder of the phase-in)''; and
(ii) by adding before the period at the end the following:
``for such year and for each subsequent year during the
phase-in described in clause (i)''; and
(B) in the second sentence--
(i) by striking ``January 1, 2011'' and inserting ``the
first date of such year''; and

[[Page H12693]]

(ii) by inserting ``and at a time'' after ``form and
manner''; and
(3) in subsection (h)(4)(E), by striking ``lesser'' and
inserting ``greater''.

SEC. 1233. VOLUNTARY ADVANCE CARE PLANNING CONSULTATION.

(a) In General.--Section 1861 of the Social Security Act
(42 U.S.C. 1395x) is amended--
(1) in subsection (s)(2)--
(A) by striking ``and'' at the end of subparagraph (DD);
(B) by adding ``and'' at the end of subparagraph (EE); and
(C) by adding at the end the following new subparagraph:
``(FF) voluntary advance care planning consultation (as
defined in subsection (hhh)(1));''; and
(2) by adding at the end the following new subsection:

``Voluntary Advance Care Planning Consultation

``(hhh)(1) Subject to paragraphs (3) and (4), the term
`voluntary advance care planning consultation' means an
optional consultation between the individual and a
practitioner described in paragraph (2) regarding advance
care planning. Such consultation may include the following,
as specified by the Secretary:
``(A) An explanation by the practitioner of advance care
planning, including a review of key questions and
considerations, advance directives (including living wills
and durable powers of attorney) and their uses.
``(B) An explanation by the practitioner of the role and
responsibilities of a health care proxy and of the continuum
of end-of-life services and supports available, including
palliative care and hospice, and benefits for such services
and supports that are available under this title.
``(C) An explanation by the practitioner of physician
orders regarding life sustaining treatment or similar orders,
in States where such orders or similar orders exist.
``(2) A practitioner described in this paragraph is--
``(A) a physician (as defined in subsection (r)(1)); and
``(B) another health care professional (as specified by the
Secretary and who has the authority under State law to sign
orders for life sustaining treatments, such as a nurse
practitioner or physician assistant).
``(3) An individual may receive the voluntary advance care
planning care planning consultation provided for under this
subsection no more than once every 5 years unless there is a
significant change in the health or health-related condition
of the individual.
``(4) For purposes of this section, the term `order
regarding life sustaining treatment' means, with respect to
an individual, an actionable medical order relating to the
treatment of that individual that effectively communicates
the individual's preferences regarding life sustaining
treatment, is signed and dated by a practitioner, and is in a
form that permits it to be followed by health care
professionals across the continuum of care.''.
(b) Construction.--The voluntary advance care planning
consultation described in section 1861(hhh) of the Social
Security Act, as added by subsection (a), shall be completely
optional. Nothing in this section shall--
(1) require an individual to complete an advance directive,
an order for life sustaining treatment, or other advance care
planning document;
(2) require an individual to consent to restrictions on the
amount, duration, or scope of medical benefits an individual
is entitled to receive under this title; or
(3) encourage the promotion of suicide or assisted suicide.
(c) Payment.--Section 1848(j)(3) of such Act (42 U.S.C.
1395w-4(j)(3)) is amended by inserting ``(2)(FF),'' after
``(2)(EE),''.
(d) Frequency Limitation.--Section 1862(a) of such Act (42
U.S.C. 1395y(a)) is amended--
(1) in paragraph (1)--
(A) in subparagraph (N), by striking ``and'' at the end;
(B) in subparagraph (O) by striking the semicolon at the
end and inserting ``, and''; and
(C) by adding at the end the following new subparagraph:
``(P) in the case of voluntary advance care planning
consultations (as defined in paragraph (1) of section
1861(hhh)), which are performed more frequently than is
covered under such section;''; and
(2) in paragraph (7), by striking ``or (K)'' and inserting
``(K), or (P)''.
(e) Effective Date.--The amendments made by this section
shall apply to consultations furnished on or after January 1,
2011.

SEC. 1234. PART B SPECIAL ENROLLMENT PERIOD AND WAIVER OF
LIMITED ENROLLMENT PENALTY FOR TRICARE
BENEFICIARIES.

(a) Part B Special Enrollment Period.--
(1) In general.--Section 1837 of the Social Security Act
(42 U.S.C. 1395p) is amended by adding at the end the
following new subsection:
``(l)(1) In the case of any individual who is a covered
beneficiary (as defined in section 1072(5) of title 10,
United States Code) at the time the individual is entitled to
hospital insurance benefits under part A under section 226(b)
or section 226A and who is eligible to enroll but who has
elected not to enroll (or to be deemed enrolled) during the
individual's initial enrollment period, there shall be a
special enrollment period described in paragraph (2).
``(2) The special enrollment period described in this
paragraph, with respect to an individual, is the 12-month
period beginning on the day after the last day of the initial
enrollment period of the individual or, if later, the 12-
month period beginning with the month the individual is
notified of enrollment under this section.
``(3) In the case of an individual who enrolls during the
special enrollment period provided under paragraph (1), the
coverage period under this part shall begin on the first day
of the month in which the individual enrolls or, at the
option of the individual, on the first day of the second
month following the last month of the individual's initial
enrollment period.
``(4) The Secretary of Defense shall establish a method for
identifying individuals described in paragraph (1) and
providing notice to them of their eligibility for enrollment
during the special enrollment period described in paragraph
(2).''.
(2) Effective date.--The amendment made by paragraph (1)
shall apply to elections made on or after the date of the
enactment of this Act.
(b) Waiver of Increase of Premium.--
(1) In general.--Section 1839(b) of the Social Security Act
(42 U.S.C. 1395r(b)) is amended by striking ``section
1837(i)(4)'' and inserting ``subsection (i)(4) or (l) of
section 1837''.
(2) Effective date.--
(A) In general.--The amendment made by paragraph (1) shall
apply with respect to elections made on or after the date of
the enactment of this Act.
(B) Rebates for certain disabled and esrd beneficiaries.--
(i) In general.--With respect to premiums for months on or
after January 2005 and before the month of the enactment of
this Act, no increase in the premium shall be effected for a
month in the case of any individual who is a covered
beneficiary (as defined in section 1072(5) of title 10,
United States Code) at the time the individual is entitled to
hospital insurance benefits under part A of title XVIII of
the Social Security Act under section 226(b) or 226A of such
Act, and who is eligible to enroll, but who has elected not
to enroll (or to be deemed enrolled), during the individual's
initial enrollment period, and who enrolls under this part
within the 12-month period that begins on the first day of
the month after the month of notification of entitlement
under this part.
(ii) Consultation with department of defense.--The
Secretary of Health and Human Services shall consult with the
Secretary of Defense in identifying individuals described in
this paragraph.
(iii) Rebates.--The Secretary of Health and Human Services
shall establish a method for providing rebates of premium
increases paid for months on or after January 1, 2005, and
before the month of the enactment of this Act for which a
penalty was applied and collected.

SEC. 1235. EXCEPTION FOR USE OF MORE RECENT TAX YEAR IN CASE
OF GAINS FROM SALE OF PRIMARY RESIDENCE IN
COMPUTING PART B INCOME-RELATED PREMIUM.

(a) In General.--Section 1839(i)(4)(C)(ii)(II) of the
Social Security Act (42 U.S.C. 1395r(i)(4)(C)(ii)(II)) is
amended by inserting ``sale of primary residence,'' after
``divorce of such individual,''.
(b) Effective Date.--The amendment made by subsection (a)
shall apply to premiums and payments for years beginning with
2011.

SEC. 1236. DEMONSTRATION PROGRAM ON USE OF PATIENT DECISIONS
AIDS.

(a) In General.--The Secretary of Health and Human
Services, acting through the Center for Medicare and Medicaid
Innovation established under section 1115A of the Social
Security Act (as added by section 1907) and consistent with
the applicable provisions of such section, shall establish a
shared decision making demonstration program (in this
subsection referred to as the ``program'') under the Medicare
program using patient decision aids to meet the objective of
improving the understanding by Medicare beneficiaries of
their medical treatment options, as compared to comparable
Medicare beneficiaries who do not participate in a shared
decision making process using patient decision aids.
(b) Sites.--
(1) Enrollment.--The Secretary shall enroll in the program
not more than 30 eligible providers who have experience in
implementing, and have invested in the necessary
infrastructure to implement, shared decision making using
patient decision aids.
(2) Application.--An eligible provider seeking to
participate in the program shall submit to the Secretary an
application at such time and containing such information as
the Secretary may require.
(3) Preference.--In enrolling eligible providers in the
program, the Secretary shall give preference to eligible
providers that--
(A) have documented experience in using patient decision
aids for the conditions identified by the Secretary and in
using shared decision making;
(B) have the necessary information technology
infrastructure to collect the information required by the
Secretary for reporting purposes; and
(C) are trained in how to use patient decision aids and
shared decision making.
(c) Follow-up Counseling Visit.--
(1) In general.--An eligible provider participating in the
program shall routinely schedule Medicare beneficiaries for a
counseling visit after the viewing of such a patient decision
aid to answer any questions

[[Page H12694]]

the beneficiary may have with respect to the medical care of
the condition involved and to assist the beneficiary in
thinking through how their preferences and concerns relate to
their medical care.
(2) Payment for follow-up counseling visit.--The Secretary
shall establish procedures for making payments for such
counseling visits provided to Medicare beneficiaries under
the program. Such procedures shall provide for the
establishment--
(A) of a code (or codes) to represent such services; and
(B) of a single payment amount for such service that
includes the professional time of the health care provider
and a portion of the reasonable costs of the infrastructure
of the eligible provider such as would be made under the
applicable payment systems to that provider for similar
covered services.
(d) Costs of Aids.--An eligible provider participating in
the program shall be responsible for the costs of selecting,
purchasing, and incorporating such patient decision aids into
the provider's practice, and reporting data on quality and
outcome measures under the program.
(e) Funding.--The Secretary shall provide for the transfer
from the Federal Supplementary Medical Insurance Trust Fund
established under section 1841 of the Social Security Act (42
U.S.C. 1395t) of such funds as are necessary for the costs of
carrying out the program.
(f) Waiver Authority.--The Secretary may waive such
requirements of titles XI and XVIII of the Social Security
Act (42 U.S.C. 1301 et seq. and 1395 et seq.) as may be
necessary for the purpose of carrying out the program.
(g) Report.--Not later than 12 months after the date of
completion of the program, the Secretary shall submit to
Congress a report on such program, together with
recommendations for such legislation and administrative
action as the Secretary determines to be appropriate. The
final report shall include an evaluation of the impact of the
use of the program on health quality, utilization of health
care services, and on improving the quality of life of such
beneficiaries.
(h) Definitions.--In this section:
(1) Eligible provider.--The term ``eligible provider''
means the following:
(A) A primary care practice.
(B) A specialty practice.
(C) A multispecialty group practice.
(D) A hospital.
(E) A rural health clinic.
(F) A Federally qualified health center (as defined in
section 1861(aa)(4) of the Social Security Act (42 U.S.C.
1395x(aa)(4)).
(G) An integrated delivery system.
(H) A State cooperative entity that includes the State
government and at least one other health care provider which
is set up for the purpose of testing shared decision making
and patient decision aids.
(2) Patient decision aid.--The term ``patient decision
aid'' means an educational tool (such as the Internet, a
video, or a pamphlet) that helps patients (or, if
appropriate, the family caregiver of the patient) understand
and communicate their beliefs and preferences related to
their treatment options, and to decide with their health care
provider what treatments are best for them based on their
treatment options, scientific evidence, circumstances,
beliefs, and preferences.
(3) Shared decision making.--The term ``shared decision
making'' means a collaborative process between patient and
clinician that engages the patient in decision making,
provides patients with information about trade-offs among
treatment options, and facilitates the incorporation of
patient preferences and values into the medical plan.

TITLE III--PROMOTING PRIMARY CARE, MENTAL HEALTH SERVICES, AND
COORDINATED CARE

SEC. 1301. ACCOUNTABLE CARE ORGANIZATION PILOT PROGRAM.

Title XVIII of the Social Security Act is amended by
inserting after section 1866D, as added by section 1152(f),
the following new section:

``accountable care organization pilot program

``Sec. 1866E.  (a) Establishment.--
``(1) In General.--The Secretary shall conduct a pilot
program (in this section referred to as the `pilot program')
to test different payment incentive models, including (to the
extent practicable) the specific payment incentive models
described in subsection (c), designed to reduce the growth of
expenditures and improve health outcomes in the provision of
items and services under this title to applicable
beneficiaries (as defined in subsection (e)) by qualifying
accountable care organizations (as defined in subsection
(b)(1)) in order to--
``(A) promote accountability for a patient population and
coordinate items and services under parts A and B (and may
include Part D, if the Secretary determines appropriate);
``(B) encourage investment in infrastructure and redesigned
care processes for high quality and efficient service
delivery; and
``(C) reward physician practices and other physician
organizational models for the provision of high quality and
efficient health care services.
``(2) Scope.--The Secretary shall set specific goals for
the number of accountable care organizations, participating
practitioners, and patients served in the initial tests under
the pilot program to ensure that the pilot program is of
sufficient size and scope to--
``(A) test the approach involved in a variety of settings,
including urban, rural, and underserved areas; and
``(B) subject to subsection (g)(1), disseminate such
approach rapidly on a national basis.
To the extent that the Secretary finds a qualifying
accountable care organization model to be successful in
improving quality and reducing costs, the Secretary shall
seek to implement such models on as large a geographic scale
as practical and economical.
``(b) Qualifying Accountable Care Organizations (ACOs).--
``(1) Qualifying aco defined.--In this section:
``(A) In general.--The terms `qualifying accountable care
organization' and `qualifying ACO' mean a group of physicians
or other physician organizational model (as defined in
subparagraph (D)) that--
``(i) is organized at least in part for the purpose of
providing physicians' services; and
``(ii) meets such criteria as the Secretary determines to
be appropriate to participate in the pilot program, including
the criteria specified in paragraph (2).
``(B) Inclusion of other providers of services and
suppliers.--Nothing in this subsection shall be construed as
preventing a qualifying ACO from including a hospital or any
other provider of services or supplier furnishing items or
services for which payment may be made under this title that
is affiliated with the ACO under an arrangement structured so
that such provider or supplier participates in the pilot
program and shares in any incentive payments under the pilot
program.
``(C) Physician.--The term `physician' includes, except as
the Secretary may otherwise provide, any individual who
furnishes services for which payment may be made as
physicians' services under this title.
``(D) Other physician organizational model.--The term
`other physician organization model' means, with respect to a
qualifying ACO any model of organization under which
physicians enter into agreements with other providers of
services for the purposes of participation in the pilot
program in order to provide high quality and efficient health
care services and share in any incentive payments under such
program
``(E) Other services.--Nothing in this paragraph shall be
construed as preventing a qualifying ACO from furnishing
items or services, for which payment may not be made under
this title, for purposes of achieving performance goals under
the pilot program.
``(2) Qualifying criteria.--The following are criteria
described in this paragraph for an organized group of
physicians to be a qualifying ACO:
``(A) The group has a legal structure that would allow the
group to receive and distribute incentive payments under this
section.
``(B) The group includes a sufficient number of primary
care physicians (regardless of specialty) for the applicable
beneficiaries for whose care the group is accountable (as
determined by the Secretary).
``(C) The group reports on quality measures in such form,
manner, and frequency as specified by the Secretary (which
may be for the group, for providers of services and
suppliers, or both).
``(D) The group reports to the Secretary (in a form, manner
and frequency as specified by the Secretary) such data as the
Secretary determines appropriate to monitor and evaluate the
pilot program.
``(E) The group provides notice to applicable beneficiaries
regarding the pilot program (as determined appropriate by the
Secretary).
``(F) The group contributes to a best practices network or
website, that shall be maintained by the Secretary for the
purpose of sharing strategies on quality improvement, care
coordination, and efficiency that the groups believe are
effective.
``(G) The group utilizes patient-centered processes of
care, including those that emphasize patient and caregiver
involvement in planning and monitoring of ongoing care
management plan.
``(H) The group meets other criteria determined to be
appropriate by the Secretary.
``(c) Specific Payment Incentive Models.--The specific
payment incentive models described in this subsection are the
following:
``(1) Performance target model.--Under the performance
target model under this paragraph (in this paragraph referred
to as the `performance target model'):
``(A) In general.--A qualifying ACO qualifies to receive an
incentive payment if expenditures for items and services for
applicable beneficiaries are less than a target spending
level or a target rate of growth. The incentive payment shall
be made only if savings are greater than would result from
normal variation in expenditures for items and services
covered under parts A and B (and may include Part D, if the
Secretary determines appropriate).
``(B) Computation of performance target.--
``(i) In general.--The Secretary shall establish a
performance target for each qualifying ACO comprised of a
base amount (described in clause (ii)) increased to the
current year by an adjustment factor (described in clause
(iii)). Such a target may be established on a per capita
basis or adjusted for risk, as the Secretary determines to be
appropriate.

[[Page H12695]]

``(ii) Base amount.--For purposes of clause (i), the base
amount in this subparagraph is equal to the average total
payments (or allowed charges) under parts A and B (and may
include part D, if the Secretary determines appropriate) for
applicable beneficiaries for whom the qualifying ACO
furnishes items and services in a base period determined by
the Secretary. Such base amount may be determined on a per
capita basis or adjusted for risk.
``(iii) Adjustment factor.--For purposes of clause (i), the
adjustment factor in this clause may equal an annual per
capita amount that reflects changes in expenditures from the
period of the base amount to the current year that would
represent an appropriate performance target for applicable
beneficiaries (as determined by the Secretary).
``(iv) Rebasing.--Under this model the Secretary shall
periodically rebase the base expenditure amount described in
clause (ii).
``(C) Meeting target.--
``(i) In general.--Subject to clause (ii), a qualifying ACO
that meets or exceeds annual quality and performance targets
for a year shall receive an incentive payment for such year
equal to a portion (as determined appropriate by the
Secretary) of the amount by which payments under this title
for such year are estimated to be below the performance
target for such year, as determined by the Secretary. The
Secretary may establish a cap on incentive payments for a
year for a qualifying ACO.
``(ii) Limitation.--The Secretary shall limit incentive
payments to each qualifying ACO under this paragraph as
necessary to ensure that the aggregate expenditures with
respect to applicable beneficiaries for such ACOs under this
title (inclusive of incentive payments described in this
subparagraph) do not exceed the amount that the Secretary
estimates would be expended for such ACO for such
beneficiaries if the pilot program under this section were
not implemented.
``(D) Reporting and other requirements.--In carrying out
such model, the Secretary may (as the Secretary determines to
be appropriate) incorporate reporting requirements, incentive
payments, and penalties related to the physician quality
reporting initiative (PQRI), electronic prescribing,
electronic health records, and other similar initiatives
under section 1848, and may use alternative criteria than
would otherwise apply under such section for determining
whether to make such payments. The incentive payments
described in this subparagraph shall not be included in the
limit described in subparagraph (C)(ii) or in the performance
target model described in this paragraph.
``(2) Partial capitation model.--
``(A) In general.--Subject to subparagraph (B), a partial
capitation model described in this paragraph (in this
paragraph referred to as a `partial capitation model') is a
model in which a qualifying ACO would be at financial risk
for some, but not all, of the items and services covered
under parts A and B (and may include part D, if the Secretary
determines appropriate), such as at risk for some or all
physicians' services or all items and services under part B.
The Secretary may limit a partial capitation model to ACOs
that are highly integrated systems of care and to ACOs
capable of bearing risk, as determined to be appropriate by
the Secretary.
``(B) No additional program expenditures.--Payments to a
qualifying ACO for items and services under this title for
applicable beneficiaries for a year under the partial
capitation model shall be established in a manner that does
not result in spending more for such ACO for such
beneficiaries than would otherwise be expended for such ACO
for such beneficiaries for such year if the pilot program
were not implemented, as estimated by the Secretary.
``(3) Other payment models.--
``(A) In general.--Subject to subparagraph (B), the
Secretary may develop other payment models that meet the
goals of this pilot program to improve quality and
efficiency.
``(B) No additional program expenditures.--Subparagraph (B)
of paragraph (2) shall apply to a payment model under
subparagraph (A) in a similar manner as such subparagraph (B)
applies to the payment model under paragraph (2).
``(d) Annual Quality Targets.--
``(1) In general.--The Secretary shall establish annual
quality targets that qualifying ACOs must meet to receive
incentive payments, operate at financial risk, or otherwise
participate in alternative financing models under this
section. The Secretary shall establish a process for
developing annual targets based on ACO reporting of multiple
quality measures. In selecting measures the Secretary shall--
``(A) for years one and two of each ACOs participation in
the pilot program established by this section, require
reporting of a starter set of measures focused on clinical
care, care coordination and patient experience of care; and
``(B) for each subsequent year, require reporting of a more
comprehensive set of clinical outcomes measures, care
coordination measures and patient experience of care
measures.
``(2) Measure selection.--To the extent feasible, the
Secretary shall select measures that reflect national
priorities for quality improvement and patient-centered care
consistent with the measures developed under section
1192(c)(1).
``(e) Applicable Beneficiaries.--
``(1) In general.--In this section, the term `applicable
beneficiary' means, with respect to a qualifying ACO, an
individual who--
``(A) is enrolled under part B and entitled to benefits
under part A;
``(B) is not enrolled in a Medicare Advantage plan under
part C or a PACE program under section 1894; and
``(C) meets such other criteria as the Secretary determines
appropriate, which may include criteria relating to frequency
of contact with physicians in the ACO
``(2) Following applicable beneficiaries.--The Secretary
may monitor data on expenditures and quality of services
under this title after an applicable beneficiary discontinues
receiving services under this title through a qualifying ACO.
``(f) Implementation.--
``(1) Starting date.--The pilot program shall begin no
later than January 1, 2012. An agreement with a qualifying
ACO under the pilot program may cover a multi-year period of
between 3 and 5 years.
``(2) Waiver.--The Secretary may waive such provisions of
this title (including section 1877) and title XI in the
manner the Secretary determines necessary in order implement
the pilot program.
``(3) Performance results reports.--The Secretary shall
report performance results to qualifying ACOs under the pilot
program at least annually.
``(4) Limitations on review.--There shall be no
administrative or judicial review under section 1869, section
1878, or otherwise of--
``(A) the elements, parameters, scope, and duration of the
pilot program;
``(B) the selection of qualifying ACOs for the pilot
program;
``(C) the establishment of targets, measurement of
performance, determinations with respect to whether savings
have been achieved and the amount of savings;
``(D) determinations regarding whether, to whom, and in
what amounts incentive payments are paid; and
``(E) decisions about the extension of the program under
subsection (h), expansion of the program under subsection (i)
or extensions under subsections (j) or (k).
``(5) Administration.--Chapter 35 of title 44, United
States Code shall not apply to this section.
``(g) Evaluation; Monitoring.--
``(1) In general.--The Secretary shall evaluate the payment
incentive model for each qualifying ACO under the pilot
program to assess impacts on beneficiaries, providers of
services, suppliers and the program under this title. The
Secretary shall make such evaluation publicly available
within 60 days of the date of completion of such report.
``(2) Monitoring.--The Inspector General of the Department
of Health and Human Services shall provide for monitoring of
the operation of ACOs under the pilot program with regard to
violations of section 1877 (popularly known as the `Stark
law').
``(h) Extension of Pilot Agreement With Successful
Organizations.--
``(1) Reports to congress.--Not later than 2 years after
the date the first agreement is entered into under this
section, and biennially thereafter for six years, the
Secretary shall submit to Congress and make publicly
available a report on the use of ACO payment models under the
pilot program. Each report shall address the impact of the
use of those models on expenditures, access, and quality
under this title.
``(2) Extension.--Subject to the report provided under
paragraph (1), with respect to a qualifying ACO, the
Secretary may extend the duration of the agreement for such
ACO under the pilot program as the Secretary determines
appropriate if--
``(A) the ACO receives incentive payments with respect to
any of the first 4 years of the pilot agreement and is
consistently meeting quality standards or
``(B) the ACO is consistently exceeding quality standards
and is not increasing spending under the program.
``(3) Termination.--The Secretary may terminate an
agreement with a qualifying ACO under the pilot program if
such ACO did not receive incentive payments or consistently
failed to meet quality standards in any of the first 3 years
under the program.
``(i) Expansion to Additional ACOs.--
``(1) Testing and refinement of payment incentive models.--
Subject to the evaluation described in subsection (g), the
Secretary may enter into agreements under the pilot program
with additional qualifying ACOs to further test and refine
payment incentive models with respect to qualifying ACOs.
``(2) Expanding use of successful models to program
implementation.--
``(A) In general.--Subject to subparagraph (B), the
Secretary may issue regulations to implement, on a permanent
basis, 1 or more models if, and to the extent that, such
models are beneficial to the program under this title, as
determined by the Secretary.
``(B) Certification.--The Chief Actuary of the Centers for
Medicare & Medicaid Services shall certify that 1 or more of
such models described in subparagraph (A) would result in
estimated spending that would be less than what spending
would otherwise be estimated to be in the absence of such
expansion.
``(j) Treatment of Physician Group Practice
Demonstration.--
``(1) Extension.--The Secretary may enter in to an
agreement with a qualifying ACO under the demonstration under
section

[[Page H12696]]

1866A, subject to rebasing and other modifications deemed
appropriate by the Secretary, until the pilot program under
this section is operational.
``(2) Transition.--For purposes of extension of an
agreement with a qualifying ACO under subsection (h)(2), the
Secretary shall treat receipt of an incentive payment for a
year by an organization under the physician group practice
demonstration pursuant to section 1866A as a year for which
an incentive payment is made under such subsection, as long
as such practice group practice organization meets the
criteria under subsection (b)(2).
``(k) Additional Provisions.--
``(1) Authority for separate incentive arrangements.--The
Secretary may create separate incentive arrangements
(including using multiple years of data, varying thresholds,
varying shared savings amounts, and varying shared savings
limits) for different categories of qualifying ACOs to
reflect variation in average annual attributable expenditures
and other matters the Secretary deems appropriate.
``(2) Encouragement of participation of smaller
organizations.--In order to encourage the participation of
smaller accountable care organizations under the pilot
program, the Secretary may limit a qualifying ACO's exposure
to high cost patients under the program.
``(3) Involvement in private payer and other third party
arrangements.--The Secretary may give preference to ACOs who
are participating in similar arrangements with other payers.
``(4) Antidiscrimination limitation.--The Secretary shall
not enter into an agreement with an entity to provide health
care items or services under the pilot program, or with an
entity to administer the program, unless such entity
guarantees that it will not deny, limit, or condition the
coverage or provision of benefits under the program, for
individuals eligible to be enrolled under such program, based
on any health status-related factor described in section
2702(a)(1) of the Public Health Service Act.
``(5) Funding.--For purposes of administering and carrying
out the pilot program, other than for payments for items and
services furnished under this title and incentive payments
under subsection (c)(1), in addition to funds otherwise
appropriated, there are appropriated to the Secretary for the
Center for Medicare & Medicaid Services Program Management
Account $25,000,000 for each of fiscal years 2010 through
2014 and $20,000,000 for fiscal year 2015. Amounts
appropriated under this paragraph for a fiscal year shall be
available until expended.
``(6) No duplication in payments to physicians in multiple
pilots.--The Secretary shall not make payments under this
section to any physician group that is paid under section
1866F (relating to medical homes) or section 1866G (relating
to independence at home).''.

SEC. 1302. MEDICAL HOME PILOT PROGRAM.

(a) In General.--Title XVIII of the Social Security Act is
amended by inserting after section 1866E, as inserted by
section 1301, the following new section:

``medical home pilot program

``Sec. 1866F.  (a) Establishment and Medical Home Models.--
``(1) Establishment of pilot program.--The Secretary shall
establish a medical home pilot program (in this section
referred to as the `pilot program') for the purpose of
evaluating the feasibility and advisability of reimbursing
qualified patient-centered medical homes for furnishing
medical home services (as defined under subsection (b)(1)) to
beneficiaries (as defined in subsection (b)(4)) and to
targeted high need beneficiaries (as defined in subsection
(c)(1)(C)).
``(2) Scope.--Subject to subsection (g), the Secretary
shall set specific goals for the number of practices and
communities, and the number of patients served, under the
pilot program in the initial tests to ensure that the pilot
program is of sufficient size and scope to--
``(A) test the approach involved in a variety of settings,
including urban, rural, and underserved areas; and
``(B) subject to subsection (e)(1), disseminate such
approach rapidly on a national basis.
To the extent that the Secretary finds a medical home model
to be successful in improving quality and reducing costs, the
Secretary shall implement such model on as large a geographic
scale as practical and economical.
``(3) Models of medical homes in the pilot program.--The
pilot program shall evaluate each of the following medical
home models:
``(A) Independent patient-centered medical home model.--
Independent patient-centered medical home model under
subsection (c).
``(B) Community-based medical home model.--Community-based
medical home model under subsection (d).
``(4) Participation of nurse practitioners and physician
assistants.--
``(A) Nothing in this section shall be construed as
preventing a nurse practitioner from leading a patient
centered medical home so long as--
``(i) all the requirements of this section are met; and
``(ii) the nurse practitioner is acting in a manner that is
consistent with State law.
``(B) Nothing in this section shall be construed as
preventing a physician assistant from participating in a
patient centered medical home so long as--
``(i) all the requirements of this section are met; and
``(ii) the physician assistant is acting in a manner that
is consistent with State law.
``(b) Definitions.--For purposes of this section:
``(1) Patient-centered medical home services.--The term
`patient-centered medical home services' means services
that--
``(A) provide beneficiaries with direct and ongoing access
to a primary care or principal care physician or nurse
practitioner who accepts responsibility for providing first
contact, continuous and comprehensive care to such
beneficiary;
``(B) coordinate the care provided to a beneficiary by a
team of individuals at the practice level across office,
provider of services, and home settings led by a primary care
or principal care physician or nurse practitioner, as needed
and appropriate;
``(C) provide for all the patient's health care needs or
take responsibility for appropriately arranging care with
other qualified physicians or providers for all stages of
life;
``(D) provide continuous access to care and communication
with participating beneficiaries;
``(E) provide support for patient self-management,
proactive and regular patient monitoring, support for family
caregivers, use patient-centered processes, and coordination
with community resources;
``(F) integrate readily accessible, clinically useful
information on participating patients that enables the
practice to treat such patients comprehensively and
systematically; and
``(G) implement evidence-based guidelines and apply such
guidelines to the identified needs of beneficiaries over time
and with the intensity needed by such beneficiaries.
``(2) Primary care.--The term `primary care' means health
care that is provided by a physician, nurse practitioner, or
physician assistant who practices in the field of family
medicine, general internal medicine, geriatric medicine, or
pediatric medicine.
``(3) Principal care.--The term `principal care' means
integrated, accessible health care that is provided by a
physician who is a medical specialist or subspecialist that
addresses the majority of the personal health care needs of
patients with chronic conditions requiring the specialist's
or subspecialist's expertise, and for whom the specialist or
subspecialist assumes care management.
``(4) Beneficiaries.--The term `beneficiaries' means, with
respect to a qualifying medical home, an individual who--
``(A) is enrolled under part B and entitled to benefits
under part A;
``(B) is not enrolled in a Medicare Advantage plan under
part C or a PACE program under section 1894; and
``(C) meets such other criteria as the Secretary determines
appropriate.
``(c) Independent Patient-centered Medical Home Model.--
``(1) In general.--
``(A) Payment authority.--Under the independent patient-
centered medical home model under this subsection, the
Secretary shall make payments for medical home services
furnished by an independent patient-centered medical home (as
defined in subparagraph (B)) pursuant to paragraph (3) for
targeted high need beneficiaries (as defined in subparagraph
(C)).
``(B) Independent patient-centered medical home defined.--
In this section, the term `independent patient-centered
medical home' means a physician-directed or nurse-
practitioner-directed practice that is qualified under
paragraph (2) as--
``(i) providing beneficiaries with patient-centered medical
home services; and
``(ii) meets such other requirements as the Secretary may
specify.
``(C) Targeted high need beneficiary defined.--For purposes
of this subsection, the term `targeted high need beneficiary'
means a beneficiary who, based on a risk score as specified
by the Secretary, is generally within the upper 50th
percentile of Medicare beneficiaries.
``(D) Beneficiary election to participate.--The Secretary
shall determine an appropriate method of ensuring that
beneficiaries have agreed to participate in the pilot
program.
``(E) Implementation.--The pilot program under this
subsection shall begin no later than 12 months after the date
of the enactment of this section and shall operate for 5
years.
``(2) Qualification process for patient-centered medical
homes.--The Secretary shall establish a process for practices
to qualify as medical homes.
``(3)  Payment.--
``(A) Establishment of methodology.--The Secretary shall
establish a methodology for the payment for medical home
services furnished by independent patient-centered medical
homes. Under such methodology, the Secretary shall adjust
payments to medical homes based on beneficiary risk scores to
ensure that higher payments are made for higher risk
beneficiaries.
``(B) Per beneficiary per month payments.--Under such
payment methodology, the Secretary shall pay independent
patient-centered medical homes a monthly fee for each
targeted high need beneficiary who consents to receive
medical home services through such medical home.
``(C) Prospective payment.--The fee under subparagraph (B)
shall be paid on a prospective basis.

[[Page H12697]]

``(D) Amount of payment.--In determining the amount of such
fee, the Secretary shall consider the following:
``(i) The clinical work and practice expenses involved in
providing the medical home services provided by the
independent patient-centered medical home (such as providing
increased access, care coordination, population disease
management, and teaching self-care skills for managing
chronic illnesses) for which payment is not made under this
title as of the date of the enactment of this section.
``(ii) Allow for differential payments based on
capabilities of the independent patient-centered medical
home.
``(iii) Use appropriate risk-adjustment in determining the
amount of the per beneficiary per month payment under this
paragraph in a manner that ensures that higher payments are
made for higher risk beneficiaries.
``(4) Encouraging participation of variety of practices.--
The pilot program under this subsection shall be designed to
include the participation of physicians in practices with
fewer than 10 full-time equivalent physicians, as well as
physicians in larger practices, particularly in underserved
and rural areas, as well as federally qualified health
centers, and rural health centers.
``(d) Community-based Medical Home Model.--
``(1) In general.--
``(A) Authority for payments.--Under the community-based
medical home model under this subsection (in this section
referred to as the `CBMH model'), the Secretary shall make
payments for the furnishing of medical home services by a
community-based medical home (as defined in subparagraph (B))
pursuant to paragraph (5)(B) for beneficiaries.
``(B) Community-based medical home defined.--In this
section, the term `community-based medical home' means a
nonprofit community-based or State-based organization or a
State that is certified under paragraph (2) as meeting the
following requirements:
``(i) The organization provides beneficiaries with medical
home services.
``(ii) The organization provides medical home services
under the supervision of and in close collaboration with the
primary care or principal care physician, nurse practitioner,
or physician assistant designated by the beneficiary as his
or her community-based medical home provider.
``(iii) The organization employs community health workers,
including nurses or other non-physician practitioners, lay
health workers, or other persons as determined appropriate by
the Secretary, that assist the primary or principal care
physician, nurse practitioner, or physician assistant in
chronic care management activities such as teaching self-care
skills for managing chronic illnesses, transitional care
services, care plan setting, nutritional counseling,
medication therapy management services for patients with
multiple chronic diseases, or help beneficiaries access the
health care and community-based resources in their local
geographic area.
``(iv) The organization meets such other requirements as
the Secretary may specify.
``(2) Qualification process for community-based medical
homes.--The Secretary shall establish a process to provide
for the review and qualification of community-based medical
homes pursuant to criteria established by the Secretary.
``(3) Duration.--The pilot program for community-based
medical homes under this subsection shall start no later than
2 years after the date of the enactment of this section. Each
demonstration site under the pilot program shall operate for
a period of up to 5 years after the initial implementation
phase, without regard to the receipt of a initial
implementation funding under paragraph (6).
``(4) Preference.--In selecting sites for the CBMH model,
the Secretary shall give preference to applications which
seek to eliminate health disparities, as defined in section
3171 of the Public Health Service Act and may give preference
to any of the following:
``(A) Applications that propose to coordinate health care
items and services under this title for chronically ill
beneficiaries who rely, for primary care, on small physician
or nurse practitioner practices, federally qualified health
centers, rural health clinics, or other settings with limited
resources and scope of services.
``(B) Applications that include other third-party payors
that furnish medical home services for chronically ill
patients covered by such third-party payors.
``(C) Applications from States that propose to use the
medical home model to coordinate health care services for--
``(i) individuals enrolled under this title;
``(ii) individuals enrolled under title XIX; and
``(iii) full-benefit dual eligible individuals (as defined
in section 1935(c)(6)),
with chronic diseases across a variety of health care
settings.
``(5)  Payments.--
``(A) Establishment of methodology.--The Secretary shall
establish a methodology for the payment for medical home
services furnished under the CBMH model.
``(B) Per beneficiary per month payments.--Under such
payment methodology, the Secretary shall make two separate
monthly payments for each beneficiary who consents to receive
medical home services through such medical home, as follows:
``(i) Payment to community-based organization.--One monthly
payment to a community-based or State-based organization or
State.
``(ii) Payment to primary or principal care practice.--One
monthly payment to the primary or principal care practice for
such beneficiary.
``(C) Prospective payment.--The payments under subparagraph
(B) shall be paid on a prospective basis.
``(D) Amount of payment.--In determining the amount of such
payment under subparagraph (B), the Secretary shall consider
the following:
``(i) The clinical work and practice expenses involved in
providing the medical home services provided by the primary
or principal care practice (such as providing increased
access, care coordination, care planning, population disease
management, and teaching self-care skills for managing
chronic illnesses) for which payment is not made under this
title as of the date of the enactment of this section.
``(ii) Use appropriate risk-adjustment in determining the
amount of the per beneficiary per month payment under this
paragraph.
``(iii) In the case of the models described in
subparagraphs (B) and (C) of paragraph (4), the Secretary may
determine an appropriate payment amount.
``(6) Initial implementation funding.--The Secretary may
make available initial implementation funding to a non-profit
community based or State-based organization or a State that
is participating in the pilot program under this subsection.
Such organization shall provide the Secretary with a detailed
implementation plan that includes how such funds will be
used. The Secretary shall select a territory of the United
States as one of the locations in which to implement the
pilot program under this subsection, unless no organization
in a territory is able to comply with the requirements under
paragraph (1)(B).
``(e) Expansion of Program.--
``(1) Evaluation of cost and quality.--The Secretary shall
evaluate the pilot program to determine--
``(A) the extent to which medical homes result in--
``(i) improvement in the quality and coordination of items
and services under this title, particularly with regard to
the care of complex patients;
``(ii) improvement in reducing health disparities;
``(iii) reductions in preventable hospitalizations;
``(iv) prevention of readmissions;
``(v) reductions in emergency room visits;
``(vi) improvement in health outcomes, including patient
functional status where applicable;
``(vii) improvement in patient satisfaction;
``(viii) improved efficiency of care such as reducing
duplicative diagnostic tests and laboratory tests; and
``(ix) reductions in health care expenditures; and
``(B) the feasability and advisability of reimbursing
medical homes for medical home services under this title on a
permanent basis.
``(2) Report.--Not later than 60 days after the date of
completion of the evaluation under paragraph (1), the
Secretary shall submit to Congress and make available to the
public a report on the findings of the evaluation under
paragraph (1) and the extent to which standards for the
certification of medical homes need to be periodically
updated.
``(3) Expansion of program.--
``(A) In general.--Subject to the results of the evaluation
under paragraph (1) and subparagraph (B), the Secretary may
issue regulations to implement, on a permanent basis, one or
more models, if, and to the extent that such model or models,
are beneficial to the program under this title, including
that such implementation will improve quality of care, as
determined by the Secretary.
``(B) Certification requirement.--The Secretary may not
issue such regulations unless the Chief Actuary of the
Centers for Medicare & Medicaid Services certifies that the
expansion of the components of the pilot program described in
subparagraph (A) would result in estimated spending under
this title that would be no more than the level of spending
that the Secretary estimates would otherwise be spent under
this title in the absence of such expansion.
``(C) Updated standards.--The Secretary shall periodically
review and update the standards for qualification as an
independent patient centered medical home and as a community
based medical home and shall establish a process for ensuring
that medical homes meet such updated standards, as applicable
``(f) Administrative Provisions.--
``(1) No duplication in payments for individuals in medical
homes.--During any month, the Secretary may not make payments
under this section under more than one model or through more
than one medical home under any model for the furnishing of
medical home services to an individual.
``(2) No effect on payment for medical visits.--Payments
made under this section are in addition to, and have no
effect on the amount of, payment for medical visits made
under this title
``(3) Administration.--Chapter 35 of title 44, United
States Code shall not apply to this section.
``(4) No duplication in physician pilot participation.--The
Secretary shall not

[[Page H12698]]

make payments to an independent or community based medical
home both under this section and section 1866E or 1866G,
unless the pilot program under this section has been
implemented on a permanent basis under subsection (e)(3).
``(5) Waiver.--The Secretary may waive such provisions of
this title and title XI in the manner the Secretary
determines necessary in order to implement this section.
``(g) Funding.--
``(1) Operational costs.--For purposes of administering and
carrying out the pilot program (including the design,
implementation, technical assistance for and evaluation of
such program), in addition to funds otherwise available,
there shall be transferred from the Federal Supplementary
Medical Insurance Trust Fund under section 1841 to the
Secretary for the Centers for Medicare & Medicaid Services
Program Management Account $6,000,000 for each of fiscal
years 2010 through 2014. Amounts appropriated under this
paragraph for a fiscal year shall be available until
expended.
``(2) Patient-centered medical home services.--In addition
to funds otherwise available, there shall be available to the
Secretary for the Centers for Medicare & Medicaid Services,
from the Federal Supplementary Medical Insurance Trust Fund
under section 1841--
``(A) $200,000,000 for each of fiscal years 2010 through
2014 for payments for medical home services under subsection
(c)(3); and
``(B) $125,000,000 for each of fiscal years 2012 through
2016, for payments under subsection (d)(5).
Amounts available under this paragraph for a fiscal year
shall be available until expended.
``(3) Initial implementation.--In addition to funds
otherwise available, there shall be available to the
Secretary for the Centers for Medicare & Medicaid Services,
from the Federal Supplementary Medical Insurance Trust Fund
under section 1841, $2,500,000 for each of fiscal years 2010
through 2012, under subsection (d)(6). Amounts available
under this paragraph for a fiscal year shall be available
until expended.
``(h) Treatment of TRHCA Medicare Medical Home
Demonstration Funding.--
``(1) In addition to funds otherwise available for payment
of medical home services under subsection (c)(3), there shall
also be available the amount provided in subsection (g) of
section 204 of division B of the Tax Relief and Health Care
Act of 2006 (42 U.S.C. 1395b-1 note), as added by section 133
of the Medicare Improvements for Patients and Providers Act
of 2008 (Public Law 110-275).
``(2) Notwithstanding section 1302(c) of the Affordable
Health Care for America Act, in addition to funds provided in
paragraph (1) and subsection (g)(2)(A), the funding for
medical home services that would otherwise have been
available if such section 204 medical home demonstration had
been implemented (without regard to subsection (g) of such
section) shall be available to the independent patient-
centered medical home model described in subsection (c).''.
(b) Effective Date.--The amendment made by this section
shall apply to services furnished on or after the date of the
enactment of this Act.
(c) Conforming Repeal.--Section 204 of division B of the
Tax Relief and Health Care Act of 2006 (42 U.S.C. 1395b-1
note), as amended by section 133(a)(2) of the Medicare
Improvements for Patients and Providers Act of 2008 (Public
Law 110-275), is repealed.

SEC. 1303. PAYMENT INCENTIVE FOR SELECTED PRIMARY CARE
SERVICES.

(a) In General.--Section 1833 of the Social Security Act is
amended by inserting after subsection (o) the following new
subsection:
``(p) Primary Care Payment Incentives.--
``(1) In general.--In the case of primary care services (as
defined in paragraph (2)) furnished on or after January 1,
2011, by a primary care practitioner (as defined in paragraph
(3)) for which amounts are payable under section 1848, in
addition to the amount otherwise paid under this part there
shall also be paid to the practitioner (or to an employer or
facility in the cases described in clause (A) of section
1842(b)(6)) (on a monthly or quarterly basis) from the
Federal Supplementary Medical Insurance Trust Fund an amount
equal 5 percent (or 10 percent if the practitioner
predominately furnishes such services in an area that is
designated (under section 332(a)(1)(A) of the Public Health
Service Act) as a primary care health professional shortage
area.
``(2) Primary care services defined.--In this subsection,
the term `primary care services'--
``(A) mean evaluation and management services, without
regard to the specialty of the physician furnishing the
services, that are procedure codes (for services covered
under this title) for--
``(i) services in the category designated Evaluation and
Management in the Health Care Common Procedure Coding System
(established by the Secretary under section 1848(c)(5) as of
December 31, 2009, and as subsequently modified by the
Secretary); and
``(ii) preventive services (as defined in section 1861(iii)
for which payment is made under this section; and
``(B) includes services furnished by another health care
professional that would be described in subparagraph (A) if
furnished by a physician.
``(3) Primary care practitioner defined.--In this
subsection, the term `primary care practitioner'--
``(A) means a physician or other health care practitioner
(including a nurse practitioner) who--
``(i) specializes in family medicine, general internal
medicine, general pediatrics, geriatrics, or obstetrics and
gynecology; and
``(ii) has allowed charges for primary care services that
account for at least 50 percent of the physician's or
practitioner's total allowed charges under section 1848, as
determined by the Secretary for the most recent period for
which data are available; and
``(B) includes a physician assistant who is under the
supervision of a physician described in subparagraph (A).
``(4) Limitation on review.--There shall be no
administrative or judicial review under section 1869, section
1878, or otherwise, respecting--
``(A) any determination or designation under this
subsection;
``(B) the identification of services as primary care
services under this subsection; and
``(C) the identification of a practitioner as a primary
care practitioner under this subsection.
``(5) Coordination with other payments.--
``(A) With other primary care incentives.--The provisions
of this subsection shall not be taken into account in
applying subsections (m) and (u) and any payment under such
subsections shall not be taken into account in computing
payments under this subsection.
``(B) With quality incentives.--Payments under this
subsection shall not be taken into account in determining the
amounts that would otherwise be paid under this part for
purposes of section 1834(g)(2)(B).''.
(b) Conforming Amendments.--
(1) Section 1833(m) of such Act (42 U.S.C. 1395l(m)) is
amended by redesignating paragraph (4) as paragraph (5) and
by inserting after paragraph (3) the following new paragraph:
``(4) The provisions of this subsection shall not be taken
into account in applying subsections (m) or (u) and any
payment under such subsections shall not be taken into
account in computing payments under this subsection.''.
(2) Section 1848(m)(5)(B) of such Act (42 U.S.C. 1395w-
4(m)(5)(B)) is amended by inserting ``, (p),'' after ``(m)''.
(3) Section 1848(o)(1)(B)(iv) of such Act (42 U.S.C. 1395w-
4(o)(1)(B)(iv)) is amended by inserting ``primary care''
before ``health professional shortage area''.

SEC. 1304. INCREASED REIMBURSEMENT RATE FOR CERTIFIED NURSE-
MIDWIVES.

(a) In General.--Section 1833(a)(1)(K) of the Social
Security Act (42 U.S.C.1395l(a)(1)(K)) is amended by striking
``(but in no event'' and all that follows through ``performed
by a physician)''.
(b) Effective Date.--The amendment made by subsection (a)
shall apply to services furnished on or after January 1,
2011.

SEC. 1305. COVERAGE AND WAIVER OF COST-SHARING FOR PREVENTIVE
SERVICES.

(a) Medicare Covered Preventive Services Defined.--Section
1861 of the Social Security Act (42 U.S.C. 1395x), as amended
by section 1233(a)(1)(B), is amended by adding at the end the
following new subsection:

``Medicare Covered Preventive Services

``(iii)(1) Subject to the succeeding provisions of this
subsection, the term `Medicare covered preventive services'
means the following:
``(A) Prostate cancer screening tests (as defined in
subsection (oo)).
``(B) Colorectal cancer screening tests (as defined in
subsection (pp).
``(C) Diabetes outpatient self-management training services
(as defined in subsection (qq)).
``(D) Screening for glaucoma for certain individuals (as
described in subsection (s)(2)(U)).
``(E) Medical nutrition therapy services for certain
individuals (as described in subsection (s)(2)(V)).
``(F) An initial preventive physical examination (as
defined in subsection (ww)).
``(G) Cardiovascular screening blood tests (as defined in
subsection (xx)(1)).
``(H) Diabetes screening tests (as defined in subsection
(yy)).
``(I) Ultrasound screening for abdominal aortic aneurysm
for certain individuals (as described in subsection
(s)(2)(AA)).
``(J) Federally approved and recommended vaccines and their
administration as described in subsection (s)(10).
``(K) Screening mammography (as defined in subsection
(jj)).
``(L) Screening pap smear and screening pelvic exam (as
defined in subsection (nn)).
``(M) Bone mass measurement (as defined in subsection
(rr)).
``(N) Kidney disease education services (as defined in
subsection (ggg)).
``(O) Additional preventive services (as defined in
subsection (ddd)).
``(2) With respect to specific Medicare covered preventive
services, the limitations and conditions described in the
provisions referenced in paragraph (1) with respect to such
services shall apply.''.
(b) Payment and Elimination of Cost-sharing.--
(1) In general.--
(A) In general.--Section 1833(a) of the Social Security Act
(42 U.S.C. 1395l(a)) is amended by adding after and below
paragraph (9) the following:
``With respect to Medicare covered preventive services, in
any case in which the payment rate otherwise provided under
this part

[[Page H12699]]

is computed as a percent of less than 100 percent of an
actual charge, fee schedule rate, or other rate, such
percentage shall be increased to 100 percent.''.
(B) Application to sigmoidoscopies and colonoscopies.--
Section 1834(d) of such Act (42 U.S.C. 1395m(d)) is amended--
(i) in paragraph (2)(C), by amending clause (ii) to read as
follows:
``(ii) No coinsurance.--In the case of a beneficiary who
receives services described in clause (i), there shall be no
coinsurance applied.''; and
(ii) in paragraph (3)(C), by amending clause (ii) to read
as follows:
``(ii) No coinsurance.--In the case of a beneficiary who
receives services described in clause (i), there shall be no
coinsurance applied.''.
(2) Elimination of coinsurance in outpatient hospital
settings.--
(A) Exclusion from opd fee schedule.--Section
1833(t)(1)(B)(iv) of the Social Security Act (42 U.S.C.
1395l(t)(1)(B)(iv)) is amended by striking ``screening
mammography (as defined in section 1861(jj)) and diagnostic
mammography'' and inserting ``diagnostic mammograms and
Medicare covered preventive services (as defined in section
1861(iii)(1))''.
(B) Conforming amendments.--Section 1833(a)(2) of the
Social Security Act (42 U.S.C. 1395l(a)(2)) is amended--
(i) in subparagraph (F), by striking ``and'' after the
semicolon at the end;
(ii) in subparagraph (G), by adding ``and'' at the end; and
(iii) by adding at the end the following new subparagraph:
``(H) with respect to additional preventive services (as
defined in section 1861(ddd)) furnished by an outpatient
department of a hospital, the amount determined under
paragraph (1)(W);''.
(3) Waiver of application of deductible for all preventive
services.--The first sentence of section 1833(b) of the
Social Security Act (42 U.S.C. 1395l(b)) is amended--
(A) in clause (1), by striking ``items and services
described in section 1861(s)(10)(A)'' and inserting
``Medicare covered preventive services (as defined in section
1861(iii))'';
(B) by inserting ``and'' before ``(4)''; and
(C) by striking clauses (5) through (8).
(4) Application to providers of services.--Section
1866(a)(2)(A)(ii) of such Act (42 U.S.C. 1395cc(a)(2)(A)(ii))
is amended by inserting ``other than for Medicare covered
preventive services and'' after ``for such items and services
(''.
(c) Effective Date.--The amendments made by this section
shall apply to services furnished on or after January 1,
2011.
(d) Preventive Services.--
(1) Report to congress on barriers to preventive
services.--Not later than 12 months after the date of the
enactment of this Act, the Secretary of Health and Human
Services shall report to Congress on barriers, if any, facing
Medicare beneficiaries in accessing the benefit to abdominal
aortic aneurysm screening and other preventative services
through the Welcome to Medicare Physical Exam.
(2) Abdominal aortic aneurysm screen access.--The Secretary
shall, to the extent practical, identify and implement
policies promoting proper use of abdominal aortic aneurysm
screening among Medicare beneficiaries at risk for such
aneurysms.

SEC. 1306. WAIVER OF DEDUCTIBLE FOR COLORECTAL CANCER
SCREENING TESTS REGARDLESS OF CODING,
SUBSEQUENT DIAGNOSIS, OR ANCILLARY TISSUE
REMOVAL.

(a) In General.--Section 1833 of the Social Security Act
(42 U.S.C. 1395l(b)), as amended by section 1305(b), is
further amended--
(1) in subsection (a), in the sentence added by section
1305(b)(1)(A), by inserting ``(including services described
in the last sentence of section 1833(b))'' after ``preventive
services''; and
(2) in subsection (b), by adding at the end the following
new sentence: ``Clause (1) of the first sentence of this
subsection shall apply with respect to a colorectal cancer
screening test regardless of the code that is billed for the
establishment of a diagnosis as a result of the test, or for
the removal of tissue or other matter or other procedure that
is furnished in connection with, as a result of, and in the
same clinical encounter as, the screening test.''.
(b) Effective Date.--The amendment made by subsection (a)
shall apply to items and services furnished on or after
January 1, 2011.

SEC. 1307. EXCLUDING CLINICAL SOCIAL WORKER SERVICES FROM
COVERAGE UNDER THE MEDICARE SKILLED NURSING
FACILITY PROSPECTIVE PAYMENT SYSTEM AND
CONSOLIDATED PAYMENT.

(a) In General.--Section 1888(e)(2)(A)(ii) of the Social
Security Act (42 U.S.C. 1395yy(e)(2)(A)(ii)) is amended by
inserting ``clinical social worker services,'' after
``qualified psychologist services,''.
(b) Conforming Amendment.--Section 1861(hh)(2) of the
Social Security Act (42 U.S.C. 1395x(hh)(2)) is amended by
striking ``and other than services furnished to an inpatient
of a skilled nursing facility which the facility is required
to provide as a requirement for participation''.
(c) Effective Date.--The amendments made by this section
shall apply to items and services furnished on or after
October 1, 2010.

SEC. 1308. COVERAGE OF MARRIAGE AND FAMILY THERAPIST SERVICES
AND MENTAL HEALTH COUNSELOR SERVICES.

(a) Coverage of Marriage and Family Therapist Services.--
(1) Coverage of services.--Section 1861(s)(2) of the Social
Security Act (42 U.S.C. 1395x(s)(2)), as amended by section
1235, is amended--
(A) in subparagraph (EE), by striking ``and'' at the end;
(B) in subparagraph (FF), by adding ``and'' at the end; and
(C) by adding at the end the following new subparagraph:
``(GG) marriage and family therapist services (as defined
in subsection (jjj));''.
(2) Definition.--Section 1861 of the Social Security Act
(42 U.S.C. 1395x), as amended by sections 1233 and 1305, is
amended by adding at the end the following new subsection:

``Marriage and Family Therapist Services

``(jjj)(1) The term `marriage and family therapist
services' means services performed by a marriage and family
therapist (as defined in paragraph (2)) for the diagnosis and
treatment of mental illnesses, which the marriage and family
therapist is legally authorized to perform under State law
(or the State regulatory mechanism provided by State law) of
the State in which such services are performed, as would
otherwise be covered if furnished by a physician or as
incident to a physician's professional service, but only if
no facility or other provider charges or is paid any amounts
with respect to the furnishing of such services.
``(2) The term `marriage and family therapist' means an
individual who--
``(A) possesses a master's or doctoral degree which
qualifies for licensure or certification as a marriage and
family therapist pursuant to State law;
``(B) after obtaining such degree has performed at least 2
years of clinical supervised experience in marriage and
family therapy; and
``(C) is licensed or certified as a marriage and family
therapist in the State in which marriage and family therapist
services are performed.''.
(3) Provision for payment under part b.--Section
1832(a)(2)(B) of the Social Security Act (42 U.S.C.
1395k(a)(2)(B)) is amended by adding at the end the following
new clause:
``(v) marriage and family therapist services;''.
(4) Amount of payment.--
(A) In general.--Section 1833(a)(1) of the Social Security
Act (42 U.S.C. 1395l(a)(1)) is amended--
(i) by striking ``and'' before ``(W)''; and
(ii) by inserting before the semicolon at the end the
following: ``, and (X) with respect to marriage and family
therapist services under section 1861(s)(2)(GG), the amounts
paid shall be 80 percent of the lesser of the actual charge
for the services or 75 percent of the amount determined for
payment of a psychologist under clause (L)''.
(B) Development of criteria with respect to consultation
with a health care professional.--The Secretary of Health and
Human Services shall, taking into consideration concerns for
patient confidentiality, develop criteria with respect to
payment for marriage and family therapist services for which
payment may be made directly to the marriage and family
therapist under part B of title XVIII of the Social Security
Act (42 U.S.C. 1395j et seq.) under which such a therapist
must agree to consult with a patient's attending or primary
care physician or nurse practitioner in accordance with such
criteria.
(5) Exclusion of marriage and family therapist services
from skilled nursing facility prospective payment system.--
Section 1888(e)(2)(A)(ii) of the Social Security Act (42
U.S.C. 1395yy(e)(2)(A)(ii)), as amended by section 1307(a),
is amended by inserting ``marriage and family therapist
services (as defined in subsection (jjj)(1)),'' after
``clinical social worker services,''.
(6) Coverage of marriage and family therapist services
provided in rural health clinics and federally qualified
health centers.--Section 1861(aa)(1)(B) of the Social
Security Act (42 U.S.C. 1395x(aa)(1)(B)) is amended by
striking ``or by a clinical social worker (as defined in
subsection (hh)(1)),'' and inserting ``, by a clinical social
worker (as defined in subsection (hh)(1)), or by a marriage
and family therapist (as defined in subsection (jjj)(2)),''.
(7) Inclusion of marriage and family therapists as
practitioners for assignment of claims.--Section
1842(b)(18)(C) of the Social Security Act (42 U.S.C.
1395u(b)(18)(C)) is amended by adding at the end the
following new clause:
``(vii) A marriage and family therapist (as defined in
section 1861(jjj)(2)).''.
(b) Coverage of Mental Health Counselor Services.--
(1) Coverage of services.--Section 1861(s)(2) of the Social
Security Act (42 U.S.C. 1395x(s)(2)), as previously amended,
is further amended--
(A) in subparagraph (FF), by striking ``and'' at the end;
(B) in subparagraph (GG), by inserting ``and'' at the end;
and
(C) by adding at the end the following new subparagraph:
``(HH) mental health counselor services (as defined in
subsection (kkk)(1));''.
(2) Definition.--Section 1861 of the Social Security Act
(42 U.S.C. 1395x), as previously amended, is amended by
adding at the end the following new subsection:

``Mental Health Counselor Services

``(kkk)(1) The term `mental health counselor services'
means services performed by a

[[Page H12700]]

mental health counselor (as defined in paragraph (2)) for the
diagnosis and treatment of mental illnesses which the mental
health counselor is legally authorized to perform under State
law (or the State regulatory mechanism provided by the State
law) of the State in which such services are performed, as
would otherwise be covered if furnished by a physician or as
incident to a physician's professional service, but only if
no facility or other provider charges or is paid any amounts
with respect to the furnishing of such services.
``(2) The term `mental health counselor' means an
individual who--
``(A) possesses a master's or doctor's degree which
qualifies the individual for licensure or certification for
the practice of mental health counseling in the State in
which the services are performed;
``(B) after obtaining such a degree has performed at least
2 years of supervised mental health counselor practice; and
``(C) is licensed or certified as a mental health counselor
or professional counselor by the State in which the services
are performed.''.
(3) Provision for payment under part b.--Section
1832(a)(2)(B) of the Social Security Act (42 U.S.C.
1395k(a)(2)(B)), as amended by subsection (a)(3), is further
amended--
(A) by striking ``and'' at the end of clause (iv);
(B) by adding ``and'' at the end of clause (v); and
(C) by adding at the end the following new clause:
``(vi) mental health counselor services;''.
(4) Amount of payment.--
(A) In general.--Section 1833(a)(1) of the Social Security
Act (42 U.S.C. 1395l(a)(1)), as amended by subsection (a), is
further amended--
(i) by striking ``and'' before ``(X)''; and
(ii) by inserting before the semicolon at the end the
following: ``, and (Y), with respect to mental health
counselor services under section 1861(s)(2)(HH), the amounts
paid shall be 80 percent of the lesser of the actual charge
for the services or 75 percent of the amount determined for
payment of a psychologist under clause (L)''.
(B) Development of criteria with respect to consultation
with a physician.--The Secretary of Health and Human Services
shall, taking into consideration concerns for patient
confidentiality, develop criteria with respect to payment for
mental health counselor services for which payment may be
made directly to the mental health counselor under part B of
title XVIII of the Social Security Act (42 U.S.C. 1395j et
seq.) under which such a counselor must agree to consult with
a patient's attending or primary care physician in accordance
with such criteria.
(5) Exclusion of mental health counselor services from
skilled nursing facility prospective payment system.--Section
1888(e)(2)(A)(ii) of the Social Security Act (42 U.S.C.
1395yy(e)(2)(A)(ii)), as amended by section 1307(a) and
subsection (a), is amended by inserting ``mental health
counselor services (as defined in section 1861(kkk)(1)),''
after ``marriage and family therapist services (as defined in
subsection (jjj)(1)),''.
(6) Coverage of mental health counselor services provided
in rural health clinics and federally qualified health
centers.--Section 1861(aa)(1)(B) of the Social Security Act
(42 U.S.C. 1395x(aa)(1)(B)), as amended by subsection (a), is
amended by striking ``or by a marriage and family therapist
(as defined in subsection (jjj)(2)),'' and inserting ``by a
marriage and family therapist (as defined in subsection
(jjj)(2)), or a mental health counselor (as defined in
subsection (kkk)(2)),''.
(7) Inclusion of mental health counselors as practitioners
for assignment of claims.--Section 1842(b)(18)(C) of the
Social Security Act (42 U.S.C. 1395u(b)(18)(C)), as amended
by subsection (a)(7), is amended by adding at the end the
following new clause:
``(viii) A mental health counselor (as defined in section
1861(kkk)(2)).''.
(c) Effective Date.--The amendments made by this section
shall apply to items and services furnished on or after
January 1, 2011.

SEC. 1309. EXTENSION OF PHYSICIAN FEE SCHEDULE MENTAL HEALTH
ADD-ON.

Section 138(a)(1) of the Medicare Improvements for Patients
and Providers Act of 2008 (Public Law 110-275) is amended by
striking ``December 31, 2009'' and inserting ``December 31,
2011''.

SEC. 1310. EXPANDING ACCESS TO VACCINES.

(a) In General.--Paragraph (10) of section 1861(s) of the
Social Security Act (42 U.S.C. 1395w(s)) is amended to read
as follows:
``(10) federally approved and recommended vaccines (as
defined in subsection (lll)) and their respective
administration;''.
(b) Federally Approved and Recommended Vaccines Defined.--
Section 1861 of such Act is further amended by adding at the
end the following new subsection:

``Federally Approved and Recommended Vaccines

``(lll) The term `federally approved and recommended
vaccine' means a vaccine that--
``(1) is licensed under section 351 of the Public Health
Service Act, approved under the Federal Food, Drug, and
Cosmetic Act, or authorized for emergency use under section
564 of the Federal, Food, Drug, and Cosmetic Act; and
``(2) is recommended by the Director of the Centers for
Disease Control and Prevention.''.
(c) Conforming Amendments.--
(1) Section 1833 of such Act (42 U.S.C. 1395l) is amended,
in each of subsections (a)(1)(B), (a)(2)(G), and (a)(3)(A),
by striking ``1861(s)(10)(A)'' and inserting ``1861(s)(10)''
each place it appears.
(2) Section 1842(o)(1)(A)(iv) of such Act (42 U.S.C.
1395u(o)(1)(A)(iv)) is amended--
(A) by striking ``subparagraph (A) or (B) of''; and
(B) by inserting before the period the following: ``and
before January 1, 2011, and influenza vaccines furnished on
or after January 1, 2011''.
(3) Section 1847A(c)(6) of such Act (42 U.S.C. 1395w-
3a(c)(6)) is amended--
(A) in subparagraph (D)(i), by inserting ``, including a
vaccine furnished on or after January 1, 2010''; and
(B) by the following new paragraph:
``(H) Implementation.--Chapter 35 of title 44, United
States Code shall not apply to manufacturer provision of
information pursuant to section 1927(b)(3)(A)(iii) or
subsection (f)(2) for purposes of implementation of this
section.''.
(4) Section 1860D-2(e)(1) of such Act (42 U.S.C. 1395w-
102(e)(1)) is amended by striking ``such term includes a
vaccine'' and all that follows through ``its administration)
and''.
(5) Section 1861(ww)(2)(A) of such Act (42 U.S.C.
1395x(ww)(2)(A))) is amended by striking ``Pneumococcal,
influenza, and hepatitis B vaccine and administration'' and
inserting ``federally approved or authorized vaccines (as
defined in subsection (lll)) and their respective
administration''.
(6) Section 1927(b)(3)(A)(iii) of such Act (42 U.S.C.
1396r-8(b)(3)(A)(iii)) is amended, in the matter following
subclause (III), by inserting ``(A)(iv) (including influenza
vaccines furnished on or after January 1, 2011),'' after
``described in subparagraph''.
(7) Section 1847A(f) of such Act (42 U.S.C. 1395w-3a(f)) is
amended--
(A) by striking ``For'' and inserting ``(1) In general.--
For'';
(B) by indenting paragraph (1), as redesignated in
subparagraph (A), 2 ems to the left; and--
(C) by adding at the end the following new paragraph:
``(2) Treatment of certain manufacturers.--In the case of a
manufacturer of a drug or biological described in
subparagraphs (A)(iv), (C), (D), (E), or (G) of section
1842(o)(1) that does not have a rebate agreement under
section 1927(a), no payment may be made under this part for
such drug or biological if such manufacturer does not submit
the information described in section 1927(b)(3)(A)(iii) in
the same manner as if the manufacturer had such a rebate
agreement in effect. Subparagraphs (C) and (D) of section
1927(b)(3) shall apply to information reported pursuant to
the previous sentence in the same manner as such
subparagraphs apply with respect to information reported
pursuant to such section.''.''.
(d) Effective Dates.--The amendments made--
(1) by this section (other than by subsection (c)(6)) shall
apply to vaccines administered on or after January 1, 2011;
and
(2) by subsection (c)(6) shall apply to calendar quarters
beginning on or after January 1, 2010.

SEC. 1311. EXPANSION OF MEDICARE-COVERED PREVENTIVE SERVICES
AT FEDERALLY QUALIFIED HEALTH CENTERS.

(a) In General.--Section 1861(aa)(3)(A) of the Social
Security Act (42 U.S.C. 1395w (aa)(3)(A)) is amended to read
as follows:
``(A) services of the type described subparagraphs (A)
through (C) of paragraph (1) and services described in
section 1861(iii); and''.
(b) Effective Date.--The amendment made by subsection (a)
shall apply not later than January 1, 2011.

SEC. 1312. INDEPENDENCE AT HOME DEMONSTRATION PROGRAM.

Title XVIII of the Social Security Act is amended by
inserting after section 1866F, as inserted by section 1302,
the following new section:

``independence at home medical practice demonstration program

``Sec. 1866G.  (a) Establishment.--
``(1) In general.--The Secretary shall conduct a
demonstration program (in this section referred to as the
`demonstration program') to test a payment incentive and
service delivery model that utilizes physician and nurse
practitioner directed home-based primary care teams designed
to reduce expenditures and improve health outcomes in the
provision of items and services under this title to
applicable beneficiaries (as defined in subsection (d)).
``(2) Requirement.--The demonstration program shall test
whether a model described in paragraph (1), which is
accountable for providing comprehensive, coordinated,
continuous, and accessible care to high-need populations at
home and coordinating health care across all treatment
settings, results in--
``(A) reducing preventable hospitalizations;
``(B) preventing hospital readmissions;
``(C) reducing emergency room visits;
``(D) improving health outcomes commensurate with the
beneficiaries' stage of chronic illness;
``(E) improving the efficiency of care, such as by reducing
duplicative diagnostic and laboratory tests;
``(F) reducing the cost of health care services covered
under this title; and
``(G) achieving beneficiary and family caregiver
satisfaction.
``(b) Independence at Home Medical Practice.--

[[Page H12701]]

``(1) Independence at home medical practice defined.--In
this section:
``(A) In general.--The term `independence at home medical
practice' means a legal entity that--
``(i) is comprised of an individual physician or nurse
practitioner or group of physicians and nurse practitioners
that provides care as part of a team that includes
physicians, nurses, physician assistants, pharmacists, and
other health and social services staff as appropriate who
have experience providing home-based primary care to
applicable beneficiaries, make in-home visits, and are
available 24 hours per day, 7 days per week to carry out
plans of care that are tailored to the individual
beneficiary's chronic conditions and designed to achieve the
results in subsection (a);
``(ii) is organized at least in part for the purpose of
providing physicians' services;
``(iii) has documented experience in providing home-based
primary care services to high cost chronically ill
beneficiaries, as determined appropriate by the Secretary;
``(iv) includes at least 200 applicable beneficiaries as
defined in subsection (d);
``(v) has entered into an agreement with the Secretary;
``(vi) uses electronic health information systems, remote
monitoring, and mobile diagnostic technology; and
``(vii) meets such other criteria as the Secretary
determines to be appropriate to participate in the
demonstration program.
``(B) Physician.--The term `physician' includes, except as
the Secretary may otherwise provide, any individual who
furnishes services for which payment may be made as
physicians' services and has the medical training or
experience to fulfill the physician's role described in
subparagraph (A)(i).
``(2) Participation of nurse practitioners and physician
assistants.--Nothing in this section shall be construed to
prevent a nurse practitioner or physician assistant from
participating in, or leading, a home-based primary care team
as part of an independence at home medical practice if--
``(A) all the requirements of this section are met;
``(B) the nurse practitioner or physician assistant, as the
case may be, is acting consistent with State law; and
``(C) the nurse practitioner or physician assistant has the
medical training or experience to fulfill the nurse
practitioner or physician assistant role described in
paragraph (1)(A)(i).
``(3) Inclusion of providers and practitioners.--Nothing in
this subsection shall be construed as preventing an
independence at home medical practice from including a
provider of services or a participating practitioner
described in section 1842(b)(18)(C) that is affiliated with
the practice under an arrangement structured so that such
provider of services or practitioner participates in the
demonstration program and shares in any savings under the
demonstration program.
``(4) Quality and performance standards.--
``(A) In general.--An independence at home medical practice
participating in the demonstration program shall report on
quality measures (in such form, manner, and frequency as
specified by the Secretary, which may be for the group, for
providers of services and suppliers, or both) and report to
the Secretary (in a form, manner, and frequency as specified
by the Secretary) such data as the Secretary determines
appropriate to monitor and evaluate the demonstration
program.
``(B) Development of quality performance standards.--The
Secretary shall develop quality performance standards for
independence at home medical practices participating in the
demonstration program.
``(c) Shared Savings Payment Methodology.--
``(1) Establishment of target spending level.--The
Secretary shall establish annual target spending levels for
items and services covered under parts A and B furnished to
applicable beneficiaries by qualifying independence at home
medical practices under this section. The Secretary may set
an aggregate target spending level for all qualifying
practices, or may set different target spending levels for
groups of practices or a single practice. Such target
spending levels may be determined on a per capita basis and
shall take into account normal variation in expenditures for
items and services covered under parts A and B furnished to
such beneficiaries. The target shall also be adjusted for the
size of the practice, number of practices included in the
target spending level, characteristics of applicable
beneficiaries and such other factors as the Secretary
determines appropriate. The Secretary may periodically adjust
or rebase the target spending level under this paragraph.
``(2) Shared savings amounts.--
``(A) In general.--Subject to subparagraph (B), qualifying
independence at home medical practices are eligible to
receive an incentive payment under this section if aggregate
expenditures for a year for applicable beneficiaries are less
than the target spending level for qualifying independence at
home medical practices for such year. An incentive payment
for such year shall be equal to a portion (as determined by
the Secretary) of the amount by which total payments for
applicable beneficiaries under parts A and B for such year
are estimated to be less than 5 percent less than the target
spending level for such year, as determined by the Secretary.
``(B) Apportionment of savings.--The Secretary shall
designate how, and to what extent, an incentive payment under
this section is to be apportioned among qualifying
independence at home medical practices, taking into account
the size of the practice, characteristics of the individuals
enrolled in each practice, performance on quality performance
measures, and such other factors as the Secretary determines
appropriate.
``(3) Savings to the medicare program.--The Secretary shall
limit incentive payments to each qualifying independence at
home medical practice under this paragraph, with respect to a
year, as necessary to ensure that the aggregate expenditures
for items and services under parts A and B with respect to
applicable beneficiaries for such independence at home
medical practice (inclusive of shared savings payments) do
not exceed the amount that the Secretary estimates would be
expended for such items and services for such beneficiaries
during such year (taking into account normal variation in
expenditures and other factors the Secretary deems
appropriate) if the demonstration program under this section
were not implemented, minus 5 percent.
``(d) Applicable Beneficiaries.--
``(1) Definition.--In this section, the term `applicable
beneficiary' means, with respect to a qualifying independence
at home medical practice, an individual who the practice has
determined--
``(A) is entitled to benefits under part A and enrolled for
benefits under part B;
``(B) is not enrolled in a Medicare Advantage plan under
part C or a PACE program under section 1894;
``(C) has 2 or more chronic illnesses, such as congestive
heart failure, diabetes, other dementias designated by the
Secretary, chronic obstructive pulmonary disease, ischemic
heart disease, stroke, Alzheimer's Disease and
neurodegenerative diseases, and other diseases and conditions
designated by the Secretary which result in high costs under
this title;
``(D) within the past 12 months has had a nonelective
hospital admission;
``(E) within the past 12 months has received acute or
subacute rehabilitation services;
``(F) has 2 or more functional dependencies requiring the
assistance of another person (such as bathing, dressing,
toileting, walking, or feeding); and
``(G) meets such other criteria as the Secretary determines
appropriate.
``(2) Patient election to participate.--The Secretary shall
determine an appropriate method of ensuring that applicable
beneficiaries have agreed to enroll in an independence at
home medical practice under the demonstration program.
Enrollment in the demonstration program shall be voluntary.
``(3) Beneficiary access to services.--Nothing in this
section shall be construed as encouraging physicians or nurse
practitioners to limit applicable beneficiary access to
services covered under this title and applicable
beneficiaries shall not be required to relinquish access to
any benefit under this title as a condition of receiving
services from an independence at home medical practice.
``(e) Implementation.--
``(1) Starting date.--The demonstration program shall begin
not later than January 1, 2012. An agreement with an
independence at home medical practice under the demonstration
program may cover not more than a 3-year period.
``(2) No physician duplication in demonstration
participation.--The Secretary shall not pay an independence
at home medical practice under this section that participates
in section 1866D or section 1866E.
``(3) No beneficiary duplication in demonstration
participation.--The Secretary shall ensure that no applicable
beneficiary enrolled in an independence at home medical
practice under this section is participating in the programs
under section 1866D or section 1866E.
``(4) Preference.--In approving an independence at home
medical practice, the Secretary shall give preference to
practices that are--
``(A) located in high-cost areas of the country;
``(B) have experience in furnishing health care services to
applicable beneficiaries in the home; and
``(C) use electronic medical records, health information
technology, and individualized plans of care.
``(5) Number of practices.--
``(A) In general.--Subject to subparagraph (B), the
Secretary shall enter into agreements with as many
independence at home medial practices as practicable and
consistent with this subsection to test the potential of the
independence at home medical practice model under this
section in order to achieve the results described in
subsection (a) across practices serving varying numbers of
applicable beneficiaries.
``(B) Limitation.--In selecting qualified independence at
home medial practices to participate under the demonstration
program, the Secretary shall limit the number of applicable
beneficiaries that may participate in the demonstration
program to 10,000.
``(6) Waiver.--The Secretary may waive such provisions of
this title and title XI as the Secretary determines necessary
in order to implement the demonstration program.
``(7) Administration.--Chapter 35 of title 44, United
States Code, shall not apply to this section.

[[Page H12702]]

``(f) Evaluation and Monitoring.--
``(1) In general.--The Secretary shall evaluate each
independence at home medical practice under the demonstration
program to assess whether the practice achieved the results
described in subsection (a).
``(2) Following applicable beneficiaries.--The Secretary
may monitor data on expenditures and quality of services
under this title after an applicable beneficiary discontinues
receiving services under this title through a qualifying
independence at home medical practice.
``(g) Reports to Congress.--The Secretary shall conduct an
independent evaluation of the demonstration program and
submit to Congress a final report, including best practices
under the demonstration program. Such report shall include an
analysis of the demonstration program on coordination of
care, expenditures under this title, applicable beneficiary
access to services, and the quality of health care services
provided to applicable beneficiaries.
``(h) Funding.--For purposes of administering and carrying
out the demonstration program, other than for payments for
items and services furnished under this title and shared
savings under subsection (c), in addition to funds otherwise
appropriated, there shall be transferred to the Secretary for
the Center for Medicare & Medicaid Services Program
Management Account from the Federal Hospital Insurance Trust
Fund under section 1817 and the Federal Supplementary Medical
Insurance Trust Fund under section 1841 $5,000,000 for each
of fiscal years 2010 through 2015. Amounts transferred under
this subsection for a fiscal year shall be available until
expended.
``(i) Antidiscrimination Limitation.--The Secretary shall
not enter into an agreement with an entity to provide health
care items or services under the demonstration program unless
such entity guarantees that for individuals eligible to be
enrolled in such program, the entity will not deny, limit, or
condition the coverage or provision of benefits to which the
individual would have otherwise been entitled to on the basis
of health status if not included in this program.
``(j) Termination.--The Secretary may terminate an
agreement with an independence at home medical practice if
such practice does not receive incentive payments under
subsection (c)(2) or consistently fails to meet quality
standards.''.

SEC. 1313. RECOGNITION OF CERTIFIED DIABETES EDUCATORS AS
CERTIFIED PROVIDERS FOR PURPOSES OF MEDICARE
DIABETES OUTPATIENT SELF-MANAGEMENT TRAINING
SERVICES.

(a) In General.--Section 1861(qq) of the Social Security
Act (42 U.S.C. 1395x(qq)) is amended--
(1) in paragraph (1), by inserting ``or by a certified
diabetes educator (as defined in paragraph (3))'' after
``paragraph (2)(B)''; and
(2) by adding at the end the following new paragraphs:
``(3) For purposes of paragraph (1), the term `certified
diabetes educator' means an individual who--
``(A) is licensed or registered by the State in which the
services are performed as a health care professional;
``(B) specializes in teaching individuals with diabetes to
develop the necessary skills and knowledge to manage the
individual's diabetic condition; and
``(C) is certified as a diabetes educator by a recognized
certifying body (as defined in paragraph (4)).
``(4)(A) For purposes of paragraph (3)(C), the term
`recognized certifying body' means--
``(i) the National Certification Board for Diabetes
Educators, or
``(ii) a certifying body for diabetes educators, which is
recognized by the Secretary as authorized to grant
certification of diabetes educators for purposes of this
subsection pursuant to standards established by the
Secretary, if the Secretary determines such Board or body,
respectively, meets the requirement of subparagraph (B).
``(B) The National Certification Board for Diabetes
Educators or a certifying body for diabetes educators meets
the requirement of this subparagraph, with respect to the
certification of an individual, if the Board or body,
respectively, is incorporated and registered to do business
in the United States and requires as a condition of such
certification each of the following:
``(i) The individual has a qualifying credential in a
specified health care profession.
``(ii) The individual has professional practice experience
in diabetes self-management training that includes a minimum
number of hours and years of experience in such training.
``(iii) The individual has successfully completed a
national certification examination offered by such entity.
``(iv) The individual periodically renews certification
status following initial certification.''.
(b) Effective Date.--The amendments made by subsection (a)
shall apply to diabetes outpatient self-management training
services furnished on or after the first day of the first
calendar year that is at least 6 months after the date of the
enactment of this Act.

TITLE IV--QUALITY

Subtitle A--Comparative Effectiveness Research

SEC. 1401. COMPARATIVE EFFECTIVENESS RESEARCH.

(a) In General.--Title XI of the Social Security Act is
amended by adding at the end the following new part:

``Part D--Comparative Effectiveness Research

``comparative effectiveness research

``Sec. 1181.  (a) Center for Comparative Effectiveness
Research Established.--
``(1) In general.--The Secretary shall establish within the
Agency for Healthcare Research and Quality a Center for
Comparative Effectiveness Research (in this section referred
to as the `Center') to conduct, support, and synthesize
research (including research conducted or supported under
section 1013 of the Medicare Prescription Drug, Improvement,
and Modernization Act of 2003) with respect to the outcomes,
effectiveness, and appropriateness of health care services
and procedures in order to identify the manner in which
diseases, disorders, and other health conditions can most
effectively and appropriately be prevented, diagnosed,
treated, and managed clinically.
``(2) Duties.--The Center shall--
``(A) conduct, support, and synthesize research relevant to
the comparative effectiveness of the full spectrum of health
care items, services and systems, including pharmaceuticals,
medical devices, medical and surgical procedures, and other
medical interventions;
``(B) conduct and support systematic reviews of clinical
research, including original research conducted subsequent to
the date of the enactment of this section;
``(C) continuously develop rigorous scientific
methodologies for conducting comparative effectiveness
studies, and use such methodologies appropriately;
``(D) submit to the Comparative Effectiveness Research
Commission, the Secretary, and Congress appropriate relevant
reports described in subsection (d)(2);
``(E) not later than one year after the date of the
enactment of this section, enter into an arrangement under
which the Institute of Medicine of the National Academy of
Sciences shall conduct an evaluation and report on standards
of evidence for highly credible research;
``(F) encourage, as appropriate, the development and use of
clinical registries and the development of clinical
effectiveness research data networks from electronic health
records, post marketing drug and medical device surveillance
efforts, and other forms of electronic health data; and
``(G) appoint clinical perspective advisory panels for
research priorities under this section, which shall consult
with patients and other stakeholders and advise the Center on
research questions, methods, and evidence gaps in terms of
clinical outcomes for the specific research inquiry to be
examined with respect to such priority to ensure that the
information produced from such research is clinically
relevant to decisions made by clinicians and patients at the
point of care.
``(3) Powers.--
``(A) Obtaining official data.--The Center may secure
directly from any department or agency of the United States
information necessary to enable it to carry out this section.
Upon request of the Center, the head of such department or
agency shall furnish that information to the Center on an
agreed upon schedule.
``(B) Data collection.--In order to carry out its
functions, the Center shall--
``(i) utilize existing information, both published and
unpublished, where possible, collected and assessed either by
its own staff or under other arrangements made in accordance
with this section;
``(ii) carry out, or award grants or contracts for,
original research and experimentation, where existing
information is inadequate; and
``(iii) adopt procedures allowing any interested party to
submit information for the use by the Center in making
reports and recommendations.
In carrying out clause (ii), the Center may award grants or
contracts (or provide for intergovernmental transfers, as
applicable) to private entities and governmental agencies
with experience in conducting comparative effectiveness
research, such as the National Institutes of Health and other
relevant Federal health agencies.
``(C) Access of gao to information.--The Comptroller
General shall have unrestricted access to all deliberations,
records, and nonproprietary data of the Center and Commission
under subsection (b), immediately upon request.
``(D) Periodic audit.--The Center and Commission under
subsection (b) shall be subject to periodic audit by the
Comptroller General.
``(b) Comparative Effectiveness Research Commission.--
``(1) In general.--There is established an independent
Comparative Effectiveness Research Commission (in this
section referred to as the `Commission') to advise the Center
and evaluate the activities carried out by the Center under
subsection (a) to ensure such activities result in highly
credible research and information resulting from such
research.
``(2) Duties.--The Commission shall--
``(A)(i) recommend to the Center national priorities for
research described in subsection (a) which shall take into
account--
``(I) disease incidence, prevalence, and burden in the
United States;
``(II) evidence gaps in terms of clinical outcomes;

[[Page H12703]]

``(III) variations in practice, delivery, and outcomes by
geography, treatment site, provider type, disability,
variation in age group (including children, adolescents,
adults, and seniors), racial and ethnic background, gender,
genetic and molecular subtypes, and other appropriate
populations or subpopulations; and
``(IV) the potential for new evidence concerning certain
categories, health care services, or treatments to improve
patient health and well-being, and the quality of care; and
``(ii) in making such recommendations consult with a broad
array of public and private stakeholders, including patients
and health care providers and payers;
``(B) monitor the appropriateness of use of the CERTF
described in subsection (g) with respect to the timely
production of comparative effectiveness research recommended
to be a national priority under subparagraph (A);
``(C) identify highly credible research methods and
standards of evidence for such research to be considered by
the Center;
``(D) review the methodologies developed by the center
under subsection (a)(2)(C);
``(E) support forums to increase stakeholder awareness and
permit stakeholder feedback on the efforts of the Center to
advance methods and standards that promote highly credible
research;
``(F) make recommendations to the Center for policies that
would allow for public access of data produced under this
section, in accordance with appropriate privacy and
proprietary practices, while ensuring that the information
produced through such data is timely and credible;
``(G) make recommendations to the Center for the priority
for periodic reviews of previous comparative effectiveness
research and studies conducted by the Center under subsection
(a);
``(H) at least annually review the processes of the Center
and make reports to Congress and the President regarding
research conducted, supported, or synthesized by the Center
to confirm that the information produced by such research is
objective, credible, consistent with standards of evidence
developed under this section, and developed through a
transparent process that includes consultations with
appropriate stakeholders;
``(I) make recommendations to the Center for the broad
dissemination, consistent with subsection (e), of the
findings of research conducted and supported under this
section that enables clinicians, patients, consumers, and
payers to make more informed health care decisions that
improve quality and value; and
``(J) at least twice each year, hold a public meeting with
an opportunity for stakeholder input.
The reports under subparagraph (H) shall not be submitted to
the Office of Management and Budget or to any other Federal
agency or executive department for any purpose prior to
transmittal to Congress and the President. Such reports shall
be published on the public internet website of the Commission
after the date of such transmittal.
``(3) Composition of commission.--
``(A) In general.--The members of the Commission shall
consist of--
``(i) the Director of the Agency for Healthcare Research
and Quality or their designee;
``(ii) the Chief Medical Officer of the Centers for
Medicare & Medicaid Services or their designee;
``(iii) the Director of the National Institutes of Health
or their designee; and
``(iv) 16 additional members who shall represent broad
constituencies of stakeholders including clinicians,
patients, researchers, third-party payers, and consumers of
Federal and State beneficiary programs.
Of such members, at least 10 shall be practicing physicians,
health care practitioners, consumers, or patients.
``(B) Qualifications.--
``(i) Diverse representation of perspectives.--The members
of the Commission shall represent a broad range of
perspectives and shall collectively have experience in the
following areas:

``(I) Epidemiology.
``(II) Health services research.
``(III) Bioethics.
``(IV) Decision sciences.
``(V) Health disparities.
``(VI) Health economics.

``(ii) Diverse representation of health care community.--At
least one member shall represent each of the following health
care communities:

``(I) Patients.
``(II) Health care consumers.
``(III) Practicing Physicians, including surgeons.
``(IV) Other health care practitioners engaged in clinical
care.
``(V) Organizations with proven expertise in racial and
ethnic minority health research.
``(VI) Employers.
``(VII) Public payers.
``(VIII) Insurance plans.
``(IX) Clinical researchers who conduct research on behalf
of pharmaceutical or device manufacturers.

``(C) Limitation.--No more than 3 of the Members of the
Commission may be representatives of pharmaceutical or device
manufacturers and such representatives shall be clinical
researchers described under subparagraph (B)(ii)(IX).
``(4) Appointment.--The Comptroller General shall appoint
the members of the Commission.
``(5) Chairman; vice chairman.--The Comptroller General
shall designate a member of the Commission, at the time of
appointment of the member, as Chairman and a member as Vice
Chairman for that term of appointment, except that in the
case of vacancy of the Chairmanship or Vice Chairmanship, the
Comptroller General may designate another member for the
remainder of that member's term. The Chairman shall serve as
an ex officio member of the National Advisory Council of the
Agency for Health Care Research and Quality under section
931(c)(3)(B) of the Public Health Service Act.
``(6) Terms.--
``(A) In general.--Except as provided in subparagraph (B),
each member of the Commission shall be appointed for a term
of 4 years.
``(B) Terms of initial appointees.--Of the members first
appointed--
``(i) 8 shall be appointed for a term of 4 years; and
``(ii) 8 shall be appointed for a term of 3 years.
``(7) Compensation.--While serving on the business of the
Commission (including travel time), a member of the
Commission shall be entitled to compensation at the per diem
equivalent of the rate provided for level IV of the Executive
Schedule under section 5315 of title 5, United States Code;
and while so serving away from home and the member's regular
place of business, a member may be allowed travel expenses,
as authorized by the Director of the Commission.
``(8) Director and staff; experts and consultants.--Subject
to such review as the Comptroller General deems necessary to
assure the efficient administration of the Commission, the
Commission may--
``(A) appoint and set the compensation for an Executive
Director (subject to the approval of the Comptroller General)
and such other personnel as Federal employees under section
2105 of title 5, United States Code, as may be necessary to
carry out its duties (without regard to the provisions of
title 5, United States Code, governing appointments in the
competitive service);
``(B) seek such assistance and support as may be required
in the performance of its duties from appropriate Federal
departments and agencies;
``(C) enter into contracts or make other arrangements, as
may be necessary for the conduct of the work of the
Commission (without regard to section 3709 of the Revised
Statutes (41 U.S.C. 5));
``(D) make advance, progress, and other payments which
relate to the work of the Commission;
``(E) provide transportation and subsistence for persons
serving without compensation; and
``(F) prescribe such rules and regulations as it deems
necessary with respect to the internal organization and
operation of the Commission.
``(9) Obtaining official data.--The Commission may secure
directly from any department or agency of the United States
information necessary to enable the Commission to carry out
this section. Upon request of the Chairman of the Commission,
the head of such department or agency shall furnish the
information to the Commission on an agreed upon schedule.
``(10) Availability of reports.--The Commission shall
transmit to the Secretary a copy of each report submitted
under this subsection and shall make such reports available
to the public.
``(11) Coordination.--To enhance effectiveness and
coordination, the Secretary is encouraged, to the greatest
extent possible, to seek coordination between the Commission
and the National Advisory Council of the Agency for
Healthcare Research and Quality.
``(12) Conflicts of interest.--
``(A) In general.--In appointing the members of the
Commission or a clinical perspective advisory panel described
in subsection (a)(2)(G), the Comptroller General or the
Secretary, respectively, shall take into consideration any
financial interest (as defined in subparagraph (D)),
consistent with this paragraph, and develop a plan for
managing any identified conflicts.
``(B) Evaluation and criteria.--When considering an
appointment to the Commission or a clinical perspective
advisory panel described subsection (a)(2)(G), the
Comptroller General or the Secretary, respectively, shall
review the expertise of the individual and the financial
disclosure report filed by the individual pursuant to the
Ethics in Government Act of 1978 for each individual under
consideration for the appointment, so as to reduce the
likelihood that an appointed individual will later require a
written determination as referred to in section 208(b)(1) of
title 18, United States Code, a written certification as
referred to in section 208(b)(3) of title 18, United States
Code, or a waiver as referred to in subparagraph (D)(iii) for
service on the Commission at a meeting of the Commission.
``(C) Disclosures; prohibitions on participation;
waivers.--
``(i) Disclosure of financial interest.--Prior to a meeting
of the Commission or a clinical perspective advisory panel
described in subsection (a)(2)(G) regarding a `particular
matter' (as that term is used in section 208 of title 18,
United States Code), each member of the Commission or the
clinical perspective advisory panel who is a full-time

[[Page H12704]]

Government employee or special Government employee shall
disclose to the Comptroller General or Secretary,
respectively, financial interests in accordance with
requiring a waiver under section 208(b) of title 18, United
States Code, or other interests as deemed relevant by the
Secretary.
``(ii) Prohibitions on participation.--Except as provided
under clause (iii), a member of the Commission or a clinical
perspective advisory panel described in subsection (a)(2)(G)
may not participate with respect to a particular matter
considered in meeting of the Commission or the clinical
perspective advisory panel if such member has a financial
interest that could be affected by the advice given to the
Secretary with respect to such matter, excluding interests
exempted in regulations issued by the Director of the Office
of Government Ethics as too remote or inconsequential to
affect the integrity of the services of the Government
officers or employees to which such regulations apply.
``(iii) Waiver.--If the Comptroller General or Secretary,
as applicable, determines it necessary to afford the
Commission or a clinical perspective advisory panel described
in subsection (a)(2)(G) essential expertise, the Comptroller
General or Secretary, respectively, may grant a waiver of the
prohibition in clause (ii) to permit a member described in
such subparagraph to--

``(I) participate as a non-voting member with respect to a
particular matter considered in a meeting of the Commission
or a clinical perspective advisory panel, respectively; or
``(II) participate as a voting member with respect to a
particular matter considered in a meeting of the Commission.

``(iv) Limitation on waivers and other exceptions.--

``(I) Determination of allowable exceptions for the
commission.--The number of waivers granted to members of the
Commission cannot exceed one-half of the total number of
members for the Commission.
``(II) Prohibition on voting status on clinical perspective
advisory panels.--No voting member of any clinical
perspective advisory panel shall be in receipt of a waiver.
No more than two nonvoting members of any clinical
perspective advisory panel shall receive a waiver.

``(D) Financial interest defined.--For purposes of this
paragraph, the term `financial interest' means a financial
interest under section 208(a) of title 18, United States
Code.
``(13) Application of faca.--The Federal Advisory Committee
Act (other than section 14 of such Act) shall apply to the
Commission to the extent that the provisions of such Act do
not conflict with the requirements of this subsection.
``(c) Research Requirements.--Any research conducted,
supported, or synthesized under this section shall meet the
following requirements:
``(1) Ensuring transparency, credibility, and access.--
``(A) The establishment of a research agenda by the Center
shall be informed by the national priorities for research
recommended under subsection (b)(2)(A).
``(B) The establishment of the agenda and conduct of the
research shall be insulated from inappropriate political or
stakeholder influence.
``(C) Methods of conducting such research shall be
scientifically based.
``(D) Consistent with applicable law, all aspects of the
prioritization of research, conduct of the research, and
development of conclusions based on the research shall be
transparent to all stakeholders.
``(E) Consistent with applicable law, the process and
methods for conducting such research shall be publicly
documented and available to all stakeholders.
``(F) Throughout the process of such research, the Center
shall provide opportunities for all stakeholders involved to
review and provide public comment on the methods and findings
of such research.
``(G) Such research shall consider advice given to the
Center by the clinical perspective advisory panel for the
particular national research priority.
``(2) Stakeholder input.--
``(A) In general.--The Commission shall consult with
patients, health care providers, health care consumer
representatives, and other appropriate stakeholders with an
interest in the research through a transparent process
recommended by the Commission.
``(B) Specific areas of consultation.--Consultation shall
include where deemed appropriate by the Commission--
``(i) recommending research priorities and questions;
``(ii) recommending research methodologies; and
``(iii) advising on and assisting with efforts to
disseminate research findings.
``(C) Ombudsman.--The Secretary shall designate a patient
ombudsman. The ombudsman shall--
``(i) serve as an available point of contact for any
patients with an interest in proposed comparative
effectiveness studies by the Center; and
``(ii) ensure that any comments from patients regarding
proposed comparative effectiveness studies are reviewed by
the Center.
``(3) Taking into account potential differences.--Research
shall--
``(A) be designed, as appropriate, to take into account the
potential for differences in the effectiveness of health care
items, services, and systems used with various subpopulations
such as racial and ethnic minorities, women, different age
groups (including children, adolescents, adults, and
seniors), individuals with disabilities, and individuals with
different comorbidities and genetic and molecular subtypes;
and--
``(B) seek, as feasible and appropriate, to include members
of such subpopulations as subjects in the research.
``(d) Public Access to Comparative Effectiveness
Information.--
``(1) In general.--Not later than 90 days after receipt by
the Center or Commission, as applicable, of a relevant report
described in paragraph (2) made by the Center, Commission, or
clinical perspective advisory panel under this section,
appropriate information contained in such report shall be
posted on the official public Internet site of the Center and
of the Commission, as applicable.
``(2) Relevant reports described.--For purposes of this
section, a relevant report is each of the following submitted
by the Center or a grantee or contractor of the Center:
``(A) Any interim or progress reports as deemed appropriate
by the Secretary.
``(B) Stakeholder comments.
``(C) A final report.
``(e) Dissemination and Incorporation of Comparative
Effectiveness Information.--
``(1) Dissemination.--The Center shall provide for the
dissemination of appropriate findings produced by research
supported, conducted, or synthesized under this section to
health care providers, patients, vendors of health
information technology focused on clinical decision support,
relevant expert organizations (as defined in subsection
(i)(3)(A)), and Federal and private health plans, and other
relevant stakeholders. In disseminating such findings the
Center shall--
``(A) convey findings of research so that they are
comprehensible and useful to patients and providers in making
health care decisions;
``(B) discuss findings and other considerations specific to
certain sub-populations, risk factors, and comorbidities as
appropriate;
``(C) include considerations such as limitations of
research and what further research may be needed, as
appropriate;
``(D) not include any data that the dissemination of which
would violate the privacy of research participants or violate
any confidentiality agreements made with respect to the use
of data under this section; and
``(E) assist the users of health information technology
focused on clinical decision support to promote the timely
incorporation of such findings into clinical practices and
promote the ease of use of such incorporation.
``(2) Dissemination protocols and strategies.--The Center
shall develop protocols and strategies for the appropriate
dissemination of research findings in order to ensure
effective communication of findings and the use and
incorporation of such findings into relevant activities for
the purpose of informing higher quality and more effective
and efficient decisions regarding medical items and services.
In developing and adopting such protocols and strategies, the
Center shall consult with stakeholders concerning the types
of dissemination that will be most useful to the end users of
information and may provide for the utilization of multiple
formats for conveying findings to different audiences,
including dissemination to individuals with limited English
proficiency.
``(f) Reports to Congress.--
``(1) Annual reports.--Beginning not later than one year
after the date of the enactment of this section, the Director
of the Agency of Healthcare Research and Quality shall submit
to Congress an annual report on the activities of the Center,
as well as the research, conducted under this section. Each
such report shall include a discussion of the Center's
compliance with subsection (c)(3)(B), including any reasons
for lack of compliance with such subsection.
``(2) Recommendation for fair share per capita amount for
all-payer financing.--Beginning not later than December 31,
2011, the Secretary shall submit to Congress an annual
recommendation for a fair share per capita amount described
in subsection (c)(1) of section 9511 of the Internal Revenue
Code of 1986 for purposes of funding the CERTF under such
section.
``(3) Analysis and review.--Not later than December 31,
2013, the Secretary, in consultation with the Commission,
shall submit to Congress a report on all activities conducted
or supported under this section as of such date. Such report
shall include an evaluation of the overall costs of such
activities and an analysis of the backlog of any research
proposals approved by the Center but not funded.
``(g) Funding of Comparative Effectiveness Research.--For
fiscal year 2010 and each subsequent fiscal year, amounts in
the Comparative Effectiveness Research Trust Fund (referred
to in this section as the `CERTF') under section 9511 of the
Internal Revenue Code of 1986 shall be available in
accordance with such section, without the need for further
appropriations and without fiscal year limitation, to carry
out this section.
``(h) Construction.--
``(1) Coverage.--Nothing in this section shall be
construed--
``(A) to permit the Center or Commission to mandate
coverage, reimbursement, or other policies for any public or
private payer; or

[[Page H12705]]

``(B) as preventing the Secretary from covering the routine
costs of clinical care received by an individual entitled to,
or enrolled for, benefits under title XVIII, XIX, or XXI in
the case where such individual is participating in a clinical
trial and such costs would otherwise be covered under such
title with respect to the beneficiary.
``(2) Reports and findings.--None of the reports submitted
under this section or research findings disseminated by the
Center or Commission shall be construed as mandates, for
payment, coverage, or treatment.
``(3) Protecting the physician-patient relationship.--
Nothing in this section shall be construed to authorize any
Federal officer or employee to exercise any supervision or
control over the practice of medicine.
``(i) Consultation With Relevant Expert Organizations.--
``(1) Consultation prior to initiation of research.--Prior
to recommending priorities or initiating research described
in this section, the Commission or the Center shall consult
with the relevant expert organizations responsible for
standards and protocols of clinical excellence. Such
consultation shall be consistent with the processes
established under subsection (c)(2).
``(2) Consultation in dissemination of research.--Any
dissemination of research from the Commission or the Center
and findings made by the Commission or the Center shall be
consistent with processes established under subsection (e)
and shall--
``(A) be based upon evidence-based medicine; and
``(B) take into consideration standards and protocols of
clinical excellence developed by relevant expert
organizations.
``(3) Definitions.--For purposes of this subsection:
``(A) Relevant expert organizations.--The term `relevant
expert organization' means an organization with expertise in
the rigorous application of evidence-based scientific methods
for the design of clinical studies, the interpretation of
clinical data, and the development of national clinical
practice guidelines, including a voluntary health
organization, clinical specialty, or other professional
organization that represents physicians based on the field of
medicine in which each such physician practices or is board
certified.
``(B) Standards and protocols of clinical excellence.--The
term `standards and protocols of clinical excellence' means
clinical or practice guidelines that consist of a set of
directions or principles that is based on evidence and is
designed to assist a health care practitioner with decisions
about appropriate diagnostic, therapeutic, or other clinical
procedures for specific clinical circumstances.
``(j) Research May Not Be Used To Deny or Ration Care.--
Nothing in this section shall be construed to make more
stringent or otherwise change the standards or requirements
for coverage of items and services under this Act.''.
(b) Comparative Effectiveness Research Trust Fund;
Financing for the Trust Fund.--For the provision establishing
a Comparative Effectiveness Research Trust Fund and financing
such Trust Fund, see section 1802.

Subtitle B--Nursing Home Transparency

PART 1--IMPROVING TRANSPARENCY OF INFORMATION ON SKILLED NURSING
FACILITIES, NURSING FACILITIES, AND OTHER LONG-TERM CARE FACILITIES

SEC. 1411. REQUIRED DISCLOSURE OF OWNERSHIP AND ADDITIONAL
DISCLOSABLE PARTIES INFORMATION.

(a) In General.--Section 1124 of the Social Security Act
(42 U.S.C. 1320a-3) is amended by adding at the end the
following new subsection:
``(c) Required Disclosure of Ownership and Additional
Disclosable Parties Information.--
``(1) Disclosure.--A facility (as defined in paragraph
(6)(B)) shall have the information described in paragraph (3)
available--
``(A) during the period beginning on the date of the
enactment of this subsection and ending on the date such
information is made available to the public under section
1411(b) of the Affordable Health Care for America Act, for
submission to the Secretary, the Inspector General of the
Department of Health and Human Services, the State in which
the facility is located, and the State long-term care
ombudsman in the case where the Secretary, the Inspector
General, the State, or the State long-term care ombudsman
requests such information; and
``(B) beginning on the effective date of the final
regulations promulgated under paragraph (4)(A), for reporting
such information in accordance with such final regulations.
Nothing in subparagraph (A) shall be construed as authorizing
a facility to dispose of or delete information described in
such subparagraph after the effective date of the final
regulations promulgated under paragraph (4)(A).
``(2) Public availability of information.--During the
period described in paragraph (1)(A), a facility shall--
``(A) make the information described in paragraph (3)
available to the public upon request and update such
information as may be necessary to reflect changes in such
information; and
``(B) post a notice of the availability of such information
in the lobby of the facility in a prominent manner.
``(3) Information described.--
``(A) In general.--The following information is described
in this paragraph:
``(i) The information described in subsections (a) and (b),
subject to subparagraph (C).
``(ii) The identity of and information on--

``(I) each member of the governing body of the facility,
including the name, title, and period of service of each such
member;
``(II) each person or entity who is an officer, director,
member, partner, trustee, or managing employee of the
facility, including the name, title, and date of start of
service of each such person or entity; and
``(III) each person or entity who is an additional
disclosable party of the facility.

``(iii) A description of the organizational structure and
the relationship of each person and entity described in
subclauses (II) and (III) of clause (ii) to the facility and
to one another.
``(B) Special rule where information is already reported or
submitted.--To the extent that information reported by a
facility to the Internal Revenue Service on Form 990,
information submitted by a facility to the Securities and
Exchange Commission, or information otherwise submitted to
the Secretary or any other Federal agency contains the
information described in clauses (i), (ii), or (iii) of
subparagraph (A), the Secretary may allow, to the extent
practicable, such Form or such information to meet the
requirements of paragraph (1) and to be submitted in a manner
specified by the Secretary.
``(C) Special rule.--In applying subparagraph (A)(i)--
``(i) with respect to subsections (a) and (b), `ownership
or control interest' shall include direct or indirect
interests, including such interests in intermediate entities;
and
``(ii) subsection (a)(3)(A)(ii) shall include the owner of
a whole or part interest in any mortgage, deed of trust,
note, or other obligation secured, in whole or in part, by
the entity or any of the property or assets thereof, if the
interest is equal to or exceeds 5 percent of the total
property or assets of the entirety.
``(4) Reporting.--
``(A) In general.--Not later than the date that is 2 years
after the date of the enactment of this subsection, the
Secretary shall promulgate regulations requiring a facility
to report the information described in paragraph (3) to the
Secretary in a standardized format, and such other
regulations as are necessary to carry out this subsection.
Such regulations shall specify the frequency of reporting, as
determined by the Secretary. Such final regulations shall
also require--
``(i) the reporting of such information on or after the
first day of the first calendar quarter beginning after the
date that is 90 days after the date on which such final
regulations are published in the Federal Register; and--
``(ii) the certification, as a condition of participation
under the program under title XVIII or XIX, that such
information is accurate and current.
``(B) Guidance.--The Secretary shall provide guidance and
technical assistance to States on how to adopt the
standardized format under subparagraph (A).
``(5) No effect on existing reporting requirements.--
Nothing in this subsection shall reduce, diminish, or alter
any reporting requirement for a facility that is in effect as
of the date of the enactment of this subsection.
``(6) Definitions.--In this subsection:
``(A) Additional disclosable party.--The term `additional
disclosable party' means, with respect to a facility, any
person or entity who, through ownership interest, partnership
interest, contract, or otherwise--
``(i) directly or indirectly exercises operational,
financial, administrative, or managerial control or direction
over the facility or a part thereof, or provides policies or
procedures for any of the operations of the facility, or
provides financial or cash management services to the
facility;
``(ii) leases or subleases real property to the facility,
or owns a whole or part interest equal to or exceeding 5
percent of the total value of such real property;
``(iii) lends funds or provides a financial guarantee to
the facility in an amount which is equal to or exceeds
$50,000; or
``(iv) provides management or administrative services,
clinical consulting services, or accounting or financial
services to the facility.
``(B) Facility.--The term `facility' means a disclosing
entity which is--
``(i) a skilled nursing facility (as defined in section
1819(a)); or
``(ii) a nursing facility (as defined in section 1919(a)).
``(C) Managing employee.--The term `managing employee'
means, with respect to a facility, an individual (including a
general manager, business manager, administrator, director,
or consultant) who directly or indirectly manages, advises,
or supervises any element of the practices, finances, or
operations of the facility.
``(D) Organizational structure.--The term `organizational
structure' means, in the case of--
``(i) a corporation, the officers, directors, and
shareholders of the corporation who have an ownership
interest in the corporation which is equal to or exceeds 5
percent;
``(ii) a limited liability company, the members and
managers of the limited liability company (including, as
applicable, what percentage each member and manager has of
the ownership interest in the limited liability company);

[[Page H12706]]

``(iii) a general partnership, the partners of the general
partnership;
``(iv) a limited partnership, the general partners and any
limited partners of the limited partnership who have an
ownership interest in the limited partnership which is equal
to or exceeds 10 percent;
``(v) a trust, the trustees of the trust;
``(vi) an individual, contact information for the
individual; and
``(vii) any other person or entity, such information as the
Secretary determines appropriate.''.
(b) Public Availability of Information.--Not later than the
date that is 1 year after the date on which the final
regulations promulgated under section 1124(c)(4)(A) of the
Social Security Act, as added by subsection (a), are
published in the Federal Register, the information reported
in accordance with such final regulations shall be made
available to the public in accordance with procedures
established by the Secretary of Health and Human Services.
(c) Conforming Amendments.--
(1) Skilled nursing facilities.--Section 1819(d)(1) of the
Social Security Act (42 U.S.C. 1395i-3(d)(1)) is amended by
striking subparagraph (B) and redesignating subparagraph (C)
as subparagraph (B).
(2) Nursing facilities.--Section 1919(d)(1) of the Social
Security Act (42 U.S.C. 1396r(d)(1)) is amended by striking
subparagraph (B) and redesignating subparagraph (C) as
subparagraph (B).

SEC. 1412. ACCOUNTABILITY REQUIREMENTS.

(a) Effective Compliance and Ethics Programs.--
(1) Skilled nursing facilities.--Section 1819(d)(1) of the
Social Security Act (42 U.S.C. 1395i-3(d)(1)), as amended by
section 1411(c)(1), is amended by adding at the end the
following new subparagraph:
``(C) Compliance and ethics programs.--
``(i) Requirement.--On or after the first day of the first
calendar quarter beginning after the date that is 1 year
after the date on which regulations developed under clause
(ii) are published in the Federal Register, a skilled nursing
facility shall, with respect to the entity that operates or
controls the facility (in this subparagraph referred to as
the `operating organization' or `organization'), have in
operation a compliance and ethics program that is effective
in preventing and detecting criminal, civil, and
administrative violations under this Act and in promoting
quality of care consistent with such regulations.
``(ii) Development of regulations.--

``(I) In general.--Not later than the date that is 2 years
after the date of the enactment of this subparagraph, the
Secretary, in consultation with the Inspector General of the
Department of Health and Human Services, shall promulgate
regulations for an effective compliance and ethics program
for operating organizations, which may include a model
compliance program.
``(II) Design of regulations.--Such regulations with
respect to specific elements or formality of a program may
vary with the size of the organization, such that larger
organizations should have a more formal and rigorous program
and include established written policies defining the
standards and procedures to be followed by its employees.
Such requirements shall specifically apply to the corporate
level management of multi-unit nursing home chains.
``(III) Evaluation.--Not later than 3 years after the date
on which compliance and ethics programs established under
this subparagraph are in operation pursuant to clause (i),
the Secretary shall complete an evaluation of such programs.
Such evaluation shall determine if such programs led to
changes in deficiency citations, changes in quality
performance, or changes in other metrics of resident quality
of care. The Secretary shall submit to Congress a report on
such evaluation and shall include in such report such
recommendations regarding changes in the requirements for
such programs as the Secretary determines appropriate.

``(iii) Requirements for compliance and ethics programs.--
In this subparagraph, the term `compliance and ethics
program' means, with respect to a skilled nursing facility, a
program of the operating organization that--

``(I) has been reasonably designed, implemented, and
enforced so that it generally will be effective in preventing
and detecting criminal, civil, and administrative violations
under this Act and in promoting quality of care; and
``(II) includes at least the required components specified
in clause (iv).

``(iv) Required components of program.--The required
components of a compliance and ethics program of an
organization are the following:

``(I) The organization must have established compliance
standards and procedures to be followed by its employees,
contractors, and other agents that are reasonably capable of
reducing the prospect of criminal, civil, and administrative
violations under this Act.
``(II) Specific individuals within high-level personnel of
the organization must have been assigned overall
responsibility to oversee compliance with such standards and
procedures and have sufficient resources and authority to
assure such compliance.
``(III) The organization must have used due care not to
delegate substantial discretionary authority to individuals
whom the organization knew, or should have known through the
exercise of due diligence, had a propensity to engage in
criminal, civil, and administrative violations under this
Act.
``(IV) The organization must have taken steps to
communicate effectively its standards and procedures to all
employees and other agents, such as by requiring
participation in training programs or by disseminating
publications that explain in a practical manner what is
required.
``(V) The organization must have taken reasonable steps to
achieve compliance with its standards, such as by utilizing
monitoring and auditing systems reasonably designed to detect
criminal, civil, and administrative violations under this Act
by its employees and other agents and by having in place and
publicizing a reporting system whereby employees and other
agents could report violations by others within the
organization without fear of retribution.
``(VI) The standards must have been consistently enforced
through appropriate disciplinary mechanisms, including, as
appropriate, discipline of individuals responsible for the
failure to detect an offense.
``(VII) After an offense has been detected, the
organization must have taken all reasonable steps to respond
appropriately to the offense and to prevent further similar
offenses, including repayment of any funds to which it was
not entitled and any necessary modification to its program to
prevent and detect criminal, civil, and administrative
violations under this Act.
``(VIII) The organization must periodically undertake
reassessment of its compliance program to identify changes
necessary to reflect changes within the organization and its
facilities.

``(v) Coordination.--The provisions of this subparagraph
shall apply with respect to a skilled nursing facility in
lieu of section 1874(d).''.
(2) Nursing facilities.--Section 1919(d)(1) of the Social
Security Act (42 U.S.C. 1396r(d)(1)), as amended by section
1411(c)(2), is amended by adding at the end the following new
subparagraph:
``(C) Compliance and ethics program.--
``(i) Requirement.--On or after the first day of the first
calendar quarter beginning after the date that is 1 year
after the date on which regulations developed under clause
(ii) are published in the Federal Register, a skilled nursing
facility shall, with respect to the entity that operates or
controls the facility (in this subparagraph referred to as
the `operating organization' or `organization'), have in
operation a compliance and ethics program that is effective
in preventing and detecting criminal, civil, and
administrative violations under this Act and in promoting
quality of care consistent with such regulations.
``(iii) Development of regulations.--

``(I) In general.--Not later than the date that is 2 years
after the date of the enactment of this subparagraph, the
Secretary, in consultation with the Inspector General of the
Department of Health and Human Services, shall promulgate
regulations for an effective compliance and ethics program
for operating organizations, which may include a model
compliance program.
``(II) Design of regulations.--Such regulations with
respect to specific elements or formality of a program may
vary with the size of the organization, such that larger
organizations should have a more formal and rigorous program
and include established written policies defining the
standards and procedures to be followed by its employees.
Such requirements shall specifically apply to the corporate
level management of multi-unit nursing home chains.
``(III) Evaluation.--Not later than 3 years after the date
on which compliance and ethics programs established under
this subparagraph are in operation pursuant to clause (i),
the Secretary shall complete an evaluation of such programs.
Such evaluation shall determine if such programs led to
changes in deficiency citations, changes in quality
performance, or changes in other metrics of resident quality
of care. The Secretary shall submit to Congress a report on
such evaluation and shall include in such report such
recommendations regarding changes in the requirements for
such programs as the Secretary determines appropriate.

``(v) Requirements for compliance and ethics programs.--In
this subparagraph, the term `compliance and ethics program'
means, with respect to a nursing facility, a program of the
operating organization that--

``(I) has been reasonably designed, implemented, and
enforced so that it generally will be effective in preventing
and detecting criminal, civil, and administrative violations
under this Act and in promoting quality of care; and
``(II) includes at least the required components specified
in clause (iv).

``(vi) Required components of program.--The required
components of a compliance and ethics program of an
organization are the following:

``(I) The organization must have established compliance
standards and procedures to be followed by its employees and
other agents that are reasonably capable of reducing the
prospect of criminal, civil, and administrative violations
under this Act.
``(II) Specific individuals within high-level personnel of
the organization must have been assigned overall
responsibility to oversee compliance with such standards and
procedures and has sufficient resources and authority to
assure such compliance.

[[Page H12707]]

``(III) The organization must have used due care not to
delegate substantial discretionary authority to individuals
whom the organization knew, or should have known through the
exercise of due diligence, had a propensity to engage in
criminal, civil, and administrative violations under this
Act.
``(IV) The organization must have taken steps to
communicate effectively its standards and procedures to all
employees and other agents, such as by requiring
participation in training programs or by disseminating
publications that explain in a practical manner what is
required.
``(V) The organization must have taken reasonable steps to
achieve compliance with its standards, such as by utilizing
monitoring and auditing systems reasonably designed to detect
criminal, civil, and administrative violations under this Act
by its employees and other agents and by having in place and
publicizing a reporting system whereby employees and other
agents could report violations by others within the
organization without fear of retribution.
``(VI) The standards must have been consistently enforced
through appropriate disciplinary mechanisms, including, as
appropriate, discipline of individuals responsible for the
failure to detect an offense.
``(VII) After an offense has been detected, the
organization must have taken all reasonable steps to respond
appropriately to the offense and to prevent further similar
offenses, including repayment of any funds to which it was
not entitled and any necessary modification to its program to
prevent and detect criminal, civil, and administrative
violations under this Act.
``(VIII) The organization must periodically undertake
reassessment of its compliance program to identify changes
necessary to reflect changes within the organization and its
facilities.

``(vii) Coordination.--The provisions of this subparagraph
shall apply with respect to a nursing facility in lieu of
section 1902(a)(77).''.
(b) Quality Assurance and Performance Improvement
Program.--
(1) Skilled nursing facilities.--Section 1819(b)(1)(B) of
the Social Security Act (42 U.S.C. 1396r(b)(1)(B)) is
amended--
(A) by striking ``assurance'' and inserting ``assurance and
quality assurance and performance improvement program'';
(B) by designating the matter beginning with ``A skilled
nursing facility'' as a clause (i) with the heading ``In
general.--'' and the appropriate indentation;
(C) in clause (i) (as so designated by subparagraph (B)),
by redesignating clauses (i) and (ii) as subclauses (I) and
(II), respectively; and
(D) by adding at the end the following new clause:
``(ii) Quality assurance and performance improvement
program.--

``(I) In general.--Not later than December 31, 2011, the
Secretary shall establish and implement a quality assurance
and performance improvement program (in this clause referred
to as the `QAPI program') for skilled nursing facilities,
including multi-unit chains of such facilities. Under the
QAPI program, the Secretary shall establish standards
relating to such facilities and provide technical assistance
to such facilities on the development of best practices in
order to meet such standards. Not later than 1 year after the
date on which the regulations are promulgated under subclause
(II), a skilled nursing facility must submit to the Secretary
a plan for the facility to meet such standards and implement
such best practices, including how to coordinate the
implementation of such plan with quality assessment and
assurance activities conducted under clause (i).
``(II) Regulations.--The Secretary shall promulgate
regulations to carry out this clause.''.

(2) Nursing facilities.--Section 1919(b)(1)(B) of the
Social Security Act (42 U.S.C. 1396r(b)(1)(B)) is amended--
(A) by striking ``assurance'' and inserting ``assurance and
quality assurance and performance improvement program'';
(B) by designating the matter beginning with ``A nursing
facility'' as a clause (i) with the heading ``In general.--''
and the appropriate indentation; and
(C) by adding at the end the following new clause:
``(ii) Quality assurance and performance improvement
program.--

``(I) In general.--Not later than December 31, 2011, the
Secretary shall establish and implement a quality assurance
and performance improvement program (in this clause referred
to as the `QAPI program') for nursing facilities, including
multi-unit chains of such facilities. Under the QAPI program,
the Secretary shall establish standards relating to such
facilities and provide technical assistance to such
facilities on the development of best practices in order to
meet such standards. Not later than 1 year after the date on
which the regulations are promulgated under subclause (II), a
nursing facility must submit to the Secretary a plan for the
facility to meet such standards and implement such best
practices, including how to coordinate the implementation of
such plan with quality assessment and assurance activities
conducted under clause (i).
``(II) Regulations.--The Secretary shall promulgate
regulations to carry out this clause.''.

(3) Proposal to revise quality assurance and performance
improvement programs.--The Secretary shall implement policies
that modify and strengthen quality assurance and performance
improvement programs in skilled nursing facilities and
nursing facilities on a periodic basis, as determined by the
Secretary.
(4) Facility plan.--Not later than 1 year after the date on
which the regulations are promulgated under subclause (II) of
clause (ii) of sections 1819(b)(1)(B) and 1919(b)(1)(B) of
the Social Security Act, as added by paragraphs (1) and (2),
a skilled nursing facility and a nursing facility must submit
to the Secretary a plan for the facility to meet the
standards under such regulations and implement such best
practices, including how to coordinate the implementation of
such plan with quality assessment and assurance activities
conducted under clause (i) of such sections.
(c) GAO Study on Nursing Facility Undercapitalization.--
(1) In general.--The Comptroller General of the United
States shall conduct a study that examines the following:
(A) The extent to which corporations that own or operate
large numbers of nursing facilities, taking into account
ownership type (including private equity and control
interests), are undercapitalizing such facilities.
(B) The effects of such undercapitalization on quality of
care, including staffing and food costs, at such facilities.
(C) Options to address such undercapitalization, such as
requirements relating to surety bonds, liability insurance,
or minimum capitalization.
(2) Report.--Not later than 18 months after the date of the
enactment of this Act, the Comptroller General shall submit
to Congress a report on the study conducted under paragraph
(1).
(3) Nursing facility.--In this subsection, the term
``nursing facility'' includes a skilled nursing facility.

SEC. 1413. NURSING HOME COMPARE MEDICARE WEBSITE.

(a) Skilled Nursing Facilities.--
(1) In general.--Section 1819 of the Social Security Act
(42 U.S.C. 1395i-3) is amended--
(A) by redesignating subsection (i) as subsection (j); and
(B) by inserting after subsection (h) the following new
subsection:
``(i) Nursing Home Compare Website.--
``(1) Inclusion of additional information.--
``(A) In general.--The Secretary shall ensure that the
Department of Health and Human Services includes, as part of
the information provided for comparison of nursing homes on
the official Internet website of the Federal Government for
Medicare beneficiaries (commonly referred to as the `Nursing
Home Compare' Medicare website) (or a successor website), the
following information in a manner that is prominent, easily
accessible, readily understandable to consumers of long-term
care services, and searchable:
``(i) Information that is reported to the Secretary under
section 1124(c)(4).
``(ii) Information on the `Special Focus Facility program'
(or a successor program) established by the Centers for
Medicare and Medicaid Services, according to procedures
established by the Secretary. Such procedures shall provide
for the inclusion of information with respect to, and the
names and locations of, those facilities that, since the
previous quarter--

``(I) were newly enrolled in the program;
``(II) are enrolled in the program and have failed to
significantly improve;
``(III) are enrolled in the program and have significantly
improved;
``(IV) have graduated from the program; and
``(V) have closed voluntarily or no longer participate
under this title.

``(iii) Staffing data for each facility (including resident
census data and data on the hours of care provided per
resident per day) based on data submitted under subsection
(b)(8)(C), including information on staffing turnover and
tenure, in a format that is clearly understandable to
consumers of long-term care services and allows such
consumers to compare differences in staffing between
facilities and State and national averages for the
facilities. Such format shall include--

``(I) concise explanations of how to interpret the data
(such as a plain English explanation of data reflecting
`nursing home staff hours per resident day');
``(II) differences in types of staff (such as training
associated with different categories of staff);
``(III) the relationship between nurse staffing levels and
quality of care; and
``(IV) an explanation that appropriate staffing levels vary
based on patient case mix.

``(iv) Links to State internet websites with information
regarding State survey and certification programs, links to
Form 2567 State inspection reports (or a successor form) on
such websites, information to guide consumers in how to
interpret and understand such reports, and the facility plan
of correction or other response to such report.
``(v) The standardized complaint form developed under
subsection (f)(8), including explanatory material on what
complaint forms are, how they are used, and how to file a
complaint with the State survey and certification program and
the State long-term care ombudsman program.

[[Page H12708]]

``(vi) Summary information on the number, type, severity,
and outcome of substantiated complaints.
``(vii) The number of adjudicated instances of criminal
violations by employees of a nursing facility--

``(I) that were committed inside the facility;
``(II) with respect to such instances of violations or
crimes committed inside of the facility that were the
violations or crimes of abuse, neglect, and exploitation,
criminal sexual abuse, or other violations or crimes that
resulted in serious bodily injury; and

``(viii) The number of civil monetary penalties levied
against the facility, employees, contractors, and other
agents.
``(ix) Any other information that the Secretary determines
appropriate.

The facility shall not make available under clause (iv)
identifying information on complainants or residents.
``(B) Deadline for provision of information.--
``(i) In general.--Except as provided in clause (ii), the
Secretary shall ensure that the information described in
subparagraph (A) is included on such website (or a successor
website) not later than 1 year after the date of the
enactment of this subsection.
``(ii) Exception.--The Secretary shall ensure that the
information described in subparagraph (A)(i) and (A)(iii) is
included on such website (or a successor website) not later
than 1 year after the dates on which the data are submitted
to the Secretary pursuant to section 1124(c)(4) and
subsection (b)(8)(C), respectively.
``(2) Review and modification of website.--
``(A) In general.--The Secretary shall establish a
process--
``(i) to review the accuracy, clarity of presentation,
timeliness, and comprehensiveness of information reported on
such website as of the day before the date of the enactment
of this subsection; and
``(ii) not later than 1 year after the date of the
enactment of this subsection, to modify or revamp such
website in accordance with the review conducted under clause
(i).
``(B) Consultation.--In conducting the review under
subparagraph (A)(i), the Secretary shall consult with--
``(i) State long-term care ombudsman programs;
``(ii) consumer advocacy groups;
``(iii) provider stakeholder groups; and
``(iv) any other representatives of programs or groups the
Secretary determines appropriate.''.
(2) Timeliness of submission of survey and certification
information.--
(A) In general.--Section 1819(g)(5) of the Social Security
Act (42 U.S.C. 1395i-3(g)(5)) is amended by adding at the end
the following new subparagraph:
``(E) Submission of survey and certification information to
the secretary.--In order to improve the timeliness of
information made available to the public under subparagraph
(A) and provided on the Nursing Home Compare Medicare website
under subsection (i), each State shall submit information
respecting any survey or certification recommendation made
respecting a skilled nursing facility (including any
enforcement actions taken by the State or any Federal
enforcement action recommended by the State) to the Secretary
not later than the date on which the State sends such
information to the facility. The Secretary shall use the
information submitted under the preceding sentence to update
the information provided on the Nursing Home Compare Medicare
website as expeditiously as practicable but not less
frequently than quarterly.''.
(B) Effective date.--The amendment made by this paragraph
shall take effect 1 year after the date of the enactment of
this Act.
(3) Special focus facility program.--Section 1819(f) of
such Act is amended by adding at the end the following new
paragraph:
``(8) Special focus facility program.--
``(A) In general.--The Secretary shall conduct a special
focus facility program for enforcement of requirements for
skilled nursing facilities that the Secretary has identified
as having a poor compliance history or that substantially
failed to meet applicable requirements of this Act.
``(B) Periodic surveys.--Under such program the Secretary
shall conduct surveys of each facility in the program not
less than once every 6 months.''.
(b) Nursing Facilities.--
(1) In general.--Section 1919 of the Social Security Act
(42 U.S.C. 1396r) is amended--
(A) by redesignating subsection (i) as subsection (j); and
(B) by inserting after subsection (h) the following new
subsection:
``(i) Nursing Home Compare Website.--
``(1) Inclusion of additional information.--
``(A) In general.--The Secretary shall ensure that the
Department of Health and Human Services includes, as part of
the information provided for comparison of nursing homes on
the official internet website of the Federal Government for
Medicare beneficiaries (commonly referred to as the `Nursing
Home Compare' Medicare website) (or a successor website), the
following information in a manner that is prominent, easily
accessible, readily understandable to consumers of long-term
care services, and searchable:
``(i) Information that is reported to the Secretary under
section 1124(c)(4)
``(ii) Information on the `Special Focus Facility program'
(or a successor program) established by the Centers for
Medicare & Medicaid Services, according to procedures
established by the Secretary. Such procedures shall provide
for the inclusion of information with respect to, and the
names and locations of, those facilities that, since the
previous quarter--

``(I) were newly enrolled in the program;
``(II) are enrolled in the program and have failed to
significantly improve;
``(III) are enrolled in the program and have significantly
improved;
``(IV) have graduated from the program; and
``(V) have closed voluntarily or no longer participate
under this title.

``(iii) Staffing data for each facility (including resident
census data and data on the hours of care provided per
resident per day) based on data submitted under subsection
(b)(8)(C)(ii), including information on staffing turnover and
tenure, in a format that is clearly understandable to
consumers of long-term care services and allows such
consumers to compare differences in staffing between
facilities and State and national averages for the
facilities. Such format shall include--

``(I) concise explanations of how to interpret the data
(such as plain English explanation of data reflecting
`nursing home staff hours per resident day');
``(II) differences in types of staff (such as training
associated with different categories of staff);
``(III) the relationship between nurse staffing levels and
quality of care; and
``(IV) an explanation that appropriate staffing levels vary
based on patient case mix.

``(iv) Links to State internet websites with information
regarding State survey and certification programs, links to
Form 2567 State inspection reports (or a successor form) on
such websites, information to guide consumers in how to
interpret and understand such reports, and the facility plan
of correction or other response to such report.
``(v) The standardized complaint form developed under
subsection (f)(10), including explanatory material on what
complaint forms are, how they are used, and how to file a
complaint with the State survey and certification program and
the State long-term care ombudsman program.
``(vi) Summary information on the number, type, severity,
and outcome of substantiated complaints.
``(vii) The number of adjudicated instances of criminal
violations by employees of a nursing facility--

``(I) that were committed inside of the facility; and
``(II) with respect to such instances of violations or
crimes committed inside of the facility that were the
violations or crimes of abuse, neglect, and exploitation,
criminal sexual abuse, or other violations or crimes that
resulted in serious bodily injury.

``(viii) the number of civil monetary penalties levied
against the facility, employees, contractors, and other
agents.
``(ix) Any other information that the Secretary determines
appropriate.

The facility shall not make available under clause (ii)
identifying information about complainants or residents.
``(B) Deadline for provision of information.--
``(i) In general.--Except as provided in clause (ii), the
Secretary shall ensure that the information described in
subparagraph (A) is included on such website (or a successor
website) not later than 1 year after the date of the
enactment of this subsection.
``(ii) Exception.--The Secretary shall ensure that the
information described in subparagraph (A)(i) and (A)(iii) is
included on such website (or a successor website) not later
than 1 year after the dates on which the data are submitted
to the Secretary pursuant to section 1124(c)(4) and
subsection (b)(8)(C), respectively.
``(2) Review and modification of website.--
``(A) In general.--The Secretary shall establish a
process--
``(i) to review the accuracy, clarity of presentation,
timeliness, and comprehensiveness of information reported on
such website as of the day before the date of the enactment
of this subsection; and
``(ii) not later than 1 year after the date of the
enactment of this subsection, to modify or revamp such
website in accordance with the review conducted under clause
(i).
``(B) Consultation.--In conducting the review under
subparagraph (A)(i), the Secretary shall consult with--
``(i) State long-term care ombudsman programs;
``(ii) consumer advocacy groups;
``(iii) provider stakeholder groups;
``(iv) skilled nursing facility employees and their
representatives; and
``(v) any other representatives of programs or groups the
Secretary determines appropriate.''.
(2) Timeliness of submission of survey and certification
information.--
(A) In general.--Section 1919(g)(5) of the Social Security
Act (42 U.S.C. 1396r(g)(5)) is amended by adding at the end
the following new subparagraph:
``(E) Submission of survey and certification information to
the secretary.--In order to improve the timeliness of
information made available to the public under subparagraph
(A) and provided on the Nursing

[[Page H12709]]

Home Compare Medicare website under subsection (i), each
State shall submit information respecting any survey or
certification recommendation made respecting a nursing
facility (including any enforcement actions taken by the
State or any Federal enforcement action recommended by the
State) to the Secretary not later than the date on which the
State sends such information to the facility. The Secretary
shall use the information submitted under the preceding
sentence to update the information provided on the Nursing
Home Compare Medicare website as expeditiously as practicable
but not less frequently than quarterly.''.
(B) Effective date.--The amendment made by this paragraph
shall take effect 1 year after the date of the enactment of
this Act.
(3) Special focus facility program.--Section 1919(f) of
such Act is amended by adding at the end of the following new
paragraph:
``(10) Special focus facility program.--
``(A) In general.--The Secretary shall conduct a special
focus facility program for enforcement of requirements for
nursing facilities that the Secretary has identified as
having a poor compliance history or that substantially failed
to meet applicable requirements of this Act.
``(B) Periodic surveys.--Under such program the Secretary
shall conduct surveys of each facility in the program not
less often than once every 6 months.''.
(c) Availability of Reports on Surveys, Certifications, and
Complaint Investigations.--
(1) Skilled nursing facilities.--Section 1819(d)(1) of the
Social Security Act (42 U.S.C. 1395i-3(d)(1)), as amended by
sections 1411 and 1412, is amended by adding at the end the
following new subparagraph:
``(D) Availability of survey, certification, and complaint
investigation reports.--A skilled nursing facility must--
``(i) have reports with respect to any surveys,
certifications, and complaint investigations made respecting
the facility during the 3 preceding years available for any
individual to review upon request; and
``(ii) post notice of the availability of such reports in
areas of the facility that are prominent and accessible to
the public.
The facility shall not make available under clause (i)
identifying information about complainants or residents.''.
(2) Nursing facilities.--Section 1919(d)(1) of the Social
Security Act (42 U.S.C. 1396r(d)(1)), as amended by sections
1411 and 1412, is amended by adding at the end the following
new subparagraph:
``(D) Availability of survey, certification, and complaint
investigation reports.--A nursing facility must--
``(i) have reports with respect to any surveys,
certifications, and complaint investigations made respecting
the facility during the 3 preceding years available for any
individual to review upon request; and
``(ii) post notice of the availability of such reports in
areas of the facility that are prominent and accessible to
the public.

The facility shall not make available under clause (i)
identifying information about complainants or residents.''.
(3) Effective date.--The amendments made by this subsection
shall take effect 1 year after the date of the enactment of
this Act.
(d) Guidance to States on Form 2567 State Inspection
Reports and Complaint Investigation Reports.--
(1) Guidance.--The Secretary of Health and Human Services
(in this subtitle referred to as the ``Secretary'') shall
provide guidance to States on how States can establish
electronic links to Form 2567 State inspection reports (or a
successor form), complaint investigation reports, and a
facility's plan of correction or other response to such Form
2567 State inspection reports (or a successor form) on the
Internet website of the State that provides information on
skilled nursing facilities and nursing facilities and the
Secretary shall, if possible, include such information on
Nursing Home Compare.
(2) Requirement.--Section 1902(a)(9) of the Social Security
Act (42 U.S.C. 1396a(a)(9)) is amended--
(A) by striking ``and'' at the end of subparagraph (B);
(B) by striking the semicolon at the end of subparagraph
(C) and inserting ``, and''; and
(C) by adding at the end the following new subparagraph:
``(D) that the State maintain a consumer-oriented website
providing useful information to consumers regarding all
skilled nursing facilities and all nursing facilities in the
State, including for each facility, Form 2567 State
inspection reports (or a successor form), complaint
investigation reports, the facility's plan of correction, and
such other information that the State or the Secretary
considers useful in assisting the public to assess the
quality of long term care options and the quality of care
provided by individual facilities;''.
(3) Definitions.--In this subsection:
(A) Nursing facility.--The term ``nursing facility'' has
the meaning given such term in section 1919(a) of the Social
Security Act (42 U.S.C. 1396r(a)).
(B) Secretary.--The term ``Secretary'' means the Secretary
of Health and Human Services.
(C) Skilled nursing facility.--The term ``skilled nursing
facility'' has the meaning given such term in section 1819(a)
of the Social Security Act (42 U.S.C. 1395i-3(a)).

SEC. 1414. REPORTING OF EXPENDITURES.

Section 1888 of the Social Security Act (42 U.S.C. 1395yy)
is amended by adding at the end the following new subsection:
``(f) Reporting of Direct Care Expenditures.--
``(1) In general.--For cost reports submitted under this
title for cost reporting periods beginning on or after the
date that is no more than two years after the redesign of the
report specified in subparagraph (2), skilled nursing
facilities shall--
``(A) separately report expenditures for wages and benefits
for direct care staff (breaking out (at a minimum) registered
nurses, licensed professional nurses, certified nurse
assistants, and other medical and therapy staff); and
``(B) take into account agency and contract staff in a
manner to be determined by the Administrator.
``(2) Modification of form.--The Secretary, in consultation
with private sector accountants experienced with skilled
nursing facility cost reports, shall redesign such reports to
meet the requirement of paragraph (1) not later than 2 years
after the date of the enactment of this subsection.
``(3) Categorization by functional accounts.--Beginning
with cost reports submitted under paragraph (1) , the
Secretary, working in consultation with the Medicare Payment
Advisory Commission, the Inspector General of the Department
of Health and Human Services, and other expert parties the
Secretary determines appropriate, shall categorize the
expenditures listed on cost reports, as modified under
paragraph (1), submitted by skilled nursing facilities,
regardless of any source of payment for such expenditures,
for each skilled nursing facility into the following
functional accounts on an annual basis:
``(A) Spending on direct care services (including nursing,
therapy, and medical services).
``(B) Spending on indirect care (including housekeeping and
dietary services).
``(C) Capital assets (including building and land costs).
``(D) Administrative services costs.
``(4) Availability of information submitted.--The Secretary
shall establish procedures to make information on
expenditures submitted under this subsection readily
available to interested parties upon request, subject to such
requirements as the Secretary may specify under the
procedures established under this paragraph.''.

SEC. 1415. STANDARDIZED COMPLAINT FORM.

(a) Skilled Nursing Facilities.--
(1) Development by the secretary.--Section 1819(f) of the
Social Security Act (42 U.S.C. 1395i-3(f)), as amended by
section 1413(a)(3), is amended by adding at the end the
following new paragraph:
``(9) Standardized complaint form.--The Secretary shall
develop a standardized complaint form for use by a resident
(or a person acting on the resident's behalf) in filing a
complaint with a State survey and certification agency and a
State long-term care ombudsman program with respect to a
skilled nursing facility.''.
(2) State requirements.--Section 1819(e) of the Social
Security Act (42 U.S.C. 1395i-3(e)) is amended by adding at
the end the following new paragraph:
``(6) Complaint processes and whistle-blower protection.--
``(A) Complaint forms.--The State must make the
standardized complaint form developed under subsection (f)(9)
available upon request to--
``(i) a resident of a skilled nursing facility;
``(ii) any person acting on the resident's behalf; and
``(iii) any person who works at a skilled nursing facility
or is a representative of such a worker.
``(B) Complaint resolution process.--The State must
establish a complaint resolution process in order to ensure
that a resident, the legal representative of a resident of a
skilled nursing facility, or other responsible party is not
retaliated against if the resident, legal representative, or
responsible party has complained, in good faith, about the
quality of care or other issues relating to the skilled
nursing facility, that the legal representative of a resident
of a skilled nursing facility or other responsible party is
not denied access to such resident or otherwise retaliated
against if such representative party has complained, in good
faith, about the quality of care provided by the facility or
other issues relating to the facility, and that a person who
works at a skilled nursing facility is not retaliated against
if the worker has complained, in good faith, about quality of
care or services or an issue relating to the quality of care
or services provided at the facility, whether the resident,
legal representative, other responsible party, or worker used
the form developed under subsection (f)(9) or some other
method for submitting the complaint. Such complaint
resolution process shall include--
``(i) procedures to assure accurate tracking of complaints
received, including notification to the complainant that a
complaint has been received;
``(ii) procedures to determine the likely severity of a
complaint and for the investigation of the complaint;
``(iii) deadlines for responding to a complaint and for
notifying the complainant of the outcome of the
investigation; and
``(iv) procedures to ensure that the identity of the
complainant will be kept confidential.

[[Page H12710]]

``(C) Whistleblower protection.--
``(i) Prohibition against retaliation.--No person who works
at a skilled nursing facility may be penalized,
discriminated, or retaliated against with respect to any
aspect of employment, including discharge, promotion,
compensation, terms, conditions, or privileges of employment,
or have a contract for services terminated, because the
person (or anyone acting at the person's request) complained,
in good faith, about the quality of care or services provided
by a skilled nursing facility or about other issues relating
to quality of care or services, whether using the form
developed under subsection (f)(9) or some other method for
submitting the complaint.
``(ii) Retaliatory reporting.--A skilled nursing facility
may not file a complaint or a report against a person who
works (or has worked at the facility) with the appropriate
State professional disciplinary agency because the person (or
anyone acting at the person's request) complained in good
faith, as described in clause (i).
``(iii) Relief.--Any person aggrieved by a violation of
clause (i) or clause (ii) may, in a civil action, obtain all
appropriate relief, including reinstatement, reimbursement of
lost wages, compensation, and benefits, and exemplary damages
where warranted, and such other relief as the court deems
appropriate, as well as costs of suit and reasonable attorney
and expert witness fees.
``(iv) Rights not waivable.--The rights protected by this
paragraph may not be diminished by contract or other
agreement, and nothing in this paragraph shall be construed
to diminish any greater or additional protection provided by
Federal or State law or by contract or other agreement.
``(v) Requirement to post notice of employee rights.--Each
skilled nursing facility shall post conspicuously in an
appropriate location a sign (in a form specified by the
Secretary) specifying the rights of persons under this
paragraph and including a statement that an employee may file
a complaint with the Secretary against a skilled nursing
facility that violates the provisions of this paragraph and
information with respect to the manner of filing such a
complaint.
``(D) Rule of construction.--Nothing in this paragraph
shall be construed as preventing a resident of a skilled
nursing facility (or a person acting on the resident's
behalf) from submitting a complaint in a manner or format
other than by using the standardized complaint form developed
under subsection (f)(9) (including submitting a complaint
orally).
``(E) Good faith defined.--For purposes of this paragraph,
an individual shall be deemed to be acting in good faith with
respect to the filing of a complaint if the individual
reasonably believes--
``(i) the information reported or disclosed in the
complaint is true; and
``(ii) the violation of this title has occurred or may
occur in relation to such information.''.
(b) Nursing Facilities.--
(1) Development by the secretary.--Section 1919(f) of the
Social Security Act (42 U.S.C. 1395i-3(f)), as amended by
section 1413(b), is amended by adding at the end the
following new paragraph:
``(11) Standardized complaint form.--The Secretary shall
develop a standardized complaint form for use by a resident
(or a person acting on the resident's behalf) in filing a
complaint with a State survey and certification agency and a
State long-term care ombudsman program with respect to a
nursing facility.''.
(2) State requirements.--Section 1919(e) of the Social
Security Act (42 U.S.C. 1395i-3(e)) is amended by adding at
the end the following new paragraph:
``(8) Complaint processes and whistleblower protection.--
``(A) Complaint forms.--The State must make the
standardized complaint form developed under subsection
(f)(11) available upon request to--
``(i) a resident of a nursing facility;
``(ii) any person acting on the resident's behalf; and
``(iii) any person who works at a nursing facility or a
representative of such a worker.
``(B) Complaint resolution process.--The State must
establish a complaint resolution process in order to ensure
that a resident, the legal representative of a resident of a
nursing facility, or other responsible party is not
retaliated against if the resident, legal representative, or
responsible party has complained, in good faith, about the
quality of care or other issues relating to the nursing
facility, that the legal representative of a resident of a
nursing facility or other responsible party is not denied
access to such resident or otherwise retaliated against if
such representative party has complained, in good faith,
about the quality of care provided by the facility or other
issues relating to the facility, and that a person who works
at a nursing facility is not retaliated against if the worker
has complained, in good faith, about quality of care or
services or an issue relating to the quality of care or
services provided at the facility, whether the resident,
legal representative, other responsible party, or worker used
the form developed under subsection (f)(11) or some other
method for submitting the complaint. Such complaint
resolution process shall include--
``(i) procedures to assure accurate tracking of complaints
received, including notification to the complainant that a
complaint has been received;
``(ii) procedures to determine the likely severity of a
complaint and for the investigation of the complaint;
``(iii) deadlines for responding to a complaint and for
notifying the complainant of the outcome of the
investigation; and
``(iv) procedures to ensure that the identity of the
complainant will be kept confidential.
``(C) Whistleblower protection.--
``(i) Prohibition against retaliation.--No person who works
at a nursing facility may be penalized, discriminated, or
retaliated against with respect to any aspect of employment,
including discharge, promotion, compensation, terms,
conditions, or privileges of employment, or have a contract
for services terminated, because the person (or anyone acting
at the person's request) complained, in good faith, about the
quality of care or services provided by a nursing facility or
about other issues relating to quality of care or services,
whether using the form developed under subsection (f)(11) or
some other method for submitting the complaint.
``(ii) Retaliatory reporting.--A nursing facility may not
file a complaint or a report against a person who works (or
has worked at the facility with the appropriate State
professional disciplinary agency because the person (or
anyone acting at the person's request) complained in good
faith, as described in clause (i).
``(iii) Relief.--Any person aggrieved by a violation of
clause (i) or clause (ii) may, in a civil action, obtain all
appropriate relief, including reinstatement, reimbursement of
lost wages, compensation, and benefits, and exemplary damages
where warranted, and such other relief as the court deems
appropriate, as well as costs of suit and reasonable attorney
and expert witness fees.
``(iv) Rights not waivable.--The rights protected by this
paragraph may not be diminished by contract or other
agreement, and nothing in this paragraph shall be construed
to diminish any greater or additional protection provided by
Federal or State law or by contract or other agreement.
``(v) Requirement to post notice of employee rights.--Each
nursing facility shall post conspicuously in an appropriate
location a sign (in a form specified by the Secretary)
specifying the rights of persons under this paragraph and
including a statement that an employee may file a complaint
with the Secretary against a nursing facility that violates
the provisions of this paragraph and information with respect
to the manner of filing such a complaint.
``(D) Rule of construction.--Nothing in this paragraph
shall be construed as preventing a resident of a nursing
facility (or a person acting on the resident's behalf) from
submitting a complaint in a manner or format other than by
using the standardized complaint form developed under
subsection (f)(11) (including submitting a complaint orally).
``(E) Good faith defined.--For purposes of this paragraph,
an individual shall be deemed to be acting in good faith with
respect to the filing of a complaint if the individual
reasonably believes--
``(i) the information reported or disclosed in the
complaint is true; and
``(ii) the violation of this title has occurred or may
occur in relation to such information.''.
(c) Effective Date.--The amendments made by this section
shall take effect 1 year after the date of the enactment of
this Act.

SEC. 1416. ENSURING STAFFING ACCOUNTABILITY.

(a) Skilled Nursing Facilities.--Section 1819(b)(8) of the
Social Security Act (42 U.S.C. 1395i-3(b)(8)) is amended by
adding at the end the following new subparagraph:
``(C) Submission of staffing information based on payroll
data in a uniform format.--On and after the first day of the
first calendar quarter beginning after the date that is 2
years after the date of enactment of this subparagraph, and
after consulting with State long-term care ombudsman
programs, consumer advocacy groups, provider stakeholder
groups, employees and their representatives, and other
parties the Secretary deems appropriate, the Secretary shall
require a skilled nursing facility to electronically submit
to the Secretary direct care staffing information (including
information with respect to agency and contract staff) based
on payroll and other verifiable and auditable data in a
uniform format (according to specifications established by
the Secretary in consultation with such programs, groups, and
parties). Such specifications shall require that the
information submitted under the preceding sentence--
``(i) specify the category of work a certified employee
performs (such as whether the employee is a registered nurse,
licensed practical nurse, licensed vocational nurse,
certified nursing assistant, therapist, or other medical
personnel);
``(ii) include resident census data and information on
resident case mix;
``(iii) include a regular reporting schedule; and
``(iv) include information on employee turnover and tenure
and on the hours of care provided by each category of
certified employees referenced in clause (i) per resident per
day.
Nothing in this subparagraph shall be construed as preventing
the Secretary from requiring submission of such information
with respect to specific categories, such as nursing staff,
before other categories of certified employees. Information
under this subparagraph with respect to agency and contract

[[Page H12711]]

staff shall be kept separate from information on employee
staffing.''.
(b) Nursing Facilities.--Section 1919(b)(8) of the Social
Security Act (42 U.S.C. 1396r(b)(8)) is amended by adding at
the end the following new subparagraph:
``(C) Submission of staffing information based on payroll
data in a uniform format.--On and after the first day of the
first calendar quarter beginning after the date that is 2
years after the date of enactment of this subparagraph, and
after consulting with State long-term care ombudsman
programs, consumer advocacy groups, provider stakeholder
groups, employees and their representatives, and other
parties the Secretary deems appropriate, the Secretary shall
require a nursing facility to electronically submit to the
Secretary direct care staffing information (including
information with respect to agency and contract staff) based
on payroll and other verifiable and auditable data in a
uniform format (according to specifications established by
the Secretary in consultation with such programs, groups, and
parties). Such specifications shall require that the
information submitted under the preceding sentence--
``(i) specify the category of work a certified employee
performs (such as whether the employee is a registered nurse,
licensed practical nurse, licensed vocational nurse,
certified nursing assistant, therapist, or other medical
personnel);
``(ii) include resident census data and information on
resident case mix;
``(iii) include a regular reporting schedule; and
``(iv) include information on employee turnover and tenure
and on the hours of care provided by each category of
certified employees referenced in clause (i) per resident per
day.

Nothing in this subparagraph shall be construed as preventing
the Secretary from requiring submission of such information
with respect to specific categories, such as nursing staff,
before other categories of certified employees. Information
under this subparagraph with respect to agency and contract
staff shall be kept separate from information on employee
staffing.''.

SEC. 1417. NATIONWIDE PROGRAM FOR NATIONAL AND STATE
BACKGROUND CHECKS ON DIRECT PATIENT ACCESS
EMPLOYEES OF LONG-TERM CARE FACILITIES AND
PROVIDERS.

(a) In General.--The Secretary of Health and Human Services
(in this section referred to as the ``Secretary''), shall
establish a program to identify efficient, effective, and
economical procedures for long term care facilities or
providers to conduct background checks on prospective direct
patient access employees on a nationwide basis (in this
subsection, such program shall be referred to as the
``nationwide program''). The Secretary shall carry out the
nationwide program under similar terms and conditions as the
pilot program under section 307 of the Medicare Prescription
Drug, Improvement, and Modernization Act of 2003 (Public Law
108-173; 117 Stat. 2257), including the prohibition on hiring
abusive workers and the authorization of the imposition of
penalties by a participating State under subsections
(b)(3)(A) and (b)(6), respectively, of such section 307. The
program under this subsection shall contain the following
modifications to such pilot program:
(1) Agreements.--
(A) Newly participating states.--The Secretary shall enter
into agreements with each State--
(i) that the Secretary has not entered into an agreement
with under subsection (c)(1) of such section 307;
(ii) that agrees to conduct background checks under the
nationwide program on a Statewide basis; and
(iii) that submits an application to the Secretary
containing such information and at such time as the Secretary
may specify.

Under such an agreement a State may agree to cover and
reimburse each long-term care facility or provider for all
costs attributable to conducting background checks and
screening described in this subsection that were not
otherwise required to be conducted by such long-term care
facility or provider before the enactment of this subsection,
except that Federal funding with respect to such
reimbursement shall be limited to the amount made available
to the State from funds under subsection (b)(1).
(B) Certain previously participating states.--The Secretary
shall enter into agreements with each State--
(i) that the Secretary has entered into an agreement with
under such subsection (c)(1);
(ii) that agrees to conduct background checks under the
nationwide program on a Statewide basis; and
(iii) that submits an application to the Secretary
containing such information and at such time as the Secretary
may specify.

Under such an agreement a State may agree to cover and
reimburse each long-term care facility or provider for all
costs attributable to conducting background checks and
screening described in this subsection that were not
otherwise required to be conducted by such long-term care
facility or provider before the enactment of this subsection,
except that Federal funding with respect to such
reimbursement shall be limited to the amount made available
to the State from funds under subsection (b)(1).
(2) Nonapplication of selection criteria.--The selection
criteria required under subsection (c)(3)(B) of such section
307 shall not apply.
(3) Required fingerprint check as part of criminal
background check.--The procedures established under
subsection (b)(1) of such section 307 shall--
(A) require that the long-term care facility or provider
(or the designated agent of the long-term care facility or
provider) obtain State and national criminal or other
background checks on the prospective employee through such
means as the Secretary determines appropriate that utilize a
search of State-based abuse and neglect registries and
databases, including the abuse and neglect registries of
another State in the case where a prospective employee
previously resided in that State, State criminal history
records, the records of any proceedings in the State that may
contain disqualifying information about prospective employees
(such as proceedings conducted by State professional
licensing and disciplinary boards and State Medicaid Fraud
Control Units), and Federal criminal history records,
including a fingerprint check using the Integrated Automated
Fingerprint Identification System of the Federal Bureau of
Investigation; and
(B) require States to describe and test methods that reduce
duplicative fingerprinting, including providing for the
development of ``rap back'' capability by the State such
that, if a direct patient access employee of a long-term care
facility or provider is convicted of a crime following the
initial criminal history background check conducted with
respect to such employee, and the employee's fingerprints
match the prints on file with the State law enforcement
department, the department will immediately inform the State
and the State will immediately inform the long-term care
facility or provider which employs the direct patient access
employee of such conviction.
(4) State requirements.--An agreement entered into under
paragraph (1) shall require that a participating State--
(A) be responsible for monitoring compliance with the
requirements of the nationwide program;
(B) have procedures in place to--
(i) conduct screening and criminal or other background
checks under the nationwide program in accordance with the
requirements of this section;
(ii) monitor compliance by long-term care facilities and
providers with the procedures and requirements of the
nationwide program;
(iii) as appropriate, provide for a provisional period of
employment by a long-term care facility or provider of a
direct patient access employee, not to exceed 60 days,
pending completion of the required criminal history
background check and, in the case where the employee has
appealed the results of such background check, pending
completion of the appeals process, during which the employee
shall be subject to direct on-site supervision (in accordance
with procedures established by the State to ensure that a
long-term care facility or provider furnishes such direct on-
site supervision);
(iv) provide an independent process by which a provisional
employee or an employee may appeal or dispute the accuracy of
the information obtained in a background check performed
under the nationwide program, including the specification of
criteria for appeals for direct patient access employees
found to have disqualifying information which shall include
consideration of the passage of time, extenuating
circumstances, demonstration of rehabilitation, and relevancy
of the particular disqualifying information with respect to
the current employment of the individual;
(v) provide for the designation of a single State agency as
responsible for--

(I) overseeing the coordination of any State and national
criminal history background checks requested by a long-term
care facility or provider (or the designated agent of the
long-term care facility or provider) utilizing a search of
State and Federal criminal history records, including a
fingerprint check of such records;
(II) overseeing the design of appropriate privacy and
security safeguards for use in the review of the results of
any State or national criminal history background checks
conducted regarding a prospective direct patient access
employee to determine whether the employee has any conviction
for a relevant crime;
(III) immediately reporting to the long-term care facility
or provider that requested the criminal history background
check the results of such review; and
(IV) in the case of an employee with a conviction for a
relevant crime that is subject to reporting under section
1128E of the Social Security Act (42 U.S.C. 1320a-7e),
reporting the existence of such conviction to the database
established under that section;

(vi) determine which individuals are direct patient access
employees (as defined in paragraph (6)(B)) for purposes of
the nationwide program;
(vii) as appropriate, specify offenses, including
convictions for violent crimes, for purposes of the
nationwide program; and
(viii) describe and test methods that reduce duplicative
fingerprinting, including providing for the development of
``rap back'' capability such that, if a direct patient access
employee of a long-term care facility or provider is
convicted of a crime following the initial criminal history
background check conducted with respect to such employee, and
the employee's fingerprints match the prints on file with the
State law enforcement department--

[[Page H12712]]

(I) the department will immediately inform the State agency
designated under clause (v) and such agency will immediately
inform the facility or provider which employs the direct
patient access employee of such conviction; and
(II) the State will provide, or will require the facility
to provide, to the employee a copy of the results of the
criminal history background check conducted with respect to
the employee at no charge in the case where the individual
requests such a copy.

Background checks and screenings under this subsection shall
be valid for a period of no longer than 2 years, as
determined by the State and approved by the Secretary.
(5) Payments.--
(A) Newly participating states.--
(i) In general.--As part of the application submitted by a
State under paragraph (1)(A)(iii), the State shall guarantee,
with respect to the costs to be incurred by the State in
carrying out the nationwide program, that the State will make
available (directly or through donations from public or
private entities) a particular amount of non-Federal
contributions, as a condition of receiving the Federal match
under clause (ii).
(ii) Federal match.--The payment amount to each State that
the Secretary enters into an agreement with under paragraph
(1)(A) shall be 3 times the amount that the State guarantees
to make available under clause (i).
(B) Previously participating states.--
(i) In general.--As part of the application submitted by a
State under paragraph (1)(B)(iii), the State shall guarantee,
with respect to the costs to be incurred by the State in
carrying out the nationwide program, that the State will make
available (directly or through donations from public or
private entities) a particular amount of non-Federal
contributions, as a condition of receiving the Federal match
under clause (ii).
(ii) Federal match.--The payment amount to each State that
the Secretary enters into an agreement with under paragraph
(1)(B) shall be 3 times the amount that the State guarantees
to make available under clause (i).
(6) Definitions.--Under the nationwide program:
(A) Long-term care facility or provider.--The term ``long-
term care facility or provider'' means the following
facilities or providers which receive payment for services
under title XVIII or XIX of the Social Security Act:
(i) A skilled nursing facility (as defined in section
1819(a) of the Social Security Act (42 U.S.C. 1395i-3(a))).
(ii) A nursing facility (as defined in section 1919(a) of
such Act (42 U.S.C. 1396r(a))).
(iii) A home health agency.
(iv) A provider of hospice care (as defined in section
1861(dd)(1) of such Act (42 U.S.C. 1395x(dd)(1))).
(v) A long-term care hospital (as described in section
1886(d)(1)(B)(iv) of such Act (42 U.S.C.
1395ww(d)(1)(B)(iv))).
(vi) A provider of personal care services.
(vii) A provider of adult day care.
(viii) A residential care provider that arranges for, or
directly provides, long-term care services, including an
assisted living facility that provides a nursing home level
of care conveyed by State licensure or State definition.
(ix) An intermediate care facility for the mentally
retarded (as defined in section 1905(d) of such Act (42
U.S.C. 1396d(d))).
(x) Any other facility or provider of long-term care
services under such titles as the participating State
determines appropriate.
(B) Direct patient access employee.--The term ``direct
patient access employee'' means any individual who has access
to a patient or resident of a long-term care facility or
provider through employment or through a contract with such
facility or provider and has duties that involve (or may
involve) one-on-one contact with a patient or resident of the
facility or provider, as determined by the State for purposes
of the nationwide program. Such term does not include a
volunteer unless the volunteer has duties that are equivalent
to the duties of a direct patient access employee and those
duties involve (or may involve) one-on-one contact with a
patient or resident of the long-term care facility or
provider.
(7) Evaluation and report.--
(A) Evaluation.--The Inspector General of the Department of
Health and Human Services shall conduct an evaluation of the
nationwide program. Such evaluation shall include--
(i) a review of the various procedures implemented by
participating States for long-term care facilities or
providers, including staffing agencies, to conduct background
checks of direct patient access employees and identify the
most efficient, effective, and economical procedures for
conducting such background checks;
(ii) an assessment of the costs of conducting such
background checks (including start-up and administrative
costs);
(iii) a determination of the extent to which conducting
such background checks leads to any unintended consequences,
including a reduction in the available workforce for such
facilities or providers;
(iv) an assessment of the impact of the program on reducing
the number of incidents of neglect, abuse, and
misappropriation of resident property to the extent
practicable; and
(v) an evaluation of other aspects of the program, as
determined appropriate by the Secretary.
(B) Report.--Not later than 180 days after the completion
of the nationwide program, the Inspector General of the
Department of Health and Human Services shall submit a report
to Congress containing the results of the evaluation
conducted under subparagraph (A).
(b) Funding.--
(1) Notification.--The Secretary of Health and Human
Services shall notify the Secretary of the Treasury of the
amount necessary to carry out the nationwide program under
this section, including costs for the Department of Health
and Human Services to administer and evaluate the program,
for the period of fiscal years 2010 through 2012, except that
in no case shall such amount exceed $160,000,000.
(2) Transfer of funds.--Out of any funds in the Treasury
not otherwise appropriated, the Secretary of the Treasury
shall provide for the transfer to the Secretary of Health and
Human Services of the amount specified as necessary to carry
out the nationwide program under paragraph (1). Such amount
shall remain available until expended.

PART 2--TARGETING ENFORCEMENT

SEC. 1421. CIVIL MONEY PENALTIES.

(a) Skilled Nursing Facilities.--
(1) In general.--Section 1819(h)(2)(B)(ii) of the Social
Security Act (42 U.S.C. 1395i-3(h)(2)(B)(ii)) is amended to
read as follows:
``(ii) Authority with respect to civil money penalties.--

``(I) Amount.--The Secretary may impose a civil money
penalty in the applicable per instance or per day amount (as
defined in subclause (II) and (III)) for each day or
instance, respectively, of noncompliance (as determined
appropriate by the Secretary).
``(II) Applicable per instance amount.--In this clause, the
term `applicable per instance amount' means--

``(aa) in the case where the deficiency is found to be a
direct proximate cause of death of a resident of the
facility, an amount not to exceed $100,000.
``(bb) in each case of a deficiency where the facility is
cited for actual harm or immediate jeopardy, an amount not
less than $3,050 and not more than $25,000; and
``(cc) in each case of any other deficiency, an amount not
less than $250 and not to exceed $3050.

``(III) Applicable per day amount.--In this clause, the
term `applicable per day amount' means--

``(aa) in each case of a deficiency where the facility is
cited for actual harm or immediate jeopardy, an amount not
less than $3,050 and not more than $25,000 and
``(bb) in each case of any other deficiency, an amount not
less than $250 and not to exceed $3,050.

``(IV) Reduction of civil money penalties in certain
circumstances.--Subject to subclauses (V) and (VI), in the
case where a facility self-reports and promptly corrects a
deficiency for which a penalty was imposed under this clause
not later than 10 calendar days after the date of such
imposition, the Secretary may reduce the amount of the
penalty imposed by not more than 50 percent.
``(V) Prohibition on reduction for certain deficiencies.--

``(aa) Repeat deficiencies.--The Secretary may not reduce
under subclause (IV) the amount of a penalty if the
deficiency is a repeat deficiency.
``(bb) Certain other deficiencies.--The Secretary may not
reduce under subclause (IV) the amount of a penalty if the
penalty is imposed for a deficiency described in subclause
(II)(aa) or (III)(aa) and the actual harm or widespread harm
immediately jeopardizes the health or safety of a resident or
residents of the facility, or if the penalty is imposed for a
deficiency described in subclause (II)(bb).

``(VI) Limitation on aggregate reductions.--The aggregate
reduction in a penalty under subclause (IV) may not exceed 35
percent on the basis of self-reporting, on the basis of a
waiver of an appeal (as provided for under regulations under
section 488.436 of title 42, Code of Federal Regulations), or
on the basis of both.
``(VII) Collection of civil money penalties.--In the case
of a civil money penalty imposed under this clause, the
Secretary--

``(aa) subject to item (cc), shall, not later than 30 days
after the date of imposition of the penalty, provide the
opportunity for the facility to participate in an independent
informal dispute resolution process, established by the State
survey agency, which generates a written record prior to the
collection of such penalty, but such opportunity shall not
affect the responsibility of the State survey agency for
making final recommendations for such penalties;
``(bb) in the case where the penalty is imposed for each
day of noncompliance, shall not impose a penalty for any day
during the period beginning on the initial day of the
imposition of the penalty and ending on the day on which the
informal dispute resolution process under item (aa) is
completed;
``(cc) may provide for the collection of such civil money
penalty and the placement of such amounts collected in an
escrow account under the direction of the Secretary on the
earlier of the date on which the informal dispute resolution
process under item (aa) is completed or the date that is 90
days after the date of the imposition of the penalty;
``(dd) may provide that such amounts collected are kept in
such account pending the resolution of any subsequent
appeals;
``(ee) in the case where the facility successfully appeals
the penalty, may provide for

[[Page H12713]]

the return of such amounts collected (plus interest) to the
facility; and
``(ff) in the case where all such appeals are unsuccessful,
may provide that some portion of such amounts collected may
be used to support activities that benefit residents,
including assistance to support and protect residents of a
facility that closes (voluntarily or involuntarily) or is
decertified (including offsetting costs of relocating
residents to home and community-based settings or another
facility), projects that support resident and family councils
and other consumer involvement in assuring quality care in
facilities, and facility improvement initiatives approved by
the Secretary (including joint training of facility staff and
surveyors, technical assistance for facilities under quality
assurance programs, the appointment of temporary management,
and other activities approved by the Secretary).

``(VIII) Procedure.--The provisions of section 1128A (other
than subsections (a) and (b) and except to the extent that
such provisions require a hearing prior to the imposition of
a civil money penalty) shall apply to a civil money penalty
under this clause in the same manner as such provisions apply
to a penalty or proceeding under section 1128A(a).''.

(2) Conforming amendment.--The second sentence of section
1819(h)(5) of the Social Security Act (42 U.S.C. 1395i-
3(h)(5)) is amended by inserting ``(ii),''after ``(i),''.
(b) Nursing Facilities.--
(1) Penalties imposed by the state.--
(A) In general.--Section 1919(h)(2) of the Social Security
Act (42 U.S.C. 1396r(h)(2)) is amended--
(i) in subparagraph (A)(ii), by striking the first sentence
and inserting the following: ``A civil money penalty in
accordance with subparagraph (G).''; and
(ii) by adding at the end the following new subparagraph:
``(G) Civil money penalties.--
``(i) In general.--The State may impose a civil money
penalty under subparagraph (A)(ii) in the applicable per
instance or per day amount (as defined in subclause (II) and
(III)) for each day or instance, respectively, of
noncompliance (as determined appropriate by the Secretary).
``(ii) Applicable per instance amount.--In this
subparagraph, the term `applicable per instance amount'
means--

``(I) in the case where the deficiency is found to be a
direct proximate cause of death of a resident of the
facility, an amount not to exceed $100,000.
``(II) in each case of a deficiency where the facility is
cited for actual harm or immediate jeopardy, an amount not
less than $3,050 and not more than $25,000; and
``(III) in each case of any other deficiency, an amount not
less than $250 and not to exceed $3050.

``(iii) Applicable per day amount.--In this subparagraph,
the term `applicable per day amount' means--

``(I) in each case of a deficiency where the facility is
cited for actual harm or immediate jeopardy, an amount not
less than $3,050 and not more than $25,000 and
``(II) in each case of any other deficiency, an amount not
less than $250 and not to exceed $3,050.

``(iv) Reduction of civil money penalties in certain
circumstances.--Subject to clauses (v) and (vi), in the case
where a facility self-reports and promptly corrects a
deficiency for which a penalty was imposed under subparagraph
(A)(ii) not later than 10 calendar days after the date of
such imposition, the State may reduce the amount of the
penalty imposed by not more than 50 percent.
``(v) Prohibition on reduction for certain deficiencies.--

``(I) Repeat deficiencies.--The State may not reduce under
clause (iv) the amount of a penalty if the State had reduced
a penalty imposed on the facility in the preceding year under
such clause with respect to a repeat deficiency.
``(II) Certain other deficiencies.--The State may not
reduce under clause (iv) the amount of a penalty if the
penalty is imposed for a deficiency described in clause
(ii)(II) or (iii)(I) and the actual harm or widespread harm
that immediately jeopardizes the health or safety of a
resident or residents of the facility, or if the penalty is
imposed for a deficiency described in clause (ii)(I).
``(III) Limitation on aggregate reductions.--The aggregate
reduction in a penalty under clause (iv) may not exceed 35
percent on the basis of self-reporting, on the basis of a
waiver of an appeal (as provided for under regulations under
section 488.436 of title 42, Code of Federal Regulations), or
on the basis of both.

``(vi) Collection of civil money penalties.--In the case of
a civil money penalty imposed under subparagraph (A)(ii), the
State--

``(I) subject to subclause (III), shall, not later than 30
days after the date of imposition of the penalty, provide the
opportunity for the facility to participate in an independent
informal dispute resolution process, established by the State
survey agency, which generates a written record prior to the
collection of such penalty, but such opportunity shall not
affect the responsibility of the State survey agency for
making final recommendations for such penalties;
``(II) in the case where the penalty is imposed for each
day of noncompliance, shall not impose a penalty for any day
during the period beginning on the initial day of the
imposition of the penalty and ending on the day on which the
informal dispute resolution process under subclause (I) is
completed;
``(III) may provide for the collection of such civil money
penalty and the placement of such amounts collected in an
escrow account under the direction of the State on the
earlier of the date on which the informal dispute resolution
process under subclause (I) is completed or the date that is
90 days after the date of the imposition of the penalty;
``(IV) may provide that such amounts collected are kept in
such account pending the resolution of any subsequent
appeals;
``(V) in the case where the facility successfully appeals
the penalty, may provide for the return of such amounts
collected (plus interest) to the facility; and
``(VI) in the case where all such appeals are unsuccessful,
may provide that such funds collected shall be used for the
purposes described in the second sentence of subparagraph
(A)(ii).''.

(B) Conforming amendment.--The second sentence of section
1919(h)(2)(A)(ii) of the Social Security Act (42 U.S.C.
1396r(h)(2)(A)(ii)) is amended by inserting before the period
at the end the following: ``, and some portion of such funds
may be used to support activities that benefit residents,
including assistance to support and protect residents of a
facility that closes (voluntarily or involuntarily) or is
decertified (including offsetting costs of relocating
residents to home and community-based settings or another
facility), projects that support resident and family councils
and other consumer involvement in assuring quality care in
facilities, and facility improvement initiatives approved by
the Secretary (including joint training of facility staff and
surveyors, providing technical assistance to facilities under
quality assurance programs, the appointment of temporary
management, and other activities approved by the
Secretary)''.
(2) Penalties imposed by the secretary.--
(A) In general.--Section 1919(h)(3)(C)(ii) of the Social
Security Act (42 U.S.C. 1396r(h)(3)(C)) is amended to read as
follows:
``(ii) Authority with respect to civil money penalties.--

``(I) Amount.--Subject to subclause (II), the Secretary may
impose a civil money penalty in an amount not to exceed
$10,000 for each day or each instance of noncompliance (as
determined appropriate by the Secretary).
``(II) Reduction of civil money penalties in certain
circumstances.--Subject to subclause (III), in the case where
a facility self-reports and promptly corrects a deficiency
for which a penalty was imposed under this clause not later
than 10 calendar days after the date of such imposition, the
Secretary may reduce the amount of the penalty imposed by not
more than 50 percent.
``(III) Prohibition on reduction for repeat deficiencies.--
The Secretary may not reduce the amount of a penalty under
subclause (II) if the Secretary had reduced a penalty imposed
on the facility in the preceding year under such subclause
with respect to a repeat deficiency.
``(IV) Collection of civil money penalties.--In the case of
a civil money penalty imposed under this clause, the
Secretary--

``(aa) subject to item (bb), shall, not later than 30 days
after the date of imposition of the penalty, provide the
opportunity for the facility to participate in an independent
informal dispute resolution process which generates a written
record prior to the collection of such penalty;
``(bb) in the case where the penalty is imposed for each
day of noncompliance, shall not impose a penalty for any day
during the period beginning on the initial day of the
imposition of the penalty and ending on the day on which the
informal dispute resolution process under item (aa) is
completed;
``(cc) may provide for the collection of such civil money
penalty and the placement of such amounts collected in an
escrow account under the direction of the Secretary on the
earlier of the date on which the informal dispute resolution
process under item (aa) is completed or the date that is 90
days after the date of the imposition of the penalty;
``(dd) may provide that such amounts collected are kept in
such account pending the resolution of any subsequent
appeals;
``(ee) in the case where the facility successfully appeals
the penalty, may provide for the return of such amounts
collected (plus interest) to the facility; and
``(ff) in the case where all such appeals are unsuccessful,
may provide that some portion of such amounts collected may
be used to support activities that benefit residents,
including assistance to support and protect residents of a
facility that closes (voluntarily or involuntarily) or is
decertified (including offsetting costs of relocating
residents to home and community-based settings or another
facility), projects that support resident and family councils
and other consumer involvement in assuring quality care in
facilities, and facility improvement initiatives approved by
the Secretary (including joint training of facility staff and
surveyors, technical assistance for facilities under quality
assurance programs, the appointment of temporary management,
and other activities approved by the Secretary).

``(V) Procedure.--The provisions of section 1128A (other
than subsections (a) and (b) and except to the extent that
such provisions require a hearing prior to the imposition of
a civil money penalty) shall apply to a civil money penalty
under this clause in the same

[[Page H12714]]

manner as such provisions apply to a penalty or proceeding
under section 1128A(a).''.

(B) Conforming amendment.--Section 1919(h)(8) of the Social
Security Act (42 U.S.C. 1396r(h)(5)(8)) is amended by
inserting ``and in paragraph (3)(C)(ii)'' after ``paragraph
(2)(A)''.
(c) Effective Date.--The amendments made by this section
shall take effect 1 year after the date of the enactment of
this Act.

SEC. 1422. NATIONAL INDEPENDENT MONITOR PILOT PROGRAM.

(a) Establishment.--
(1) In general.--The Secretary, in consultation with the
Inspector General of the Department of Health and Human
Services, shall establish a pilot program (in this section
referred to as the ``pilot program'') to develop, test, and
implement use of an independent monitor to oversee interstate
and large intrastate chains of skilled nursing facilities and
nursing facilities.
(2) Selection.--The Secretary shall select chains of
skilled nursing facilities and nursing facilities described
in paragraph (1) to participate in the pilot program from
among those chains that submit an application to the
Secretary at such time, in such manner, and containing such
information as the Secretary may require.
(3) Duration.--The Secretary shall conduct the pilot
program for a two-year period.
(4) Implementation.--The Secretary shall implement the
pilot program not later than one year after the date of the
enactment of this Act.
(b) Requirements.--The Secretary shall evaluate chains
selected to participate in the pilot program based on
criteria selected by the Secretary, including where evidence
suggests that one or more facilities of the chain are
experiencing serious safety and quality of care problems.
Such criteria may include the evaluation of a chain that
includes one or more facilities participating in the
``Special Focus Facility'' program (or a successor program)
or one or more facilities with a record of repeated serious
safety and quality of care deficiencies.
(c) Responsibilities of the Independent Monitor.--An
independent monitor that enters into a contract with the
Secretary to participate in the conduct of such program
shall--
(1) conduct periodic reviews and prepare root-cause quality
and deficiency analyses of a chain to assess if facilities of
the chain are in compliance with State and Federal laws and
regulations applicable to the facilities;
(2) undertake sustained oversight of the chain, whether
publicly or privately held, to involve the owners of the
chain and the principal business partners of such owners in
facilitating compliance by facilities of the chain with State
and Federal laws and regulations applicable to the
facilities;
(3) analyze the management structure, distribution of
expenditures, and nurse staffing levels of facilities of the
chain in relation to resident census, staff turnover rates,
and tenure;
(4) report findings and recommendations with respect to
such reviews, analyses, and oversight to the chain and
facilities of the chain, to the Secretary and to relevant
States; and
(5) publish the results of such reviews, analyses, and
oversight.
(d) Implementation of Recommendations.--
(1) Receipt of finding by chain.--Not later than 10 days
after receipt of a finding of an independent monitor under
subsection (c)(4), a chain participating in the pilot program
shall submit to the independent monitor a report--
(A) outlining corrective actions the chain will take to
implement the recommendations in such report; or
(B) indicating that the chain will not implement such
recommendations and why it will not do so.
(2) Receipt of report by independent monitor.--Not later
than 10 days after the date of receipt of a report submitted
by a chain under paragraph (1), an independent monitor shall
finalize its recommendations and submit a report to the chain
and facilities of the chain, the Secretary, and the State (or
States) involved, as appropriate, containing such final
recommendations.
(e) Cost of Appointment.--A chain shall be responsible for
a portion of the costs associated with the appointment of
independent monitors under the pilot program. The chain shall
pay such portion to the Secretary (in an amount and in
accordance with procedures established by the Secretary).
(f) Waiver Authority.--The Secretary may waive such
requirements of titles XVIII and XIX of the Social Security
Act (42 U.S.C. 1395 et seq.; 1396 et seq.) as may be
necessary for the purpose of carrying out the pilot program.
(g) Authorization of Appropriations.--There are authorized
to be appropriated such sums as may be necessary to carry out
this section.
(h) Definitions.--In this section:
(1) Facility.--The term ``facility'' means a skilled
nursing facility or a nursing facility.
(2) Nursing facility.--The term ``nursing facility'' has
the meaning given such term in section 1919(a) of the Social
Security Act (42 U.S.C. 1396r(a)).
(3) Secretary.--The term ``Secretary'' means the Secretary
of Health and Human Services, acting through the Assistant
Secretary for Planning and Evaluation.
(4) Skilled nursing facility.--The term ``skilled nursing
facility'' has the meaning given such term in section 1819(a)
of the Social Security Act (42 U.S.C. 1395(a)).
(i) Evaluation and Report.--
(1) Evaluation.--The Inspector General of the Department of
Health and Human Services shall evaluate the pilot program.
Such evaluation shall--
(A) determine whether the independent monitor program
should be established on a permanent basis; and
(B) if the Inspector General determines that the
independent monitor program should be established on a
permanent basis, recommend appropriate procedures and
mechanisms for such establishment.
(2) Report.--Not later than 180 days after the completion
of the pilot program, the Inspector General shall submit to
Congress and the Secretary a report containing the results of
the evaluation conducted under paragraph (1), together with
recommendations for such legislation and administrative
action as the Inspector General determines appropriate.

SEC. 1423. NOTIFICATION OF FACILITY CLOSURE.

(a) Skilled Nursing Facilities.--
(1) In general.--Section 1819(c) of the Social Security Act
(42 U.S.C. 1395i-3(c)) is amended by adding at the end the
following new paragraph:
``(7) Notification of facility closure.--
``(A) In general.--Any individual who is the administrator
of a skilled nursing facility must--
``(i) submit to the Secretary, the State long-term care
ombudsman, residents of the facility, and the legal
representatives of such residents or other responsible
parties, written notification of an impending closure--

``(I) subject to subclause (II), not later than the date
that is 60 days prior to the date of such closure; and
``(II) in the case of a facility where the Secretary
terminates the facility's participation under this title, not
later than the date that the Secretary determines
appropriate;

``(ii) ensure that the facility does not admit any new
residents on or after the date on which such written
notification is submitted; and
``(iii) include in the notice a plan for the transfer and
adequate relocation of the residents of the facility by a
specified date prior to closure that has been approved by the
State, including assurances that the residents will be
transferred to the most appropriate facility or other setting
in terms of quality, services, and location, taking into
consideration the needs and best interests of each resident.
``(B) Relocation.--
``(i) In general.--The State shall ensure that, before a
facility closes, all residents of the facility have been
successfully relocated to another facility or an alternative
home and community-based setting.
``(ii) Continuation of payments until residents
relocated.--The Secretary may, as the Secretary determines
appropriate, continue to make payments under this title with
respect to residents of a facility that has submitted a
notification under subparagraph (A) during the period
beginning on the date such notification is submitted and
ending on the date on which the resident is successfully
relocated.''.
(2) Conforming amendments.--Section 1819(h)(4) of the
Social Security Act (42 U.S.C. 1395i-3(h)(4)) is amended--
(A) in the first sentence, by striking ``the Secretary
shall terminate'' and inserting ``the Secretary, subject to
subsection (c)(7), shall terminate''; and
(B) in the second sentence, by striking ``subsection
(c)(2)'' and inserting ``paragraphs (2) and (7) of subsection
(c)''.
(b) Nursing Facilities.--
(1) In general.--Section 1919(c) of the Social Security Act
(42 U.S.C. 1396r(c)) is amended by adding at the end the
following new paragraph:
``(9) Notification of facility closure.--
``(A) In general.--Any individual who is an administrator
of a nursing facility must--
``(i) submit to the Secretary, the State long-term care
ombudsman, residents of the facility, and the legal
representatives of such residents or other responsible
parties, written notification of an impending closure--

``(I) subject to subclause (II), not later than the date
that is 60 days prior to the date of such closure; and
``(II) in the case of a facility where the Secretary
terminates the facility's participation under this title, not
later than the date that the Secretary determines
appropriate;

``(ii) ensure that the facility does not admit any new
residents on or after the date on which such written
notification is submitted; and
``(iii) include in the notice a plan for the transfer and
adequate relocation of the residents of the facility by a
specified date prior to closure that has been approved by the
State, including assurances that the residents will be
transferred to the most appropriate facility or other setting
in terms of quality, services, and location, taking into
consideration the needs and best interests of each resident.
``(B) Relocation.--
``(i) In general.--The State shall ensure that, before a
facility closes, all residents of the facility have been
successfully relocated to another facility or an alternative
home and community-based setting.
``(ii) Continuation of payments until residents
relocated.--The Secretary may, as the Secretary determines
appropriate, continue to make payments under this title with
respect to residents of a facility that

[[Page H12715]]

has submitted a notification under subparagraph (A) during
the period beginning on the date such notification is
submitted and ending on the date on which the resident is
successfully relocated.''.
(c) Effective Date.--The amendments made by this section
shall take effect 1 year after the date of the enactment of
this Act.

PART 3--IMPROVING STAFF TRAINING

SEC. 1431. DEMENTIA AND ABUSE PREVENTION TRAINING.

(a) Skilled Nursing Facilities.--Section
1819(f)(2)(A)(i)(I) of the Social Security Act (42 U.S.C.
1395i-3(f)(2)(A)(i)(I)) is amended by inserting ``(including,
in the case of initial training and, if the Secretary
determines appropriate, in the case of ongoing training,
dementia management training and resident abuse prevention
training)'' after ``curriculum''.
(b) Nursing Facilities.--Section 1919(f)(2)(A)(i)(I) of the
Social Security Act (42 U.S.C. 1396r(f)(2)(A)(i)(I)) is
amended by inserting ``(including, in the case of initial
training and, if the Secretary determines appropriate, in the
case of ongoing training, dementia management training and
resident abuse prevention training)'' after ``curriculum''.
(c) Effective Date.--The amendments made by this section
shall take effect 1 year after the date of the enactment of
this Act.

SEC. 1432. STUDY AND REPORT ON TRAINING REQUIRED FOR
CERTIFIED NURSE AIDES AND SUPERVISORY STAFF.

(a) Study.--
(1) In general.--The Secretary shall conduct a study on the
content of training for certified nurse aides and supervisory
staff of skilled nursing facilities and nursing facilities.
The study shall include an analysis of the following:
(A) Whether the number of initial training hours for
certified nurse aides required under sections
1819(f)(2)(A)(i)(II) and 1919(f)(2)(A)(i)(II) of the Social
Security Act (42 U.S.C. 1395i-3(f)(2)(A)(i)(II);
1396r(f)(2)(A)(i)(II)) should be increased from 75 and, if
so, what the required number of initial training hours should
be, including any recommendations for the content of such
training (including training related to dementia).
(B) Whether requirements for ongoing training under such
sections 1819(f)(2)(A)(i)(II) and 1919(f)(2)(A)(i)(II) should
be increased from 12 hours per year, including any
recommendations for the content of such training.
(2) Consultation.--In conducting the analysis under
paragraph (1)(A), the Secretary shall consult with States
that, as of the date of the enactment of this Act, require
more than 75 hours of training for certified nurse aides.
(3) Definitions.--In this section:
(A) Nursing facility.--The term ``nursing facility'' has
the meaning given such term in section 1919(a) of the Social
Security Act (42 U.S.C. 1396r(a)).
(B) Secretary.--The term ``Secretary'' means the Secretary
of Health and Human Services, acting through the Assistant
Secretary for Planning and Evaluation.
(C) Skilled nursing facility.--The term ``skilled nursing
facility'' has the meaning given such term in section 1819(a)
of the Social Security Act (42 U.S.C. 1395(a)).
(b) Report.--Not later than 2 years after the date of the
enactment of this Act, the Secretary shall submit to Congress
a report containing the results of the study conducted under
subsection (a), together with recommendations for such
legislation and administrative action as the Secretary
determines appropriate.

SEC. 1433. QUALIFICATION OF DIRECTOR OF FOOD SERVICES OF A
SKILLED NURSING FACILITY OR NURSING FACILITY.

(a) Medicare.--Section 1819(b)(4)(A) of the Social Security
Act (42 U.S.C. 1395i-3(b)(4)(A)) is amended by adding at the
end the following: ``With respect to meeting the staffing
requirement imposed by the Secretary to carry out clause
(iv), the full-time director of food services of the
facility, if not a qualified dietitian (as defined in section
483.35(a)(2) of title 42, Code of Federal Regulations, as in
effect as of the date of the enactment of this sentence),
shall be a Certified Dietary Manager meeting the requirements
of the Certifying Board for Dietary Managers, or a Dietetic
Technician, Registered meeting the requirements of the
Commission on Dietetic Registration or have equivalent
military, academic, or other qualifications (as specified by
the Secretary).''.
(b) Medicaid.--Section 1919(b)(4)(A) of the Social Security
Act (42 U.S.C. 1396r(b)(4)(A)) is amended by adding at the
end the following: ``With respect to meeting the staffing
requirement imposed by the Secretary to carry out clause
(iv), the full-time director of food services of the
facility, if not a qualified dietitian (as defined in section
483.35(a)(2) of title 42, Code of Federal Regulations, as in
effect as of the date of the enactment of this sentence),
shall be a Certified Dietary Manager meeting the requirements
of the Certifying Board for Dietary Managers, or a Dietetic
Technician, Registered meeting the requirements of the
Commission on Dietetic Registration or have equivalent
military, academic, or other qualifications (as specified by
the Secretary).''.
(c) Effective Date.--The amendments made by this section
shall take effect on the date that is 180 days after the date
of enactment of this Act.

Subtitle C--Quality Measurements

SEC. 1441. ESTABLISHMENT OF NATIONAL PRIORITIES FOR QUALITY
IMPROVEMENT.

Title XI of the Social Security Act, as amended by section
1401(a), is further amended by adding at the end the
following new part:

``Part E--Quality Improvement

``establishment of national priorities for performance improvement

``Sec. 1191.  (a) Establishment of National Priorities by
the Secretary.--The Secretary shall establish and
periodically update, not less frequently than triennially,
national priorities for performance improvement.
``(b) Recommendations for National Priorities.--In
establishing and updating national priorities under
subsection (a), the Secretary shall solicit and consider
recommendations from multiple outside stakeholders.
``(c) Considerations in Setting National Priorities.--With
respect to such priorities, the Secretary shall ensure that
priority is given to areas in the delivery of health care
services in the United States that--
``(1) contribute to a large burden of disease, including
those that address the health care provided to patients with
prevalent, high-cost chronic diseases;
``(2) have the greatest potential to decrease morbidity and
mortality in this country, including those that are designed
to eliminate harm to patients;
``(3) have the greatest potential for improving the
performance, affordability, and patient-centeredness of
health care, including those due to variations in care;
``(4) address health disparities across groups and areas;
and
``(5) have the potential for rapid improvement due to
existing evidence, standards of care or other reasons.
``(d) Definitions.--In this part:
``(1) Consensus-based entity.--The term `consensus-based
entity' means an entity with a contract with the Secretary
under section 1890.
``(2) Quality measure.--The term `quality measure' means a
national consensus standard for measuring the performance and
improvement of population health, or of institutional
providers of services, physicians, and other health care
practitioners in the delivery of health care services.
``(e) Funding.--
``(1) In general.--The Secretary shall provide for the
transfer, from the Federal Hospital Insurance Trust Fund
under section 1817 and the Federal Supplementary Medical
Insurance Trust Fund under section 1841 (in such proportion
as the Secretary determines appropriate), of $2,000,000, for
the activities under this section for each of the fiscal
years 2010 through 2014.
``(2) Authorization of appropriations.--For purposes of
carrying out the provisions of this section, in addition to
funds otherwise available, out of any funds in the Treasury
not otherwise appropriated, there are appropriated to the
Secretary of Health and Human Services $2,000,000 for each of
the fiscal years 2010 through 2014.''.

SEC. 1442. DEVELOPMENT OF NEW QUALITY MEASURES; GAO
EVALUATION OF DATA COLLECTION PROCESS FOR
QUALITY MEASUREMENT.

Part E of title XI of the Social Security Act, as added by
section 1441, is amended by adding at the end the following
new sections:

``SEC. 1192. DEVELOPMENT OF NEW QUALITY MEASURES.

``(a) Agreements With Qualified Entities.--
``(1) In general.--The Secretary shall enter into
agreements with qualified entities to develop quality
measures for the delivery of health care services in the
United States.
``(2) Form of agreements.--The Secretary may carry out
paragraph (1) by contract, grant, or otherwise.
``(3) Recommendations of consensus-based entity.--In
carrying out this section, the Secretary shall--
``(A) seek public input; and
``(B) take into consideration recommendations of the
consensus-based entity with a contract with the Secretary
under section 1890(a).
``(b) Determination of Areas Where Quality Measures Are
Required.--Consistent with the national priorities
established under this part and with the programs
administered by the Centers for Medicare & Medicaid Services
and in consultation with other relevant Federal agencies, the
Secretary shall determine areas in which quality measures for
assessing health care services in the United States are
needed.
``(c) Development of Quality Measures.--
``(1) Patient-centered and population-based measures.--In
entering into agreements under subsection (a), the Secretary
shall give priority to the development of quality measures
that allow the assessment of--
``(A) health outcomes, presence of impairment, and
functional status of patients;
``(B) the continuity and coordination of care and care
transitions for patients across providers and health care
settings, including end of life care;
``(C) patient experience and patient engagement;
``(D) the safety, effectiveness, and timeliness of care;

[[Page H12716]]

``(E) health disparities including those associated with
individual race, ethnicity, age, gender, place of residence
or language; and
``(F) the efficiency and resource use in the provision of
care.
``(2) Use of funds.--An entity that enters into an
agreement under subsection (a) shall develop quality measures
that--
``(A) to the extent feasible, have the ability to be
collected through the use of health information technologies
supporting better delivery of health care services; and
``(B) are available free of charge to users for the use of
such measures.
``(3) Availability of measures.--The Secretary shall make
quality measures developed under this section available to
the public.
``(4) Testing of proposed measures.--The Secretary may use
amounts made available under subsection (f) to fund the
testing of proposed quality measures by qualified entities.
Testing funded under this paragraph shall include testing of
the feasibility and usability of proposed measures.
``(5) Updating of endorsed measures.--The Secretary may use
amounts made available under subsection (f) to fund the
updating (and testing, if applicable) by consensus-based
entities of quality measures that have been previously
endorsed by such an entity as new evidence is developed, in a
manner consistent with section 1890(b)(3).
``(d) Qualified Entities.--Before entering into agreements
with a qualified entity, the Secretary shall ensure that the
entity is a public, private, or academic institution with
technical expertise in the area of health quality
measurement.
``(e) Application for Grant.--A grant may be made under
this section only if an application for the grant is
submitted to the Secretary and the application is in such
form, is made in such manner, and contains such agreements,
assurances, and information as the Secretary determines to be
necessary to carry out this section.
``(f) Funding.--
``(1) In general.--The Secretary shall provide for the
transfer, from the Federal Hospital Insurance Trust Fund
under section 1817 and the Federal Supplementary Medical
Insurance Trust Fund under section 1841 (in such proportion
as the Secretary determines appropriate), of $25,000,000, to
the Secretary for purposes of carrying out this section for
each of the fiscal years 2010 through 2014.
``(2) Authorization of appropriations.--For purposes of
carrying out the provisions of this section, in addition to
funds otherwise available, out of any funds in the Treasury
not otherwise appropriated, there are appropriated to the
Secretary of Health and Human Services $25,000,000 for each
of the fiscal years 2010 through 2014.

``SEC. 1193. GAO EVALUATION OF DATA COLLECTION PROCESS FOR
QUALITY MEASUREMENT.

``(a) GAO Evaluations.--The Comptroller General of the
United States shall conduct periodic evaluations of the
implementation of the data collection processes for quality
measures used by the Secretary.
``(b) Considerations.--In carrying out the evaluation under
subsection (a), the Comptroller General shall determine--
``(1) whether the system for the collection of data for
quality measures provides for validation of data as relevant
and scientifically credible;
``(2) whether data collection efforts under the system use
the most efficient and cost-effective means in a manner that
minimizes administrative burden on persons required to
collect data and that adequately protects the privacy of
patients' personal health information and provides data
security;
``(3) whether standards under the system provide for an
appropriate opportunity for physicians and other clinicians
and institutional providers of services to review and correct
findings; and
``(4) the extent to which quality measures are consistent
with section 1192(c)(1) or result in direct or indirect costs
to users of such measures.
``(c) Report.--The Comptroller General shall submit reports
to Congress and to the Secretary containing a description of
the findings and conclusions of the results of each such
evaluation.''.

SEC. 1443. MULTI-STAKEHOLDER PRE-RULEMAKING INPUT INTO
SELECTION OF QUALITY MEASURES.

Section 1808 of the Social Security Act (42 U.S.C. 1395b-9)
is amended by adding at the end the following new subsection:
``(d) Multi-stakeholder Pre-rulemaking Input Into Selection
of Quality Measures.--
``(1) List of measures.--Not later than December 1 before
each year (beginning with 2011), the Secretary shall make
public a list of measures being considered for selection for
quality measurement by the Secretary in rulemaking with
respect to payment systems under this title beginning in the
payment year beginning in such year and for payment systems
beginning in the calendar year following such year, as the
case may be.
``(2) Consultation on selection of endorsed quality
measures.--A consensus-based entity that has entered into a
contract under section 1890 shall, as part of such contract,
convene multi-stakeholder groups to provide recommendations
on the selection of individual or composite quality measures,
for use in reporting performance information to the public or
for use in public health care programs.
``(3) Multi-stakeholder input.--Not later than February 1
of each year (beginning with 2011), the consensus-based
entity described in paragraph (2) shall transmit to the
Secretary the recommendations of multi-stakeholder groups
provided under paragraph (2). Such recommendations shall be
included in the transmissions the consensus-based entity
makes to the Secretary under the contract provided for under
section 1890.
``(4) Requirement for transparency in process.--
``(A) In general.--In convening multi-stakeholder groups
under paragraph (2) with respect to the selection of quality
measures, the consensus-based entity described in such
paragraph shall provide for an open and transparent process
for the activities conducted pursuant to such convening.
``(B) Selection of organizations participating in multi-
stakeholder groups.--The process under paragraph (2) shall
ensure that the selection of representatives of multi-
stakeholder groups includes provision for public nominations
for, and the opportunity for public comment on, such
selection.
``(5) Use of input.--The respective proposed rule shall
contain a summary of the recommendations made by the multi-
stakeholder groups under paragraph (2), as well as other
comments received regarding the proposed measures, and the
extent to which such proposed rule follows such
recommendations and the rationale for not following such
recommendations.
``(6) Multi-stakeholder groups.--For purposes of this
subsection, the term `multi-stakeholder groups' means, with
respect to a quality measure, a voluntary collaborative of
organizations representing persons interested in or affected
by the use of such quality measure, such as the following:
``(A) Hospitals and other institutional providers.
``(B) Physicians.
``(C) Health care quality alliances.
``(D) Nurses and other health care practitioners.
``(E) Health plans.
``(F) Patient advocates and consumer groups.
``(G) Employers.
``(H) Public and private purchasers of health care items
and services.
``(I) Labor organizations.
``(J) Relevant departments or agencies of the United
States.
``(K) Biopharmaceutical companies and manufacturers of
medical devices.
``(L) Licensing, credentialing, and accrediting bodies.
``(7) Funding.--
``(A) In general.--The Secretary shall provide for the
transfer, from the Federal Hospital Insurance Trust Fund
under section 1817 and the Federal Supplementary Medical
Insurance Trust Fund under section 1841 (in such proportion
as the Secretary determines appropriate), of $1,000,000, to
the Secretary for purposes of carrying out this subsection
for each of the fiscal years 2010 through 2014.
``(B) Authorization of appropriations.--For purposes of
carrying out the provisions of this subsection, in addition
to funds otherwise available, out of any funds in the
Treasury not otherwise appropriated, there are appropriated
to the Secretary of Health and Human Services $1,000,000 for
each of the fiscal years 2010 through 2014.''.

SEC. 1444. APPLICATION OF QUALITY MEASURES.

(a) Inpatient Hospital Services.--Section 1886(b)(3)(B) of
such Act (42 U.S.C. 1395ww(b)(3)(B)) is amended by adding at
the end the following new clause:
``(x)(I) Subject to subclause (II), for purposes of
reporting data on quality measures for inpatient hospital
services furnished during fiscal year 2012 and each
subsequent fiscal year, the quality measures specified under
clause (viii) shall be measures selected by the Secretary
from measures that have been endorsed by the entity with a
contract with the Secretary under section 1890(a).
``(II) In the case of a specified area or medical topic
determined appropriate by the Secretary for which a feasible
and practical quality measure has not been endorsed by the
entity with a contract under section 1890(a), the Secretary
may specify a measure that is not so endorsed as long as due
consideration is given to measures that have been endorsed or
adopted by a consensus organization identified by the
Secretary. The Secretary shall submit such a non-endorsed
measure to the entity for consideration for endorsement. If
the entity considers but does not endorse such a measure and
if the Secretary does not phase-out use of such measure, the
Secretary shall include the rationale for continued use of
such a measure in rulemaking.''.
(b) Outpatient Hospital Services.--Section 1833(t)(17) of
such Act (42 U.S.C. 1395l(t)(17)) is amended by adding at the
end the following new subparagraph:
``(F) Use of endorsed quality measures.--The provisions of
clause (x) of section 1886(b)(3)(C) shall apply to quality
measures for covered OPD services under this paragraph in the
same manner as such provisions apply to quality measures for
inpatient hospital services.''.
(c) Physicians' Services.--Section 1848(k)(2)(C)(ii) of
such Act (42 U.S.C. 1395w-4(k)(2)(C)(ii)) is amended by
adding at the end the following: ``The Secretary shall submit
such a non-endorsed measure to the entity for consideration
for endorsement. If the entity considers but does not endorse
such a measure and if the Secretary does not phase-out use of
such measure, the Secretary shall include the rationale for
continued use of such a measure in rulemaking.''.

[[Page H12717]]

(d) Renal Dialysis Services.--Section 1881(h)(2)(B)(ii) of
such Act (42 U.S.C. 1395rr(h)(2)(B)(ii)) is amended by adding
at the end the following: ``The Secretary shall submit such a
non-endorsed measure to the entity for consideration for
endorsement. If the entity considers but does not endorse
such a measure and if the Secretary does not phase-out use of
such measure, the Secretary shall include the rationale for
continued use of such a measure in rulemaking.''.
(e) Endorsement of Standards.--Section 1890(b)(2) of the
Social Security Act (42 U.S.C. 1395aaa(b)(2)) is amended by
adding after and below subparagraph (B) the following:
``If the entity does not endorse a measure, such entity shall
explain the reasons and provide suggestions about changes to
such measure that might make it a potentially endorsable
measure.''.
(f) Effective Date.--Except as otherwise provided, the
amendments made by this section shall apply to quality
measures applied for payment years beginning with 2012 or
fiscal year 2012, as the case may be.

SEC. 1445. CONSENSUS-BASED ENTITY FUNDING.

Section 1890(d) of the Social Security Act (42 U.S.C.
1395aaa(d)) is amended by striking ``for each of fiscal years
2009 through 2012'' and inserting ``for fiscal year 2009, and
$12,000,000 for each of the fiscal years 2010 through 2012''.

SEC. 1446. QUALITY INDICATORS FOR CARE OF PEOPLE WITH
ALZHEIMER'S DISEASE.

(a) Quality Indicators.--The Secretary of Health and Human
Services shall develop quality indicators for the provision
of medical services to people with Alzheimer's disease and
other dementias and a plan for implementing the indicators to
measure the quality of care provided for people with these
conditions by physicians, hospitals, and other appropriate
providers of services and suppliers.
(b) Report.--The Secretary shall submit a report to the
Committees on Energy and Commerce and Ways and Means of the
United States House of Representatives and to the Committees
on Finance and Health, Education, Labor, and Pensions of the
United States Senate not later than 24 months after the date
of the enactment of this Act setting forth the status of
their efforts to implement the requirements of subsection
(a).

Subtitle D--Physician Payments Sunshine Provision

SEC. 1451. REPORTS ON FINANCIAL RELATIONSHIPS BETWEEN
MANUFACTURERS AND DISTRIBUTORS OF COVERED
DRUGS, DEVICES, BIOLOGICALS, OR MEDICAL
SUPPLIES UNDER MEDICARE, MEDICAID, OR CHIP AND
PHYSICIANS AND OTHER HEALTH CARE ENTITIES AND
BETWEEN PHYSICIANS AND OTHER HEALTH CARE
ENTITIES.

(a) In General.--Part A of title XI of the Social Security
Act (42 U.S.C. 1301 et seq.), as amended by section 1631(a),
is further amended by inserting after section 1128G the
following new section:

``SEC. 1128H. FINANCIAL REPORTS ON PHYSICIANS' FINANCIAL
RELATIONSHIPS WITH MANUFACTURERS AND
DISTRIBUTORS OF COVERED DRUGS, DEVICES,
BIOLOGICALS, OR MEDICAL SUPPLIES UNDER
MEDICARE, MEDICAID, OR CHIP AND WITH ENTITIES
THAT BILL FOR SERVICES UNDER MEDICARE.

``(a) Reporting of Payments or Other Transfers of Value.--
``(1) In general.--Except as provided in this subsection,
not later than March 31, 2011, and annually thereafter, each
applicable manufacturer or distributor that provides a
payment or other transfer of value to a covered recipient, or
to an entity or individual at the request of or designated on
behalf of a covered recipient, shall submit to the Secretary,
in such electronic form as the Secretary shall require, the
following information with respect to the preceding calendar
year:
``(A) With respect to the covered recipient, the
recipient's name, business address, physician specialty, and
national provider identifier.
``(B) With respect to the payment or other transfer of
value, other than a drug sample--
``(i) its value and date;
``(ii) the name of the related drug, device, or supply, if
available, to the level of specificity available; and
``(iii) a description of its form, indicated (as
appropriate for all that apply) as--

``(I) cash or a cash equivalent;
``(II) in-kind items or services;
``(III) stock, a stock option, or any other ownership
interest, dividend, profit, or other return on investment; or
``(IV) any other form (as defined by the Secretary).

``(C) With respect to a drug sample, the name, number,
date, and dosage units of the sample.
``(2) Aggregate reporting.--Information submitted by an
applicable manufacturer or distributor under paragraph (1)
shall include the aggregate amount of all payments or other
transfers of value provided by the manufacturer or
distributor to covered recipients (and to entities or
individuals at the request of or designated on behalf of a
covered recipient) during the year involved, including all
payments and transfers of value regardless of whether such
payments or transfer of value were individually disclosed.
``(3) Special rule for certain payments or other transfers
of value.--In the case where an applicable manufacturer or
distributor provides a payment or other transfer of value to
an entity or individual at the request of or designated on
behalf of a covered recipient, the manufacturer or
distributor shall disclose that payment or other transfer of
value under the name of the covered recipient.
``(4) Delayed reporting for payments made pursuant to
product development agreements.--In the case of a payment or
other transfer of value made to a covered recipient by an
applicable manufacturer or distributor pursuant to a product
development agreement for services furnished in connection
with the development of a new drug, device, biological, or
medical supply, the applicable manufacturer or distributor
may report the value and recipient of such payment or other
transfer of value in the first reporting period under this
subsection in the next reporting deadline after the earlier
of the following:
``(A) The date of the approval or clearance of the covered
drug, device, biological, or medical supply by the Food and
Drug Administration.
``(B) Two calendar years after the date such payment or
other transfer of value was made.
``(5) Delayed reporting for payments made pursuant to
clinical investigations.--In the case of a payment or other
transfer of value made to a covered recipient by an
applicable manufacturer or distributor in connection with a
clinical investigation regarding a new drug, device,
biological, or medical supply, the applicable manufacturer or
distributor may report as required under this section in the
next reporting period under this subsection after the earlier
of the following:
``(A) The date that the clinical investigation is
registered on the website maintained by the National
Institutes of Health pursuant to section 671 of the Food and
Drug Administration Amendments Act of 2007.
``(B) Two calendar years after the date such payment or
other transfer of value was made.
``(6) Confidentiality.--Information described in paragraph
(4) or (5) shall be considered confidential and shall not be
subject to disclosure under section 552 of title 5, United
States Code, or any other similar Federal, State, or local
law, until or after the date on which the information is made
available to the public under such paragraph.
``(7) Physicians in self-insured health plans.--Nothing in
this subsection shall be construed to require the disclosure
of a payment or other transfer of value to a physician by a
self-insured health plan.
``(b) Reporting of Ownership Interest by Physicians.--
``(1) Hospitals and other entities that bill medicare.--Not
later than March 31 of each year (beginning with 2011), each
hospital or other health care entity (not including a
Medicare Advantage organization) that bills the Secretary
under part A or part B of title XVIII for services shall
report on the ownership shares (other than ownership shares
described in section 1877(c)) of each physician who, directly
or indirectly, owns an interest in the entity.
``(2) Additional physician ownership.--Not later than March
31 of each year (beginning with 2011), in addition to the
requirement under subsection (a)(1), any applicable
manufacturer, applicable group purchasing organization, or
applicable distributor shall submit to the Secretary, in such
electronic form as the Secretary shall require, the following
information regarding any ownership or investment interest
(other than an ownership or investment interest in a publicly
traded security and mutual fund, as described in section
1877(c)) held by a physician (or an immediate family member
of such physician (as defined for purposes of section
1877(a))) in the applicable manufacturer, applicable group
purchasing organization or applicable distributor during the
preceding year:
``(A) The dollar amount invested by each physician holding
such an ownership or investment interest.
``(B) The value and terms of each such ownership or
investment interest.
``(C) Any payment or other transfer of value provided to a
physician holding such an ownership or investment interest
(or to an entity or individual at the request of or
designated on behalf of a physician holding such an ownership
or investment interest), including the information described
in clauses (i) through (iii) of paragraph (a)(1)(B), and
information described in subsection (f)(8)(A) and (f)(8)(B).
``(D) Any other information regarding the ownership or
investment interest the Secretary determines appropriate.
``(3) Definitions.--In this subsection:
``(A) Physician.--The term `physician' includes a
physician's immediate family members (as defined for purposes
of section 1877(a)).
``(B) Applicable group purchasing organization.--The term
`applicable group purchasing organization' means any
organization or other entity (as defined by the Secretary)
that purchases, arranges for, or negotiates the purchase of a
covered drug, device, biological, or medical supply.
``(4) Study of practice patterns in advanced diagnostic
imaging and radiation oncology services.--The Comptroller
General of the United States shall conduct a study to
evaluate the extent of use of physician self-referral
arrangements and the effects of such arrangements on the cost
of

[[Page H12718]]

providing advanced diagnostic imaging and radiation oncology
services to Medicare beneficiaries under title XVIII. The
study shall be completed and submitted to Congress not later
than July 1, 2011.
``(c) Public Availability.--
``(1) In general.--The Secretary shall establish procedures
to ensure that, not later than September 30, 2011, and on
June 30 of each year beginning thereafter, the information
submitted under subsections (a) and (b), other than
information regard drug samples, with respect to the
preceding calendar year is made available through an Internet
website that--
``(A) is searchable and is in a format that is clear and
understandable;
``(B) contains information that is presented by the name of
the applicable manufacturer or distributor, the name of the
covered recipient, the business address of the covered
recipient, the specialty (if applicable) of the covered
recipient, the value of the payment or other transfer of
value, the date on which the payment or other transfer of
value was provided to the covered recipient, the form of the
payment or other transfer of value, indicated (as
appropriate) under subsection (a)(1)(B)(ii), the nature of
the payment or other transfer of value, indicated (as
appropriate) under subsection (a)(1)(B)(iii), and the name of
the covered drug, device, biological, or medical supply, as
applicable;
``(C) contains information that is able to be easily
aggregated and downloaded;
``(D) contains a description of any enforcement actions
taken to carry out this section, including any penalties
imposed under subsection (d), during the preceding year;
``(E) contains background information on industry-physician
relationships;
``(F) in the case of information submitted with respect to
a payment or other transfer of value described in subsection
(a)(5), lists such information separately from the other
information submitted under subsection (a) and designates
such separately listed information as funding for clinical
research;
``(G) contains any other information the Secretary
determines would be helpful to the average consumer; and
``(H) provides the covered recipient an opportunity to
submit corrections to the information made available to the
public with respect to the covered recipient.
``(2) Accuracy of reporting.--The accuracy of the
information that is submitted under subsections (a) and (b)
and made available under paragraph (1) shall be the
responsibility of the reporting entity reporting under
subsection (a) or (b), as applicable. The Secretary shall
establish procedures to ensure that the covered recipient is
provided with an opportunity to submit corrections to the
applicable reporting entity with regard to information made
public with respect to the covered recipient and, under such
procedures, the corrections shall be transmitted to the
Secretary.
``(3) Special rule for drug samples.--Information relating
to drug samples provided under subsection (a) shall not be
made available to the public by the Secretary but may be made
available outside the Department of Health and Human Services
by the Secretary for research or legitimate business purposes
pursuant to data use agreements.
``(4) Special rule for national provider identifiers.--
Information relating to national provider identifiers
provided under subsection (a) shall not be made available to
the public by the Secretary but may be made available outside
the Department of Health and Human Services by the Secretary
for research or legitimate business purposes pursuant to data
use agreements.
``(d) Penalties for Noncompliance.--
``(1) Failure to report.--
``(A) In general.--Subject to subparagraph (B), except as
provided in paragraph (2), any reporting entity that fails to
submit information required under subsection (a) or (b), as
applicable, in a timely manner in accordance with regulations
promulgated to carry out such applicable subsection shall be
subject to a civil money penalty of not less than $1,000, but
not more than $10,000, for each payment or other transfer of
value or ownership or investment interest not reported as
required under such subsection. Such penalty shall be imposed
and collected in the same manner as civil money penalties
under subsection (a) of section 1128A are imposed and
collected under that section.
``(B) Limitation.--The total amount of civil money
penalties imposed under subparagraph (A), with respect to
each annual submission of information under subsection (a) by
a reporting entity, shall not exceed $150,000.
``(2) Knowing failure to report.--
``(A) In general.--Subject to subparagraph (B), any
reporting entity that knowingly fails to submit information
required under subsection (a) or (b), as applicable, in a
timely manner in accordance with regulations promulgated to
carry out such applicable subsection, shall be subject to a
civil money penalty of not less than $10,000, but not more
than $100,000, for each payment or other transfer of value or
ownership or investment interest not reported as required
under such subsection. Such penalty shall be imposed and
collected in the same manner as civil money penalties under
subsection (a) of section 1128A are imposed and collected
under that section.
``(B) Limitation.--The total amount of civil money
penalties imposed under subparagraph (A) with respect to each
annual submission of information under subsection (a) or (b)
by an applicable reporting entity shall not exceed
$1,000,000, or, if greater, 0.1 percentage of the total
annual revenues of the reporting entity.
``(3) Use of funds.--Funds collected by the Secretary as a
result of the imposition of a civil money penalty under this
subsection shall be used to carry out this section.
``(4) Enforcement through state attorneys general.--The
attorney general of a State, after providing notice to the
Secretary of an intent to proceed under this paragraph in a
specific case and providing the Secretary with an opportunity
to bring an action under this subsection and the Secretary
declining such opportunity, may proceed under this subsection
against an applicable manufacturer or distributor in the
State.
``(e) Annual Report to Congress.--Not later than April 1 of
each year beginning with 2011, the Secretary shall submit to
Congress a report that includes the following:
``(1) The information submitted under this section during
the preceding year, aggregated for each applicable reporting
entity that submitted such information during such year.
``(2) A description of any enforcement actions taken to
carry out this section, including any penalties imposed under
subsection (d), during the preceding year.
``(f) Definitions.--In this section:
``(1) Applicable distributor.--The term `applicable
distributor' means--
``(A) any entity, other than an applicable group purchasing
organization, that buys and resells, or receives a commission
or other similar form of payment, from another seller, for
selling or arranging for the sale of a covered drug, device,
biological, or medical supply; or
``(B) any entity under common ownership with such an entity
described in subparagraph (A) and which provides assistance
or support to such entity so described with respect to the
production, preparation, propagation, compounding,
conversion, processing, marketing, or distribution of a
covered drug, device, biological, or medical supply.

Such term does not include a wholesale pharmaceutical
distributor.
``(2) Applicable manufacturer.--The term `applicable
manufacturer' means any entity which is engaged in the
production, preparation, propagation, compounding,
conversion, processing, marketing, or manufacturer-direct
distribution of a covered drug, device, biological, or
medical supply (or any entity under common ownership with
such entity and which provides assistance or support to such
entity with respect to the production, preparation,
propagation, compounding, conversion, processing, marketing,
or distribution or a covered drug, device, biological, or
medical supply). For purposes of this section only, such term
does not include a retail pharmacy licensed under State law.
``(3) Clinical investigation.--The term `clinical
investigation' means any experiment involving one or more
human subjects, or materials derived from human subjects, in
which a drug or device is administered, dispensed, or used.
``(4) Covered drug, device, biological, or medical
supply.--The term `covered' means, with respect to a drug,
device, biological, or medical supply, such a drug, device,
biological, or medical supply for which payment is available
under title XVIII or a State plan under title XIX or XXI (or
a waiver of such a plan).
``(5) Covered recipient.--The term `covered recipient'
means the following:
``(A) A physician.
``(B) A physician group practice.
``(C) Any other prescriber of a covered drug, device,
biological, or medical supply.
``(D) A pharmacy or pharmacist.
``(E) A health insurance issuer, group health plan, or
other entity offering a health benefits plan, including any
employee of such an issuer, plan, or entity.
``(F) A pharmacy benefit manager, including any employee of
such a manager.
``(G) A hospital.
``(H) A medical school.
``(I) A sponsor of a continuing medical education program.
``(J) A patient advocacy or disease specific group.
``(K) A organization of health care professionals.
``(L) A biomedical researcher.
``(M) A group purchasing organization.
``(6) Employee.--The term `employee' has the meaning given
such term in section 1877(h)(2).
``(7) Knowingly.--The term `knowingly' has the meaning
given such term in section 3729(b) of title 31, United States
Code.
``(8) Payment or other transfer of value.--
``(A) In general.--The term `payment or other transfer of
value' means a transfer of anything of value for or of any of
the following:
``(i) Gift, food, or entertainment.
``(ii) Travel or trip.
``(iii) Honoraria.
``(iv) Research funding or grant.
``(v) Education or conference funding.
``(vi) Consulting fees.
``(vii) Ownership or investment interest and royalties or
license fee.
``(B) Inclusions.--Subject to subparagraph (C), the term
`payment or other transfer of value' includes any
compensation, gift, honorarium, speaking fee, consulting fee,
travel, services, dividend, profit distribution, stock or
stock option grant, or any ownership or investment interest
held by a physician in a

[[Page H12719]]

manufacturer (excluding a dividend or other profit
distribution from, or ownership or investment interest in, a
publicly traded security or mutual fund (as described in
section 1877(c))).
``(C) Exclusions.--The term `payment or other transfer of
value' does not include the following:
``(i) Any payment or other transfer of value provided by an
applicable manufacturer or distributor to a covered recipient
where the amount transferred to, requested by, or designated
on behalf of the covered recipient does not exceed $5.
``(ii) The loan of a covered device for a short-term trial
period, not to exceed 90 days, to permit evaluation of the
covered device by the covered recipient.
``(iii) Items or services provided under a contractual
warranty, including the replacement of a covered device,
where the terms of the warranty are set forth in the purchase
or lease agreement for the covered device.
``(iv) A transfer of anything of value to a covered
recipient when the covered recipient is a patient and not
acting in the professional capacity of a covered recipient.
``(v) In-kind items used for the provision of charity care.
``(vi) A dividend or other profit distribution from, or
ownership or investment interest in, a publicly traded
security and mutual fund (as described in section 1877(c)).
``(vii) Compensation paid by an applicable manufacturer or
distributor to a covered recipient who is directly employed
by and works solely for such manufacturer or distributor.
``(viii) Payments made to a covered recipient by an
applicable manufacturer or by a health plan affiliated with
an applicable manufacturer for medical care provided to
employees of such manufacturer or their dependents.
``(ix) Any discount (including a rebate).
``(x) Any payment or other transfer of value that is made
to a covered recipient indirectly through an entity other
than the applicable manufacturer in connection with an
activity or service--

``(I) in which the applicable manufacturer is unaware of
the identity of the covered recipient and is not using such
activity or service to market its product to the covered
recipient; and
``(II) that is not designed to market or promote the
product to the covered recipient.

``(xi) In the case of an applicable manufacturer who offers
a self-insured plan, payments for the provision of health
care to employees under the plan.
``(9) Physician.--The term `physician' has the meaning
given that term in section 1861(r). For purposes of this
section, such term does not include a physician who is an
employee of the applicable manufacturer that is required to
submit information under subsection (a).
``(10) Reporting entity.--The term `reporting entity'
means--
``(A) with respect to the reporting requirement under
subsection (a), an applicable manufacturer or distributor of
a covered drug, device, biological, or medical supply
required to report under such subsection; and
``(B) with respect to the reporting requirement under
subsection (b), a hospital, other health care entity,
applicable manufacturer, applicable distributor, or
applicable group purchasing organization required to report
physician ownership under such subsection.
``(g) Annual Reports to States.--Not later than April 1 of
each year beginning with 2011, the Secretary shall submit to
States a report that includes a summary of the information
submitted under subsections (a), (b), and (e) during the
preceding year with respect to covered recipients or other
hospitals and entities in the State.
``(h) Relation to State Laws.--
``(1) In general.--Effective on January 1, 2011, subject to
paragraph (2), the provisions of this section shall preempt
any law or regulation of a State or of a political
subdivision of a State that requires an applicable
manufacturer and applicable distributor (as such terms are
defined in subsection (f)) to disclose or report, in any
format, the type of information (described in subsection (a))
regarding a payment or other transfer of value provided by
the manufacturer to a covered recipient (as so defined).
``(2) No preemption of additional requirements.--Paragraph
(1) shall not preempt any statute or regulation of a State or
political subdivision of a State that requires any of the
following:
``(A) The disclosure or reporting of information not of the
type required to be disclosed or reported under this section.
``(B) The disclosure or reporting, in any format, of
information described in subsection (f)(8)(C), except in the
case of information described in clause (i) of subsection
(f)(8)(C).
``(C) The disclosure or reporting, in any format, of the
type of information by any person or entity other than an
applicable manufacturer (as so defined) or a covered
recipient (as defined in subsection (f)).
``(D) The disclosure or reporting, in any format, of the
type of information required to be disclosed or reported
under this section to a Federal, State, or local governmental
agency for public health surveillance, investigation, or
other public health purposes or health oversight purposes.

Nothing in paragraph (1) shall be construed to limit the
discovery or admissibility of information described in this
paragraph in a criminal, civil, or administrative
proceeding.''.
(b) Availability of Information From the Disclosure of
Financial Relationship Report (DFRR).--The Secretary of
Health and Human Services shall submit to Congress a report
on the full results of the Disclosure of Physician Financial
Relationships surveys required pursuant to section 5006 of
the Deficit Reduction Act of 2005. Such report shall be
submitted to Congress not later than the date that is 6
months after the date such surveys are collected and shall be
made publicly available on an Internet website of the
Department of Health and Human Services.
(c) GAO Report.--Not later than December 31, 2012, the
Comptroller General of the United States shall submit to
Congress a report on section 1128H of the Social Security
Act, as added by subsection (a). Such report shall address
the extent to which important transfers of value are being
adequately reported under such section (including unreported
transfers required by such section as well as transfers not
required to be reported by such section), the impact on
States of the federal preemption provision under subsection
(h) of such section, whether changes have occurred in the
pattern of payments as a result of efforts to evade reporting
requirements, a description of the financial relationships
subject to delayed reporting under subsection (a) of such
section, and any recommended improvements to the collection
or the analysis of data reported under such section.

Subtitle E--Public Reporting on Health Care-Associated Infections

SEC. 1461. REQUIREMENT FOR PUBLIC REPORTING BY HOSPITALS AND
AMBULATORY SURGICAL CENTERS ON HEALTH CARE-
ASSOCIATED INFECTIONS.

(a) In General.--Title XI of the Social Security Act is
amended by inserting after section 1138 the following
section:

``SEC. 1138A. REQUIREMENT FOR PUBLIC REPORTING BY HOSPITALS
AND AMBULATORY SURGICAL CENTERS ON HEALTH CARE-
ASSOCIATED INFECTIONS.

``(a) Reporting Requirement.--
``(1) In general.--The Secretary shall provide that a
hospital (as defined in subsection (g)) or ambulatory
surgical center meeting the requirements of titles XVIII or
XIX may participate in the programs established under such
titles only if, in accordance with this section, the hospital
or center reports such information on health care-associated
infections that develop in the hospital or center (and such
demographic information associated with such infections) as
the Secretary specifies.
``(2) Reporting protocols.-- Such information shall be
reported in accordance with reporting protocols established
by the Secretary through the Director of the Centers for
Disease Control and Prevention (in this section referred to
as the `CDC') and to the National Healthcare Safety Network
of the CDC or under such another reporting system of such
Centers as determined appropriate by the Secretary in
consultation with such Director.
``(3) Coordination with hit.--The Secretary, through the
Director of the CDC and the Office of the National
Coordinator for Health Information Technology, shall ensure
that the transmission of information under this subsection is
coordinated with systems established under the HITECH Act,
where appropriate.
``(4) Procedures to ensure the validity of information.--
The Secretary shall establish procedures regarding the
validity of the information submitted under this subsection
in order to ensure that such information is appropriately
compared across hospitals and centers. Such procedures shall
address failures to report as well as errors in reporting.
``(5) Implementation.--Not later than 1 year after the date
of enactment of this section, the Secretary, through the
Director of CDC, shall promulgate regulations to carry out
this section.
``(b) Public Posting of Information.--The Secretary shall
promptly post, on the official public Internet site of the
Department of Health and Human Services, the information
reported under subsection (a). Such information shall be set
forth in a manner that allows for the comparison of
information on health care-associated infections--
``(1) among hospitals and ambulatory surgical centers; and
``(2) by demographic information.
``(c) Annual Report to Congress.--On an annual basis the
Secretary shall submit to the Congress a report that
summarizes each of the following:
``(1) The number and types of health care-associated
infections reported under subsection (a) in hospitals and
ambulatory surgical centers during such year.
``(2) Factors that contribute to the occurrence of such
infections, including health care worker immunization rates.
``(3) Based on the most recent information available to the
Secretary on the composition of the professional staff of
hospitals and ambulatory surgical centers, the number of
certified infection control professionals on the staff of
hospitals and ambulatory surgical centers.

[[Page H12720]]

``(4) The total increases or decreases in health care costs
that resulted from increases or decreases in the rates of
occurrence of each such type of infection during such year.
``(5) Recommendations, in coordination with the Center for
Quality Improvement established under section 931 of the
Public Health Service Act, for best practices to eliminate
the rates of occurrence of each such type of infection in
hospitals and ambulatory surgical centers.
``(d) Non-preemption of State Laws.--Nothing in this
section shall be construed as preempting or otherwise
affecting any provision of State law relating to the
disclosure of information on health care-associated
infections or patient safety procedures for a hospital or
ambulatory surgical center.
``(e) Health Care-associated Infection.--For purposes of
this section:
``(1) In general.--The term `health care-associated
infection' means an infection that develops in a patient who
has received care in any institutional setting where health
care is delivered and is related to receiving health care.
``(2) Related to receiving health care.--The term `related
to receiving health care', with respect to an infection,
means that the infection was not incubating or present at the
time health care was provided.
``(f) Application to Critical Access Hospitals.--For
purposes of this section, the term `hospital' includes a
critical access hospital, as defined in section
1861(mm)(1).''.
(b) Effective Date.--With respect to section 1138A of the
Social Security Act (as inserted by subsection (a) of this
section), the requirement under such section that hospitals
and ambulatory surgical centers submit reports takes effect
on such date (not later than 2 years after the date of the
enactment of this Act) as the Secretary of Health and Human
Services shall specify. In order to meet such deadline, the
Secretary may implement such section through guidance or
other instructions.
(c) GAO Report.--Not later than 18 months after the date of
the enactment of this Act, the Comptroller General of the
United States shall submit to Congress a report on the
program established under section 1138A of the Social
Security Act, as inserted by subsection (a). Such report
shall include an analysis of the appropriateness of the types
of information required for submission, compliance with
reporting requirements, the success of the validity
procedures established, and any conflict or overlap between
the reporting required under such section and any other
reporting systems mandated by either the States or the
Federal Government.
(d) Report on Additional Data.--Not later than 18 months
after the date of the enactment of this Act, the Secretary of
Health and Human Services shall submit to the Congress a
report on the appropriateness of expanding the requirements
under such section to include additional information (such as
health care worker immunization rates), in order to improve
health care quality and patient safety.

TITLE V--MEDICARE GRADUATE MEDICAL EDUCATION

SEC. 1501. DISTRIBUTION OF UNUSED RESIDENCY POSITIONS.

(a) In General.--Section 1886(h) of the Social Security Act
(42 U.S.C. 1395ww(h)) is amended--
(1) in paragraph (4)(F)(i), by striking ``paragraph (7)''
and inserting ``paragraphs (7) and (8)'';
(2) in paragraph (4)(H)(i), by striking ``paragraph (7)''
and inserting ``paragraphs (7) and (8)'';
(3) in paragraph (7)(E), by inserting ``and paragraph (8)''
after ``this paragraph''; and
(4) by adding at the end the following new paragraph:
``(8) Additional redistribution of unused residency
positions.--
``(A) Reductions in limit based on unused positions.--
``(i) Programs subject to reduction.--If a hospital's
reference resident level (specified in clause (ii)) is less
than the otherwise applicable resident limit (as defined in
subparagraph (C)(ii)), effective for portions of cost
reporting periods occurring on or after July 1, 2011, the
otherwise applicable resident limit shall be reduced by 90
percent of the difference between such otherwise applicable
resident limit and such reference resident level.
``(ii) Reference resident level.--

``(I) In general.--Except as otherwise provided in a
subsequent subclause, the reference resident level specified
in this clause for a hospital is the highest resident level
for any of the 3 most recent cost reporting periods (ending
before the date of the enactment of this paragraph) of the
hospital for which a cost report has been settled (or, if
not, submitted (subject to audit)), as determined by the
Secretary.
``(II) Use of most recent accounting period to recognize
expansion of existing programs.--If a hospital submits a
timely request to increase its resident level due to an
expansion, or planned expansion, of an existing residency
training program that is not reflected on the most recent
settled or submitted cost report, after audit and subject to
the discretion of the Secretary, subject to subclause (IV),
the reference resident level for such hospital is the
resident level that includes the additional residents
attributable to such expansion or establishment, as
determined by the Secretary. The Secretary is authorized to
determine an alternative reference resident level for a
hospital that submitted to the Secretary a timely request,
before the start of the 2009-2010 academic year, for an
increase in its reference resident level due to a planned
expansion.
``(III) Special provider agreement.--In the case of a
hospital described in paragraph (4)(H)(v), the reference
resident level specified in this clause is the limitation
applicable under subclause (I) of such paragraph.
``(IV) Previous redistribution.--The reference resident
level specified in this clause for a hospital shall be
increased to the extent required to take into account an
increase in resident positions made available to the hospital
under paragraph (7)(B) that are not otherwise taken into
account under a previous subclause.

``(iii) Affiliation.--The provisions of clause (i) shall be
applied to hospitals which are members of the same affiliated
group (as defined by the Secretary under paragraph
(4)(H)(ii)) and to the extent the hospitals can demonstrate
that they are filling any additional  resident slots
allocated to other hospitals through an affiliation
agreement, the Secretary shall adjust the determination of
available slots accordingly, or which the Secretary otherwise
has permitted the resident positions (under section 402 of
the Social Security Amendments of 1967) to be aggregated for
purposes of applying the resident position limitations under
this subsection.
``(B) Redistribution.--
``(i) In general.--The Secretary shall increase the
otherwise applicable resident limit for each qualifying
hospital that submits an application under this subparagraph
by such number as the Secretary may approve for portions of
cost reporting periods occurring on or after July 1, 2011.
The estimated aggregate number of increases in the otherwise
applicable resident limit under this subparagraph may not
exceed the Secretary's estimate of the aggregate reduction in
such limits attributable to subparagraph (A).
``(ii) Requirements for qualifying hospitals.--A hospital
is not a qualifying hospital for purposes of this paragraph
unless the following requirements are met:

``(I) Maintenance of primary care resident level.--The
hospital maintains the number of primary care residents at a
level that is not less than the base level of primary care
residents increased by the number of additional primary care
resident positions provided to the hospital under this
subparagraph. For purposes of this subparagraph, the `base
level of primary care residents' for a hospital is the level
of such residents as of a base period (specified by the
Secretary), determined without regard to whether such
positions were in excess of the otherwise applicable resident
limit for such period but taking into account the application
of subclauses (II) and (III) of subparagraph (A)(ii).
``(II) Dedicated assignment of additional resident
positions to primary care.--The hospital assigns all such
additional resident positions for primary care residents.
``(III) Accreditation.--The hospital's residency programs
in primary care are fully accredited or, in the case of a
residency training program not in operation as of the base
year, the hospital is actively applying for such
accreditation for the program for such additional resident
positions (as determined by the Secretary).

``(iii) Considerations in redistribution.--In determining
for which qualifying hospitals the increase in the otherwise
applicable resident limit is provided under this
subparagraph, the Secretary shall take into account the
demonstrated likelihood of the hospital filling the positions
within the first 3 cost reporting periods beginning on or
after July 1, 2011, made available under this subparagraph,
as determined by the Secretary.
``(iv) Priority for certain hospitals.--In determining for
which qualifying hospitals the increase in the otherwise
applicable resident limit is provided under this
subparagraph, the Secretary shall distribute the increase to
qualifying hospitals based on the following criteria:

``(I) The Secretary shall give preference to hospitals that
had a reduction in resident training positions under
subparagraph (A).
``(II) The Secretary shall give preference to hospitals
with 3-year primary care residency training programs, such as
family practice and general internal medicine.
``(III) The Secretary shall give preference to hospitals
insofar as they have in effect formal arrangements (as
determined by the Secretary) that place greater emphasis upon
training in Federally qualified health centers, rural health
clinics, and other nonprovider settings, and to hospitals
that receive additional payments under subsection (d)(5)(F)
and emphasize training in an outpatient department.
``(IV) The Secretary shall give preference to hospitals
with a number of positions (as of July 1, 2009) in excess of
the otherwise applicable resident limit for such period.
``(V) The Secretary shall give preference to hospitals that
place greater emphasis upon training in a health professional
shortage area (designated under section 332 of the Public
Health Service Act) or a health professional needs area
(designated under section 2211 of such Act).
``(VI) The Secretary shall give preference to hospitals in
States that have low resident-to-population ratios (including
a greater preference for those States with lower resident-to-
population ratios).

[[Page H12721]]

``(v) Limitation.--In no case shall more than 20 full-time
equivalent additional residency positions be made available
under this subparagraph with respect to any hospital.
``(vi) Application of per resident amounts for primary
care.--With respect to additional residency positions in a
hospital attributable to the increase provided under this
subparagraph, the approved FTE resident amounts are deemed to
be equal to the hospital per resident amounts for primary
care and nonprimary care computed under paragraph (2)(D) for
that hospital.
``(vii) Distribution.--The Secretary shall distribute the
increase in resident training positions to qualifying
hospitals under this subparagraph not later than July 1,
2011.
``(C) Resident level and limit defined.--In this paragraph:
``(i) The term `resident level' has the meaning given such
term in paragraph (7)(C)(i).
``(ii) The term `otherwise applicable resident limit'
means, with respect to a hospital, the limit otherwise
applicable under subparagraphs (F)(i) and (H) of paragraph
(4) on the resident level for the hospital determined without
regard to this paragraph but taking into account paragraph
(7)(A).
``(D) Maintenance of primary care resident level.--In
carrying out this paragraph, the Secretary shall require
hospitals that receive additional resident positions under
subparagraph (B)--
``(i) to maintain records, and periodically report to the
Secretary, on the number of primary care residents in its
residency training programs; and
``(ii) as a condition of payment for a cost reporting
period under this subsection for such positions, to maintain
the level of such positions at not less than the sum of--

``(I) the base level of primary care resident positions (as
determined under subparagraph (B)(ii)(I)) before receiving
such additional positions; and
``(II) the number of such additional positions.''.

(b) IME.--
(1) In general.--Section 1886(d)(5)(B)(v) of the Social
Security Act (42 U.S.C. 1395ww(d)(5)(B)(v)), in the third
sentence, is amended--
(A) by striking ``subsection (h)(7)'' and inserting
``subsections (h)(7) and (h)(8)''; and
(B) by striking ``it applies'' and inserting ``they
apply''.
(2) Conforming provision.--Section 1886(d)(5)(B) of the
Social Security Act (42 U.S.C. 1395ww(d)(5)(B)) is amended by
adding at the end the following clause:
``(x) For discharges occurring on or after July 1, 2011,
insofar as an additional payment amount under this
subparagraph is attributable to resident positions
distributed to a hospital under subsection (h)(8)(B), the
indirect teaching adjustment factor shall be computed in the
same manner as provided under clause (ii) with respect to
such resident positions.''.
(c) Conforming Amendment.--Section 422(b)(2) of the
Medicare Prescription Drug, Improvement, and Modernization
Act of 2003 (Public Law 108-173) is amended by striking
``section 1886(h)(7)'' and all that follows and inserting
``paragraphs (7) and (8) of subsection (h) of section 1886 of
the Social Security Act.''.

SEC. 1502. INCREASING TRAINING IN NONPROVIDER SETTINGS.

(a) Direct GME.--Section 1886(h)(4)(E) of the Social
Security Act (42 U.S.C. 1395ww(h)) is amended--
(1) by designating the first sentence as a clause (i) with
the heading ``In general.--'' and appropriate indentation;
(2) by striking ``shall be counted and that all the time''
and inserting ``shall be counted and that--

``(I) effective for cost reporting periods beginning before
July 1, 2009, all the time'';

(3) in subclause (I), as inserted by paragraph (1), by
striking the period at the end and inserting ``; and''; and
(A) by inserting after subclause (I), as so inserted, the
following:

``(II) effective for cost reporting periods beginning on or
after July 1, 2009, all the time so spent by a resident shall
be counted towards the determination of full-time
equivalency, without regard to the setting in which the
activities are performed, if the hospital incurs the costs of
the stipends and fringe benefits of the resident during the
time the resident spends in that setting.

Any hospital claiming under this subparagraph for time spent
in a nonprovider setting shall maintain and make available to
the Secretary records regarding the amount of such time and
such amount in comparison with amounts of such time in such
base year as the Secretary shall specify.''.
(b) IME.--Section 1886(d)(5)(B)(iv) of the Social Security
Act (42 U.S.C. 1395ww(d)(5)(B)(iv)) is amended--
(1) by striking ``(iv) Effective for discharges occurring
on or after October 1, 1997'' and inserting ``(iv)(I)
Effective for discharges occurring on or after October 1,
1997, and before July 1, 2009''; and
(2) by inserting after subclause (I), as inserted by
paragraph (1), the following new subclause:
``(II) Effective for discharges occurring on or after July
1, 2009, all the time spent by an intern or resident in
patient care activities at an entity in a nonprovider setting
shall be counted towards the determination of full-time
equivalency if the hospital incurs the costs of the stipends
and fringe benefits of the intern or resident during the time
the intern or resident spends in that setting.''.
(c) OIG Study on Impact on Training.--The Inspector General
of the Department of Health and Human Services shall analyze
the data collected by the Secretary of Health and Human
Services from the records made available to the Secretary
under section 1886(h)(4)(E) of the Social Security Act, as
amended by subsection (a), in order to assess the extent to
which there is an increase in time spent by medical residents
in training in nonprovider settings as a result of the
amendments made by this section. Not later than 4 years after
the date of the enactment of this Act, the Inspector General
shall submit a report to Congress on such analysis and
assessment.
(d) Demonstration Project for Approved Teaching Health
Centers.--
(1) In general.--The Secretary of Health and Human Services
shall conduct a demonstration project under which an approved
teaching health center (as defined in paragraph (3)) would be
eligible for payment under subsections (h) and (k) of section
1886 of the Social Security Act (42 U.S.C. 1395ww) of amounts
for its own direct costs of graduate medical education
activities for primary care residents, as well as for the
direct costs of graduate medical education activities of its
contracting hospital for such residents, in a manner similar
to the manner in which such payments would be made to a
hospital if the hospital were to operate such a program.
(2) Conditions.--Under the demonstration project--
(A) an approved teaching health center shall contract with
an accredited teaching hospital to carry out the inpatient
responsibilities of the primary care residency program of the
hospital involved and is responsible for payment to the
hospital for the hospital's costs of the salary and fringe
benefits for residents in the program;
(B) the number of primary care residents of the center
shall not count against the contracting hospital's resident
limit; and
(C) the contracting hospital shall agree not to diminish
the number of residents in its primary care residency
training program.
(3) Approved teaching health center defined.--In this
subsection, the term ``approved teaching health center''
means a nonprovider setting, such as a Federally qualified
health center or rural health clinic (as defined in section
1861(aa) of the Social Security Act), that develops and
operates an accredited primary care residency program for
which funding would be available if it were operated by a
hospital.

SEC. 1503. RULES FOR COUNTING RESIDENT TIME FOR DIDACTIC AND
SCHOLARLY ACTIVITIES AND OTHER ACTIVITIES.

(a) Direct GME.--Section 1886(h) of the Social Security Act
(42 U.S.C. 1395ww(h)) is amended--
(1) in paragraph (4)(E), as amended by section 1502(a)--
(A) in clause (i), by striking ``Such rules'' and inserting
``Subject to clause (ii), such rules''; and
(B) by adding at the end the following new clause:
``(ii) Treatment of certain nonprovider and didactic
activities.--Such rules shall provide that all time spent by
an intern or resident in an approved medical residency
training program in a nonprovider setting that is primarily
engaged in furnishing patient care (as defined in paragraph
(5)(K)) in nonpatient care activities, such as didactic
conferences and seminars, but not including research not
associated with the treatment or diagnosis of a particular
patient, as such time and activities are defined by the
Secretary, shall be counted toward the determination of full-
time equivalency.'';
(2) in paragraph (4), by adding at the end the following
new subparagraph:
``(I) Treatment of certain time in approved medical
residency training programing.--In determining the hospital's
number of full-time equivalent residents for purposes of this
subsection, all the time that is spent by an intern or
resident in an approved medical residency training program on
vacation, sick leave, or other approved leave, as such time
is defined by the Secretary, and that does not prolong the
total time the resident is participating in the approved
program beyond the normal duration of the program shall be
counted toward the determination of full-time equivalency.'';
and
(3) in paragraph (5), by adding at the end the following
new subparagraph:
``(K) Nonprovider setting that is primarily engaged in
furnishing patient care.--The term `nonprovider setting that
is primarily engaged in furnishing patient care' means a
nonprovider setting in which the primary activity is the care
and treatment of patients, as defined by the Secretary.''.
(b) IME Determinations.--Section 1886(d)(5)(B) of such Act
(42 U.S.C. 1395ww(d)(5)(B)), as amended by section 1501(b),
is amended by adding at the end the following new clause:
``(xi)(I) The provisions of subparagraph (I) of subsection
(h)(4) shall apply under this subparagraph in the same manner
as they apply under such subsection.
``(II) In determining the hospital's number of full-time
equivalent residents for purposes of this subparagraph, all
the time spent by an intern or resident in an approved
medical residency training program in nonpatient care
activities, such as didactic conferences and seminars, as
such time and activities are defined by the Secretary, that
occurs in the

[[Page H12722]]

hospital shall be counted toward the determination of full-
time equivalency if the hospital--
``(aa) is recognized as a subsection (d) hospital;
``(bb) is recognized as a subsection (d) Puerto Rico
hospital;
``(cc) is reimbursed under a reimbursement system
authorized under section 1814(b)(3); or
``(dd) is a provider-based hospital outpatient department.
``(III) In determining the hospital's number of full-time
equivalent residents for purposes of this subparagraph, all
the time spent by an intern or resident in an approved
medical residency training program in research activities
that are not associated with the treatment or diagnosis of a
particular patient, as such time and activities are defined
by the Secretary, shall not be counted toward the
determination of full-time equivalency.''.
(c) Effective Dates; Application.--
(1) In general.--Except as otherwise provided, the
Secretary of Health and Human Services shall implement the
amendments made by this section in a manner so as to apply to
cost reporting periods beginning on or after January 1, 1983.
(2) Direct gme.--Section 1886(h)(4)(E)(ii) of the Social
Security Act, as added by subsection (a)(1)(B), shall apply
to cost reporting periods beginning on or after July 1, 2008.
(3) IME.--Section 1886(d)(5)(B)(x)(III) of the Social
Security Act, as added by subsection (b), shall apply to cost
reporting periods beginning on or after October 1, 2001. Such
section, as so added, shall not give rise to any inference on
how the law in effect prior to such date should be
interpreted.
(4) Application.--The amendments made by this section shall
not be applied in a manner that requires reopening of any
settled hospital cost reports as to which there is not a
jurisdictionally proper appeal pending as of the date of the
enactment of this Act on the issue of payment for indirect
costs of medical education under section 1886(d)(5)(B) of the
Social Security Act or for direct graduate medical education
costs under section 1886(h) of such Act.

SEC. 1504. PRESERVATION OF RESIDENT CAP POSITIONS FROM CLOSED
HOSPITALS.

(a) Direct GME.--Section 1886(h)(4)(H) of the Social
Security Act (42 U.S.C. Section 1395ww(h)(4)(H)) is amended
by adding at the end the following new clause:
``(vi) Redistribution of residency slots after a hospital
closes.--

``(I) In general.--The Secretary shall, by regulation,
establish a process consistent with subclauses (II) and (III)
under which, in the case where a hospital (other than a
hospital described in clause (v)) with an approved medical
residency program in a State closes on or after the date that
is 2 years before the date of the enactment of this clause,
the Secretary shall increase the otherwise applicable
resident limit under this paragraph for other hospitals in
the State in accordance with this clause.
``(II) Process for hospitals in certain areas.--In
determining for which hospitals the increase in the otherwise
applicable resident limit described in subclause (I) is
provided, the Secretary shall establish a process to provide
for such increase to one or more hospitals located in the
State. Such process shall take into consideration the
recommendations submitted to the Secretary by the senior
health official (as designated by the chief executive officer
of such State) if such recommendations are submitted not
later than 180 days after the date of the hospital closure
involved (or, in the case of a hospital that closed after the
date that is 2 years before the date of the enactment of this
clause, 180 days after such date of enactment).
``(III) Limitation.--The estimated aggregate number of
increases in the otherwise applicable resident limits for
hospitals under this clause shall be equal to the estimated
number of resident positions in the approved medical
residency programs that closed on or after the date described
in subclause (I).''.

(b) No Effect on Temporary FTE Cap Adjustments.--The
amendments made by this section shall not effect any
temporary adjustment to a hospital's FTE cap under section
413.79(h) of title 42, Code of Federal Regulations (as in
effect on the date of enactment of this Act) and shall not
affect the application of section 1886(h)(4)(H)(v) of the
Social Security Act.
(c) Conforming Amendments.--
(1) Section 422(b)(2) of the Medicare Prescription Drug,
Improvement, and Modernization Act of 2003 (Public Law 108-
173), as amended by section 1501(c), is amended by striking
``(7) and'' and inserting ``(4)(H)(vi), (7), and''.
(2) Section 1886(h)(7)(E) of the Social Security Act (42
U.S.C. 1395ww(h)(7)(E)) is amended by inserting ``or under
paragraph (4)(H)(vi)'' after ``under this paragraph''.

SEC. 1505. IMPROVING ACCOUNTABILITY FOR APPROVED MEDICAL
RESIDENCY TRAINING.

(a) Specification of Goals for Approved Medical Residency
Training Programs.--Section 1886(h)(1) of the Social Security
Act (42 U.S.C. 1395ww(h)(1)) is amended--
(1) by designating the matter beginning with
``Notwithstanding'' as a subparagraph (A) with the heading
``In general.--'' and with appropriate indentation; and
(2) by adding at the end the following new subparagraph:
``(B) Goals and accountability for approved medical
residency training programs.--The goals of medical residency
training programs are to foster a physician workforce so that
physicians are trained to be able to do the following:
``(i) Work effectively in various health care delivery
settings, such as nonprovider settings.
``(ii) Coordinate patient care within and across settings
relevant to their specialties.
``(iii) Understand the relevant cost and value of various
diagnostic and treatment options.
``(iv) Work in inter-professional teams and multi-
disciplinary team-based models in provider and nonprovider
settings to enhance safety and improve quality of patient
care.
``(v) Be knowledgeable in methods of identifying systematic
errors in health care delivery and in implementing systematic
solutions in case of such errors, including experience and
participation in continuous quality improvement projects to
improve health outcomes of the population the physicians
serve.
``(vi) Be meaningful EHR users (as determined under section
1848(o)(2)) in the delivery of care and in improving the
quality of the health of the community and the individuals
that the hospital serves.''
(b) GAO Study on Evaluation of Training Programs.--
(1) In general.--The Comptroller General of the United
States shall conduct a study to evaluate the extent to which
medical residency training programs--
(A) are meeting the goals described in section
1886(h)(1)(B) of the Social Security Act, as added by
subsection (a), in a range of residency programs, including
primary care and other specialties; and
(B) have the appropriate faculty expertise to teach the
topics required to achieve such goals.
(2) Report.--Not later than 18 months after the date of the
enactment of this Act, the Comptroller General shall submit
to Congress a report on such study and shall include in such
report recommendations as to how medical residency training
programs could be further encouraged to meet such goals
through means such as--
(A) development of curriculum requirements; and
(B) assessment of the accreditation processes of the
Accreditation Council for Graduate Medical Education and the
American Osteopathic Association and effectiveness of those
processes in accrediting medical residency programs that meet
the goals referred to in paragraph (1)(A).

TITLE VI--PROGRAM INTEGRITY

Subtitle A--Increased Funding to Fight Waste, Fraud, and Abuse

SEC. 1601. INCREASED FUNDING AND FLEXIBILITY TO FIGHT FRAUD
AND ABUSE.

(a) In General.--Section 1817(k) of the Social Security Act
(42 U.S.C. 1395i(k)) is amended--
(1) by adding at the end the following new paragraph:
``(7) Additional funding.--In addition to the funds
otherwise appropriated to the Account from the Trust Fund
under paragraphs (3) and (4) and for purposes described in
paragraphs (3)(C) and (4)(A), there are hereby appropriated
an additional $100,000,000 to such Account from such Trust
Fund for each fiscal year beginning with 2011. The funds
appropriated under this paragraph shall be allocated in the
same proportion as the total funding appropriated with
respect to paragraphs (3)(A) and (4)(A) was allocated with
respect to fiscal year 2010, and shall be available without
further appropriation until expended.''.
(2) in paragraph (4)(A)--
(A) by inserting ``for activities described in paragraph
(3)(C) and'' after ``necessary''; and
(B) by inserting ``until expended'' after
``appropriation''.
(b) Flexibility in Pursuing Fraud and Abuse.--Section
1893(a) of the Social Security Act (42 U.S.C. 1395ddd(a)) is
amended by inserting ``, or otherwise,'' after ``entities''.

Subtitle B--Enhanced Penalties for Fraud and Abuse

SEC. 1611. ENHANCED PENALTIES FOR FALSE STATEMENTS ON
PROVIDER OR SUPPLIER ENROLLMENT APPLICATIONS.

(a) In General.--Section 1128A(a) of the Social Security
Act (42 U.S.C. 1320a-7a(a)) is amended--
(1) in paragraph (1)(D), by striking all that follows ``in
which the person was excluded'' and inserting ``under Federal
law from the Federal health care program under which the
claim was made, or'';
(2) by striking ``or'' at the end of paragraph (6);
(3) in paragraph (7), by inserting at the end ``or'';
(4) by inserting after paragraph (7) the following new
paragraph:
``(8) knowingly makes or causes to be made any false
statement, omission, or misrepresentation of a material fact
in any application, agreement, bid, or contract to
participate or enroll as a provider of services or supplier
under a Federal health care program, including managed care
organizations under title XIX, Medicare Advantage
organizations under part C of title XVIII, prescription drug
plan sponsors under part D of title XVIII, and entities that
apply to participate as providers of services or suppliers in
such managed care organizations and such plans;'';
(5) in the matter following paragraph (8), as inserted by
paragraph (4), by striking ``or

[[Page H12723]]

in cases under paragraph (7), $50,000 for each such act)''
and inserting ``in cases under paragraph (7), $50,000 for
each such act, or in cases under paragraph (8), $50,000 for
each false statement, omission, or misrepresentation of a
material fact)''; and
(6) in the second sentence, by striking ``for a lawful
purpose)'' and inserting ``for a lawful purpose, or in cases
under paragraph (8), an assessment of not more than 3 times
the amount claimed as the result of the false statement,
omission, or misrepresentation of material fact claimed by a
provider of services or supplier whose application to
participate contained such false statement, omission, or
misrepresentation)''.
(b) Effective Date.--The amendments made by subsection (a)
shall apply to acts committed on or after January 1, 2010.

SEC. 1612. ENHANCED PENALTIES FOR SUBMISSION OF FALSE
STATEMENTS MATERIAL TO A FALSE CLAIM.

(a) In General.--Section 1128A(a) of the Social Security
Act (42 U.S.C. 1320a-7a(a)), as amended by section 1611, is
further amended--
(1) in paragraph (7), by striking ``or'' at the end;
(2) in paragraph (8), by inserting ``or'' at the end; and
(3) by inserting after paragraph (8), the following new
paragraph:
``(9) knowingly makes, uses, or causes to be made or used,
a false record or statement material to a false or fraudulent
claim for payment for items and services furnished under a
Federal health care program;''; and
(4) in the matter following paragraph (9), as inserted by
paragraph (3)--
(A) by striking ``or in cases under paragraph (8)'' and
inserting ``in cases under paragraph (8)''; and
(B) by striking ``a material fact)'' and inserting ``a
material fact, in cases under paragraph (9), $50,000 for each
false record or statement)''.
(b) Effective Date.--The amendments made by subsection (a)
shall apply to acts committed on or after January 1, 2010.

SEC. 1613. ENHANCED PENALTIES FOR DELAYING INSPECTIONS.

(a) In General.--Section 1128A(a) of the Social Security
Act (42 U.S.C. 1320a-7a(a)), as amended by sections 1611 and
1612, is further amended--
(1) in paragraph (8), by striking ``or'' at the end;
(2) in paragraph (9), by inserting ``or'' at the end;
(3) by inserting after paragraph (9) the following new
paragraph:
``(10) fails to grant timely access, upon reasonable
request (as defined by the Secretary in regulations), to the
Inspector General of the Department of Health and Human
Services, for the purpose of audits, investigations,
evaluations, or other statutory functions of the Inspector
General of the Department of Health and Human Services;'';
and
(4) in the matter following paragraph (10), as inserted by
paragraph (3), by inserting ``, or in cases under paragraph
(10), $15,000 for each day of the failure described in such
paragraph'' after ``false record or statement''.
(b) Ensuring Timely Inspections Relating to Contracts With
MA Organizations.--Section 1857(d)(2) of such Act (42 U.S.C.
1395w-27(d)(2)) is amended--
(1) in subparagraph (A), by inserting ``timely'' before
``inspect''; and
(2) in subparagraph (B), by inserting ``timely'' before
``audit and inspect''.
(c) Effective Date.--The amendments made by subsection (a)
shall apply to violations committed on or after January 1,
2010.

SEC. 1614. ENHANCED HOSPICE PROGRAM SAFEGUARDS.

(a) Medicare.--Part A of title XVIII of the Social Security
Act is amended by inserting after section 1819 the following
new section:

``SEC. 1819A. ASSURING QUALITY OF CARE IN HOSPICE CARE.

``(a) In General.--If the Secretary determines on the basis
of a survey or otherwise, that a hospice program that is
certified for participation under this title has demonstrated
a substandard quality of care and failed to meet such other
requirements as the Secretary may find necessary in the
interest of the health and safety of the individuals who are
provided care and services by the agency or organization
involved and determines--
``(1) that the deficiencies involved immediately jeopardize
the health and safety of the individuals to whom the program
furnishes items and services, the Secretary shall take
immediate action to remove the jeopardy and correct the
deficiencies through the remedy specified in subsection
(b)(2)(A)(iii) or terminate the certification of the program,
and may provide, in addition, for 1 or more of the other
remedies described in subsection (b)(2)(A); or
``(2) that the deficiencies involved do not immediately
jeopardize the health and safety of the individuals to whom
the program furnishes items and services, the Secretary may--
``(A) impose intermediate sanctions developed pursuant to
subsection (b), in lieu of terminating the certification of
the program; and
``(B) if, after such a period of intermediate sanctions,
the program is still not in compliance with such
requirements, the Secretary shall terminate the certification
of the program.

If the Secretary determines that a hospice program that is
certified for participation under this title is in compliance
with such requirements but, as of a previous period, was not
in compliance with such requirements, the Secretary may
provide for a civil money penalty under subsection
(b)(2)(A)(i) for the days in which it finds that the program
was not in compliance with such requirements.
``(b) Intermediate Sanctions.--
``(1) Development and implementation.--The Secretary shall
develop and implement, by not later than July 1, 2012--
``(A) a range of intermediate sanctions to apply to hospice
programs under the conditions described in subsection (a),
and
``(B) appropriate procedures for appealing determinations
relating to the imposition of such sanctions.
``(2) Specified sanctions.--
``(A) In general.--The intermediate sanctions developed
under paragraph (1) may include--
``(i) civil money penalties in an amount not to exceed
$10,000 for each day of noncompliance or, in the case of a
per instance penalty applied by the Secretary, not to exceed
$25,000,
``(ii) denial of all or part of the payments to which a
hospice program would otherwise be entitled under this title
with respect to items and services furnished by a hospice
program on or after the date on which the Secretary
determines that intermediate sanctions should be imposed
pursuant to subsection (a)(2),
``(iii) the appointment of temporary management to oversee
the operation of the hospice program and to protect and
assure the health and safety of the individuals under the
care of the program while improvements are made,
``(iv) corrective action plans, and
``(v) in-service training for staff.

The provisions of section 1128A (other than subsections (a)
and (b)) shall apply to a civil money penalty under clause
(i) in the same manner as such provisions apply to a penalty
or proceeding under section 1128A(a). The temporary
management under clause (iii) shall not be terminated until
the Secretary has determined that the program has the
management capability to ensure continued compliance with all
requirements referred to in that clause.
``(B) Clarification.--The sanctions specified in
subparagraph (A) are in addition to sanctions otherwise
available under State or Federal law and shall not be
construed as limiting other remedies, including any remedy
available to an individual at common law.
``(C) Commencement of payment.--A denial of payment under
subparagraph (A)(ii) shall terminate when the Secretary
determines that the hospice program no longer demonstrates a
substandard quality of care and meets such other requirements
as the Secretary may find necessary in the interest of the
health and safety of the individuals who are provided care
and services by the agency or organization involved.
``(3) Secretarial authority.--The Secretary shall develop
and implement, by not later than July 1, 2011, specific
procedures with respect to the conditions under which each of
the intermediate sanctions developed under paragraph (1) is
to be applied, including the amount of any fines and the
severity of each of these sanctions. Such procedures shall be
designed so as to minimize the time between identification of
deficiencies and imposition of these sanctions and shall
provide for the imposition of incrementally more severe fines
for repeated or uncorrected deficiencies.''.
(b) Application to Medicaid.--Section 1905(o) of the Social
Security Act (42 U.S.C. 1396d(o)) is amended by adding at the
end the following new paragraph:
``(4) The provisions of section 1819A shall apply to a
hospice program providing hospice care under this title in
the same manner as such provisions apply to a hospice program
providing hospice care under title XVIII.''.
(c) Application to CHIP.--Title XXI of the Social Security
Act is amended by adding at the end the following new
section:

``SEC. 2114. ASSURING QUALITY OF CARE IN HOSPICE CARE.

``The provisions of section 1819A shall apply to a hospice
program providing hospice care under this title in the same
manner such provisions apply to a hospice program providing
hospice care under title XVIII.''.

SEC. 1615. ENHANCED PENALTIES FOR INDIVIDUALS EXCLUDED FROM
PROGRAM PARTICIPATION.

(a) In General.--Section 1128A(a) of the Social Security
Act (42 U.S.C. 1320a-7a(a)), as amended by the previous
sections, is further amended--
(1) by striking ``or'' at the end of paragraph (9);
(2) by inserting ``or'' at the end of paragraph (10);
(3) by inserting after paragraph (10) the following new
paragraph:
``(11) orders or prescribes an item or service, including
without limitation home health care, diagnostic and clinical
lab tests, prescription drugs, durable medical equipment,
ambulance services, physical or occupational therapy, or any
other item or service, during a period when the person has
been excluded from participation in a Federal health care
program, and the person knows or should know that a claim for
such item or service will be presented to such a program;'';
and

[[Page H12724]]

(4) in the matter following paragraph (11), as inserted by
paragraph (2), by striking ``$15,000 for each day of the
failure described in such paragraph'' and inserting ``$15,000
for each day of the failure described in such paragraph, or
in cases under paragraph (11), $50,000 for each order or
prescription for an item or service by an excluded
individual''.
(b) Effective Date.--The amendments made by subsection (a)
shall apply to violations committed on or after January 1,
2010.

SEC. 1616. ENHANCED PENALTIES FOR PROVISION OF FALSE
INFORMATION BY MEDICARE ADVANTAGE AND PART D
PLANS.

(a) In General.--Section 1857(g)(2)(A) of the Social
Security Act (42 U.S.C. 1395w--27(g)(2)(A)) is amended by
inserting ``except with respect to a determination under
subparagraph (E), an assessment of not more than 3 times the
amount claimed by such plan or plan sponsor based upon the
misrepresentation or falsified information involved,'' after
``for each such determination,''.
(b) Effective Date.--The amendment made by subsection (a)
shall apply to violations committed on or after January 1,
2010.

SEC. 1617. ENHANCED PENALTIES FOR MEDICARE ADVANTAGE AND PART
D MARKETING VIOLATIONS.

(a) In General.--Section 1857(g)(1) of the Social Security
Act (42 U.S.C. 1395w--27(g)(1)), as amended by section
1221(b), is amended--
(1) in subparagraph (G), by striking ``or'' at the end;
(2) by inserting after subparagraph (H) the following new
subparagraphs:
``(I) except as provided under subparagraph (C) or (D) of
section 1860D-1(b)(1), enrolls an individual in any plan
under this part without the prior consent of the individual
or the designee of the individual;
``(J) transfers an individual enrolled under this part from
one plan to another without the prior consent of the
individual or the designee of the individual or solely for
the purpose of earning a commission;
``(K) fails to comply with marketing restrictions described
in subsections (h) and (j) of section 1851 or applicable
implementing regulations or guidance; or
``(L) employs or contracts with any individual or entity
who engages in the conduct described in subparagraphs (A)
through (K) of this paragraph;''; and
(3) by adding at the end the following new sentence: ``The
Secretary may provide, in addition to any other remedies
authorized by law, for any of the remedies described in
paragraph (2), if the Secretary determines that any employee
or agent of such organization, or any provider or supplier
who contracts with such organization, has engaged in any
conduct described in subparagraphs (A) through (L) of this
paragraph.''
(b) Effective Date.--The amendments made by subsection (a)
shall apply to violations committed on or after January 1,
2010.

SEC. 1618. ENHANCED PENALTIES FOR OBSTRUCTION OF PROGRAM
AUDITS.

(a) In General.--Section 1128(b)(2) of the Social Security
Act (42 U.S.C. 1320a-7(b)(2)) is amended--
(1) in the heading, by inserting ``or audit'' after
``investigation''; and
(2) by striking ``investigation into'' and all that follows
through the period and inserting ``investigation or audit
related to--''
``(i) any offense described in paragraph (1) or in
subsection (a); or
``(ii) the use of funds received, directly or indirectly,
from any Federal health care program (as defined in section
1128B(f)).''.
(b) Effective Date.--The amendments made by subsection (a)
shall apply to violations committed on or after January 1,
2010.

SEC. 1619. EXCLUSION OF CERTAIN INDIVIDUALS AND ENTITIES FROM
PARTICIPATION IN MEDICARE AND STATE HEALTH CARE
PROGRAMS.

(a) In General.--Section 1128(c) of the Social Security
Act, as previously amended by this division, is further
amended--
(1) in the heading, by striking ``and Period'' and
inserting ``Period, and Effect''; and
(2) by adding at the end the following new paragraph:
``(4)(A) For purposes of this Act, subject to subparagraph
(C), the effect of exclusion is that no payment may be made
by any Federal health care program (as defined in section
1128B(f)) with respect to any item or service furnished--
``(i) by an excluded individual or entity; or
``(ii) at the medical direction or on the prescription of a
physician or other authorized individual when the person
submitting a claim for such item or service knew or had
reason to know of the exclusion of such individual.
``(B) For purposes of this section and sections 1128A and
1128B, subject to subparagraph (C), an item or service has
been furnished by an individual or entity if the individual
or entity directly or indirectly provided, ordered,
manufactured, distributed, prescribed, or otherwise supplied
the item or service regardless of how the item or service was
paid for by a Federal health care program or to whom such
payment was made.
``(C)(i) Payment may be made under a Federal health care
program for emergency items or services (not including items
or services furnished in an emergency room of a hospital)
furnished by an excluded individual or entity, or at the
medical direction or on the prescription of an excluded
physician or other authorized individual during the period of
such individual's exclusion.
``(ii) In the case that an individual eligible for benefits
under title XVIII or XIX submits a claim for payment for
items or services furnished by an excluded individual or
entity, and such individual eligible for such benefits did
not know or have reason to know that such excluded individual
or entity was so excluded, then, notwithstanding such
exclusion, payment shall be made for such items or services.
In such case the Secretary shall notify such individual
eligible for such benefits of the exclusion of the individual
or entity furnishing the items or services. Payment shall not
be made for items or services furnished by an excluded
individual or entity to an individual eligible for such
benefits after a reasonable time (as determined by the
Secretary in regulations) after the Secretary has notified
the individual eligible for such benefits of the exclusion of
the individual or entity furnishing the items or services.
``(iii) In the case that a claim for payment for items or
services furnished by an excluded individual or entity is
submitted by an individual or entity other than an individual
eligible for benefits under title XVIII or XIX or the
excluded individual or entity, and the Secretary determines
that the individual or entity that submitted the claim took
reasonable steps to learn of the exclusion and reasonably
relied upon inaccurate or misleading information from the
relevant Federal health care program or its contractor, the
Secretary may waive repayment of the amount paid in violation
of the exclusion to the individual or entity that submitted
the claim for the items or services furnished by the excluded
individual or entity. If a Federal health care program
contractor provided inaccurate or misleading information that
resulted in the waiver of an overpayment under this clause,
the Secretary shall take appropriate action to recover the
improperly paid amount from the contractor.''.

SEC. 1620. OIG AUTHORITY TO EXCLUDE FROM FEDERAL HEALTH CARE
PROGRAMS OFFICERS AND OWNERS OF ENTITIES
CONVICTED OF FRAUD.

Section 1128(b)(15)(A) of the Social Security Act (42
U.S.C. 1320a-7(b)(15)(A)) is amended--
(1) in clause (i)--
(A) by striking ``has'' and inserting ``had''; and
(B) by striking ``sanctioned entity and who knows or should
know (as defined in section 1128A(i)(6)) of'' and inserting
``sanctioned entity at the time of, and who knew or should
have known (as defined in section 1128A(i)(6)) of,'' ; and
(2) in clause (ii)--
(A) by striking ``is an officer'' and inserting ``was an
officer''; and
(B) by inserting before the period the following: ``at the
time of the action constituting the basis for the conviction
or exclusion described in subparagraph (B)''.

SEC. 1621. SELF-REFERRAL DISCLOSURE PROTOCOL.

(a) Development of Self-referral Disclosure Protocol.--
(1) In general.--The Secretary of Health and Human
Services, in cooperation with the Inspector General of the
Department of Health and Human Services, shall establish, not
later than 6 months after the date of the enactment of this
Act, a protocol to enable health care providers of services
and suppliers to disclose an actual or potential violation of
section 1877 of the Social Security Act (42 U.S.C. 1395nn)
pursuant to a self-referral disclosure protocol (in this
section referred to as an ``SRDP''). The SRDP shall include
direction to health care providers of services and suppliers
on--
(A) a specific person, official, or office to whom such
disclosures shall be made; and
(B) instruction on the implication of the SRDP on corporate
integrity agreements and corporate compliance agreements.
(2) Publication on internet website of srdp information.--
The Secretary shall post information on the public Internet
website of the Centers for Medicare & Medicaid Services to
inform relevant stakeholders of how to disclose actual or
potential violations pursuant to an SRDP.
(3) Relation to advisory opinions.--The SRDP shall be
separate from the advisory opinion process set forth in
regulations implementing section 1877(g) of the Social
Security Act.
(b) Reduction in Amounts Owed.--The Secretary is authorized
to reduce the amount due and owing for all violations under
section 1877 of the Social Security Act to an amount less
than that specified in subsection (g) of such section. In
establishing such amount for a violation, the Secretary may
consider the following factors:
(1) The nature and extent of the improper or illegal
practice.
(2) The timeliness of such self-disclosure.
(3) The cooperation in providing additional information
related to the disclosure.
(4) Such other factors as the Secretary considers
appropriate.
(c) Report.--Not later than 18 months after the date on
which the SRDP protocol is established under subsection
(a)(1), the Secretary shall submit to Congress a report on
the implementation of this section. Such report shall
include--
(1) the number of health care providers of services and
suppliers making disclosures pursuant to an SRDP;
(2) the amounts collected pursuant to the SRDP;
(3) the types of violations reported under the SRDP; and

[[Page H12725]]

(4) such other information as may be necessary to evaluate
the impact of this section.
(d) Relation to Other Law and Regulation.--Nothing in this
section shall affect the application of section 1128G(c) of
the Social Security Act, as added by section 1641, except, in
the case of a health care provider of services or supplier
who is a person (as defined in paragraph (4) of such section
1128G(c)) who discloses an overpayment (as defined in such
paragraph) to the Secretary of Health and Human Services
pursuant to a SRDP established under this section, the 60-day
period described in paragraph (2) of such section 1128G(c)
shall be extended with respect to the return of an
overpayment to the extent necessary for the Secretary to
determine pursuant to the SRDP the amount due and owing.

Subtitle C--Enhanced Program and Provider Protections

SEC. 1631. ENHANCED CMS PROGRAM PROTECTION AUTHORITY.

(a) In General.--Title XI of the Social Security Act (42
U.S.C. 1301 et seq.) is amended by inserting after section
1128F the following new section:

``SEC. 1128G. ENHANCED PROGRAM AND PROVIDER PROTECTIONS IN
THE MEDICARE, MEDICAID, AND CHIP PROGRAMS.

``(a) Certain Authorized Screening, Enhanced Oversight
Periods, and Enrollment Moratoria.--
``(1) In general.--For periods beginning after January 1,
2011, in the case that the Secretary determines there is a
significant risk of fraudulent activity (as determined by the
Secretary based on relevant complaints, reports, referrals by
law enforcement or other sources, data analysis, trending
information, or claims submissions by providers of services
and suppliers) with respect to a category of provider of
services or supplier of items or services, including a
category within a geographic area, under title XVIII, XIX, or
XXI, the Secretary may impose any of the following
requirements with respect to a provider of services or a
supplier (whether such provider or supplier is initially
enrolling in the program or is renewing such enrollment):
``(A) Screening under paragraph (2).
``(B) Enhanced oversight periods under paragraph (3).
``(C) Enrollment moratoria under paragraph (4).

In applying this subsection for purposes of title XIX and XXI
the Secretary may require a State to carry out the provisions
of this subsection as a requirement of the State plan under
title XIX or the child health plan under title XXI. Actions
taken and determinations made under this subsection shall not
be subject to review by a judicial tribunal.
``(2) Screening.--For purposes of paragraph (1), the
Secretary shall establish procedures under which screening is
conducted with respect to providers of services and suppliers
described in such paragraph. Such screening may include--
``(A) licensing board checks;
``(B) screening against the list of individuals and
entities excluded from the program under title XVIII, XIX, or
XXI;
``(C) the excluded provider list system;
``(D) background checks; and
``(E) unannounced pre-enrollment or other site visits.
``(3) Enhanced oversight period.--For purposes of paragraph
(1), the Secretary shall establish procedures to provide for
a period of not less than 30 days and not more than 365 days
during which providers of services and suppliers described in
such paragraph, as the Secretary determines appropriate,
would be subject to enhanced oversight, such as required or
unannounced (or required and unannounced) site visits or
inspections, prepayment review, enhanced review of claims,
and such other actions as specified by the Secretary, under
the programs under titles XVIII, XIX, and XXI. Under such
procedures, the Secretary may extend such period for more
than 365 days if the Secretary determines that after the
initial period such additional period of oversight is
necessary.
``(4) Moratorium on enrollment of providers and
suppliers.--For purposes of paragraph (1), the Secretary,
based upon a finding of a risk of serious ongoing fraud
within a program under title XVIII, XIX, or XXI, may impose a
moratorium on the enrollment of providers of services and
suppliers within a category of providers of services and
suppliers (including a category within a specific geographic
area) under such title. Such a moratorium may only be imposed
if the Secretary makes a determination that the moratorium
would not adversely impact access of individuals to care
under such program.
``(5) 90-day period of enhanced oversight for initial
claims of dme suppliers.--For periods beginning after January
1, 2011, if the Secretary determines under paragraph (1) that
there is a significant risk of fraudulent activity among
suppliers of durable medical equipment, in the case of a
supplier of durable medical equipment who is within a
category or geographic area under title XVIII identified
pursuant to such determination and who is initially enrolling
under such title, the Secretary shall, notwithstanding
section 1842(c)(2), withhold payment under such title with
respect to durable medical equipment furnished by such
supplier during the 90-day period beginning on the date of
the first submission of a claim under such title for durable
medical equipment furnished by such supplier.
``(6) Clarification.--Nothing in this subsection shall be
interpreted to preclude or limit the ability of a State to
engage in provider screening or enhanced provider oversight
activities beyond those required by the Secretary.''.
(b) Conforming Amendments.--
(1) Medicaid.--Section 1902(a) of the Social Security Act
(42 U.S.C. 42 U.S.C. 1396a(a)) is amended--
(A) in paragraph (23), by inserting before the semicolon at
the end the following: ``or by a person to whom or entity to
which a moratorium under section 1128G(a)(4) is applied
during the period of such moratorium'';
(B) in paragraph (72); by striking at the end ``and'';
(C) in paragraph (73), by striking the period at the end
and inserting ``; and''; and
(D) by adding after paragraph (73) the following new
paragraph:
``(74) provide that the State will enforce any
determination made by the Secretary under subsection (a) of
section 1128G (relating to a significant risk of fraudulent
activity with respect to a category of provider or supplier
described in such subsection (a) through use of the
appropriate procedures described in such subsection (a)), and
that the State will carry out any activities as required by
the Secretary for purposes of such subsection (a).''.
(2) CHIP.--Section 2102 of such Act (42 U.S.C. 1397bb) is
amended by adding at the end the following new subsection:
``(d) Program Integrity.--A State child health plan shall
include a description of the procedures to be used by the
State--
``(1) to enforce any determination made by the Secretary
under subsection (a) of section 1128G (relating to a
significant risk of fraudulent activity with respect to a
category of provider or supplier described in such subsection
through use of the appropriate procedures described in such
subsection); and
``(2) to carry out any activities as required by the
Secretary for purposes of such subsection.''.
(3) Medicare.--Section 1866(j) of such Act (42 U.S.C.
1395cc(j)) is amended by adding at the end the following new
paragraph:
``(3) Program integrity.--The provisions of section
1128G(a) apply to enrollments and renewals of enrollments of
providers of services and suppliers under this title.''.

SEC. 1632. ENHANCED MEDICARE, MEDICAID, AND CHIP PROGRAM
DISCLOSURE REQUIREMENTS RELATING TO PREVIOUS
AFFILIATIONS.

(a) In General.--Section 1128G of the Social Security Act,
as inserted by section 1631, is amended by adding at the end
the following new subsection:
``(b) Enhanced Program Disclosure Requirements.--
``(1) Disclosure.--A provider of services or supplier who
submits on or after July 1, 2011, an application for
enrollment and renewing enrollment in a program under title
XVIII, XIX, or XXI shall disclose (in a form and manner
determined by the Secretary) any current affiliation or
affiliation within the previous 10-year period with a
provider of services or supplier that has uncollected debt or
with a person or entity that has been suspended or excluded
under such program, subject to a payment suspension, or has
had its billing privileges revoked.
``(2) Enhanced safeguards.--If the Secretary determines
that such previous affiliation of such provider or supplier
poses a risk of fraud, waste, or abuse, the Secretary may
apply such enhanced safeguards as the Secretary determines
necessary to reduce such risk associated with such provider
or supplier enrolling or participating in the program under
title XVIII, XIX, or XXI. Such safeguards may include
enhanced oversight, such as enhanced screening of claims,
required or unannounced (or required and unannounced) site
visits or inspections, additional information reporting
requirements, and conditioning such enrollment on the
provision of a surety bond.
``(3) Authority to deny participation.--If the Secretary
determines that there has been at least one such affiliation
and that such affiliation or affiliations, as applicable, of
such provider or supplier poses a serious risk of fraud,
waste, or abuse, the Secretary may deny the application of
such provider or supplier.''.
(b) Conforming Amendments.--
(1) Medicaid.--Paragraph (74) of section 1902(a) of such
Act (42 U.S.C. 1396a(a)), as added by section 1631(b)(1), is
amended--
(A) by inserting ``or subsection (b) of such section
(relating to disclosure requirements)'' before ``, and that
the State''; and
(B) by inserting before the period the following: ``and
apply any enhanced safeguards, with respect to a provider or
supplier described in such subsection (b), as the Secretary
determines necessary under such subsection (b)''.
(2) CHIP.--Subsection (d) of section 2102 of such Act (42
U.S.C. 1397bb), as added by section 1631(b)(2), is amended--
(A) in paragraph (1), by striking at the end ``and'';
(B) in paragraph (2) by striking the period at the end and
inserting ``; and' '' and
(C) by adding at the end the following new paragraph:
``(3) to enforce any determination made by the Secretary
under subsection (b) of section 1128G (relating to disclosure
requirements) and to apply any enhanced safeguards, with
respect to a provider or supplier described in such
subsection, as the Secretary determines necessary under such
subsection.''.

[[Page H12726]]

SEC. 1633. REQUIRED INCLUSION OF PAYMENT MODIFIER FOR CERTAIN
EVALUATION AND MANAGEMENT SERVICES.

Section 1848 of the Social Security Act (42 U.S.C. 1395w-
4), as amended by section 4101 of the HITECH Act (Public Law
111-5), is amended by adding at the end the following new
subsection:
``(p) Payment Modifier for Certain Evaluation and
Management Services.--The Secretary shall establish a payment
modifier under the fee schedule under this section for
evaluation and management services (as specified in section
1842(b)(16)(B)(ii)) that result in the ordering of additional
services (such as lab tests), the prescription of drugs, the
furnishing or ordering of durable medical equipment in order
to enable better monitoring of claims for payment for such
additional services under this title, or the ordering,
furnishing, or prescribing of other items and services
determined by the Secretary to pose a high risk of waste,
fraud, and abuse. The Secretary may require providers of
services or suppliers to report such modifier in claims
submitted for payment.''.

SEC. 1634. EVALUATIONS AND REPORTS REQUIRED UNDER MEDICARE
INTEGRITY PROGRAM.

(a) In General.--Section 1893(c) of the Social Security Act
(42 U.S.C. 1395ddd(c)) is amended--
(1) in paragraph (3), by striking at the end ``and'';
(2) by redesignating paragraph (4) as paragraph (5); and
(3) by inserting after paragraph (3) the following new
paragraph:
``(4) for the contract year beginning in 2011 and each
subsequent contract year, the entity provides assurances to
the satisfaction of the Secretary that the entity will
conduct periodic evaluations of the effectiveness of the
activities carried out by such entity under the Program and
will submit to the Secretary an annual report on such
activities; and''.
(b) Reference to Medicaid Integrity Program.--For a similar
provision with respect to the Medicaid Integrity Program, see
section 1752.

SEC. 1635. REQUIRE PROVIDERS AND SUPPLIERS TO ADOPT PROGRAMS
TO REDUCE WASTE, FRAUD, AND ABUSE.

(a) In General.--Section 1866(j) of the Social Security Act
(42 U.S.C. 42 U.S.C. 1395cc(j)), as amended by section
1631(d)(3), is further amended by adding at the end the
following new paragraph:
``(4) Compliance programs for providers of services and
suppliers.--
``(A) In general.--The Secretary may not enroll (or renew
the enrollment of) a provider of services or a supplier
(other than a physician or a skilled nursing facility) under
this title if such provider of services or supplier fails to,
subject to subparagraph (E), establish a compliance program
that contains the core elements established under
subparagraph (B) and certify in a manner determined by the
Secretary, that the provider or suppler has established such
a program.
``(B) Establishment of core elements.--The Secretary, in
consultation with the Inspector General of the Department of
Health and Human Services, shall establish core elements for
a compliance program under subparagraph (A). Such elements
may include written policies, procedures, and standards of
conduct, a designated compliance officer and a compliance
committee; effective training and education pertaining to
fraud, waste, and abuse for the organization's employees, and
contractors; a confidential or anonymous mechanism, such as a
hotline, to receive compliance questions and reports of
fraud, waste, or abuse; disciplinary guidelines for
enforcement of standards; internal monitoring and auditing
procedures, including monitoring and auditing of contractors;
procedures for ensuring prompt responses to detected offenses
and development of corrective action initiatives, including
responses to potential offenses; and procedures to return all
identified overpayments to the programs under this title,
title XIX, and title XXI.
``(C) Timeline for implementation.--The Secretary shall
determine a timeline for the establishment of the core
elements under subparagraph (B) and the date on which a
provider of services and suppliers (other than physicians and
skilled nursing facilities) shall be required to have
established such a program for purposes of this subsection.
``(D) Pilot program.--The Secretary may conduct a pilot
program on the application of this subsection with respect to
a category of providers of services or suppliers (other than
physicians and skilled nursing facilities) that the Secretary
determines to be a category which is at high risk for waste,
fraud, and abuse before implementing the requirements of this
subsection to all providers of services and suppliers
described in subparagraph (C).
``(E) Treatment of skilled nursing facilities.--For the
requirement for skilled nursing facilities to establish
compliance and ethics programs see section 1819(d)(1)(C).
``(F) Construction.--Nothing in this subsection exempts a
physician from participating in a compliance program
established by a health care provider or other entity with
which the physician is employed, under contract, or
affiliated if such compliance is required by such provider or
entity.''.
(b) Reference to Similar Medicaid Provision.--For a similar
provision with respect to the Medicaid program under title
XIX of the Social Security Act, see section 1753.

SEC. 1636. MAXIMUM PERIOD FOR SUBMISSION OF MEDICARE CLAIMS
REDUCED TO NOT MORE THAN 12 MONTHS.

(a) Purpose.--In general, the 36-month period currently
allowed for claims filing under parts A, B, C, and, D of
title XVIII of the Social Security Act presents opportunities
for fraud schemes in which processing patterns of the Centers
for Medicare & Medicaid Services can be observed and
exploited. Narrowing the window for claims processing will
not overburden providers and will reduce fraud and abuse.
(b) Reducing Maximum Period for Submission.--
(1) Part a.--Section 1814(a) of the Social Security Act (42
U.S.C. 1395f(a)) is amended--
(A) in paragraph (1), by striking ``period of 3 calendar
years'' and all that follows and inserting ``period of 1
calendar year from which such services are furnished; and'';
and
(B) by adding at the end the following new sentence: ``In
applying paragraph (1), the Secretary may specify exceptions
to the 1 calendar year period specified in such paragraph.''.
(2) Part b.--Section 1835(a) of such Act (42 U.S.C.
1395n(a)) is amended--
(A) in paragraph (1), by striking ``period of 3 calendar
years'' and all that follows and inserting ``period of 1
calendar year from which such services are furnished; and'';
and
(B) by adding at the end the following new sentence: ``In
applying paragraph (1), the Secretary may specify exceptions
to the 1 calendar year period specified in such paragraph.''.
(3) Parts c and d.--Section 1857(d) of such Act is amended
by adding at the end the following new paragraph:
``(7) Period for submission of claims.--The contract shall
require an MA organization or PDP sponsor to require any
provider of services under contract with, in partnership
with, or affiliated with such organization or sponsor to
ensure that, with respect to items and services furnished by
such provider to an enrollee of such organization, written
request, signed by such enrollee, except in cases in which
the Secretary finds it impracticable for the enrollee to do
so, is filed for payment for such items and services in such
form, in such manner, and by such person or persons as the
Secretary may by regulation prescribe, no later than the
close of the 1 calendar year period after such items and
services are furnished. In applying the previous sentence,
the Secretary may specify exceptions to the 1 calendar year
period specified.''.
(c) Effective Date.--The amendments made by subsection (b)
shall be effective for items and services furnished on or
after January 1, 2011.

SEC. 1637. PHYSICIANS WHO ORDER DURABLE MEDICAL EQUIPMENT OR
HOME HEALTH SERVICES REQUIRED TO BE MEDICARE
ENROLLED PHYSICIANS OR ELIGIBLE PROFESSIONALS.

(a) DME.--Section 1834(a)(11)(B) of the Social Security Act
(42 U.S.C. 1395m(a)(11)(B)) is amended by striking
``physician'' and inserting ``physician enrolled under
section 1866(j) or other professional, as determined by the
Secretary''.
(b) Home Health Services.--
(1) Part a.--Section 1814(a)(2) of such Act (42 U.S.C.
1395(a)(2)) is amended in the matter preceding subparagraph
(A) by inserting ``in the case of services described in
subparagraph (C), a physician enrolled under section 1866(j)
or other professional, as determined by the Secretary,''
before ``or, in the case of services''.
(2) Part b.--Section 1835(a)(2) of such Act (42 U.S.C.
1395n(a)(2)) is amended in the matter preceding subparagraph
(A) by inserting ``, or in the case of services described in
subparagraph (A), a physician enrolled under section 1866(j)
or other professional, as determined by the Secretary,''
after ``a physician''.
(c) Discretion to Expand Application.--The Secretary may
extend the requirement applied by the amendments made by
subsections (a) and (b) to durable medical equipment and home
health services (relating to requiring certifications and
written orders to be made by enrolled physicians and health
professions) to other categories of items or services under
this title, including covered part D drugs as defined in
section 1860D-2(e), if the Secretary determines that such
application would help to reduce the risk of waste, fraud,
and abuse with respect to such other categories under title
XVIII of the Social Security Act.
(d) Effective Date.--The amendments made by this section
shall apply to written orders and certifications made on or
after July 1, 2010.

SEC. 1638. REQUIREMENT FOR PHYSICIANS TO PROVIDE
DOCUMENTATION ON REFERRALS TO PROGRAMS AT HIGH
RISK OF WASTE AND ABUSE.

(a) Physicians and Other Suppliers.--Section 1842(h) of the
Social Security Act is further amended by adding at the end
the following new paragraph
``(9) The Secretary may disenroll, for a period of not more
than one year for each act, a physician or supplier under
section 1866(j) if such physician or supplier fails to
maintain and, upon request of the Secretary, provide access
to documentation relating to written orders or requests for
payment for durable medical equipment, certifications for
home health services, or referrals for other items or
services written or ordered by such physician or supplier
under this title, as specified by the Secretary.''.
(b) Providers of Services.--Section 1866(a)(1) of such Act
(42 U.S.C. 1395cc), is amended--

[[Page H12727]]

(1) in subparagraph (U), by striking at the end ``and'';
(2) in subparagraph (V), by striking the period at the end
and adding ``; and''; and
(3) by adding at the end the following new subparagraph:
``(W) maintain and, upon request of the Secretary, provide
access to documentation relating to written orders or
requests for payment for durable medical equipment,
certifications for home health services, or referrals for
other items or services written or ordered by the provider
under this title, as specified by the Secretary.''.
(c) OIG Permissive Exclusion Authority.--Section
1128(b)(11) of the Social Security Act (42 U.S.C. 1320a-
7(b)(11)) is amended by inserting ``, ordering, referring for
furnishing, or certifying the need for'' after
``furnishing''.
(d) Effective Date.--The amendments made by this section
shall apply to orders, certifications, and referrals made on
or after January 1, 2010.

SEC. 1639. FACE-TO-FACE ENCOUNTER WITH PATIENT REQUIRED
BEFORE ELIGIBILITY CERTIFICATIONS FOR HOME
HEALTH SERVICES OR DURABLE MEDICAL EQUIPMENT.

(a) Condition of Payment for Home Health Services.--
(1) Part a.--Section 1814(a)(2)(C) of such Act is amended--
(A) by striking ``and such services'' and inserting ``such
services''; and
(B) by inserting after ``care of a physician'' the
following: ``, and, in the case of a certification or
recertification made by a physician after January 1, 2010,
prior to making such certification the physician must
document that the physician has had a face-to-face encounter
(including through use of telehealth and other than with
respect to encounters that are incident to services involved)
with the individual during the 6-month period preceding such
certification, or other reasonable timeframe as determined by
the Secretary''.
(2) Part b.--Section 1835(a)(2)(A) of the Social Security
Act is amended--
(A) by striking ``and'' before ``(iii)''; and
(B) by inserting after ``care of a physician'' the
following: ``, and (iv) in the case of a certification or
recertification after January 1, 2010, prior to making such
certification the physician must document that the physician
has had a face-to-face encounter (including through use of
telehealth and other than with respect to encounters that are
incident to services involved) with the individual during the
6-month period preceding such certification or
recertification, or other reasonable timeframe as determined
by the Secretary''.
(b) Condition of Payment for Durable Medical Equipment.--
Section 1834(a)(11)(B) of the Social Security Act (42 U.S.C.
1395m(a)(11)(B)) is amended by adding before the period at
the end the following: ``and shall require that any written
order required for payment under this subsection be written
only pursuant to the eligible health care professional
authorized to make such written order documenting that such
professional has had a face-to-face encounter (including
through use of telehealth and other than with respect to
encounters that are incident to services involved) with the
individual involved during the 6-month period preceding such
written order, or other reasonable timeframe as determined by
the Secretary''.
(c) Application to Other Areas Under Medicare.--The
Secretary may apply a face-to-face encounter requirement
similar to the requirement described in the amendments made
by subsections (a) and (b) to other items and services for
which payment is provided under title XVIII of the Social
Security Act based upon a finding that such a decision would
reduce the risk of waste, fraud, or abuse.
(d) Application to Medicaid and CHIP.--The face-to-face
encounter requirements described in the amendments made by
subsections (a) and (b) and any expanded application of
similar requirements pursuant to subsection (c) shall apply
with respect to a certification or recertification for home
health services under title XIX or XXI of the Social Security
Act, a written order for durable medical equipment under such
title, and any other applicable item or service identified
pursuant to subsection (c) for which payment is made under
such title, respectively, in the same manner and to the same
extent as such requirements apply in the case of such a
certification or recertification, written order, or other
applicable item or service so identified, respectively, under
title XVIII of such Act.

SEC. 1640. EXTENSION OF TESTIMONIAL SUBPOENA AUTHORITY TO
PROGRAM EXCLUSION INVESTIGATIONS.

(a) In General.--Section 1128(f) of the Social Security Act
(42 U.S.C. 1320a-7(f)) is amended by adding at the end the
following new paragraph:
``(4) The provisions of subsections (d) and (e) of section
205 shall apply with respect to this section to the same
extent as they are applicable with respect to title II. The
Secretary may delegate the authority granted by section
205(d) (as made applicable to this section) to the Inspector
General of the Department of Health and Human Services or the
Administrator of the Centers for Medicare & Medicaid Services
for purposes of any investigation under this section.''.
(b) Effective Date.--The amendment made by subsection (a)
shall apply to investigations beginning on or after January
1, 2010.

SEC. 1641. REQUIRED REPAYMENTS OF MEDICARE AND MEDICAID
OVERPAYMENTS.

Section 1128G of the Social Security Act, as inserted by
section 1631 and amended by section 1632, is further amended
by adding at the end the following new subsection:
``(c) Reports on and Repayment of Overpayments Identified
Through Internal Audits and Reviews.--
``(1) Reporting and returning overpayments.--If a person
knows of an overpayment, the person must--
``(A) report and return the overpayment to the Secretary,
the State, an intermediary, a carrier, or a contractor, as
appropriate, at the correct address, and
``(B) notify the Secretary, the State, intermediary,
carrier, or contractor to whom the overpayment was returned
in writing of the reason for the overpayment.
``(2) Timing.--Subject to section 1620(d) of the Affordable
Health Care for America Act, an overpayment must be reported
and returned under paragraph (1)(A) by not later than the
date that is 60 days after the date the person knows of the
overpayment.
Any known overpayment retained later than the applicable date
specified in this paragraph creates an obligation as defined
in section 3729(b)(3) of title 31 of the United States Code.
``(3) Clarification.--Repayment of any overpayments (or
refunding by withholding of future payments) by a provider of
services or supplier does not otherwise limit the provider or
supplier's potential liability for administrative obligations
such as applicable interests, fines, and penalties or civil
or criminal sanctions involving the same claim if it is
determined later that the reason for the overpayment was
related to fraud or other intentional conduct by the provider
or supplier or the employees or agents of such provider or
supplier.
``(4) Definitions.--In this subsection:
``(A) Knows.--The term `knows' has the meaning given the
terms `knowing' and `knowingly' in section 3729(b) of title
31 of the United States Code.
``(B) Overpayment.--The term ``overpayment'' means any
funds that a person receives or retains under title XVIII,
XIX, or XXI to which the person, after applicable
reconciliation (pursuant to the applicable existing process
under the respective title), is not entitled under such
title.
``(C) Person.--The term `person' means a provider of
services, supplier, Medicaid managed care organization (as
defined in section 1903(m)(1)(A)), Medicare Advantage
organization (as defined in section 1859(a)(1)), or PDP
sponsor (as defined in section 1860D-41(a)(13)), but
excluding a beneficiary.''.

SEC. 1642. EXPANDED APPLICATION OF HARDSHIP WAIVERS FOR OIG
EXCLUSIONS TO BENEFICIARIES OF ANY FEDERAL
HEALTH CARE PROGRAM.

Section 1128(c)(3)(B) of the Social Security Act (42 U.S.C.
1320a-7(c)(3)(B)) is amended by striking ``individuals
entitled to benefits under part A of title XVIII or enrolled
under part B of such title, or both'' and inserting
``beneficiaries (as defined in section 1128A(i)(5)) of that
program''.

SEC. 1643. ACCESS TO CERTAIN INFORMATION ON RENAL DIALYSIS
FACILITIES.

Section 1881(b) of the Social Security Act (42 U.S.C.
1395rr(b)) is amended by adding at the end the following new
paragraph:
``(15) For purposes of evaluating or auditing payments made
to renal dialysis facilities for items and services under
this section under paragraph (1), each such renal dialysis
facility, upon the request of the Secretary, shall provide to
the Secretary access to information relating to any ownership
or compensation arrangement between such facility and the
medical director of such facility or between such facility
and any physician.''.

SEC. 1644. BILLING AGENTS, CLEARINGHOUSES, OR OTHER ALTERNATE
PAYEES REQUIRED TO REGISTER UNDER MEDICARE.

(a) Medicare.--Section 1866(j)(1) of the Social Security
Act (42 U.S.C. 1395cc(j)(1)) is amended by adding at the end
the following new subparagraph:
``(D) Billing agents and clearinghouses required to be
registered under medicare.--Any agent, clearinghouse, or
other alternate payee that submits claims on behalf of a
health care provider must be registered with the Secretary in
a form and manner specified by the Secretary.''.
(b) Medicaid.--For a similar provision with respect to the
Medicaid program under title XIX of the Social Security Act,
see section 1759.
(c) Effective Date.--The amendment made by subsection (a)
shall apply to claims submitted on or after January 1, 2012.

SEC. 1645. CONFORMING CIVIL MONETARY PENALTIES TO FALSE
CLAIMS ACT AMENDMENTS.

Section 1128A of the Social Security Act, as amended by
sections 1611, 1612, 1613, and 1615, is further amended--
(1) in subsection (a)--
(A) in paragraph (1), by striking ``to an officer,
employee, or agent of the United States, or of any department
or agency thereof, or of any State agency (as defined in
subsection (i)(1))'';
(B) in paragraph (4)--
(i) in the matter preceding subparagraph (A), by striking
``participating in a program under title XVIII or a State
health care program'' and inserting ``participating in a
Federal health care program (as defined in section
1128B(f))''; and
(ii) in subparagraph (A), by striking ``title XVIII or a
State health care program'' and

[[Page H12728]]

inserting ``a Federal health care program (as defined in
section 1128B(f))'';
(C) by striking ``or'' at the end of paragraph (10);
(D) by inserting after paragraph (11) the following new
paragraphs:
``(12) conspires to commit a violation of this section; or
``(13) knowingly makes, uses, or causes to be made or used,
a false record or statement material to an obligation to pay
or transmit money or property to a Federal health care
program, or knowingly conceals or knowingly and improperly
avoids or decreases an obligation to pay or transmit money or
property to a Federal health care program;''; and
(E) in the matter following paragraph (13), as inserted by
subparagraph (D)--
(i) by striking ``or'' before ``in cases under paragraph
(11)''; and
(ii) by inserting ``, in cases under paragraph (12),
$50,000 for any violation described in this section committed
in furtherance of the conspiracy involved; or in cases under
paragraph (13), $50,000 for each false record or statement,
or concealment, avoidance, or decrease'' after ``by an
excluded individual''; and
(F) in the second sentence, by striking ``such false
statement, omission, or misrepresentation)'' and inserting
``such false statement or misrepresentation, in cases under
paragraph (12), an assessment of not more than 3 times the
total amount that would otherwise apply for any violation
described in this section committed in furtherance of the
conspiracy involved, or in cases under paragraph (13), an
assessment of not more than 3 times the total amount of the
obligation to which the false record or statement was
material or that was avoided or decreased)''.
(2) in subsection (c)(1), by striking ``six years'' and
inserting ``10 years''; and
(3) in subsection (i)--
(A) by amending paragraph (2) to read as follows:
``(2) The term `claim' means any application, request, or
demand, whether under contract, or otherwise, for money or
property for items and services under a Federal health care
program (as defined in section 1128B(f)), whether or not the
United States or a State agency has title to the money or
property, that--
``(A) is presented or caused to be presented to an officer,
employee, or agent of the United States, or of any department
or agency thereof, or of any State agency (as defined in
subsection (i)(1)); or
``(B) is made to a contractor, grantee, or other recipient
if the money or property is to be spent or used on the
Federal health care program's behalf or to advance a Federal
health care program interest, and if the Federal health care
program--
``(i) provides or has provided any portion of the money or
property requested or demanded; or
``(ii) will reimburse such contractor, grantee, or other
recipient for any portion of the money or property which is
requested or demanded.'';
(B) by amending paragraph (3) to read as follows:
``(3) The term `item or service' means, without limitation,
any medical, social, management, administrative, or other
item or service used in connection with or directly or
indirectly related to a Federal health care program.'';
(C) in paragraph (6)--
(i) in subparagraph (C), by striking at the end ``or'';
(ii) in the first subparagraph (D), by striking at the end
the period and inserting ``; or''; and
(iii) by redesignating the second subparagraph (D) as a
subparagraph (E);
(D) by amending paragraph (7) to read as follows:
``(7) The terms `knowing', `knowingly', and `should know'
mean that a person, with respect to information--
``(A) has actual knowledge of the information;
``(B) acts in deliberate ignorance of the truth or falsity
of the information; or
``(C) acts in reckless disregard of the truth or falsity of
the information;
and require no proof of specific intent to defraud.''; and
(E) by adding at the end the following new paragraphs:
``(8) The term `obligation' means an established duty,
whether or not fixed, arising from an express or implied
contractual, grantor-grantee, or licensor-licensee
relationship, from a fee-based or similar relationship, from
statute or regulation, or from the retention of any
overpayment.
``(9) The term `material' means having a natural tendency
to influence, or be capable of influencing, the payment or
receipt of money or property.''.

SEC. 1646. REQUIRING PROVIDER AND SUPPLIER PAYMENTS UNDER
MEDICARE TO BE MADE THROUGH DIRECT DEPOSIT OR
ELECTRONIC FUNDS TRANSFER (EFT) AT INSURED
DEPOSITORY INSTITUTIONS.

(a) Medicare.--Section 1874 of the Social Security Act (42
U.S.C. 1395kk) is amended by adding at the end the following
new subsection:
``(e) Limitation on Payment to Providers of Services and
Suppliers.--No payment shall be made under this title for
items and services furnished by a provider of services or
supplier unless each payment to the provider of services or
supplier is in the form of direct deposit or electronic funds
transfer to the provider of services' or supplier's account,
as applicable, at a depository institution (as defined in
section 19(b)(1)(A) of the Federal Reserve Act.''.
(b) Effective Date.--The amendments made by this section
shall apply to each payment made to a provider of services,
provider, or supplier on or after such date (not later than
July 1, 2012) as the Secretary of Health and Human Services
shall specify, regardless of when the items and services for
which such payment is made were furnished.

SEC. 1647. INSPECTOR GENERAL FOR THE HEALTH CHOICES
ADMINISTRATION.

(a) Establishment; Appointment.--There is hereby
established an Office of Inspector General for the Health
Choices Administration, to be headed by the Inspector General
for the Health Choices Administration to be appointed by the
President, by and with the advice and consent of the Senate.
(b) Amendments to the Inspector General Act of 1978.--
(1) Application to health choices administration.--Section
12 of the Inspector General Act of 1978 (5 U.S.C. App.) is
amended--
(A) in paragraph (1), by striking ``or the Federal
Cochairpersons of the Commissions established under section
15301 of title 40, United States Code'' and inserting ``the
Federal Cochairpersons of the Commissions established under
section 15301 of title 40, United States Code; or the
Commissioner of the Health Choices Administration established
under section 241 of the Affordable Health Care for America
Act''; and
(B) in paragraph (2), by striking ``or the Commissions
established under section 15301 of title 40, United States
Code'' and inserting ``the Commissions established under
section 15301 of title 40, United States Code, or the Health
Choices Administration established under section 241 of the
Affordable Health Care for America Act''.
(2) Special provisions relating to health choices
administration and hhs.--The Inspector General Act of 1978 (5
U.S.C. App.) is further amended by inserting after section 8L
the following new section:

``SEC. 8M SPECIAL PROVISIONS RELATING TO THE HEALTH CHOICES
ADMINISTRATION AND THE DEPARTMENT OF HEALTH AND
HUMAN SERVICES.

``(a) The Inspector General of the Health Choices
Administration shall--
``(1) have the authority to conduct, supervise, and
coordinate audits, evaluations, and investigations of the
programs and operations of the Health Choices Administration
established under section 241 of the Affordable Health Care
for America Act, including matters relating to fraud, abuse,
and misconduct in connection with the admission and continued
participation of any health benefits plan participating in
the Health Insurance Exchange established under section 301
of such Act;
``(2) have the authority to conduct audits, evaluations,
and investigations relating to any private Exchange-
participating health benefits plan, as defined in section
201(c) of such Act;
``(3) have the authority, in consultation with the Office
of Inspector General for the Department of Health and Human
Services and subject to subsection (b), to conduct audits,
evaluations, and investigations relating to the public health
insurance option established under section 321 of such Act;
and
``(4) have access to all relevant records necessary to
carry out this section, including records relating to claims
paid by Exchange-participating health benefits plans.
``(b) Authority granted to the Health Choices
Administration and the Inspector General of the Health
Choices Administration by the Affordable Health Care for
America Act does not limit the duties, authorities, and
responsibilities of the Office of Inspector General for the
Department of Health and Human Services, as in existence as
of the date of the enactment of the Affordable Health Care
for America Act, to oversee programs and operations of such
department. The Office of Inspector General for the
Department of Health and Human Services retains primary
jurisdiction over fraud and abuse in connection with payments
made under the public health insurance option established
under section 321 of such Act and administered by the
Department of Health and Human Services.''.
(3) Application of rule of construction.--Section 8J of the
Inspector General Act of 1978 (5 U.S.C. App.) is amended by
striking ``or 8H'' and inserting ``, 8H, or 8M''.
(c) Effective Date.--The provisions of and amendments made
by this section shall take effect on the date of the
enactment of this Act.

Subtitle D--Access to Information Needed to Prevent Fraud, Waste, and
Abuse

SEC. 1651. ACCESS TO INFORMATION NECESSARY TO IDENTIFY FRAUD,
WASTE, AND ABUSE.

(a) GAO Access.--Subchapter II of chapter 7 of title 31,
United States Code, is amended by adding at the end the
following:

``Sec. 721. Access to certain information

``No provision of the Social Security Act shall be
construed to limit, amend, or supersede the authority of the
Comptroller General to obtain any information, to inspect any
record, or to interview any officer or employee under section
716 of this title, including with respect to any information
disclosed to or obtained by the Secretary of Health and Human
Services under part C or D of title XVIII of the Social
Security Act.''.
(b) Access to Medicare Part D Data Program Integrity
Purposes.--

[[Page H12729]]

(1) Provision of information as condition of payment.--
Section 1860D-15(d)(2)(B) of the Social Security Act (42
U.S.C. 1395w-115(d)(2)(B)) is amended--
(A) by striking ``may be used by officers'' and all that
follows through the period and inserting ``may be used by--
''; and
(B) by adding at the end the following clauses:
``(i) officers, employees, and contractors of the
Department of Health and Human Services only for the purposes
of, and to the extent necessary in, carrying out this
section; and
``(ii) the Inspector General of the Department of Health
and Human Services, the Administrator of the Centers for
Medicare & Medicaid Services, and the Attorney General only
for the purposes of protecting the integrity of the programs
under this title and title XIX; conducting the activities
described in section 1893 and subparagraphs (A) through (E)
of section 1128C(a)(1); and for investigation, audit,
evaluation, oversight,
and law enforcement purposes to the extent consistent with
applicable law.''.
(2) General disclosure of information.--Section 1860D-
15(f)(2) of the Social Security Act (42 U.S.C. 1395w-
115(f)(2)) is amended--
(A) by striking ``may be used by officers'' and all that
follows through the period and inserting ``may be used by--
''; and
(B) by adding at the end the following subparagraphs:
``(A) officers, employees, and contractors of the
Department of Health and Human Services only for the purposes
of, and to the extent necessary in, carrying out this
section; and
``(B) the Inspector General of the Department of Health and
Human Services, the Administrator of the Centers for Medicare
& Medicaid Services, and the Attorney General only for the
purposes of protecting the integrity of the programs under
this title and title XIX; conducting the activities described
in section 1893 and subparagraphs (A) through (E) of section
1128C(a)(1); and for investigation, audit, evaluation,
oversight,
and law enforcement purposes to the extent consistent with
applicable law.''.

SEC. 1652. ELIMINATION OF DUPLICATION BETWEEN THE HEALTHCARE
INTEGRITY AND PROTECTION DATA BANK AND THE
NATIONAL PRACTITIONER DATA BANK.

(a) In General.--To eliminate duplication between the
Healthcare Integrity and Protection Data Bank (HIPDB)
established under section 1128E of the Social Security Act
and the National Practitioner Data Bank (NPBD) established
under the Health Care Quality Improvement Act of 1986,
section 1128E of the Social Security Act (42 U.S.C. 1320a-7e)
is amended--
(1) in subsection (a), by striking ``Not later than'' and
inserting ``Subject to subsection (h), not later than'';
(2) in the first sentence of subsection (d)(2), by striking
``(other than with respect to requests by Federal
agencies)''; and
(3) by adding at the end the following new subsection:
``(h) Sunset of the Healthcare Integrity and Protection
Data Bank; Transition Process.--Effective upon the enactment
of this subsection, the Secretary shall implement a process
to eliminate duplication between the Healthcare Integrity and
Protection Data Bank (in this subsection referred to as the
`HIPDB' established pursuant to subsection (a) and the
National Practitioner Data Bank (in this subsection referred
to as the `NPDB') as implemented under the Health Care
Quality Improvement Act of 1986 and section 1921 of this Act,
including systems testing necessary to ensure that
information formerly collected in the HIPDB will be
accessible through the NPDB, and other activities necessary
to eliminate duplication between the two data banks. Upon the
completion of such process, notwithstanding any other
provision of law, the Secretary shall cease the operation of
the HIPDB and shall collect information required to be
reported under the preceding provisions of this section in
the NPDB. Except as otherwise provided in this subsection,
the provisions of subsections (a) through (g) shall continue
to apply with respect to the reporting of (or failure to
report), access to, and other treatment of the information
specified in this section.''.
(b) Elimination of the Responsibility of the HHS Office of
the Inspector General.--Section 1128C(a)(1) of the Social
Security Act (42 U.S.C. 1320a-7c(a)(1)) is amended--
(1) in subparagraph (C), by adding at the end ``and'';
(2) in subparagraph (D), by striking at the end ``, and''
and inserting a period; and
(3) by striking subparagraph (E).
(c) Special Provision for Access to the National
Practitioner Data Bank by the Department of Veterans
Affairs.--
(1) In general.--Notwithstanding any other provision of
law, during the one year period that begins on the effective
date specified in subsection (e)(1), the information
described in paragraph (2) shall be available from the
National Practitioner Data Bank (described in section 1921 of
the Social Security Act) to the Secretary of Veterans Affairs
without charge.
(2) Information described.--For purposes of paragraph (1),
the information described in this paragraph is the
information that would, but for the amendments made by this
section, have been available to the Secretary of Veterans
Affairs from the Healthcare Integrity and Protection Data
Bank.
(d) Funding.--Notwithstanding any provisions of this Act,
sections 1128E(d)(2) and 1817(k)(3) of the Social Security
Act, or any other provision of law, there shall be available
for carrying out the transition process under section
1128E(h) of the Social Security Act over the period required
to complete such process, and for operation of the National
Practitioner Data Bank until such process is completed,
without fiscal year limitation--
(1) any fees collected pursuant to section 1128E(d)(2) of
such Act; and
(2) such additional amounts as necessary, from
appropriations available to the Secretary and to the Office
of the Inspector General of the Department of Health and
Human Services under clauses (i) and (ii), respectively, of
section 1817(k)(3)(A) of such Act, for costs of such
activities during the first 12 months following the date of
the enactment of this Act.
(e) Effective Date.--The amendments made--
(1) by subsection (a)(2) shall take effect on the first day
after the Secretary of Health and Human Services certifies
that the process implemented pursuant to section 1128E(h) of
the Social Security Act (as added by subsection (a)(3)) is
complete; and
(2) by subsection (b) shall take effect on the earlier of
the date specified in paragraph (1) or the first day of the
second succeeding fiscal year after the fiscal year during
which this Act is enacted.

SEC. 1653. COMPLIANCE WITH HIPAA PRIVACY AND SECURITY
STANDARDS.

The provisions of sections 262(a) and 264 of the Health
Insurance Portability and Accountability Act of 1996 (and
standards promulgated pursuant to such sections) and the
Privacy Act of 1974 shall apply with respect to the
provisions of this subtitle and amendments made by this
subtitle.

SEC. 1654. DISCLOSURE OF MEDICARE FRAUD AND ABUSE HOTLINE
NUMBER ON EXPLANATION OF BENEFITS.

(a) In General.--Section 1804 of the Social Security Act
(42 U.S.C. 1395b-2) is amended by adding at the end the
following new subsection:
``(d) Any statement or notice containing an explanation of
the benefits available under this title, including the notice
required by subsection (a), distributed for periods after
July 1, 2011, shall prominently display in a manner
prescribed by the Secretary a separate toll-free telephone
number maintained by the Secretary for the receipt of
complaints and information about waste, fraud, and abuse in
the provision or billing of services under this title.''.
(b) Conforming Amendments.--Section 1804(c) of the Social
Security Act (42 U.S.C. 1395b-2(c)) is amended--
(1) in paragraph (2), by adding ``and'' at the end;
(2) in paragraph (3), by striking ``; and'' and inserting a
period; and
(3) by striking paragraph (4).

TITLE VII--MEDICAID AND CHIP

Subtitle A--Medicaid and Health Reform

SEC. 1701. ELIGIBILITY FOR INDIVIDUALS WITH INCOME BELOW 150
PERCENT OF THE FEDERAL POVERTY LEVEL.

(a) Eligibility for Non-traditional Individuals With Income
Below 150 Percent of the Federal Poverty Level.--
(1) Full medicaid benefits for non-medicare eligible
individuals.--Section 1902(a)(10)(A)(i) of the Social
Security Act (42 U.S.C. 1396b(a)(10)(A)(i)) is amended--
(A) by striking ``or'' at the end of subclause (VI);
(B) by adding ``or'' at the end of subclause (VII); and
(C) by adding at the end the following new subclause:

``(VIII) who are under 65 years of age, who are not
described in a previous subclause of this clause, who are not
entitled to hospital insurance benefits under part A of title
XVIII, and whose family income (determined using
methodologies and procedures specified by the Secretary in
consultation with the Health Choices Commissioner) does not
exceed 150 percent of the income official poverty line (as
defined by the Office of Management and Budget, and revised
annually in accordance with section 673(2) of the Omnibus
Budget Reconciliation Act of 1981) applicable to a family of
the size involved;''.

(2) Medicare cost sharing assistance for medicare-eligible
individuals.--Section 1902(a)(10)(E) of such Act (42 U.S.C.
1396b(a)(10)(E)) is amended--
(A) in clause (iii), by striking ``and'' at the end;
(B) in clause (iv), by adding ``and'' at the end; and
(C) by adding at the end the following new clause:
``(v) for making medical assistance available for medicare
cost-sharing described in subparagraphs (B) and (C) of
section 1905(p)(3), for individuals under 65 years of age who
would be qualified medicare beneficiaries described in
section 1905(p)(1) but for the fact that their income exceeds
the income level established by the State under section
1905(p)(2) but is less than 150 percent of the official
poverty line (referred to in such section) for a family of
the size involved; and''.
(3) Increased fmap for non-traditional full medicaid
eligible individuals.--Section 1905 of such Act (42 U.S.C.
1396d) is amended--
(A) in the first sentence of subsection (b), by striking
``and'' before ``(4)'' and by inserting before the period at
the end the following: ``, and (5) 100 percent (for periods
before 2015 and 91 percent for periods beginning

[[Page H12730]]

with 2015) with respect to amounts described in subsection
(y)''; and
(B) by adding at the end the following new subsection:
``(y) Additional Expenditures Subject to Increased FMAP.--
For purposes of section 1905(b)(5), the amounts described in
this subsection are the following:
``(1) Amounts expended for medical assistance for
individuals described in subclause (VIII) of section
1902(a)(10)(A)(i).''.
(4) Construction.--Nothing in this subsection shall be
construed as not providing for coverage under subparagraph
(A)(i)(VIII) or (E)(v) of section 1902(a)(10) of the Social
Security Act, as added by paragraphs (1) and (2), or an
increased FMAP under the amendments made by paragraph (3),
for an individual who has been provided medical assistance
under title XIX of the Act under a demonstration waiver
approved under section 1115 of such Act or with State funds.
(5) Conforming amendments.--
(A) Section 1903(f)(4) of the Social Security Act (42
U.S.C. 1396b(f)(4)) is amended--
(i) by inserting ``1902(a)(10)(A)(i)(VIII),'' after
``1902(a)(10)(A)(i)(VII),''; and
(ii) by inserting ``1902(a)(10)(E)(v),'' before
``1905(p)(1)''.
(B) Section 1905(a) of such Act (42 U.S.C. 1396d(a)), as
amended by sections 1714(a)(4) and 1731(c), is further
amended, in the matter preceding paragraph (1)--
(i) by striking ``or'' at the end of clause (xiv);
(ii) by adding ``or'' at the end of clause (xv); and
(iii) by inserting after clause (xv) the following:
``(xvi) individuals described in section
1902(a)(10)(A)(i)(VIII),''.
(b) Eligibility for Traditional Medicaid Eligible
Individuals With Income Not Exceeding 150 Percent of the
Federal Poverty Level .--
(1) In general.--Section 1902(a)(10)(A)(i) of the Social
Security Act (42 U.S.C. 1396b(a)(10)(A)(i)), as amended by
subsection (a), is amended--
(A) by striking ``or'' at the end of subclause (VII); and
(B) by adding at the end the following new subclauses:

``(IX) who are over 18, and under 65 years of age, who
would be eligible for medical assistance under the State plan
under subclause (I) or section 1931 (based on the income
standards, methodologies, and procedures in effect as of June
16, 2009) but for income, who are in families whose income
does not exceed 150 percent of the income official poverty
line (as defined by the Office of Management and Budget, and
revised annually in accordance with section 673(2) of the
Omnibus Budget Reconciliation Act of 1981) applicable to a
family of the size involved; or
``(X) beginning with 2014, who are under 19, years of age,
who would be eligible for medical assistance under the State
plan under subclause (I), (IV) (insofar as it relates to
subsection (l)(1)(B)), (VI), or (VII) (based on the income
standards, methodologies, and procedures in effect as of June
16, 2009) but for income, who are in families whose income
does not exceed 150 percent of the income official poverty
line (as defined by the Office of Management and Budget, and
revised annually in accordance with section 673(2) of the
Omnibus Budget Reconciliation Act of 1981) applicable to a
family of the size involved; or
``(XI) beginning with 2014, who are under 19 years of age,
who are not described in subclause (X), and who would be
eligible for child health assistance under a State child
health plan insofar as such plan provides benefits under this
title (as described in section 2101(a)(2)) based on such plan
as in effect as of June 16, 2009; or''.

(2) Increased fmap for certain traditional medicaid
eligible individuals.--
(A) Increased fmap for adults.--Section 1905(y) of such Act
(42 U.S.C. 1396d(y)), as added by subsection (a)(2)(B), is
amended by inserting ``or (IX)'' after ``(VIII)''.
(B) Enhanced fmap for children.--Section 1905(b)(4) of such
Act is amended by inserting ``1902(a)(10)(A)(i)(X),
1902(a)(10)(A)(i)(XI), or'' after ``on the basis of
section''.
(3) Construction.--Nothing in this subsection shall be
construed as not providing for coverage under subclause (IX),
(X), or (XI) of section 1902(a)(10)(A)(i) of the Social
Security Act, as added by paragraph (1), or an increased or
enhanced FMAP under the amendments made by paragraph (2), for
an individual who has been provided medical assistance under
title XIX of the Act under a demonstration waiver approved
under section 1115 of such Act or with State funds.
(4) Conforming amendment.--Section 1903(f)(4) of the Social
Security Act (42 U.S.C. 1396b(f)(4)), as amended by
subsection (a)(4), is amended by inserting
``1902(a)(10)(A)(i)(IX), 1902(a)(10)(A)(i)(X),
1902(a)(10)(A)(i)(XI),'' after ``1902(a)(10)(A)(i)(VIII),''.
(c) Increased Matching Rate for Temporary Coverage of
Certain Newborns.--Section 1905(y) of such Act, as added by
subsection (a)(3)(B), is amended by adding at the end the
following:
``(2) Amounts expended for medical assistance for children
described in section 305(d)(1) of the Affordable Health Care
for America Act during the time period specified in such
section.''.
(d) Network Adequacy.--Section 1932(a)(2) of the Social
Security Act (42 U.S.C. 1396u-2(a)(2)) is amended by adding
at the end the following new subparagraph:
``(D) Enrollment of non-traditional medicaid eligibles.--A
State may not require under paragraph (1) the enrollment in a
managed care entity of an individual described in section
1902(a)(10)(A)(i)(VIII) unless the State demonstrates, to the
satisfaction of the Secretary, that the entity, through its
provider network and other arrangements, has the capacity to
meet the health, mental health, and substance abuse needs of
such individuals.''.
(e) Effective Date.--The amendments made by this section
shall take effect on the first day of Y1, and shall apply
with respect to items and services furnished on or after such
date.

SEC. 1702. REQUIREMENTS AND SPECIAL RULES FOR CERTAIN
MEDICAID ELIGIBLE INDIVIDUALS.

(a) In General.--Title XIX of the Social Security Act is
amended by adding at the end the following new section:

`` requirements and special rules for certain medicaid eligible
individuals

``Sec. 1943.  (a) Coordination With NHI Exchange Through
Memorandum of Understanding.--
``(1) In general.--The State shall enter into a Medicaid
memorandum of understanding described in section 305(e)(2) of
the Affordable Health Care for America Act with the Health
Choices Commissioner, acting in consultation with the
Secretary, with respect to coordinating the implementation of
the provisions of division A of such Act with the State plan
under this title in order to ensure the enrollment of
Medicaid eligible individuals in acceptable coverage. Nothing
in this section shall be construed as permitting such
memorandum to modify or vitiate any requirement of a State
plan under this title.
``(2) Enrollment of exchange-referred individuals.--
``(A) Non-traditional individuals.--Pursuant to such
memorandum the State shall accept without further
determination the enrollment under this title of an
individual determined by the Commissioner to be a non-
traditional Medicaid eligible individual. The State shall not
do any redeterminations of eligibility for such individuals
unless the periodicity of such redeterminations is consistent
with the periodicity for redeterminations by the Commissioner
of eligibility for affordability credits under subtitle C of
title II of division A of the Affordable Health Care for
America Act, as specified under such memorandum.
``(B) Traditional individuals.--Pursuant to such
memorandum, the State shall accept without further
determination the enrollment under this title of an
individual determined by the Commissioner to be a traditional
Medicaid eligible individual. The State may do
redeterminations of eligibility of such individual consistent
with such section and the memorandum.
``(3) Determinations of eligibility for affordability
credits.--If the Commissioner determines that a State
Medicaid agency has the capacity to make determinations of
eligibility for affordability credits under subtitle C of
title II of division A of the Affordable Health Care for
America Act, under such memorandum--
``(A) the State Medicaid agency shall conduct such
determinations for any Exchange-eligible individual who
requests such a determination;
``(B) in the case that a State Medicaid agency determines
that an Exchange-eligible individual is not eligible for
affordability credits, the agency shall forward the
information on the basis of which such determination was made
to the Commissioner; and
``(C) the Commissioner shall reimburse the State Medicaid
agency for the costs of conducting such determinations.
``(4) Referrals under memorandum.--Pursuant to such
memorandum, if an individual applies to the State for
assistance in obtaining health coverage and the State
determines that the individual is not eligible for medical
assistance under this title and is not authorized under such
memorandum to make an determination with respect to
eligibility for coverage and affordability credits through
the Health Insurance Exchange, the State shall refer the
individual to the Commissioner for a determination of such
eligibility and, with the individual's authorization, provide
to the Commissioner information obtained by the State as part
of the application process.
``(5) Additional terms.--Such memorandum shall include such
additional provisions as are necessary to implement
efficiently the provisions of this section and title II of
division A of the Affordable Health Care for America Act.
``(b) Treatment of Certain Newborns.--
``(1) In general.--In the case of a child who is deemed
under section 305(d) of the Affordable Health Care for
America Act to be a Medicaid eligible individual and enrolled
under this title pursuant to such section, the State shall
provide for a determination, by not later than the end of the
period referred to in paragraph (2) of such section, of the
child's eligibility for medical assistance under this title.
``(2) Extended treatment as traditional medicaid eligible
individual.--In accordance with paragraph (2) of section
305(d) of the Affordable Health Care for America Act, in the
case of a child described in paragraph (1) of such section
who at the end of the period referred to in such paragraph is
not otherwise covered under acceptable coverage, the child
shall be deemed (until such time as

[[Page H12731]]

the child obtains such coverage or the State otherwise makes
a determination of the child's eligibility for medical
assistance under its plan under this title pursuant to
paragraph (1)) to be a Medicaid eligible individual described
in section 1902(l)(1)(B).
``(c) Definitions.--In this section:
``(1) Medicaid eligible individual.--The term `Medicaid
eligible individual' means an individual who is eligible for
medical assistance under Medicaid.
``(2) Traditional medicaid eligible individual.--The term
`traditional Medicaid eligible individual' means a Medicaid
eligible individual other than an individual who is--
``(A) a Medicaid eligible individual by reason of the
application of subclause (VIII) of section 1902(a)(10)(A)(i)
of the Social Security Act; or
``(B) a childless adult not described in section
1902(a)(10)(A) or (C) of such Act (as in effect as of the day
before the date of the enactment of this Act).
``(3) Non-traditional medicaid eligible individual.--The
term `non-traditional Medicaid eligible individual' means a
Medicaid eligible individual who is not a traditional
Medicaid eligible individual.
``(4) Memorandum.--The term `memorandum' means a Medicaid
memorandum of understanding under section 305(e)(2) of the
Affordable Health Care for America Act.
``(5) Y1.--The term `Y1' has the meaning given such term in
section 100(c) of the Affordable Health Care for America
Act.''.
(b) Conforming Amendments to Error Rate.--
(1) Section 1903(u)(1)(D) of the Social Security Act (42
U.S.C. 1396b(u)(1)(D)) is amended by adding at the end the
following new clause:
``(vi) In determining the amount of erroneous excess
payments, there shall not be included any erroneous payments
made that are attributable to an error in an eligibility
determination under subtitle C of title II of division A of
the Affordable Health Care for America Act.''.
(2) Section 2105(c)(11) of such Act (42 U.S.C.
1397ee(c)(11)) is amended by adding at the end the following
new sentence: ``Clause (vi) of section 1903(u)(1)(D) shall
apply with respect to the application of such requirements
under this title and title XIX.''.

SEC. 1703. CHIP AND MEDICAID MAINTENANCE OF ELIGIBILITY.

(a) CHIP Maintenance of Eligibility.--Section 1902 of the
Social Security Act (42 U.S.C. 1396a) is amended--
(1) in subsection (a), as amended by section
1631(b)(1)(D)--
(A) by striking ``and'' at the end of paragraph (73);
(B) by striking the period at the end of paragraph (74) and
inserting ``; and''; and
(C) by inserting after paragraph (74) the following new
paragraph:
``(75) provide for maintenance of effort under the State
child health plan under title XXI in accordance with
subsection (gg).''; and
(2) by adding at the end the following new subsection:
``(gg) CHIP Maintenance of Eligibility Requirement.--
``(1) In general.--Subject to paragraph (2), as a condition
of its State plan under this title under subsection (a)(75)
and receipt of any Federal financial assistance under section
1903(a) for calendar quarters beginning after the date of the
enactment of this subsection and before CHIP MOE termination
date specified in paragraph (3), a State shall not have in
effect eligibility standards, methodologies, or procedures
under its State child health plan under title XXI (including
any waiver under such title or demonstration project under
section 1115) that are more restrictive than the eligibility
standards, methodologies, or procedures, respectively, under
such plan (or waiver) as in effect on June 16, 2009.
``(2) Limitation.--Paragraph (1) shall not be construed as
preventing a State from imposing a limitation described in
section 2110(b)(5)(C)(i)(II) for a fiscal year in order to
limit expenditures under its State child health plan under
title XXI to those for which Federal financial participation
is available under section 2105 for the fiscal year.
``(3) CHIP moe termination date.--In paragraph (1), the
`CHIP MOE termination date' for a State is the date that is
the last day of Y1 (as defined in section 100(c) of the
Affordable Health Care for America Act).
``(4) CHIP transition report.--Not later than December 31,
2011, the Secretary shall submit to Congress a report--
``(A) that compares the benefits packages offered under an
average State child health plan under title XXI in 2011 and
to the benefit standards initially adopted under section
224(b) of the Affordable Health Care for America Act and for
affordability credits under subtitle C of title II of
division C of such Act; and
``(B) that includes such recommendations as may be
necessary to ensure that--
``(i) such coverage is at least comparable to the coverage
provided to children under such an average State child health
plan; and
``(ii) there are procedures in effect for the enrollment of
CHIP enrollees (including CHIP-eligible pregnant women) at
the end of Y1 under this title, into a qualified health
benefits plan offered through the Health Insurance Exchange,
or into other acceptable coverage (as defined for purposes of
such Act) without interruption of coverage or a written plan
of treatment.''.
(b) Medicaid Maintenance of Effort; Simplifying and
Coordinating Eligibility Rules Between Exchange and
Medicaid.--
(1) In general.--Section 1903 of such Act (42 U.S.C. 1396b)
is amended by adding at the end the following new subsection:
``(aa) Maintenance of Medicaid Effort; Simplifying and
Coordinating Eligibility Rules Between Health Insurance
Exchange and Medicaid.--
``(1) Maintenance of effort.--
``(A) In general.--Subject to subparagraph (B), a State is
not eligible for payment under subsection (a) for a calendar
quarter beginning after the date of the enactment of this
subsection if eligibility standards, methodologies, or
procedures under its plan under this title (including any
waiver under this title or demonstration project under
section 1115) that are more restrictive than the eligibility
standards, methodologies, or procedures, respectively, under
such plan (or waiver) as in effect on June 16, 2009. The
Secretary shall extend such a waiver (including the
availability of Federal financial participation under such
waiver) for such period as may be required for a State to
meet the requirement of the previous sentence.
``(B) Exception for certain demonstration projects.--In the
case of a State demonstration project under section 1115 in
effect on June 16, 2009, that permits individuals to be
eligible solely to receive a premium or cost-sharing subsidy
for individual or group health insurance coverage, effective
for coverage provided in Y1--
``(i) the Secretary shall permit the State to amend such
waiver to apply more restrictive eligibility standards,
methodologies, or procedures with respect to such individuals
under such waiver; and
``(ii) the application of such more restrictive, standards,
methodologies, or procedures under such an amendment shall
not be considered in violation of the requirement of
subparagraph (A).
``(2) Removal of asset test for certain eligibility
categories.--
``(A) In general.--A State is not eligible for payment
under subsection (a) for a calendar quarter beginning on or
after the first day of Y1 (as defined in section 100(c) of
the Affordable Health Care for America Act), if the State
applies any asset or resource test in determining (or
redetermining) eligibility of any individual on or after such
first day under any of the following:
``(i) Subclause (I), (III), (IV), (VI), (VIII), (IX), (X),
or (XI) of section 1902(a)(10)(A)(i).
``(ii) Subclause (II), (IX), (XIV) or (XVII) of section
1902(a)(10)(A)(ii).
``(iii) Section 1931(b).
``(B) Overriding contrary provisions; references.--The
provisions of this title that prevent the waiver of an asset
or resource test described in subparagraph (A) are hereby
waived.
``(C) References.--Any reference to a provision described
in a provision in subparagraph (A) shall be deemed to be a
reference to such provision as modified through the
application of subparagraphs (A) and (B).''.
(2) Conforming amendments.--(A) Section 1902(a)(10)(A) of
such Act (42 U.S.C. 1396a(a)(10)(A)) is amended, in the
matter before clause (i), by inserting ``subject to section
1903(aa)(2),'' after ``(A)''.
(B) Section 1931(b)(1) of such Act (42 U.S.C. 1396u-
1(b)(1)) is amended by inserting ``and section 1903(aa)(2)''
after ``and (3)''.
(c) Standards for Benchmark Packages.--Section 1937(b) of
such Act (42 U.S.C. 1396u-7(b)) is amended--
(1) in each of paragraphs (1) and (2), by inserting
``subject to paragraph (5),'' after ``subsection (a)(1),'';
and
(2) by adding at the end the following new paragraph:
``(5) Minimum standards.--Effective January 1, 2013, any
benchmark benefit package (or benchmark equivalent coverage
under paragraph (2)) must meet the minimum benefits and cost-
sharing standards of a basic plan offered through the Health
Insurance Exchange.''.
(d) Repeal of CHIP.--Section 2104(a) of the Social Security
Act is amended by inserting at the end the following:
``No funds shall be appropriated or authorized to be
appropriated under this section for fiscal year 2014 and
subsequent years.''.

SEC. 1704. REDUCTION IN MEDICAID DSH.

(a) Report.--
(1) In general.--Not later than January 1, 2016, the
Secretary of Health and Human Services (in this title
referred to as the ``Secretary'') shall submit to Congress a
report concerning the extent to which, based upon the impact
of the health care reforms carried out under division A in
reducing the number of uninsured individuals, there is a
continued role for Medicaid DSH. In preparing the report, the
Secretary shall consult with community-based health care
networks serving low-income beneficiaries.
(2) Matters to be included.--The report shall include the
following:
(A) Recommendations.--Recommendations regarding--
(i) the appropriate targeting of Medicaid DSH within
States; and
(ii) the distribution of Medicaid DSH among the States,
taking into account the ratio of the amount of DSH funds
allocated to a State to the number of uninsured individuals
in such State.
(B) Specification of dsh health reform methodology.--The
DSH Health Reform methodology described in paragraph (2) of
subsection (b) for purposes of implementing the requirements
of such subsection.

[[Page H12732]]

(3) Coordination with medicare dsh report.--The Secretary
shall coordinate the report under this subsection with the
report on Medicare DSH under section 1112.
(4) Medicaid dsh.--In this section, the term ``Medicaid
DSH'' means adjustments in payments under section 1923 of the
Social Security Act for inpatient hospital services furnished
by disproportionate share hospitals.
(b) Medicaid DSH Reductions.--
(1) Reductions.--
(A) In general.--For each of fiscal years 2017 through 2019
the Secretary shall effect the following reductions:
(i) Reduction dsh allotments.--The Secretary shall reduce
DSH allotments to States in the amount specified under the
DSH health reform methodology under paragraph (2) for the
State for the fiscal year.
(ii) Reductions in payments.--The Secretary shall reduce
payments to States under section 1903(a) of the Social
Security Act (42 U.S.C. 1396b(a)) for each calendar quarter
in the fiscal year, in the manner specified in subparagraph
(C), in an amount equal to \1/4\ of the DSH allotment
reduction under clause (i) for the State for the fiscal year.
(B) Aggregate reductions.--The aggregate reductions in DSH
allotments for all States under subparagraph (A)(i) shall be
equal to--
(i) $1,500,000,000 for fiscal year 2017;
(ii) $2,500,000,000 for fiscal year 2018; and
(iii) $6,000,000,000 for fiscal year 2019.
The Secretary shall distribute such aggregate reduction among
States in accordance with paragraph (2).
(C) Manner of payment reduction.--The amount of the payment
reduction under subparagraph (A)(ii) for a State for a
quarter shall be deemed an overpayment to the State under
title XIX of the Social Security Act to be disallowed against
the State's regular quarterly draw for all Medicaid spending
under section 1903(d)(2) of such Act (42 U.S.C. 1396b(d)(2)).
Such a disallowance is not subject to a reconsideration under
1116(d) of such Act (42 U.S.C. 1316(d)).
(D) Definitions.--In this section:
(i) State.--The term ``State'' means the 50 States and the
District of Columbia.
(ii) DSH allotment.--The term ``DSH allotment'' means, with
respect to a State for a fiscal year, the allotment made
under section 1923(f) of the Social Security Act (42 U.S.C.
1396r-4(f)) to the State for the fiscal year.
(2) DSH health reform methodology.--The Secretary shall
carry out paragraph (1) through use of a DSH Health Reform
methodology issued by the Secretary that imposes the largest
percentage reductions on the States that--
(A) have the lowest percentages of uninsured individuals
(determined on the basis of audited hospital cost reports)
during the most recent year for which such data are
available; or
(B) do not target their DSH payments on--
(i) hospitals with high volumes of Medicaid inpatients (as
defined in section 1923(b)(1)(A) of the Social Security Act
(42 U.S.C. 1396r-4(b)(1)(A)); and
(ii) hospitals that have high levels of uncompensated care
(excluding bad debt).
(3) DSH allotment publications.--
(A) In general.--Not later than the publication deadline
specified in subparagraph (B), the Secretary shall publish in
the Federal Register a notice specifying the DSH allotment to
each State under 1923(f) of the Social Security Act for the
respective fiscal year specified in such subparagraph,
consistent with the application of the DSH Health Reform
methodology described in paragraph (2).
(B) Publication deadline.--The publication deadline
specified in this subparagraph is--
(i) January 1, 2016, with respect to DSH allotments
described in subparagraph (A) for fiscal year 2017;
(ii) January 1, 2017, with respect to DSH allotments
described in subparagraph (A) for fiscal year 2018; and
(iii) January 1, 2018, with respect to DSH allotments
described in subparagraph (A) for fiscal year 2019.
(c) Conforming Amendments.--
(1) Section 1923(f) of the Social Security Act (42 U.S.C.
1396r-4(f)) is amended--
(A) by redesignating paragraph (7) as paragraph (8); and
(B) by inserting after paragraph (6) the following new
paragraph:
``(7) Special rule for fiscal years 2017, 2018, and 2019.--
For each of fiscal years 2017, 2018, and 2018, the DSH
allotments under this subsection are subject to reduction
under section 1704(b) of the Affordable Health Care for
America Act.''.
(2) The second sentence of section 1923(b)(4) of such Act
(42 U.S.C. 1396r-4(b)(4)) is amended by inserting before the
period the following: ``or to affect the authority of the
Secretary to issue and implement the DSH Health Reform
methodology under section 1704(b)(2) of the Affordable Health
Care for America Act''.
(d) Disproportionate Share Hospitals (DSH) and Essential
Access Hospital (EAH) Non-discrimination.--
(1) In general.--Section 1923(d) of the Social Security Act
(42 U.S.C. 1396r-4) is amended by adding at the end the
following new paragraph:
``(4) No hospital may be defined or deemed as a
disproportionate share hospital, or as an essential access
hospital (for purposes of subsection (f)(6)(A)(iv)), under a
State plan under this title or subsection (b) of this section
(including any demonstration project under section 1115)
unless the hospital--
``(A) provides services to beneficiaries under this title
without discrimination on the ground of race, color, national
origin, creed, source of payment, status as a beneficiary
under this title, or any other ground unrelated to such
beneficiary's need for the services or the availability of
the needed services in the hospital; and
``(B) makes arrangements for, and accepts, reimbursement
under this title for services provided to eligible
beneficiaries under this title.''.
(2) Effective date.--The amendment made by paragraph (1)
shall apply to expenditures made on or after July 1, 2010.

SEC. 1705. EXPANDED OUTSTATIONING.

(a) In General.--Section 1902(a)(55) of the Social Security
Act (42 U.S.C. 1396a(a)(55)) is amended by striking ``under
subsection (a)(10)(A)(i)(IV), (a)(10)(A)(i)(VI),
(a)(10)(A)(i)(VII), or (a)(10)(A)(ii)(IX)'' and inserting
``(including receipt and processing of applications of
individuals for affordability credits under subtitle C of
title II of division A of the Affordable Health Care for
America Act pursuant to a Medicaid memorandum of
understanding under section 1943(a)(1))''.
(b) Effective Date.--Except as provided in section 1790,
the amendment made by subsection (a) shall apply to services
furnished on or after July 1, 2010, without regard to whether
or not final regulations to carry out such amendment have
been promulgated by such date.

Subtitle B--Prevention

SEC. 1711. REQUIRED COVERAGE OF PREVENTIVE SERVICES.

(a) Coverage.--Section 1905 of the Social Security Act (42
U.S.C. 1396d), as amended by section 1701(a)(3)(B), is
amended--
(1) in subsection (a)(4)--
(A) by striking ``and'' before ``(C)''; and
(B) by inserting before the semicolon at the end the
following: ``; and (D) preventive services described in
subsection (z)''; and
(2) by adding at the end the following new subsection:
``(z) Preventive Services.--The preventive services
described in this subsection are services not otherwise
described in subsection (a) or (r) that the Secretary
determines are--
``(1)(A) recommended with a grade of A or B by the Task
Force for Clinical Preventive Services; or
``(B) vaccines recommended for use as appropriate by the
Director of the Centers for Disease Control and Prevention;
and
``(2) appropriate for individuals entitled to medical
assistance under this title.''.
(b) Elimination of Cost-Sharing.--
(1) Subsections (a)(2)(D) and (b)(2)(D) of section 1916 of
such Act (42 U.S.C. 1396o) are each amended by inserting
``preventive services described in section 1905(z),'' after
``emergency services (as defined by the Secretary),''.
(2) Section 1916A(a)(1) of such Act (42 U.S.C. 1396o-1
(a)(1)) is amended by inserting ``, preventive services
described in section 1905(z),'' after ``subsection (c)''.
(c) Conforming Amendment.--Section 1928 of such Act (42
U.S.C. 1396s) is amended--
(1) in subsection (c)(2)(B)(i), by striking ``the advisory
committee referred to in subsection (e)'' and inserting ``the
Director of the Centers for Disease Control and Prevention'';
(2) in subsection (e), by striking ``Advisory Committee''
and all that follows and inserting ``Director of the Centers
for Disease Control and Prevention.''; and
(3) by striking subsection (g).
(d) Effective Date.--Except as provided in section 1790,
the amendments made by this section shall apply to services
furnished on or after July 1, 2010, without regard to whether
or not final regulations to carry out such amendments have
been promulgated by such date.

SEC. 1712. TOBACCO CESSATION.

(a) Dropping Tobacco Cessation Exclusion From Covered
Outpatient Drugs.--Section 1927(d)(2) of the Social Security
Act (42 U.S.C. 1396r-8(d)(2)) is amended--
(1) by striking subparagraph (E);
(2) in subparagraph (G), by inserting before the period at
the end the following: ``, except agents approved by the Food
and Drug Administration for purposes of promoting, and when
used to promote, tobacco cessation''; and
(3) by redesignating subparagraphs (F) through (K) as
subparagraphs (E) through (J), respectively.
(b) Effective Date.--The amendments made by this section
shall apply to drugs and services furnished on or after
January 1, 2010.

SEC. 1713. OPTIONAL COVERAGE OF NURSE HOME VISITATION
SERVICES.

(a) In General.--Section 1905 of the Social Security Act
(42 U.S.C. 1396d), as amended by sections 1701(a)(3)(B) and
1711(a), is amended--
(1) in subsection (a)--
(A) in paragraph (27), by striking ``and'' at the end;
(B) by redesignating paragraph (28) as paragraph (29); and
(C) by inserting after paragraph (27) the following new
paragraph:
``(28) nurse home visitation services (as defined in
subsection (aa)); and''; and
(2) by adding at the end the following new subsection:
``(aa) The term `nurse home visitation services' means home
visits by trained

[[Page H12733]]

nurses to families with a first-time pregnant woman, or a
child (under 2 years of age), who is eligible for medical
assistance under this title, but only, to the extent
determined by the Secretary based upon evidence, that such
services are effective in one or more of the following:
``(1) Improving maternal or child health and pregnancy
outcomes or increasing birth intervals between pregnancies.
``(2) Reducing the incidence of child abuse, neglect, and
injury, improving family stability (including reduction in
the incidence of intimate partner violence), or reducing
maternal and child involvement in the criminal justice
system.
``(3) Increasing economic self-sufficiency, employment
advancement, school-readiness, and educational achievement,
or reducing dependence on public assistance.''.
(b) Effective Date.--The amendments made by this section
shall apply to services furnished on or after January 1,
2010.
(c) Construction.--Nothing in the amendments made by this
section shall be construed as affecting the ability of a
State under title XIX or XXI of the Social Security Act to
provide nurse home visitation services as part of another
class of items and services falling within the definition of
medical assistance or child health assistance under the
respective title, or as an administrative expenditure for
which payment is made under section 1903(a) or 2105(a) of
such Act, respectively, on or after the date of the enactment
of this Act.

SEC. 1714. STATE ELIGIBILITY OPTION FOR FAMILY PLANNING
SERVICES.

(a) Coverage as Optional Categorically Needy Group.--
(1) In general.--Section 1902(a)(10)(A)(ii) of the Social
Security Act (42 U.S.C. 1396a(a)(10)(A)(ii)) is amended--
(A) in subclause (XVIII), by striking ``or'' at the end;
(B) in subclause (XIX), by adding ``or'' at the end; and
(C) by adding at the end the following new subclause:

``(XX) who are described in subsection (hh) (relating to
individuals who meet certain income standards);''.

(2) Group described.--Section 1902 of such Act (42 U.S.C.
1396a), as amended by section 1703, is amended by adding at
the end the following new subsection:
``(hh)(1) Individuals described in this subsection are
individuals--
``(A) whose income does not exceed an income eligibility
level established by the State that does not exceed the
highest income eligibility level established under the State
plan under this title (or under its State child health plan
under title XXI) for pregnant women; and
``(B) who are not pregnant.
``(2) At the option of a State, individuals described in
this subsection may include individuals who, had individuals
applied on or before January 1, 2007, would have been made
eligible pursuant to the standards and processes imposed by
that State for benefits described in clause (XV) of the
matter following subparagraph (G) of subsection (a)(10)
pursuant to a demonstration project waiver granted under
section 1115.
``(3) At the option of a State, for purposes of subsection
(a)(17)(B), in determining eligibility for services under
this subsection, the State may consider only the income of
the applicant or recipient.''.
(3) Limitation on benefits.--Section 1902(a)(10) of such
Act (42 U.S.C. 1396a(a)(10)) is amended in the matter
following subparagraph (G)--
(A) by striking ``and (XIV)'' and inserting ``(XIV)''; and
(B) by inserting ``, and (XV) the medical assistance made
available to an individual described in subsection (hh) shall
be limited to family planning services and supplies described
in section 1905(a)(4)(C) including medical diagnosis and
treatment services that are provided pursuant to a family
planning service in a family planning setting'' after
``cervical cancer''.
(4) Conforming amendments.--Section 1905(a) of such Act (42
U.S.C. 1396d(a)), as amended by section 1731(c), is amended
in the matter preceding paragraph (1)--
(A) in clause (xiii), by striking ``or'' at the end;
(B) in clause (xiv), by adding ``or'' at the end; and
(C) by inserting after clause (xiv) the following:
``(xv) individuals described in section 1902(hh),''.
(b) Presumptive Eligibility.--
(1) In general.--Title XIX of the Social Security Act (42
U.S.C. 1396 et seq.) is amended by inserting after section
1920B the following:

``presumptive eligibility for family planning services

``Sec. 1920C.  (a) State Option.--State plan approved under
section 1902 may provide for making medical assistance
available to an individual described in section 1902(hh)
(relating to individuals who meet certain income eligibility
standard) during a presumptive eligibility period. In the
case of an individual described in section 1902(hh), such
medical assistance shall be limited to family planning
services and supplies described in 1905(a)(4)(C) and, at the
State's option, medical diagnosis and treatment services that
are provided in conjunction with a family planning service in
a family planning setting.
``(b) Definitions.--For purposes of this section:
``(1) Presumptive eligibility period.--The term
`presumptive eligibility period' means, with respect to an
individual described in subsection (a), the period that--
``(A) begins with the date on which a qualified entity
determines, on the basis of preliminary information, that the
individual is described in section 1902(hh); and
``(B) ends with (and includes) the earlier of--
``(i) the day on which a determination is made with respect
to the eligibility of such individual for services under the
State plan; or
``(ii) in the case of such an individual who does not file
an application by the last day of the month following the
month during which the entity makes the determination
referred to in subparagraph (A), such last day.
``(2) Qualified entity.--
``(A) In general.--Subject to subparagraph (B), the term
`qualified entity' means any entity that--
``(i) is eligible for payments under a State plan approved
under this title; and
``(ii) is determined by the State agency to be capable of
making determinations of the type described in paragraph
(1)(A).
``(B) Rule of construction.--Nothing in this paragraph
shall be construed as preventing a State from limiting the
classes of entities that may become qualified entities in
order to prevent fraud and abuse.
``(c) Administration.--
``(1) In general.--The State agency shall provide qualified
entities with--
``(A) such forms as are necessary for an application to be
made by an individual described in subsection (a) for medical
assistance under the State plan; and
``(B) information on how to assist such individuals in
completing and filing such forms.
``(2) Notification requirements.--A qualified entity that
determines under subsection (b)(1)(A) that an individual
described in subsection (a) is presumptively eligible for
medical assistance under a State plan shall--
``(A) notify the State agency of the determination within 5
working days after the date on which determination is made;
and
``(B) inform such individual at the time the determination
is made that an application for medical assistance is
required to be made by not later than the last day of the
month following the month during which the determination is
made.
``(3) Application for medical assistance.--In the case of
an individual described in subsection (a) who is determined
by a qualified entity to be presumptively eligible for
medical assistance under a State plan, the individual shall
apply for medical assistance by not later than the last day
of the month following the month during which the
determination is made.
``(d) Payment.--Notwithstanding any other provision of law,
medical assistance that--
``(1) is furnished to an individual described in subsection
(a)--
``(A) during a presumptive eligibility period;
``(B) by a entity that is eligible for payments under the
State plan; and
``(2) is included in the care and services covered by the
State plan,

shall be treated as medical assistance provided by such plan
for purposes of clause (4) of the first sentence of section
1905(b).''.
(2) Conforming amendments.--
(A) Section 1902(a)(47) of the Social Security Act (42
U.S.C. 1396a(a)(47)) is amended by inserting before the
semicolon at the end the following: ``and provide for making
medical assistance available to individuals described in
subsection (a) of section 1920C during a presumptive
eligibility period in accordance with such section''.
(B) Section 1903(u)(1)(D)(v) of such Act (42 U.S.C.
1396b(u)(1)(D)(v)) is amended--
(i) by striking ``or for'' and inserting ``for''; and
(ii) by inserting before the period the following: ``, or
for medical assistance provided to an individual described in
subsection (a) of section 1920C during a presumptive
eligibility period under such section''.
(c) Clarification of Coverage of Family Planning Services
and Supplies.--Section 1937(b) of the Social Security Act (42
U.S.C. 1396u-7(b)), as amended by section 1703(c)(2), is
amended by adding at the end the following:
``(6) Coverage of family planning services and supplies.--
Notwithstanding the previous provisions of this section, a
State may not provide for medical assistance through
enrollment of an individual with benchmark coverage or
benchmark-equivalent coverage under this section unless such
coverage includes for any individual described in section
1905(a)(4)(C), medical assistance for family planning
services and supplies in accordance with such section.''.
(d) Effective Date.--The amendments made by this section
take effect on the date of the enactment of this Act and
shall apply to items and services furnished on or after such
date.

Subtitle C--Access

SEC. 1721. PAYMENTS TO PRIMARY CARE PRACTITIONERS.

(a) In General.--
(1) Fee-for-service payments.--Section 1902 of the Social
Security Act (42 U.S.C. 1396b) as amended by sections
1703(a), 1714(a), 1731(a), and 1746, is amended--
(A) in subsection (a)(13)--
(i) by striking ``and'' at the end of subparagraph (A);
(ii) by adding ``and'' at the end of subparagraph (B); and

[[Page H12734]]

(iii) by adding at the end the following new subparagraph:
``(C) payment for primary care services (as defined in
subsection (kk)(1)) furnished by physicians (or for services
furnished by other health care professionals that would be
primary care services under such section if furnished by a
physician) at a rate not less than 80 percent of the payment
rate that would be applicable if the adjustment described in
subsection (kk)(2) were to apply to such services and
physicians or professionals (as the case may be) under part B
of title XVIII for services furnished in 2010, 90 percent of
such adjusted payment rate for services and physicians (or
professionals) furnished in 2011, or 100 percent of such
adjusted payment rate for services and physicians (or
professionals) furnished in 2012 and each subsequent year;'';
and
(B) by adding at the end the following new subsection:
``(kk) Increased Payment for Primary Care Services.--For
purposes of subsection (a)(13)(C):
``(1) Primary care services defined.--The term `primary
care services' means evaluation and management services,
without regard to the specialty of the physician furnishing
the services, that are procedure codes (for services covered
under title XVIII) for services in the category designated
Evaluation and Management in the Health Care Common Procedure
Coding System (established by the Secretary under section
1848(c)(5) as of December 31, 2009, and as subsequently
modified by the Secretary).
``(2) Adjustment.--The adjustment described in this
paragraph is the substitution of 1.25 percent for the update
otherwise provided under section 1848(d)(4) for each year
beginning with 2010.''.
(2) Under medicaid managed care plans.--Section 1932(f) of
such Act (42 U.S.C. 1396u-2(f)) is amended--
(A) in the heading, by adding at the end the following: ``;
Adequacy of Payment for Primary Care Services''; and
(B) by inserting before the period at the end the
following: ``and, in the case of primary care services
described in section 1902(a)(13)(C), consistent with the
minimum payment rates specified in such section (regardless
of the manner in which such payments are made, including in
the form of capitation or partial capitation)''.
(b) Increase in Payment Using Increased FMAP.--Section
1905(y) of the Social Security Act, as added by section
1701(a)(3)(B) and as amended by section 1701(c)(2), is
amended by adding at the end the following:
``(3)(A) The portion of the amounts expended for medical
assistance for services described in section 1902(a)(13)(C)
furnished on or after January 1, 2010, that is attributable
to the amount by which the minimum payment rate required
under such section (or, by application, section 1932(f))
exceeds the payment rate applicable to such services under
the State plan as of June 16, 2009.
``(B) Subparagraph (A) shall not be construed as preventing
the payment of Federal financial participation based on the
Federal medical assistance percentage for amounts in excess
of those specified under such subparagraph.''.
(c) Effective Date.--The amendments made by this section
shall apply to services furnished on or after January 1,
2010.

SEC. 1722. MEDICAL HOME PILOT PROGRAM.

(a) In General.--The Secretary of Health and Human Services
shall establish under this section a medical home pilot
program under which a State may apply to the Secretary for
approval of a medical home pilot project described in
subsection (b) (in this section referred to as a ``pilot
project'') for the application of the medical home concept
under title XIX of the Social Security Act. The pilot program
shall operate for a period of up to 5 years.
(b) Pilot Project Described.--
(1) In general.--A pilot project is a project that applies
one or more of the medical home models described in section
1866F(a)(3) of the Social Security Act (as inserted by
section 1302(a)) or such other model as the Secretary may
approve, to individuals (including medically fragile children
and high-risk pregnant women) who are eligible for medical
assistance under title XIX of the Social Security Act. The
Secretary shall provide for appropriate coordination of the
pilot program under this section with the medical home pilot
program under section 1866F of such Act.
(2) Limitation.--A pilot project shall be for a duration of
not more than 5 years.
(3) Consideration for certain technologies.--In considering
applications for pilots projects under this section, the
Secretary may approve a project which tests the effectiveness
of applications and devices, such as wireless patient
management technologies, that are approved by the Food and
Drug Administration and enable providers and practitioners to
communicate directly with their patients in managing chronic
illness.
(c) Additional Incentives.--In the case of a pilot project,
the Secretary may--
(1) waive the requirements of section 1902(a)(1) of the
Social Security Act (relating to statewideness) and section
1902(a)(10)(B) of such Act (relating to comparability); and
(2) increase to up to 90 percent (for the first 2 years of
the pilot program) or 75 percent (for the next 3 years) the
matching percentage for administrative expenditures (such as
those for community care workers).
(d) Medically Fragile Children.--In the case of a model
involving medically fragile children, the model shall ensure
that the patient-centered medical home services received by
each child, in addition to fulfilling the requirements under
1866F(b)(1) of the Social Security Act, provide for
continuous involvement and education of the parent or
caregiver and for assistance to the child in obtaining
necessary transitional care if a child's enrollment ceases
for any reason.
(e) Evaluation; Report.--
(1) Evaluation.--The Secretary, using the criteria
described in section 1866F(e)(1) of the Social Security Act
(as inserted by section 1123), shall conduct an evaluation of
the pilot program under this section.
(2) Report.--Not later than 60 days after the date of
completion of the evaluation under paragraph (1), the
Secretary shall submit to Congress and make available to the
public a report on the findings of the evaluation under such
paragraph.
(f) Funding.--The additional Federal financial
participation resulting from the implementation of the pilot
program under this section may not exceed in the aggregate
$1,235,000,000 over the 5-year period of the program.

SEC. 1723. TRANSLATION OR INTERPRETATION SERVICES.

(a) In General.--Section 1903(a)(2)(E) of the Social
Security Act (42 U.S.C. 1396b(a)(2)), as added by section
201(b)(2)(A) of the Children's Health Insurance Program
Reauthorization Act of 2009 (Public Law 111-3), is amended by
inserting ``and other individuals'' after ``children of
families''.
(b) Effective Date.--The amendment made by subsection (a)
shall apply to payment for translation or interpretation
services furnished on or after January 1, 2010.

SEC. 1724. OPTIONAL COVERAGE FOR FREESTANDING BIRTH CENTER
SERVICES.

(a) In General.--Section 1905 of the Social Security Act
(42 U.S.C. 1396d), as amended by section 1713(a), is
amended--
(1) in subsection (a)--
(A) by redesignating paragraph (29) as paragraph (30);
(B) in paragraph (28), by striking at the end ``and''; and
(C) by inserting after paragraph (28) the following new
paragraph:
``(29) freestanding birth center services (as defined in
subsection (l)(3)(A)) and other ambulatory services that are
offered by a freestanding birth center (as defined in
subsection (l)(3)(B)) and that are otherwise included in the
plan; and''; and
(2) in subsection (l), by adding at the end the following
new paragraph:
``(3)(A) The term `freestanding birth center services'
means services furnished to an individual at a freestanding
birth center (as defined in subparagraph (B)), including by a
licensed birth attendant (as defined in subparagraph (C)) at
such center.
``(B) The term `freestanding birth center' means a health
facility--
``(i) that is not a hospital; and
``(ii) where childbirth is planned to occur away from the
pregnant woman's residence.
``(C) The term `licensed birth attendant' means an
individual who is licensed or registered by the State
involved to provide health care at childbirth and who
provides such care within the scope of practice under which
the individual is legally authorized to perform such care
under State law (or the State regulatory mechanism provided
by State law), regardless of whether the individual is under
the supervision of, or associated with, a physician or other
health care provider. Nothing in this subparagraph shall be
construed as changing State law requirements applicable to a
licensed birth attendant.''.
(b) Effective Date.--The amendments made by this section
shall apply to items and services furnished on or after the
date of the enactment of this Act.

SEC. 1725. INCLUSION OF PUBLIC HEALTH CLINICS UNDER THE
VACCINES FOR CHILDREN PROGRAM.

Section 1928(b)(2)(A)(iii)(I) of the Social Security Act
(42 U.S.C. 1396s(b)(2)(A)(iii)(I)) is amended--
(1) by striking ``or a rural health clinic'' and inserting
``, a rural health clinic''; and
(2) by inserting ``or a public health clinic,'' after
``1905(l)(1)),''.

SEC. 1726. REQUIRING COVERAGE OF SERVICES OF PODIATRISTS.

(a) In General.--Section 1905(a)(5)(A) of the Social
Security Act (42 U.S.C. 1396d(a)(5)(A)) is amended by
striking ``section 1861(r)(1)'' and inserting ``paragraphs
(1) and (3) of section 1861(r)''.
(b) Effective Date.--Except as provided in section 1790,
the amendment made by subsection (a) shall apply to services
furnished on or after January 1, 2010.

SEC. 1726A. REQUIRING COVERAGE OF SERVICES OF OPTOMETRISTS.

(a) In General.--Section 1905(a)(5) of the Social Security
Act (42 U.S.C. 1396d(a)(5)) is amended--
(1) by striking ``and'' before ``(B)''; and
(2) by inserting before the semicolon at the end the
following: ``, and (C) medical and other health services (as
defined in section 1861(s)) as authorized by State law,
furnished by an optometrist (described in section 1861(r)(4))
to the extent such services may be performed under State
law''.
(b) Effective Date.--Except as provided in section 1790,
the amendments made by subsection (a) shall take effect 90
days after the

[[Page H12735]]

date of the enactment of this Act and shall apply to services
furnished or other actions required on or after such date.

SEC. 1727. THERAPEUTIC FOSTER CARE.

(a) Rule of Construction.--Nothing in this title shall
prevent or limit a State from covering therapeutic foster
care for eligible children in out-of-home placements under
section 1905(a) of the Social Security Act (42 U.S.C.
1396d(a)).
(b) Therapeutic Foster Care Defined.--For purposes of this
section, the term ``therapeutic foster care'' means a foster
care program that provides--
(1) to the child--
(A) structured daily activities that develop, improve,
monitor, and reinforce age-appropriate social,
communications, and behavioral skills;
(B) crisis intervention and crisis support services;
(C) medication monitoring;
(D) counseling; and
(E) case management services; and
(2) specialized training for the foster parent and
consultation with the foster parent on the management of
children with mental illnesses and related health and
developmental conditions.

SEC. 1728. ASSURING ADEQUATE PAYMENT LEVELS FOR SERVICES.

(a) In General.--Title XIX of the Social Security Act is
amended by inserting after section 1925 the following new
section:

``assuring adequate payment levels for services

``Sec. 1926.  (a) In General.--A State plan under this
title shall not be considered to meet the requirement of
section 1902(a)(30)(A) for a year (beginning with 2011)
unless, by not later than April 1 before the beginning of
such year, the State submits to the Secretary an amendment to
the plan that specifies the payment rates to be used for such
services under the plan in such year and includes in such
submission such additional data as will assist the Secretary
in evaluating the State's compliance with such requirement,
including data relating to how rates established for payments
to medicaid managed care organizations under sections 1903(m)
and 1932 take into account such payment rates.
``(b) Secretarial Review.--The Secretary, by not later than
90 days after the date of submission of a plan amendment
under subsection (a), shall--
``(1) review each such amendment for compliance with the
requirement of section 1902(a)(30)(A); and
``(2) approve or disapprove each such amendment.

If the Secretary disapproves such an amendment, the State
shall immediately submit a revised amendment that meets such
requirement.''.
(b) Effective Date.--The amendment made by subsection (a)
shall take effect on the date of the enactment of this Act.

SEC. 1729. PRESERVING MEDICAID COVERAGE FOR YOUTHS UPON
RELEASE FROM PUBLIC INSTITUTIONS.

Section 1902(a) of the Social Security Act (42 U.S.C.
1396a), as amended by section 1631(b) and 1703(a), is
amended--
(1) by striking ``and'' at the end of paragraph (74);
(2) by striking the period at the end of paragraph (75) and
inserting ``; and''; and
(3) by inserting after paragraph (75) the following new
paragraph:
``(76) provide that in the case of any youth who is 18
years of age or younger, was enrolled for medical assistance
under the State plan immediately before becoming an inmate of
a public institution, is 18 years of age or younger upon
release from such institution, and is eligible for such
medical assistance under the State plan at the time of
release from such institution--
``(A) during the period such youth is incarcerated in a
public institution, the State shall not terminate eligibility
for medical assistance under the State plan for such youth;
``(B) during the period such youth is incarcerated in a
public institution, the State shall establish a process that
ensures--
``(i) that the State does not claim federal financial
participation for services that are provided to such youth
and that are excluded under subsection 1905(a)(28)(A); and
``(ii) that the youth receives medical assistance for which
federal participation is available under this title;
``(C) on or before the date such youth is released from
such institution, the State shall ensure that such youth is
enrolled for medical assistance under this title, unless and
until there is a determination that the individual is no
longer eligible to be so enrolled; and
``(D) the State shall ensure that enrollment under
subparagraph (C) will be completed before such date so that
the youth can access medical assistance under this title
immediately upon leaving the institution.''

SEC. 1730. QUALITY MEASURES FOR MATERNITY AND ADULT HEALTH
SERVICES UNDER MEDICAID AND CHIP.

Title XI of the Social Security Act (42 U.S.C. 1301 et
seq.) is amended by inserting after section 1139A the
following new section:

``SEC. 1139B. QUALITY MEASURES FOR MATERNITY AND ADULT HEALTH
SERVICES UNDER MEDICAID AND CHIP.

``(a) Maternity Care Quality Measures Under Medicaid and
CHIP.--
``(1) Development of measures.--No later than January 1,
2011, the Secretary shall develop and publish for comment a
proposed set of measures that accurately describe the quality
of maternity care provided under State plans under titles XIX
and XXI. The Secretary shall publish a final recommended set
of such measures no later than July 1, 2011.
``(2) Standardized reporting format.--No later than January
1, 2012, the Secretary shall develop and publish a
standardized reporting format for maternity care quality
measures for use by State programs under titles XIX and XXI
to collect data from managed care entities and providers and
practitioners that participate in such programs and to report
maternity care quality measures to the Secretary.
``(b) Other Adult Health Quality Measures Under Medicaid.--
``(1) Development of measures.--The Secretary shall develop
quality measures that are not otherwise developed under
section 1192 for services received under State plans under
title XIX by individuals who are 21 years of age or older but
have not attained age 65. The Secretary shall publish such
quality measures through notice and comment rulemaking.
``(2) Standardized reporting format.--The Secretary shall
develop and publish a standardized reporting format for
quality measures developed under paragraph (1) and section
1192 for services furnished under State plans under title XIX
to individuals who are 21 years of age or older but have not
attained age 65 for use under such plans and State plans
under title XXI. The format shall enable State agencies
administering such plans to collect data from managed care
entities and providers and practitioners that participate in
such plans and to report quality measures to the Secretary.
``(c) Development Process.--With respect to the development
of quality measures under subsections (a) and (b)--
``(1) Use of qualified entities.--The Secretary may enter
into agreements with public, nonprofit, or academic
institutions with technical expertise in the area of health
quality measurement to assist in such development. The
Secretary may carry out these agreements by contract, grant,
or otherwise.
``(2) Multi-stakeholder pre-rulemaking input.--The
Secretary shall obtain the input of stakeholders with respect
to such quality measures using a process similar to that
described in section 1808(d).
``(3) Coordination.--The Secretary shall coordinate the
development of such measures under such subsections and with
the development of child health quality measures under
section 1139A.
``(d) Annual Report to Congress.--No later than January 1,
2013, and annually thereafter, the Secretary shall report to
the Committee on Energy and Commerce of the House of
Representatives the Committee on Finance of the Senate
regarding--
``(1) the availability of reliable data relating to the
quality of maternity care furnished under State plans under
titles XIX and XXI;
``(2) the availability of reliable data relating to the
quality of services furnished under State plans under title
XIX to adults who are 21 years of age or older but have not
attained age 65; and
``(3) recommendations for improving the quality of such
care and services furnished under such State plans.
``(e) Rule of Construction.--Notwithstanding any other
provision in this section, no quality measure developed,
published, or used as a basis of measurement or reporting
under this section may be used to establish an irrebuttable
presumption regarding either the medical necessity of care or
the maximum permissible coverage for any individual who
receives medical assistance under title XIX or child health
assistance under title XXI.
``(f) Appropriation.--For purposes of carrying out this
section, in addition to funds otherwise available, out of any
funds in the Treasury not otherwise appropriated, there are
appropriated $40,000,000 for the 5-fiscal-year period
beginning with fiscal year 2010. Funds appropriated under
this subsection shall remain available until expended.''.

SEC. 1730A. ACCOUNTABLE CARE ORGANIZATION PILOT PROGRAM.

(a) In General.--The Secretary of Health and Human Services
shall establish under this section an accountable care
program under which a State may apply to the Secretary for
approval of an accountable care organization pilot program
described in subsection (b) (in this section referred to as a
``pilot program'') for the application of the accountable
care organization concept under title XIX of the Social
Security Act.
(b) Pilot Program Described.--
(1) In general.--The pilot program described in this
subsection is a program that applies one or more of the
accountable care organization models described in section
1866E of the Social Security Act, as added by section 1301 of
this Act.
(2) Limitation.--The pilot program shall operate for a
period of not more than 5 years.
(c) Additional Incentives.--In the case of the pilot
program under this section, the Secretary may--
(1) waive the requirements of--
(A) section 1902(a)(1) of the Social Security Act (relating
to statewideness);
(B) section 1902(a)(10)(B) of such Act (relating to
comparability); and
(2) increase the matching percentage for administrative
expenditures up to--

[[Page H12736]]

(A) 90 percent (for the first 2 years of the pilot
program); and
(B) 75 percent (for the next 3 years).
(d) Evaluation; Report.--
(1) Evaluation.--The Secretary shall conduct an evaluation
of the pilot program under this section. In conducting such
evaluation, the Secretary shall use the criteria used under
subsection (g)(1) of section 1866E of the Social Security Act
(as inserted by section 1301 of this Act) to evaluate pilot
programs under such section.
(2) Report.--Not later than 60 days after the date of
completion of the evaluation under paragraph (1), the
Secretary shall submit to Congress and make available to the
public a report on the findings of the evaluation under such
paragraph.

SEC. 1730B. FQHC COVERAGE.

Section 1905(l)(2)(B) of the Social Security Act (42 U.S.C.
1396d(l)(2)(B)) is amended--
(1) by striking ``or'' at the end of clause (iii);
(2) by striking the semicolon at the end of clause (iv) and
inserting ``, and''; and
(3) by inserting after clause (iv) the following new
clause:
``(v) is receiving a grant under section 399Z-1 of the
Public Health Service Act;''.

Subtitle D--Coverage

SEC. 1731. OPTIONAL MEDICAID COVERAGE OF LOW-INCOME HIV-
INFECTED INDIVIDUALS.

(a) In General.--Section 1902 of the Social Security Act
(42 U.S.C. 1396a), as amended by section 1714(a)(1), is
amended--
(1) in subsection (a)(10)(A)(ii)--
(A) by striking ``or'' at the end of subclause (XIX);
(B) by adding ``or'' at the end of subclause (XX); and
(C) by adding at the end the following:

``(XXI) who are described in subsection (ii) (relating to
HIV-infected individuals);''; and

(2) by adding at the end, as amended by sections 1703 and
1714(a), the following:
``(ii) Individuals described in this subsection are
individuals not described in subsection (a)(10)(A)(i)--
``(1) who have HIV infection;
``(2) whose income (as determined under the State plan
under this title with respect to disabled individuals) does
not exceed the maximum amount of income a disabled individual
described in subsection (a)(10)(A)(i) may have and obtain
medical assistance under the plan; and
``(3) whose resources (as determined under the State plan
under this title with respect to disabled individuals) do not
exceed the maximum amount of resources a disabled individual
described in subsection (a)(10)(A)(i) may have and obtain
medical assistance under the plan.''.
(b) Enhanced Match.--The first sentence of section 1905(b)
of such Act (42 U.S.C. 1396d(b)) is amended by striking
``section 1902(a)(10)(A)(ii)(XVIII)'' and inserting
``subclause (XVIII) or (XXI) of section 1902(a)(10)(A)(ii)''.
(c) Conforming Amendments.--Section 1905(a) of such Act (42
U.S.C. 1396d(a)) is amended, in the matter preceding
paragraph (1)--
(1) by striking ``or'' at the end of clause (xii);
(2) by adding ``or'' at the end of clause (xiii); and
(3) by inserting after clause (xiii) the following:
``(xiv) individuals described in section 1902(ii),''.
(d) Exemption From Funding Limitation for Territories.--
Section 1108(g) of the Social Security Act (42 U.S.C.
1308(g)) is amended by adding at the end the following:
``(5) Disregarding medical assistance for optional low-
income hiv-infected individuals.--The limitations under
subsection (f) and the previous provisions of this subsection
shall not apply to amounts expended for medical assistance
for individuals described in section 1902(ii) who are only
eligible for such assistance on the basis of section
1902(a)(10)(A)(ii)(XXI).''.
(e) Effective Date; Sunset.--The amendments made by this
section shall apply to expenditures for calendar quarters
beginning on or after the date of the enactment of this Act,
and before January 1, 2013, without regard to whether or not
final regulations to carry out such amendments have been
promulgated by such date.

SEC. 1732. EXTENDING TRANSITIONAL MEDICAID ASSISTANCE (TMA).

Sections 1902(e)(1)(B) and 1925(f) of the Social Security
Act (42 U.S.C. 1396a(e)(1)(B), 1396r-6(f)), as amended by
section 5004(a)(1) of the American Recovery and Reinvestment
Act of 2009 (Public Law 111-5), are each amended by striking
``December 31, 2010'' and inserting ``December 31, 2012''.

SEC. 1733. REQUIREMENT OF 12-MONTH CONTINUOUS COVERAGE UNDER
CERTAIN CHIP PROGRAMS.

(a) In General.--Section 2102(b) of the Social Security Act
(42 U.S.C. 1397bb(b)) is amended by adding at the end the
following new paragraph:
``(6) Requirement for 12-month continuous eligibility.--In
the case of a State child health plan that provides child
health assistance under this title through a means other than
described in section 2101(a)(2), the plan shall provide for
implementation under this title of the 12-month continuous
eligibility option described in section 1902(e)(12) for
targeted low-income children whose family income is below 200
percent of the poverty line.''.
(b) Effective Date.--The amendment made by subsection (a)
shall apply to determinations (and redeterminations) of
eligibility made on or after January 1, 2010.

SEC. 1734. PREVENTING THE APPLICATION UNDER CHIP OF COVERAGE
WAITING PERIODS FOR CERTAIN CHILDREN.

(a) In General.--Section 2102(b)(1) of the Social Security
Act (42 U.S.C. 1397bb(b)(1)) is amended--
(1) in subparagraph (B)--
(A) in clause (iii), by striking ``and'' at the end;
(B) in clause (iv), by striking the period at the end and
inserting ``; and''; and
(C) by adding at the end the following new clause:
``(v) may not apply a waiting period (including a waiting
period to carry out paragraph (3)(C)) in the case of a child
described in subparagraph (C).''; and
(2) by adding at the end the following new subparagraph:
``(C) Description of children not subject to waiting
period.--For purposes of this paragraph, a child described in
this subparagraph is a child who, on the date an application
is submitted for such child for child health assistance under
this title, meets any of the following requirements:
``(i) Infants and toddlers.--The child is under two years
of age.
``(ii) Loss of group health plan coverage.--The child
previously had private health insurance coverage through a
group health plan or health insurance coverage offered
through an employer and lost such coverage due to--

``(I) termination of an individual's employment;
``(II) a reduction in hours that an individual works for an
employer;
``(III) elimination of an individual's retiree health
benefits; or
``(IV) termination of an individual's group health plan or
health insurance coverage offered through an employer.

``(iii) Unaffordable private coverage.--

``(I) In general.--The family of the child demonstrates
that the cost of health insurance coverage (including the
cost of premiums, co-payments, deductibles, and other cost
sharing) for such family exceeds 10 percent of the income of
such family.
``(II) Determination of family income.--For purposes of
subclause (I), family income shall be determined in the same
manner specified by the State for purposes of determining a
child's eligibility for child health assistance under this
title.''.

(b) Effective Date.--The amendments made by this section
shall take effect as of the date that is 90 days after the
date of the enactment of this Act.

SEC. 1735. ADULT DAY HEALTH CARE SERVICES.

(a) In General.--The Secretary of Health and Human Services
shall not--
(1) withhold, suspend, disallow, or otherwise deny Federal
financial participation under section 1903(a) of the Social
Security Act (42 U.S.C. 1396b(a)) for the provision of adult
day health care services, day activity and health services,
or adult medical day care services, as defined under a State
Medicaid plan approved during or before 1994, during such
period if such services are provided consistent with such
definition and the requirements of such plan; or
(2) withdraw Federal approval of any such State plan or
part thereof regarding the provision of such services (by
regulation or otherwise).
(b) Effective Date.--Subsection (a) shall apply with
respect to services provided on or after October 1, 2008.

SEC. 1736. MEDICAID COVERAGE FOR CITIZENS OF FREELY
ASSOCIATED STATES.

(a) In General.--Section 402(b)(2) of the Personal
Responsibility and Work Opportunity Reconciliation Act of
1996 (8 U.S.C. 1612(b)(2)) is amended by adding at the end
the following:
``(G) Medicaid exception for citizens of freely associated
states.--With respect to eligibility for benefits for the
designated Federal program defined in paragraph (3)(C)
(relating to the Medicaid program), section 401(a) and
paragraph (1) shall not apply to any individual who lawfully
resides in 1 of the 50 States or the District of Columbia in
accordance with the Compacts of Free Association between the
Government of the United States and the Governments of the
Federated States of Micronesia, the Republic of the Marshall
Islands, and the Republic of Palau and shall not apply, at
the option of the Governor of Puerto Rico, the Virgin
Islands, Guam, the Northern Mariana Islands, or American
Samoa as communicated to the Secretary of Health and Human
Services in writing, to any individual who lawfully resides
in the respective territory in accordance with such
Compacts.''.
(b) Exception to 5-Year Limited Eligibility.--Section
403(d) of such Act (8 U.S.C. 1613(d)) is amended--
(1) in paragraph (1), by striking ``or'' at the end;
(2) in paragraph (2), by striking the period at the end and
inserting ``; or''; and
(3) by adding at the end the following:
``(3) an individual described in section 402(b)(2)(G), but
only with respect to the designated Federal program defined
in section 402(b)(3)(C).''.
(c) Definition of Qualified Alien.--Section 431(b) of such
Act (8 U.S.C. 1641(b)) is amended--
(1) in paragraph (6), by striking ``; or'' at the end and
inserting a comma;
(2) in paragraph (7), by striking the period at the end and
inserting ``, or''; and

[[Page H12737]]

(3) by adding at the end the following:
``(8) an individual who lawfully resides in the United
States in accordance with a Compact of Free Association
referred to in section 402(b)(2)(G), but only with respect to
the designated Federal program defined in section
402(b)(3)(C) (relating to the Medicaid program).''.

SEC. 1737. CONTINUING REQUIREMENT OF MEDICAID COVERAGE OF
NONEMERGENCY TRANSPORTATION TO MEDICALLY
NECESSARY SERVICES.

(a) Requirement.--Section 1902(a)(10) of the Social
Security Act (42 U.S.C. 1396a(a)(10)) is amended--
(1) in subparagraph (A), in the matter preceding clause
(i), by striking ``and (21)'' and inserting ``, (21), and
(30)''; and
(2) in subparagraph (C)(iv), by striking ``and (17)'' and
inserting ``, (17), and (30)''.
(b) Description of Services.--Section 1905(a) of such Act
(42 U.S.C. 1395d(a)), as amended by sections 1713(a)(1) and
1724(a)(1), is amended--
(1) in paragraph (29), by striking ``and'' at the end;
(2) by redesignating paragraph (30) as paragraph (31) and
by striking the comma at the end and inserting a semicolon;
and
(3) by inserting after paragraph (29) the following new
paragraph:
``(30) nonemergency transportation to medically necessary
services, consistent with the requirement of section 431.53
of title 42, Code of Federal Regulations, as in effect as of
June 1, 2008; and''.
(c) Effective Date.--The amendments made by this section
shall take effect on the date of the enactment of this Act
and shall apply to transportation on or after such date.

SEC. 1738. STATE OPTION TO DISREGARD CERTAIN INCOME IN
PROVIDING CONTINUED MEDICAID COVERAGE FOR
CERTAIN INDIVIDUALS WITH EXTREMELY HIGH
PRESCRIPTION COSTS.

Section 1902(e) of the Social Security Act (42 U.S.C.
1396b(e)), as amended by section 203(a) of the Children's
Health Insurance Program Reauthorization Act of 2009 (Public
Law 111-3), is amended by adding at the end the following new
paragraph:
``(14)(A) At the option of the State, in the case of an
individual with extremely high prescription drug costs
described in subparagraph (B) who has been determined
(without the application of this paragraph) to be eligible
for medical assistance under this title, the State may, in
redetermining the individual's eligibility for medical
assistance under this title, disregard any family income of
the individual to the extent such income is less than an
amount that is specified by the State and does not exceed the
amount specified in subparagraph (C), or, if greater, income
equal to the cost of the orphan drugs described in
subparagraph (B)(iii).
``(B) An individual with extremely high prescription drug
costs described in this subparagraph for a 12-month period is
an individual--
``(i) who is covered under health insurance or a health
benefits plan that has a maximum lifetime limit of not less
than $1,000,000 which includes all prescription drug
coverage;
``(ii) who has exhausted all available prescription drug
coverage under the plan as of the beginning of such period;
``(iii) who incurs (or is reasonably expected to incur) on
an annual basis during the period costs for orphan drugs in
excess of the amount specified in subparagraph (C) for the
period; and
``(iv) whose annual family income (determined without
regard to this paragraph) as of the beginning of the period
does not exceed 75 percent of the amount incurred for such
drugs (as described in clause (iii)).
``(C) The amount specified in this subparagraph for a 12-
month period beginning in--
``(i) 2009 or 2010, is $200,000; or
``(ii) a subsequent year, is the amount specified in clause
(i) (or this subparagraph) for the previous year increased by
the annual rate of increase in the medical care component of
the consumer price index (U.S. city average) for the 12-month
period ending in August of the previous year.

Any amount computed under clause (ii) that is not a multiple
of $1,000 shall be rounded to the nearest multiple of $1,000.
``(D) In applying this paragraph, amounts incurred for
prescription drugs for cosmetic purposes shall not be taken
into account.
``(E) With respect to an individual described in
subparagraph (A), notwithstanding section 1916, the State
plan--
``(i) shall provide for the application of cost-sharing
that is at least nominal as determined under section 1916;
and
``(ii) may provide, consistent with section 1916A, for such
additional cost-sharing as does not exceed a maximum level of
cost-sharing that is specified by the Secretary and is
adjusted by the Secretary on an annual basis.
``(F) A State electing the option under this paragraph
shall provide for a determination on an individual's
application for continued medical assistance under this title
within 30 days of the date the application if filed with the
State.
``(G) In this paragraph:
``(i) The term `orphan drugs' means prescription drugs
designated under section 526 of the Federal Food, Drug, and
Cosmetic Act (21 U.S.C. 360bb) as a drug for a rare disease
or condition.
``(ii) The term `health benefits plan' includes coverage
under a plan offered under a State high risk pool.''.

SEC. 1739. PROVISIONS RELATING TO COMMUNITY LIVING ASSISTANCE
SERVICES AND SUPPORTS (CLASS).

(a) Coordination With CLASS Provisions.--Section 1902(a) of
the Social Security Act (42 U.S.C. 1396a(a)), as amended by
sections 1631(b), 1703(a), 1729, 1753, 1757(a), 1759(a),
1783(a), and 1907(b), is amended--
(1) in paragraph (80), by striking ``and'' at the end;
(2) in paragraph (81), by striking the period and inserting
``; and''; and
(3) by inserting after paragraph (81) the following:
``(82) provide that the State will comply with such
regulations regarding the application of primary and
secondary payor rules with respect to individuals who are
eligible for medical assistance under this title and are
eligible beneficiaries under the CLASS program established
under title XXXII of the Public Health Service Act as the
Secretary shall establish.''.
(b) Assurance of Adequate Infrastructure for the Provision
of Personal Care Attendant Workers.--Section 1902(a) of such
Act (42 U.S.C. 1396a(a)), as amended by subsection (a), is
amended--
(1) in paragraph (81), by striking ``and'' at the end;
(2) in paragraph (82), by striking the period at the end
and inserting ``; and''; and
(3) by inserting after paragraph (82), the following:
``(83) provide that, not later than 2 years after the date
of enactment of this paragraph, each State shall--
``(A) assess the extent to which entities such as providers
of home care, home health services, home and community
service providers, public authorities created to provide
personal care services to individuals eligible for medical
assistance under the State plan, and nonprofit organizations,
are serving or have the capacity to serve as fiscal agents
for, employers of, and providers of employment-related
benefits for, personal care attendant workers who provide
personal care services to individuals receiving benefits
under the CLASS program established under title XXXII of the
Public Health Service Act, including in rural and underserved
areas;
``(B) designate or create such entities to serve as fiscal
agents for, employers of, and providers of employment-related
benefits for, such workers to ensure an adequate supply of
the workers for individuals receiving benefits under the
CLASS program, including in rural and underserved areas; and
``(C) ensure that the designation or creation of such
entities will not negatively alter or impede existing
programs, models, methods, or administration of service
delivery that provide for consumer controlled or self-
directed home and community services and further ensure that
such entities will not impede the ability of individuals to
direct and control their home and community services,
including the ability to select, manage, dismiss, co-employ,
or employ such workers or inhibit such individuals from
relying on family members for the provision of personal care
services.''.
(c) Inclusion of Information on Supplemental Coverage in
the National Clearinghouse for Long-Term Care Information;
Extension of Funding.--Section 6021(d) of the Deficit
Reduction Act of 2005 (42 U.S.C. 1396p note) is amended--
(1) in paragraph (2)(A)--
(A) in clause (ii), by striking ``and'' at the end;
(B) in clause (iii), by striking the period at the end and
inserting ``; and''; and
(C) by adding at the end the following:
``(iv) include information regarding the CLASS program
established under title XXXII of the Public Health Service
Act.''; and
(2) in paragraph (3)--
(A) by striking ``2010'' and inserting ``2015''; and
(B) by adding at the end the following: ``In addition to
the amount appropriated under the previous sentence, there
are authorized to be appropriated to carry out this
subsection, $7,000,000 for each of fiscal years 2011, 2012,
and 2013.''.
(d) Effective Date.--The amendments made by this section
take effect on January 1, 2011.

SEC. 1739A. SENSE OF CONGRESS REGARDING COMMUNITY FIRST
CHOICE OPTION TO PROVIDE MEDICAID COVERAGE OF
COMMUNITY-BASED ATTENDANT SERVICES AND
SUPPORTS.

It is the sense of Congress that States should be allowed
to elect under their Medicaid State plans under title XIX of
the Social Security Act to implement a Community First Choice
Option under which--
(1) coverage of community-based attendant services and
supports furnished in homes and communities is available, at
an individual's option, to individuals who would otherwise
qualify for Medicaid institutional coverage under the
respective State plan;
(2) such supports and services include assistance to
individuals with disabilities in accomplishing activities of
daily living, instrumental activities of daily living, and
health-related tasks;
(3) the Federal matching assistance percentage (FMAP) under
such title for medical assistance for such supports and
services is enhanced;
(4) States, consistent with minimum federal standards,
ensure quality of such supports and services; and
(5) States collect and provide data to the Secretary of
Health and Human Services on

[[Page H12738]]

the cost and effectiveness and quality of supports and
services provided through such option.

Subtitle E--Financing

SEC. 1741. PAYMENTS TO PHARMACISTS.

(a) Pharmacy Reimbursement Limits.--
(1) In general.--Section 1927(e) of the Social Security Act
(42 U.S.C. 1396r-8(e)) is amended--
(A) by striking paragraph (5) and inserting the following:
``(5) Use of amp in upper payment limits.--The Secretary
shall calculate the Federal upper reimbursement limit
established under paragraph (4) as 130 percent of the
weighted average (determined on the basis of manufacturer
utilization) of monthly average manufacturer prices. Nothing
in the previous sentence shall be construed as preventing the
Secretary from performing such calculation using a smoothing
process in order to reduce significant variations from month
to month as a result of rebates, discounts, and other pricing
practices, such as in the manner such a process is used by
the Secretary in determining the average sales price of a
drug or biological under section 1847A.''
(2) Definition of amp.--Section 1927(k)(1)(B) of such Act
(42 U.S.C. 1396r-8(k)(1)(B)) is amended--
(B) in the heading, by striking ``extended to wholesalers''
and inserting ``and other payments''; and
(C) by striking ``regard to'' and all that follows through
the period and inserting the following: ``regard to--
``(i) customary prompt pay discounts extended to
wholesalers;
``(ii) bona fide service fees paid by manufacturers;
``(iii) reimbursement by manufacturers for recalled,
damaged, expired, or otherwise unsalable returned goods,
including reimbursement for the cost of the goods and any
reimbursement of costs associated with return goods handling
and processing, reverse logistics, and drug destruction;
``(iv) sales directly to, or rebates, discounts, or other
price concessions provided to, pharmacy benefit managers,
managed care organizations, health maintenance organizations,
insurers, mail order pharmacies that are not open to all
members of the public, or long term care providers, provided
that these rebates, discounts, or price concessions are not
passed through to retail pharmacies;
``(v) sales directly to, or rebates, discounts, or other
price concessions provided to, hospitals, clinics, and
physicians, unless the drug is an inhalation, infusion, or
injectable drug, or unless the Secretary determines, as
allowed for in Agency administrative procedures, that it is
necessary to include such sales, rebates, discounts, and
price concessions in order to obtain an accurate AMP for the
drug. Such a determination shall not be subject to judicial
review; or
``(vi) rebates, discounts, and other price concessions
required to be provided under agreements under subsections
(f) and (g) of section 1860D-2(f).''.
(3) Manufacturer reporting requirements.--Section
1927(b)(3)(A) of such Act (42 U.S.C. 1396r-8(b)(3)(A)) is
amended--
(A) in clause (ii), by striking ``and'' at the end;
(B) by striking the period at the end of clause (iii) and
inserting ``; and''; and
(C) by inserting after clause (iii) the following new
clause:
``(iv) not later than 30 days after the last day of each
month of a rebate period under the agreement, on the
manufacturer's total number of units that are used to
calculate the monthly average manufacturer price for each
covered outpatient drug.''.
(4) Authority to promulgate regulation.--The Secretary of
Health and Human Services may promulgate regulations to
clarify the requirements for upper payment limits and for the
determination of the average manufacturer price in an
expedited manner. Such regulations may become effective on an
interim final basis, pending opportunity for public comment.
(5) Pharmacy reimbursements through december 31, 2010.--The
specific upper limit under section 447.332 of title 42, Code
of Federal Regulations (as in effect on December 31, 2006)
applicable to payments made by a State for multiple source
drugs under a State Medicaid plan shall continue to apply
through December 31, 2010, for purposes of the availability
of Federal financial participation for such payments.
(b) Disclosure of Price Information to the Public.--Section
1927(b)(3) of such Act (42 U.S.C. 1396r-8(b)(3)) is amended--
(1) in subparagraph (A)--
(A) in clause (i), in the matter preceding subclause (I),
by inserting ``month of a'' after ``each''; and
(B) in the last sentence, by striking ``and shall,'' and
all that follows up to the period; and
(2) in subparagraph (D)(v), by inserting ``weighted''
before ``average manufacturer prices''.

SEC. 1742. PRESCRIPTION DRUG REBATES.

(a) Additional Rebate for New Formulations of Existing
Drugs.--
(1) In general.--Section 1927(c)(2) of the Social Security
Act (42 U.S.C. 1396r-8(c)(2)) is amended by adding at the end
the following new subparagraph:
``(C) Treatment of new formulations.--In the case of a drug
that is a line extension of a single source drug or an
innovator multiple source drug that is an oral solid dosage
form, the rebate obligation with respect to such drug under
this section shall be the amount computed under this section
for such new drug or, if greater, the product of--
``(i) the average manufacturer price of the line extension
of a single source drug or an innovator multiple source drug
that is an oral solid dosage form;
``(ii) the highest additional rebate (calculated as a
percentage of average manufacturer price) under this section
for any strength of the original single source drug or
innovator multiple source drug; and
``(iii) the total number of units of each dosage form and
strength of the line extension product paid for under the
State plan in the rebate period (as reported by the State).
In this subparagraph, the term `line extension' means, with
respect to a drug, a new formulation of the drug, such as an
extended release formulation.''.
(2) Effective date.--The amendment made by paragraph (1)
shall apply to drugs dispensed after December 31, 2009.
(b) Increase Minimum Rebate Percentage for Single Source
Drugs.--
(1) In general.--Section 1927(c)(1)(B)(i) of the Social
Security Act (42 U.S.C. 1396r-8(c)(1)(B)(i)) is amended--
(A) in subclause (IV), by striking ``and'' at the end;
(B) in subclause (V)--
(i) by inserting ``and before January 1, 2010'' after
``December 31, 1995,''; and
(ii) by striking the period at the end and inserting ``;
and''; and
(C) by adding at the end the following new subclause:

``(VI) after December 31, 2009, is 23.1 percent.''.

(2) Recapture of total savings due to increase.--Section
1927(b)(1) of such Act is amended by adding at the end the
following new subparagraph:
``(C) Special rule for increased minimum rebate
percentage.--
``(i) In general.--In addition to the amounts applied as a
reduction under subparagraph (B), for rebate periods
beginning on or after January 1, 2010, during a fiscal year,
the Secretary shall reduce payments to a State under section
1903(a) in the manner specified in clause (ii), in an amount
equal to the product of--

``(I) 100 percent minus the Federal medical assistance
percentage applicable to the rebate period for the State; and
``(II) the amounts received by the State under such
subparagraph that are attributable (as estimated by the
Secretary based on utilization and other data) to the
increase in the minimum rebate percentage effected by the
amendments made by section 1742(b)(1) of the Affordable
Health Care for America Act, taking into account the
additional drugs included under the amendments made by
section 1743 of such Act.

The Secretary shall adjust such payment reduction for a
calendar quarter to the extent the Secretary determines,
based upon subsequent utilization and other data, that the
reduction for such quarter was greater or less than the
amount of payment reduction that should have been made.
``(ii) Manner of payment reduction.--The amount of the
payment reduction under clause (i) for a State for a quarter
shall be deemed an overpayment to the State under this title
to be disallowed against the State's regular quarterly draw
for all Medicaid spending under section 1903(d)(2). Such a
disallowance is not subject to a reconsideration under
1116(d).''.

SEC. 1743. EXTENSION OF PRESCRIPTION DRUG DISCOUNTS TO
ENROLLEES OF MEDICAID MANAGED CARE
ORGANIZATIONS.

(a) In General.--Section 1903(m)(2)(A) of the Social
Security Act (42 U.S.C. 1396b(m)(2)(A)) is amended--
(1) in clause (xi), by striking ``and'' at the end;
(2) in clause (xii), by striking the period at the end and
inserting ``; and''; and
(3) by adding at the end the following:
``(xiii) such contract provides that the entity shall
report to the State such information, on such timely and
periodic basis as specified by the Secretary, as the State
may require in order to include, in the information submitted
by the State to a manufacturer under section 1927(b)(2)(A)
and to the Secretary under section 1927(b)(2)(C), information
on covered outpatient drugs dispensed to individuals eligible
for medical assistance who are enrolled with the entity and
for which the entity is responsible for coverage of such
drugs under this subsection.''.
(b) Conforming Amendments.--Section 1927 of such Act (42
U.S.C. 1396r-8) is amended----
(1) in the first sentence of subsection (b)(1)(A), by
inserting before the period at the end the following: ``,
including such drugs dispensed to individuals enrolled with a
medicaid managed care organization if the organization is
responsible for coverage of such drugs'';
(2) in subsection (b)(2), by adding at the end the
following new subparagraph:
``(C) Reporting on mmco drugs.--On a quarterly basis, each
State shall report to the Secretary the total amount of
rebates in dollars received from pharmacy manufacturers for
drugs provided to individuals enrolled with Medicaid managed
care organizations that contract under section 1903(m) and
such other information as the Secretary may require to carry
out paragraph (1)(C) with respect to such rebates.''; and
(3) in subsection (j)--

[[Page H12739]]

(A) in the heading by striking ``Exemption'' and inserting
``Special Rules''; and
(B) in paragraph (1), by striking ``are not subject to the
requirements of this section'' and inserting ``are subject to
the requirements of this section unless such drugs are
subject to discounts under section 340B of the Public Health
Service Act''.
(c) Effective Date.--The amendments made by this section
take effect on January 1, 2010, and shall apply to drugs
dispensed on or after such date, without regard to whether or
not final regulations to carry out such amendments have been
promulgated by such date.

SEC. 1744. PAYMENTS FOR GRADUATE MEDICAL EDUCATION.

(a) In General.--Section 1905 of the Social Security Act
(42 U.S.C. 1396d), as amended by sections 1701(a)(3)(B),
1711(a), and 1713(a), is amended by adding at the end the
following new subsection:
``(bb) Payment for Graduate Medical Education.--
``(1) In general.--The term `medical assistance' includes
payment for costs of graduate medical education consistent
with this subsection, whether provided in or outside of a
hospital.
``(2) Submission of information.--For purposes of paragraph
(1) and section 1902(a)(13)(A)(v), payment for such costs is
not consistent with this subsection unless--
``(A) the State submits to the Secretary, in a timely
manner and on an annual basis specified by the Secretary,
information on total payments for graduate medical education
and how such payments are being used for graduate medical
education, including--
``(i) the institutions and programs eligible for receiving
the funding;
``(ii) the manner in which such payments are calculated;
``(iii) the types and fields of education being supported;
``(iv) the workforce or other goals to which the funding is
being applied;
``(v) State progress in meeting such goals; and
``(vi) such other information as the Secretary determines
will assist in carrying out paragraphs (3) and (4); and
``(B) such expenditures are made consistent with such goals
and requirements as are established under paragraph (4).
``(3) Review of information.--The Secretary shall make the
information submitted under paragraph (2) available to the
Advisory Committee on Health Workforce Evaluation and
Assessment (established under section 2261 of the Public
Health Service Act). The Secretary and the Advisory Committee
shall independently review the information submitted under
paragraph (2), taking into account State and local workforce
needs.
``(4) Specification of goals and requirements.--The
Secretary shall specify by rule, initially published by not
later than December 31, 2011--
``(A) program goals for the use of funds described in
paragraph (1), taking into account recommendations of the
such Advisory Committee and the goals for approved medical
residency training programs described in section
1886(h)(1)(B); and
``(B) requirements for use of such funds consistent with
such goals.
Such rule may be effective on an interim basis pending
revision after an opportunity for public comment.''.
(b) Conforming Amendment.--Section 1902(a)(13)(A) of such
Act (42 U.S.C. 1396a(a)(13)(A)), as amended by section
1721(a)(1)(A), is amended--
(1) by striking ``and'' at the end of clause (iii);
(2) by striking the semicolon in clause (iv) and inserting
``, and''; and
(3) by adding at the end the following new clause:
``(v) in the case of hospitals and at the option of a
State, such rates may include, to the extent consistent with
section 1905(bb), payment for graduate medical education;
and''.
(c) Effective Date.--The amendments made by this section
shall take effect on the date of the enactment of this Act.
Nothing in this section shall be construed as affecting
payments made before such date under a State plan under title
XIX of the Social Security Act for graduate medical
education.

SEC. 1745. NURSING FACILITY SUPPLEMENTAL PAYMENT PROGRAM.

(a) Total Amount Available for Payments.--
(1) In general.--Out of any funds in the Treasury not
otherwise appropriated, there are appropriated to the
Secretary of Health and Human Services (in this section
referred to as the ``Secretary'') to carry out this section
$6,000,000,000, of which the following amounts shall be
available for obligation in the following years:
(A) $1,500,000,000 shall be available beginning in 2010.
(B) $1,500,000,000 shall be available beginning in 2011.
(C) $1,500,000,000 shall be available beginning in 2012.
(D) $1,500,000,000 shall be available beginning in 2013.
(2) Availability.--Funds appropriated under paragraph (1)
shall remain available until all eligible dually-certified
facilities (as defined in subsection (b)(3)) have been
reimbursed for underpayments under this section during cost
reporting periods ending during calendar years 2010 through
2013.
(3) Limitation of authority.--The Secretary may not make
payments under this section that exceed the funds
appropriated under paragraph (1).
(4) Disposition of remaining funds into mif.--Any funds
appropriated under paragraph (1) which remain available after
the application of paragraph (2) shall be deposited into the
Medicaid Improvement Fund under section 1941 of the Social
Security Act.
(b) Use of Funds.--
(1) Authority to make payments.--From the amounts available
for obligation in a year under subsection (a), the Secretary,
acting through the Administrator of the Centers for Medicare
& Medicaid Services, shall pay the amount determined under
paragraph (2) directly to an eligible dually-certified
facility for the purpose of providing funding to reimburse
such facility for furnishing quality care to Medicaid-
eligible individuals.
(2) Determination of payment amounts.--
(A) In general.--Subject to subparagraphs (B) and (C), the
payment amount determined under this paragraph for a year for
an eligible dually-certified facility shall be an amount
determined by the Secretary as reported on the facility's
latest available Medicare cost report.
(B) Limitation on payment amount.--In no case shall the
payment amount for an eligible dually-certified facility for
a year under subparagraph (A) be more than the payment
deficit described in paragraph (3)(D) for such facility as
reported on the facility's latest available Medicare cost
report.
(C) Pro-rata reduction.--If the amount available for
obligation under subsection (a) for a year (as reduced by
allowable administrative costs under this section) is
insufficient to ensure that each eligible dually-certified
facility receives the amount of payment calculated under
subparagraph (A), the Secretary shall reduce that amount of
payment with respect to each such facility in a pro-rata
manner to ensure that the entire amount available for such
payments for the year be paid.
(D) No required match.--The Secretary may not require that
a State provide matching funds for any payment made under
this subsection.
(3) Eligible dually-certified facility defined.--For
purposes of this section, the term ``eligible dually-
certified facility'' means, for a cost reporting period
ending during a year (beginning no earlier than 2010) that is
covered by the latest available Medicare cost report, a
nursing facility that meets all of the following
requirements:
(A) The facility is participating as a nursing facility
under title XIX of the Social Security Act and as a skilled
nursing facility under title XVIII of such Act during the
entire year.
(B) The base Medicaid payment rate (excluding any
supplemental payments) to the facility is not less than the
base Medicaid payment rate (excluding any supplemental
payments) to such facility as of June 16, 2009.
(C) As reported on the facility's latest Medicare cost
report--
(i) the Medicaid share of patient days for such facility is
not less than 60 percent of the combined Medicare and
Medicaid share of resident days for such facility; and
(ii) the combined Medicare and Medicaid share of resident
days for such facility, as reported on the facility's latest
available Medicare cost report, is not less than 75 percent
of the total resident days for such facility.
(D) The facility has received Medicaid reimbursement
(including any supplemental payments) for the provision of
covered services to Medicaid eligible individuals, as
reported on the facility's latest available Medicare cost
report, that is significantly less (as determined by the
Secretary) than the allowable costs (as determined by the
Secretary) incurred by the facility in providing such
services.
(E) The facility is not in the highest quartile of costs
costs per day, as determined by the Secretary and as adjusted
for case mix, wages, and type of facility.
(F) The facility provides quality care, as determined by
the Secretary, to--
(i) Medicaid eligible individuals; and
(ii) individuals who are entitled to items and services
under part A of title XVIII of the Social Security Act.
(G) In the most recent standard survey available, the
facility was not cited for any immediate jeopardy
deficiencies as defined by the Secretary.
(H) In the most recent standard survey available, the
facility maintains an appropriate staffing level to attain or
maintain the highest practicable well-being of each resident
as defined by the Secretary.
(I) The facility complies with all the requirements, as
determined by the Secretary, contained in sections 1411
through 1416 and the amendments made by such sections.
(J) The facility was not listed as a Centers for Medicare &
Medicaid Services Special Focus Facility (SFF) nor as a SFF
on a State-based list.
(4) Frequency of payment.--Payment of an amount under this
subsection to an eligible dually-certified facility shall be
made for a year in a lump sum or in such periodic payments in
such frequency as the Secretary determines appropriate.
(5) Direct payments.--Such payment--
(A) shall be made directly by the Secretary to an eligible
dually-certified facility or a contractor designated by such
facility; and
(B) shall not be made through a State.
(c) Administration.--
(1) Annual applications; deadlines.--The Secretary shall
establish a process, including

[[Page H12740]]

deadlines, under which facilities may apply on an annual
basis to qualify as eligible dually-certified facilities for
payment under subsection (b).
(2) Contracting authority.--The Secretary may enter into
one or more contracts with entities for the purpose of
implementation of this section.
(3) Limitation.--The Secretary may not spend more than 0.75
percent of the amount made available under subsection (a) in
any year on the costs of administering the program of
payments under this section for the year.
(4) Implementation.--Notwithstanding any other provision of
law, the Secretary may implement, by program instruction or
otherwise, the provisions of this section.
(5) Limitations on review.--There shall be no
administrative or judicial review of--
(A) the determination of the eligibility of a facility for
payments under subsection (b); or
(B) the determination of the amount of any payment made to
a facility under such subsection.
(d) Annual Reports.--The Secretary shall submit an annual
report to the committees with jurisdiction in the Congress on
payments made under subsection (b). Each such report shall
include information on--
(1) the facilities receiving such payments;
(2) the amount of such payments to such facilities; and
(3) the basis for selecting such facilities and the amount
of such payments.
(e) Reference to Report.--For report by the Medicaid and
CHIP Payment and Access Commission on the adequacy of
payments to nursing facilities under the Medicaid program,
see section 1900(b)(2)(B) of the Social Security Act, as
amended by section 1784.
(f) Definitions.--For purposes of this section:
(1) Dually-certified facility.--The term ``dually-certified
facility'' means a facility that is participating as a
nursing facility under title XIX of the Social Security Act
and as a skilled nursing facility under title XVIII of such
Act.
(2) Medicaid eligible individual.--The term ``Medicaid
eligible individual'' means an individual who is eligible for
medical assistance, with respect to nursing facility services
(as defined in section 1905(f) of the Social Security Act),
under title XIX of the such Act.
(3) State.--The term ``State'' means the 50 States and the
District of Columbia.

SEC. 1746. REPORT ON MEDICAID PAYMENTS.

Section 1902 of the Social Security Act (42 U.S.C. 1396),
as amended by sections 1703(a), 1714(a), and 1731(a), is
amended by adding at the end the following new subsection:
``(jj) Report on Medicaid Payments.--Each year, on or
before a date determined by the Secretary, a State
participating in the Medicaid program under this title shall
submit to the Administrator of the Centers for Medicare &
Medicaid Services--
``(1) information on the determination of rates of payment
to providers for covered services under the State plan,
including--
``(A) the final rates;
``(B) the methodologies used to determine such rates; and
``(C) justifications for the rates; and
``(2) an explanation of the process used by the State to
allow providers, beneficiaries and their representatives, and
other concerned State residents a reasonable opportunity to
review and comment on such rates, methodologies, and
justifications before the State made such rates final.''.

SEC. 1747. REVIEWS OF MEDICAID.

(a) GAO Study on FMAP.--.
(1) Study.--The Comptroller General of the United States
shall conduct a study regarding federal payments made to the
State Medicaid programs under title XIX of the Social
Security Act for the purposes of making recommendations to
Congress.
(2) Report.--Not later than February 15, 2011, the
Comptroller General shall submit to the appropriate
committees of Congress a report on the study conducted under
paragraph (1) and the effect on the federal government,
States, providers, and beneficiaries of--
(A) removing the 50 percent floor, or 83 percent ceiling,
or both, in the Federal medical assistance percentage under
section 1905(b)(1) of the Social Security Act; and
(B) revising the current formula for such Federal medical
assistance percentage to better reflect State fiscal capacity
and State effort to pay for health and long-term care
services and to better adjust for national or regional
economic downturns.
(b) GAO Study on Medicaid Administrative Costs..--
(1) Study.--The Comptroller General of the United States
shall conduct a study of the administration of the Medicaid
program by the Department of Health and Human Services, State
Medicaid agencies, and local government agencies. The report
shall address the following issues:
(A) The extent to which federal funds for each
administrative function, such as survey and certification and
claims processing, are being used effectively and
efficiently.
(B) The administrative functions on which federal Medicaid
funds are expended and the amounts of such expenditures
(whether spent directly or by contract).
(2) Report.--Not later than February 15, 2011, the
Comptroller General shall submit to the appropriate
committees of Congress a report on the study conducted under
paragraph (1).

SEC. 1748. EXTENSION OF DELAY IN MANAGED CARE ORGANIZATION
PROVIDER TAX ELIMINATION.

Effective as if included in the enactment of section 6051
of the Deficit Reduction Act of 2005 (Public Law 109-171),
subsection (b)(2)(A) of such section is amended by striking
``October 1, 2009'' and inserting ``October 1, 2010''.

SEC. 1749. EXTENSION OF ARRA INCREASE IN FMAP.

Section 5001 of the American Recovery and Reinvestment Act
of 2009 (Public Law 111-5) is amended--
(1) in subsection (a)(3), by striking ``first calendar
quarter'' and inserting ``first 3 calendar quarters'';
(2) in subsection (b)(2), by inserting before the period at
the end the following: ``and such paragraph shall not apply
to calendar quarters beginning on or after October 1, 2010'';
(3) in subsection (c)(4)(C)(ii), by striking ``December
2009'' and ``January 2010'' and inserting ``June 2010'' and
``July 2010'', respectively;
(4) in subsection (d), by inserting ``ending before October
1, 2010'' after ``entire fiscal years'' and after ``with
respect to fiscal years'';
(5) in subsection (g)(1), by striking ``September 30,
2011'' and inserting ``December 31, 2011''; and
(6) in subsection (h)(3), by striking ``December 31, 2010''
and inserting ``June 30, 2011''.

Subtitle F--Waste, Fraud, and Abuse

SEC. 1751. HEALTH CARE ACQUIRED CONDITIONS.

(a) Medicaid Non-payment for Certain Health Care-acquired
Conditions.--Section 1903(i) of the Social Security Act (42
U.S.C. 1396b(i)) is amended--
(1) by striking ``or'' at the end of paragraph (23);
(2) by striking the period at the end of paragraph (24) and
inserting ``; or''; and
(3) by inserting after paragraph (24) the following new
paragraph:
``(25) with respect to amounts expended for services
related to the presence of a condition that could be
identified by a secondary diagnostic code described in
section 1886(d)(4)(D)(iv) and for any health care acquired
condition determined as a non-covered service under title
XVIII.''.
(b) Application to CHIP.--Section 2107(e)(1)(G) of such Act
(42 U.S.C. 1397gg(e)(1)(G)) is amended by striking ``and
(17)'' and inserting ``(17), and (25)''.
(c) Permission to Include Additional Health Care-acquired
Conditions.--Nothing in this section shall prevent a State
from including additional health care-acquired conditions for
non-payment in its Medicaid program under title XIX of the
Social Security Act.
(d) Effective Date.--The amendments made by this section
shall apply to discharges occurring on or after January 1,
2010.

SEC. 1752. EVALUATIONS AND REPORTS REQUIRED UNDER MEDICAID
INTEGRITY PROGRAM.

Section 1936(c)(2)) of the Social Security Act (42 U.S.C.
1396u-7(c)(2)) is amended--
(1) by redesignating subparagraph (D) as subparagraph (E);
and
(2) by inserting after subparagraph (C) the following new
subparagraph:
``(D) For the contract year beginning in 2011 and each
subsequent contract year, the entity provides assurances to
the satisfaction of the Secretary that the entity will
conduct periodic evaluations of the effectiveness of the
activities carried out by such entity under the Program and
will submit to the Secretary an annual report on such
activities.''.

SEC. 1753. REQUIRE PROVIDERS AND SUPPLIERS TO ADOPT PROGRAMS
TO REDUCE WASTE, FRAUD, AND ABUSE.

Section 1902(a) of such Act (42 U.S.C. 42 U.S.C. 1396a(a)),
as amended by sections 1631(b)(1), 1703, and 1729, is further
amended--
(1) in paragraph (75), by striking at the end ``and'';
(2) in paragraph (76), by striking at the end the period
and inserting ``; and''; and
(3) by inserting after paragraph (76) the following new
paragraph:
``(77) provide that any provider or supplier (other than a
physician or nursing facility) providing services under such
plan shall, subject to paragraph (5) of section 1874(d),
establish a compliance program described in paragraph (1) of
such section in accordance with such section.''.

SEC. 1754. OVERPAYMENTS.

(a) In General.--Section 1903(d)(2)(C) of the Social
Security Act (42 U.S.C. 1396b(d)(2)(C)) is amended--
(1) in the first sentence, by inserting ``(or of 1 year in
the case of overpayments due to fraud)'' after ``60 days'';
and
(2) in the second sentence, by striking ``the 60 days'' and
inserting ``such period''.
(b) Effective Date.--The amendments made by subsection (a)
shall apply in the case of overpayments discovered on or
after the date of the enactment of this Act.

SEC. 1755. MANAGED CARE ORGANIZATIONS.

(a) Minimum Medical Loss Ratio.--
(1) Medicaid.--Section 1903(m)(2)(A) of the Social Security
Act (42 U.S.C. 1396b(m)(2)(A)), as amended by section
1743(a)(3), is amended--
(A) by striking ``and'' at the end of clause (xii);
(B) by striking the period at the end of clause (xiii) and
inserting ``; and''; and
(C) by adding at the end the following new clause:
``(xiv) such contract has a medical loss ratio, as
determined in accordance with a

[[Page H12741]]

methodology specified by the Secretary that is a percentage
(not less than 85 percent) as specified by the Secretary.''.
(2) CHIP.--Section 2107(e)(1) of such Act (42 U.S.C.
1397gg(e)(1)) is amended--
(A) by redesignating subparagraphs (H) through (L) as
subparagraphs (I) through (M); and
(B) by inserting after subparagraph (G) the following new
subparagraph:
``(H) Section 1903(m)(2)(A)(xiv) (relating to application
of minimum loss ratios), with respect to comparable contracts
under this title.''.
(3) Effective date.--The amendments made by this subsection
shall apply to contracts entered into or renewed on or after
July 1, 2010.
(b) Patient Encounter Data.--
(1) In general.--Section 1903(m)(2)(A)(xi) of the Social
Security Act (42 U.S.C. 1396b(m)(2)(A)(xi)) is amended by
inserting ``and for the provision of such data to the State
at a frequency and level of detail to be specified by the
Secretary'' after ``patients''.
(2) Effective date.--The amendment made by paragraph (1)
shall apply with respect to contract years beginning on or
after January 1, 2010.

SEC. 1756. TERMINATION OF PROVIDER PARTICIPATION UNDER
MEDICAID AND CHIP IF TERMINATED UNDER MEDICARE
OR OTHER STATE PLAN OR CHILD HEALTH PLAN.

(a) State Plan Requirement.--Section 1902(a)(39) of the
Social Security Act (42 U.S.C. 42 U.S.C. 1396a(a)) is amended
by inserting after ``1128A,'' the following: ``terminate the
participation of any individual or entity in such program if
(subject to such exceptions are permitted with respect to
exclusion under sections 1128(b)(3)(C) and 1128(d)(3)(B))
participation of such individual or entity is terminated
under title XVIII, any other State plan under this title, or
any child health plan under title XXI,''.
(b) Application to CHIP.--Section 2107(e)(1)(A) of such Act
(42 U.S.C. 1397gg(e)(1)(A)) is amended by inserting before
the period at the end the following: ``and section
1902(a)(39) (relating to exclusion and termination of
participation)''.
(c) Effective Date.--Except as provided in section 1790,
the amendments made by this section shall apply to services
furnished on or after January 1, 2011, without regard to
whether or not final regulations to carry out such amendments
have been promulgated by such date.

SEC. 1757. MEDICAID AND CHIP EXCLUSION FROM PARTICIPATION
RELATING TO CERTAIN OWNERSHIP, CONTROL, AND
MANAGEMENT AFFILIATIONS.

(a) State Plan Requirement.--Section 1902(a) of the Social
Security Act (42 U.S.C. 1396a(a)), as amended by sections
1631(b)(1), 1703(a), 1729, and 1753, is further amended--
(1) in paragraph (76), by striking at the end ``and'';
(2) in paragraph (77), by striking at the end the period
and inserting ``; and''; and
(3) by inserting after paragraph (77) the following new
paragraph:
``(78) provide that the State agency described in paragraph
(9) exclude, with respect to a period, any individual or
entity from participation in the program under the State plan
if such individual or entity owns, controls, or manages an
entity that (or if such entity is owned, controlled, or
managed by an individual or entity that)--
``(A) has unpaid overpayments under this title during such
period determined by the Secretary or the State agency to be
delinquent;
``(B) is suspended or excluded from participation under or
whose participation is terminated under this title during
such period; or
``(C) is affiliated with an individual or entity that has
been suspended or excluded from participation under this
title or whose participation is terminated under this title
during such period.''.
(b) Child Health Plan Requirement.--Section 2107(e)(1)(A)
of such Act (42 U.S.C. 1397gg(e)(1)(A)), as amended by
section 1756(b), is amended by striking ``section
1902(a)(39)'' and inserting ``sections 1902(a)(39) and
1902(a)(78)''.
(c) Effective Date.--Except as provided in section 1790,
the amendments made by this section shall apply to services
furnished on or after January 1, 2011, without regard to
whether or not final regulations to carry out such amendments
have been promulgated by such date.

SEC. 1758. REQUIREMENT TO REPORT EXPANDED SET OF DATA
ELEMENTS UNDER MMIS TO DETECT FRAUD AND ABUSE.

Section 1903(r)(1)(F) of the Social Security Act (42 U.S.C.
1396b(r)(1)(F)) is amended by inserting after ``necessary''
the following: ``and including, for data submitted to the
Secretary on or after July 1, 2010, data elements from the
automated data system that the Secretary determines to be
necessary for detection of waste, fraud, and abuse''.

SEC. 1759. BILLING AGENTS, CLEARINGHOUSES, OR OTHER ALTERNATE
PAYEES REQUIRED TO REGISTER UNDER MEDICAID.

(a) In General.--Section 1902(a) of the Social Security Act
(42 U.S.C. 42 U.S.C. 1396a(a)), as amended by sections
1631(b), 1703(a), 1729, 1753, and 1757(a), is further
amended--
(1) in paragraph (77); by striking at the end ``and'';
(2) in paragraph (78), by striking the period at the end
and inserting ``and''; and
(3) by inserting after paragraph (78) the following new
paragraph:
``(79) provide that any agent, clearinghouse, or other
alternate payee that submits claims on behalf of a health
care provider must register with the State and the Secretary
in a form and manner specified by the Secretary under section
1866(j)(1)(D).''.
(b) Denial of Payment.--Section 1903(i) of such Act (42
U.S.C. 1396b(i)), as amended by section 1751, is amended--
(1) by striking ``or'' at the end of paragraph (24);
(2) by striking the period at the end of paragraph (25) and
inserting ``; or''; and
(3) by inserting after paragraph (25) the following new
paragraph:
``(26) with respect to any amount paid to a billing agent,
clearinghouse, or other alternate payee that is not
registered with the State and the Secretary as required under
section 1902(a)(79).''.
(c) Effective Date.--Except as provided in section 1790,
the amendments made by this section shall apply to claims
submitted on or after January 1, 2012, without regard to
whether or not final regulations to carry out such amendments
have been promulgated by such date.

SEC. 1760. DENIAL OF PAYMENTS FOR LITIGATION-RELATED
MISCONDUCT.

(a) In General.--Section 1903(i) of the Social Security Act
(42 U.S.C. 1396b(i)), as amended by sections 1751(a) and
1759(b), is amended--
(1) by striking ``or'' at the end of paragraph (25);
(2) by striking the period at the end of paragraph (26) and
inserting ``; or''; and
(3) by inserting after paragraph (26) the following new
paragraph:
``(27) with respect to any amount expended--
``(A) on litigation in which a court imposes sanctions on
the State, its employees, or its counsel for litigation-
related misconduct; or
``(B) to reimburse (or otherwise compensate) a managed care
entity for payment of legal expenses associated with any
action in which a court imposes sanctions on the managed care
entity for litigation-related misconduct.''.
(b) Effective Date.--The amendments made by subsection (a)
shall apply to amounts expended on or after January 1, 2010.

SEC. 1761. MANDATORY STATE USE OF NATIONAL CORRECT CODING
INITIATIVE.

Section 1903(r) of the Social Security Act (42 U.S.C.
1396b(r)) is amended--
(1) in paragraph (1)(B)--
(A) in clause (ii), by striking ``and'' at the end;
(B) in clause (iii), by adding ``and'' at the end; and
(C) by adding at the end the following new clause:
``(iv) effective for claims filed on or after October 1,
2010, incorporate compatible methodologies of the National
Correct Coding Initiative administered by the Secretary (or
any successor initiative to promote correct coding and to
control improper coding leading to inappropriate payment) and
such other methodologies of that Initiative (or such other
national correct coding methodologies) as the Secretary
identifies in accordance with paragraph (4);''; and
(2) by adding at the end the following new paragraph:
``(4) Not later than September 1, 2010, the Secretary shall
do the following:
``(A) Identify those methodologies of the National Correct
Coding Initiative administered by the Secretary (or any
successor initiative to promote correct coding and to control
improper coding leading to inappropriate payment) which are
compatible to claims filed under this title.
``(B) Identify those methodologies of such Initiative (or
such other national correct coding methodologies) that should
be incorporated into claims filed under this title with
respect to items or services for which States provide medical
assistance under this title and no national correct coding
methodologies have been established under such Initiative
with respect to title XVIII.
``(C) Notify States of--
``(i) the methodologies identified under subparagraphs (A)
and (B) (and of any other national correct coding
methodologies identified under subparagraph (B)); and
``(ii) how States are to incorporate such methodologies
into claims filed under this title.
``(D) Submit a report to Congress that includes the notice
to States under subparagraph (C) and an analysis supporting
the identification of the methodologies made under
subparagraphs (A) and (B).''.

Subtitle G--Payments to the Territories

SEC. 1771. PAYMENT TO TERRITORIES.

(a) Increase in Cap.--Section 1108 of the Social Security
Act (42 U.S.C. 1308) is amended--
(1) in subsection (f), by striking ``subsection (g)'' and
inserting ``subsections (g) and (h)'';
(2) in subsection (g)(1), by striking ``With respect to''
and inserting ``Subject to subsection (h), with respect to'';
and
(3) by adding at the end the following new subsection:
``(h) Additional Increase for Fiscal Years 2011 Through
2019.--Subject to section 347(b)(1) of the Affordable Health
Care for America Act, with respect to fiscal years 2011
through 2019, the amounts otherwise determined under
subsections (f) and (g) for Puerto Rico, the Virgin Islands,
Guam, the Northern Mariana Islands and American Samoa shall
be increased by the following amounts:

[[Page H12742]]

``(1) For Puerto Rico, for fiscal year 2011, $727,600,000;
for fiscal year 2012, $775,000,000; for fiscal year 2013,
$850,000,000; for fiscal year 2014, $925,000,000; for fiscal
year 2015, $1,000,000,000; for fiscal year 2016,
$1,075,000,000; for fiscal year 2017, $1,150,000,000; for
fiscal year 2018, $1,225,000,000; and for fiscal year 2019,
$1,396,400,000.
``(2) For the Virgin Islands, for fiscal year 2011,
$34,000,000; for fiscal year 2012, $37,000,000; for fiscal
year 2013, $40,000,000; for fiscal year 2014, $43,000,000;
for fiscal year 2015, $46,000,000; for fiscal year 2016,
$49,000,000; for fiscal year 2017, $52,000,000; for fiscal
year 2018, $55,000,000; and for fiscal year 2019,
$58,000,000.
``(3) For Guam, for fiscal year 2011, $34,000,000; for
fiscal year 2012, $37,000,000; for fiscal year 2013,
$40,000,000; for fiscal year 2014, $43,000,000; for fiscal
year 2015, $46,000,000; for fiscal year 2016, $49,000,000;
for fiscal year 2017, $52,000,000; for fiscal year 2018,
$55,000,000; and for fiscal year 2019, $58,000,000.
``(4) For the Northern Mariana Islands, for fiscal year
2011, $13,500,000; fiscal year 2012, $14,500,000; for fiscal
year 2013, $15,500,000; for fiscal year 2014, $16,500,000;
for fiscal year 2015, $17,500,000; for fiscal year 2016,
$18,500,000; for fiscal year 2017, $19,500,000; for fiscal
year 2018, $21,000,000; and for fiscal year 2019,
$22,000,000.
``(5) For American Samoa, fiscal year 2011, $22,000,000;
fiscal year 2012, $23,687,500; for fiscal year 2013,
$24,687,500; for fiscal year 2014, $25,687,500; for fiscal
year 2015, $26,687,500; for fiscal year 2016, $27,687,500;
for fiscal year 2017, $28,687,500; for fiscal year 2018,
$29,687,500; and for fiscal year 2019, $30,687,500.''.
(b) Report on Achieving Medicaid Parity Payments Beginning
With Fiscal Year 2020.--
(1) In general.--Not later than October 1, 2013, the
Secretary of Health and Human Services shall submit to
Congress a report that details a plan for the transition of
each territory to full parity in Medicaid with the 50 States
and the District of Columbia in fiscal year 2020 by modifying
their existing Medicaid programs and outlining actions the
Secretary and the governments of each territory must take by
fiscal year 2020 to ensure parity in financing. Such report
shall include what the Federal medical assistance percentages
would be for each territory if the formula applicable to the
50 States were applied. Such report shall also include any
recommendations that the Secretary may have as to whether the
mandatory ceiling amounts for each territory provided for in
section 1108 of the Social Security Act (42 U.S.C. 1308)
should be increased any time before fiscal year 2020 due to
any factors that the Secretary deems relevant.
(2) Per capita data.--As part of such report the Secretary
shall include information about per capita income data that
could be used to calculate Federal medical assistance
percentages under section 1905(b) of the Social Security Act,
under section 1108(a)(8)(B) of such Act, for each territory
on how such data differ from the per capita income data used
to promulgate Federal medical assistance percentages for the
50 States. The report under this subsection shall include
recommendations on how the Federal medical assistance
percentages can be calculated for the territories beginning
in fiscal year 2020 to ensure parity with the 50 States.
(3) Subsequent reports.--The Secretary shall submit
subsequent reports to Congress in 2015, 2017, and 2019
detailing the progress that the Secretary and the governments
of each territory have made in fulfilling the actions
outlined in the plan submitted under paragraph (1).
(c) Application of FMAP for Additional Funds.--Section
1905(b) of such Act (42 U.S.C. 1396d(b)) is amended by adding
at the end the following sentence: ``Notwithstanding the
first sentence of this subsection and any other provision of
law, for fiscal years 2011 through 2019, the Federal medical
assistance percentage for Puerto Rico, the Virgin Islands,
Guam, the Northern Mariana Islands, and American Samoa shall
be the highest Federal medical assistance percentage
applicable to any of the 50 States or the District of
Columbia for the fiscal year involved, taking into account
the application of subsections (a) and (b)(1) of section 5001
of division B of the American Recovery and Reinvestment Act
of 2009 (Public Law 111-5) to such States and the District
for calendar quarters during such fiscal years for which such
subsections apply.''.
(d) Waivers.--
(1) In general.--Section 1902(j) of the Social Security Act
(42 U.S.C. 1396a(j)) is amended--
(A) by striking ``American Samoa and the Northern Mariana
Islands'' and inserting ``Puerto Rico, the Virgin Islands,
Guam, the Northern Mariana Islands, and American Samoa''; and
(B) by striking ``American Samoa or the Northern Mariana
Islands'' and inserting ``Puerto Rico, the Virgin Islands,
Guam, the Northern Mariana Islands, or American Samoa''.
(2) Effective date.--The amendments made by paragraph (1)
shall apply beginning with fiscal year 2011.
(e) Technical Assistance.--The Secretary shall provide
nonmonetary technical assistance to the governments of Puerto
Rico, the Virgin Islands, Guam, the Northern Mariana Islands,
and American Samoa in upgrading their existing computer
systems in order to anticipate meeting reporting requirements
necessary to implement the plan contained in the report under
subsection (b)(1).

Subtitle H--Miscellaneous

SEC. 1781. TECHNICAL CORRECTIONS.

(a) Technical Correction to Section 1144 of the Social
Security Act.--The first sentence of section 1144(c)(3) of
the Social Security Act (42 U.S.C. 1320b--14(c)(3)) is
amended--
(1) by striking ``transmittal''; and
(2) by inserting before the period the following: ``as
specified in section 1935(a)(4)''.
(b) Clarifying Amendment to Section 1935 of the Social
Security Act.--Section 1935(a)(4) of the Social Security Act
(42 U.S.C. 1396u--5(a)(4)), as amended by section 113(b) of
Public Law 110-275, is amended--
(1) by striking the second sentence;
(2) by redesignating the first sentence as a subparagraph
(A) with appropriate indentation and with the following
heading: ``In general.--'';
(3) by adding at the end the following subparagraphs:
``(B) Furnishing medical assistance with reasonable
promptness.--For the purpose of a State's obligation under
section 1902(a)(8) to furnish medical assistance with
reasonable promptness, the date of the electronic
transmission of low-income subsidy program data, as described
in section 1144(c), from the Commissioner of Social Security
to the State Medicaid Agency, shall constitute the date of
filing of such application for benefits under the Medicare
Savings Program.
``(C) Determining availability of medical assistance.--For
the purpose of determining when medical assistance will be
made available, the State shall consider the date of the
individual's application for the low income subsidy program
to constitute the date of filing for benefits under the
Medicare Savings Program.''.
(c) Effective Date Relating to Medicaid Agency
Consideration of Low-income Subsidy Application and Data
Transmittal.--The amendments made by subsections (a) and (b)
shall be effective as if included in the enactment of section
113(b) of Public Law 110-275.
(d) Technical Correction to Section 605 of CHIPRA.--Section
605 of the Children's Health Insurance Program
Reauthorization Act of 2009 (Public Law 111-3) is amended by
striking ``legal residents'' and inserting ``lawfully
residing in the United States''.
(e) Technical Correction to Section 1905 of the Social
Security Act.--Section 1905(a) of the Social Security Act (42
U.S.C. 1396d(a)) is amended by inserting ``or the care and
services themselves, or both'' before ``(if provided in or
after''.
(f) Clarifying Amendment to Section 1115 of the Social
Security Act.--Section 1115(a) of the Social Security Act (42
U.S.C. 1315(a)) is amended by adding at the end the
following: ``If an experimental, pilot, or demonstration
project that relates to title XIX is approved pursuant to any
part of this subsection, such project shall be treated as
part of the State plan, all medical assistance provided on
behalf of any individuals affected by such project shall be
medical assistance provided under the State plan, and all
provisions of this Act not explicitly waived in approving
such project shall remain fully applicable to all individuals
receiving benefits under the State plan.''.

SEC. 1782. EXTENSION OF QI PROGRAM.

(a) In General.--Section 1902(a)(10)(E)(iv) of the Social
Security Act (42 U.S.C. 1396b(a)(10)(E)(iv)) is amended--
(1) by striking ``sections 1933 and'' and by inserting
``section''; and
(2) by striking ``December 2010'' and inserting ``December
2012''.
(b) Elimination of Funding Limitation.--
(1) In general.--Section 1933 of such Act (42 U.S.C. 1396u-
3) is amended--
(A) in subsection (a), by striking ``who are selected to
receive such assistance under subsection (b)'';
(B) by striking subsections (b), (c), (e), and (g);
(C) in subsection (d), by striking ``furnished in a State''
and all that follows and inserting ``the Federal medical
assistance percentage shall be equal to 100 percent.''; and
(D) by redesignating subsections (d) and (f) as subsections
(b) and (c), respectively.
(2) Conforming amendment.--Section 1905(b) of such Act (42
U.S.C. 1396d(b)) is amended by striking ``1933(d)'' and
inserting ``1933(b)''.
(3) Effective date.--The amendments made by paragraph (1)
shall take effect on January 1, 2011.

SEC. 1783. ASSURING TRANSPARENCY OF INFORMATION.

(a) In General.--Section 1902(a) of the Social Security Act
(42 U.S.C. 1396a(a)), as amended by sections 1631(b),
1703(a), 1729, 1753, 1757(a), 1759(a), and 1907(b), is
amended--
(1) by striking ``and'' at the end of paragraph (79);
(2) by striking the period at the end of paragraph (80) and
inserting ``; and''; and
(3) by inserting after paragraph (80) the following new
paragraph:
``(81) provide that the State will establish and maintain
laws, in accordance with the requirements of section 1921A,
to require disclosure of information on hospital charges and
quality and to make such information available to the public
and the Secretary.''; and
(4) by inserting after section 1921 the following new
section:

[[Page H12743]]

``hospital price transparency

``Sec. 1921A.  (a) In General.--The requirements referred
to in section 1902(a)(81) are that the laws of a State must--
``(1) require reporting to the State (or its agent) by each
hospital located therein, of information on,--
``(A) the charges for the most common inpatient and
outpatient hospital services;
``(B) the Medicare and Medicaid reimbursement amount for
such services; and
``(C) if the hospitals allows for or provides reduced
charges for individuals based on financial need, the factors
considered in making determinations for reductions in
charges, including any formula for such determination and the
contact information for the specific department of a hospital
that responds to such inquiries;
``(2) provide for notice to individuals seeking or
requiring such services of the availability of information on
charges described in paragraph (1);
``(3) provide for timely access to such information,
including at least through an Internet website, by
individuals seeking or requiring such services; and
``(4) provide for timely access to information regarding
the quality of care at each hospital made publicly available
in accordance with section 501 of the Medicare Prescription
Drug, Improvement, and Modernization Act of 2003 (Public Law
108-173), section 1139A, or section 1139B.
The Secretary shall consult with stakeholders (including
those entities in section 1808(d)(6) and the National
Governors Association) through a formal process to obtain
guidance prior to issuing implementing policies under this
section.
``(b) Hospital Defined.--For purposes of this section, the
term `hospital' means an institution that meets the
requirements of paragraphs (1) and (7) of section 1861(e) and
includes those to which section 1820(c) applies.''.
(b) Effective Date; Administration.--
(1) In general.--Except as provided in paragraphs (2)(B)
and section 1790, the amendments made by subsection (a) shall
take effect on October 1, 2010.
(2) Existing programs.--
(A) In general.--The Secretary of Health and Human Services
shall establish a process by which a State with an existing
program may certify to the Secretary that its program
satisfies the requirements of section 1921A of the Social
Security Act, as inserted by subsection (a).
(B) 2-year period to become in compliance.--States that, as
of the date of the enactment of this Act, administer hospital
price transparency policies that do not meet such
requirements shall have 2 years from such date to make
necessary modifications to come into compliance and shall not
be regarded as failing to comply with such requirements
during such 2-year period.

SEC. 1784. MEDICAID AND CHIP PAYMENT AND ACCESS COMMISSION.

(a) Report on Nursing Facility Payment Policies.--Section
1900(b) of the Social Security Act (42 U.S.C. 1396(b)) is
amended by adding at the end the following new paragraph:
``(10) Reports on special topics on payment policies.--
``(A) Nursing facility payment policies.--Not later than
January 1, 2012, the Commission shall submit to Congress a
report on nursing facility payment policies under Medicaid
that includes--
``(i) information on the difference between the amount paid
by each State to nursing facilities in such State under the
Medicaid program under this title and the cost to such
facilities of providing efficient quality care to Medicaid
eligible individuals;
``(ii) an evaluation of patient outcomes and quality as a
result of the supplemental payments under section 1745(b) of
the Affordable Health Care for America Act; and
``(iii) whether adjustments should be made under the
Medicaid program to the rates that States pay skilled nursing
facilities to ensure that such rates are sufficient to
provide efficient quality care to Medicaid eligible
individuals.''.
(b) Pediatric Subspecialist Payment Policies.--Section
1900(b)(10) of the Social Security Act, as added by
subsection (a) is amended by adding at the end the following
new subparagraph:
``(B) Pediatric subspecialist payment policies.--Not later
than January 1, 2011, the Commission shall submit to Congress
a report on payment policies for pediatric subspecialist
services under Medicaid that includes--
``(i) a comprehensive review of each State's Medicaid
payment rates for inpatient and outpatient pediatric
speciality services;
``(ii) a comparison, on a State-by-State basis, of the
rates under clause (i) to Medicare payments for similar
services;
``(iii) information on any limitations in patient access to
pediatric speciality care, such as delays in receiving care
or wait times for receiving care;
``(iv) an analysis of the extent to which low Medicaid
payment rates in any State contributes to limits in access to
pediatric subspecialty services in such State; and
``(v) recommendations to ameliorate any problems found with
such payment rates or with access to such services.''.
(c) Additional Amendments.--
(1) Commission status.--Section 1900(a) of the Social
Security Act is amended by inserting ``as an agency of
Congress'' after ``established''.
(2) Expansion of scope.--Section 1900(b)(1)(A) of the
Social Security Act is amended by striking ``children's
access'' and inserting ``access by low-income children and
other eligible individuals''.
(3) Change in report deadlines.--Subparagraphs (C) and (D)
of section 1900(b)(1) of such Act are amended by striking
``2010'' and inserting ``2011'' each place it appears.
(4) Report in health reform.--Section 1900(b)(2) of such
Act is amended--
(A) in subparagraph (A)(i), by striking ``skilled'';
(B) by striking subparagraph (B);
(C) by redesignating subparagraph (C) as subparagraph (B);
and
(D) by adding at the end the following new subparagraph:
``(C) Implementation of health reform.--The implementation
of the provisions of the Affordable Health Care for America
Act that relate to Medicaid or CHIP by the Secretary, the
Health Choices Commissioner, and the States, including the
effect of such implementation on the access to needed health
care items and services by low-income individuals and
families.''.
(5) Clarification of membership.--Section 1900(c)(2)(B) of
such Act is amended by striking ``consumers'' and inserting
``individuals''.
(6) Authorization of appropriations.--
(A) Current authorization.--Section 1900(f)(2) of such Act
is amended--
(i) in the heading, by inserting ``of appropriations prior
to 2010'' after ``Authorization''; and
(ii) by striking ``There are'' and inserting ``Prior to
January 1, 2010, there are''
(B) Future authorization.--Section 1900(f) of such Act is
further amended by adding at the end the following new
paragraph: after the period the following:
``(3) Authorization of appropriations for 2010.--Beginning
on January 1, 2010, there is authorized to be appropriated
$11,800,000 to carry out the provisions of this section. Such
funds shall remain available until expended.''.

SEC. 1785. OUTREACH AND ENROLLMENT OF MEDICAID AND CHIP
ELIGIBLE INDIVIDUALS.

(a) In General.--Not later than 12 months after date of
enactment of this Act, the Secretary of Health and Human
Services shall issue guidance regarding standards and best
practices for conducting outreach to inform eligible
individuals about healthcare coverage under Medicaid under
title XIX of the Social Security Act or for child health
assistance under CHIP under title XXI of such Act, providing
assistance to such individuals for enrollment in applicable
programs, and establishing methods or procedures for
eliminating application and enrollment barriers. Such
guidance shall include provisions to ensure that outreach,
enrollment assistance, and administrative simplification
efforts are targeted specifically to vulnerable populations
such as children, unaccompanied homeless youth, victims of
abuse or trauma, individuals with mental health or substance
related disorders, and individuals with HIV/AIDS. Guidance
issued pursuant to this section relating to methods to
increase outreach and enrollment provided for under titles
XIX and XXI of the Social Security Act shall specifically
target such vulnerable and underserved populations and shall
include, but not be limited to, guidance on outstationing of
eligibility workers, express lane eligibility, residence
requirements, documentation of income and assets, presumptive
eligibility, continuous eligibility, and automatic renewal.
(b) Implementation.--In implementing the requirements under
subsection (a), the Secretary may use such authorities as are
available under law and may work with such entities as the
Secretary deems appropriate to facilitate effective
implementation of such programs. Not later than 2 years after
the enactment of this Act and annually thereafter, the
Secretary shall review and report to Congress on progress in
implementing targeted outreach, application and enrollment
assistance, and administrative simplification methods for
such vulnerable and underserved populations as are specified
in subsection (a).

SEC. 1786. PROHIBITIONS ON FEDERAL MEDICAID AND CHIP PAYMENT
FOR UNDOCUMENTED ALIENS.

Nothing in this title shall change current prohibitions
against Federal Medicaid and CHIP payments under titles XIX
and XXI of the Social Security Act on behalf of individuals
who are not lawfully present in the United States.

SEC. 1787. DEMONSTRATION PROJECT FOR STABILIZATION OF
EMERGENCY MEDICAL CONDITIONS BY INSTITUTIONS
FOR MENTAL DISEASES.

(a) Authority To Conduct Demonstration Project.--The
Secretary of Health and Human Services (in this section
referred to as the ``Secretary'') shall establish a
demonstration project under which an eligible State (as
described in subsection (c)) shall provide reimbursement
under the State Medicaid plan under title XIX of the Social
Security Act to an institution for mental diseases that is
subject to the requirements of section 1867 of the Social
Security Act (42 U.S.C. 1395dd) for the provision of medical
assistance available under such plan to an individual who--
(1) has attained age 21, but has not attained age 65;
(2) is eligible for medical assistance under such plan; and
(3) requires such medical assistance to stabilize an
emergency medical condition.
(b) In-stay Review.--The Secretary shall establish a
mechanism for in-stay review to

[[Page H12744]]

determine whether or not the patient has been stabilized (as
defined in subsection (h)(5)). This mechanism shall commence
before the third day of the inpatient stay. States
participating in the demonstration project may manage the
provision of these benefits under the project through
utilization review, authorization, or management practices,
or the application of medical necessity and appropriateness
criteria applicable to behavioral health.
(c) Eligible State Defined.--
(1) Application.--Upon approval of an application submitted
by a State described in paragraph (2), the State shall be an
eligible State for purposes of conducting a demonstration
project under this section.
(2) State described.--States shall be selected by the
Secretary in a manner so as to provide geographic diversity
on the basis of the application to conduct a demonstration
project under this section submitted by such States.
(d) Length of Demonstration Project.--The demonstration
project established under this section shall be conducted for
a period of 3 consecutive years.
(e) Limitations on Federal Funding.--
(1) Appropriation.--
(A) In general.--Out of any funds in the Treasury not
otherwise appropriated, there is appropriated to carry out
this section, $75,000,000 for fiscal year 2010.
(B) Budget authority.--Subparagraph (A) constitutes budget
authority in advance of appropriations Act and represents the
obligation of the Federal Government to provide for the
payment of the amounts appropriated under that subparagraph.
(2) 3-year availability.--Funds appropriated under
paragraph (1) shall remain available for obligation through
December 31, 2012.
(3) Limitation on payments.--In no case may--
(A) the aggregate amount of payments made by the Secretary
to eligible States under this section exceed $75,000,000; or
(B) payments be provided by the Secretary under this
section after December 31, 2012.
(4) Funds allocated to states.--The Secretary shall
allocate funds to eligible States based on their applications
and the availability of funds.
(5) Payments to states.--The Secretary shall pay to each
eligible State, from its allocation under paragraph (4), an
amount each quarter equal to the Federal medical assistance
percentage of expenditures in the quarter for medical
assistance described in subsection (a).
(f) Reports.--
(1) Annual progress reports.--The Secretary shall submit
annual reports to Congress on the progress of the
demonstration project conducted under this section.
(2) Final report and recommendation.--An evaluation shall
be conducted of the demonstration project's impact on the
functioning of the health and mental health service system
and on individuals enrolled in the Medicaid program. This
evaluation shall include collection of baseline data for one-
year prior to the initiation of the demonstration project as
well as collection of data from matched comparison states not
participating in the demonstration. The evaluation measures
shall include the following:
(A) A determination, by State, as to whether the
demonstration project resulted in increased access to
inpatient mental health services under the Medicaid program
and whether average length of stays were longer (or shorter)
for individuals admitted under the demonstration project
compared with individuals otherwise admitted in comparison
sites.
(B) An analysis, by State, regarding whether the
demonstration project produced a significant reduction in
emergency room visits for individuals eligible for assistance
under the Medicaid program or in the duration of emergency
room lengths of stay.
(C) An assessment of discharge planning by participating
hospitals that ensures access to further (non-emergency)
inpatient or residential care as well as continuity of care
for those discharged to outpatient care.
(D) An assessment of the impact of the demonstration
project on the costs of the full range of mental health
services (including inpatient, emergency and ambulatory care)
under the plan as contrasted with the comparison areas.
(E) Data on the percentage of consumers with Medicaid
coverage who are admitted to inpatient facilities as a result
of the demonstration project as compared to those admitted to
these same facilities through other means.
(F) A recommendation regarding whether the demonstration
project should be continued after December 31, 2012, and
expanded on a national basis.
(g) Waiver Authority.--
(1) In general.--The Secretary shall waive the limitation
of subdivision (B) following paragraph (28) of section
1905(a) of the Social Security Act (42 U.S.C. 1396d(a))
(relating to limitations on payments for care or services for
individuals under 65 years of age who are patients in an
institution for mental diseases) for purposes of carrying out
the demonstration project under this section.
(2) Limited other waiver authority.--The Secretary may
waive other requirements of title XIX of the Social Security
Act (including the requirements of sections 1902(a)(1)
(relating to statewideness) and 1902(1)(10)(B) (relating to
comparability)) only to extent necessary to carry out the
demonstration project under this section.
(h) Definitions.--In this section:
(1) Emergency medical condition.--The term ``emergency
medical condition'' means, with respect to an individual, an
individual who expresses suicidal or homicidal thoughts or
gestures, if determined dangerous to self or others.
(2) Federal medical assistance percentage.--The term
``Federal medical assistance percentage'' has the meaning
given that term with respect to a State under section 1905(b)
of the Social Security Act (42 U.S.C. 1396d(b)).
(3) Institution for mental diseases.--The term
``institution for mental diseases'' has the meaning given to
that term in section 1905(i) of the Social Security Act (42
U.S.C. 1396d(i)).
(4) Medical assistance.--The term ``medical assistance''
has the meaning given to that term in section 1905(a) of the
Social Security Act (42 U.S.C. 1396d(a)).
(5) Stabilized.--The term ``stabilized'' means, with
respect to an individual, that the emergency medical
condition no longer exists with respect to the individual and
the individual is no longer dangerous to self or others.
(6) State.--The term ``State'' has the meaning given that
term for purposes of title XIX of the Social Security Act (42
U.S.C. 1396 et seq.).

SEC. 1788. APPLICATION OF MEDICAID IMPROVEMENT FUND.

Section 1941(b)(1) of the Social Security Act (42 U.S.C.
1396w-1(b)(1)) is amended by striking ``from the Fund'' and
all that follows and inserting ``from the Fund, only such
amounts as may be appropriated or otherwise made available by
law.''.

SEC. 1789. TREATMENT OF CERTAIN MEDICAID BROKERS.

Section 1903(b)(4) of the Social Security Act (42 U.S.C.
1396b(b)(4)) is amended--
(1) in the matter before subparagraph (A), by inserting
after ``respect to the broker'' the following: ``(or, in the
case of subparagraph (A) and subparagraph (B)(i), if the
Inspector General of Department of Health and Human Services
finds that the broker has established and maintains
procedures to ensure the independence of its enrollment
activities from the interests of any managed care entity or
provider)''; and
(2) in subparagraph (B)--
(A) by inserting ``(i)'' after ``either''; and
(B) by inserting ``(ii)'' after ``health care provider
or''.

SEC. 1790. RULE FOR CHANGES REQUIRING STATE LEGISLATION.

In the case of a State plan for medical assistance under
title XIX of the Social Security Act which the Secretary of
Health and Human Services determines requires State
legislation (other than legislation appropriating funds) in
order for the plan to meet an additional requirement imposed
by an amendment made by this title, the State plan shall not
be regarded as failing to comply with the requirements of
such title XIX solely on the basis of its failure to meet
this additional requirement before the first day of the first
calendar quarter beginning after the close of the first
regular session of the State legislature that begins after
the date of the enactment of this Act. For purposes of the
previous sentence, in the case of a State that has a 2-year
legislative session, each year of such session shall be
deemed to be a separate regular session of the State
legislature.

TITLE VIII--REVENUE-RELATED PROVISIONS

SEC. 1801. DISCLOSURES TO FACILITATE IDENTIFICATION OF
INDIVIDUALS LIKELY TO BE INELIGIBLE FOR THE
LOW-INCOME ASSISTANCE UNDER THE MEDICARE
PRESCRIPTION DRUG PROGRAM TO ASSIST SOCIAL
SECURITY ADMINISTRATION'S OUTREACH TO ELIGIBLE
INDIVIDUALS.

(a) In General.--Paragraph (19) of section 6103(l) of the
Internal Revenue Code of 1986 is amended to read as follows:
``(19) Disclosures to facilitate identification of
individuals likely to be ineligible for low-income subsidies
under medicare prescription drug program to assist social
security administration's outreach to eligible individuals.--
``(A) In general.--Upon written request from the
Commissioner of Social Security, the following return
information (including such information disclosed to the
Social Security Administration under paragraph (1) or (5))
shall be disclosed to officers and employees of the Social
Security Administration, with respect to any taxpayer
identified by the Commissioner of Social Security--
``(i) return information for the applicable year from
returns with respect to wages (as defined in section 3121(a)
or 3401(a)) and payments of retirement income (as described
in paragraph (1) of this subsection),
``(ii) unearned income information and income information
of the taxpayer from partnerships, trusts, estates, and
subchapter S corporations for the applicable year,
``(iii) if the individual filed an income tax return for
the applicable year, the filing status, number of dependents,
income from farming, and income from self-employment, on such
return,
``(iv) if the individual is a married individual filing a
separate return for the applicable year, the social security
number (if reasonably available) of the spouse on such
return,

[[Page H12745]]

``(v) if the individual files a joint return for the
applicable year, the social security number, unearned income
information, and income information from partnerships,
trusts, estates, and subchapter S corporations of the
individual's spouse on such return, and
``(vi) such other return information relating to the
individual (or the individual's spouse in the case of a joint
return) as is prescribed by the Secretary by regulation as
might indicate that the individual is likely to be ineligible
for a low-income prescription drug subsidy under section
1860D-14 of the Social Security Act.
``(B) Applicable year.--For the purposes of this paragraph,
the term `applicable year' means the most recent taxable year
for which information is available in the Internal Revenue
Service's taxpayer information records.
``(C) Restriction on individuals for whom disclosure may be
requested.--The Commissioner of Social Security shall request
information under this paragraph only with respect to--
``(i) individuals the Social Security Administration has
identified, using all other reasonably available information,
as likely to be eligible for a low-income prescription drug
subsidy under section 1860D-14 of the Social Security Act and
who have not applied for such subsidy, and
``(ii) any individual the Social Security Administration
has identified as a spouse of an individual described in
clause (i).
``(D) Restriction on use of disclosed information.--Return
information disclosed under this paragraph may be used only
by officers and employees of the Social Security
Administration solely for purposes of identifying individuals
likely to be ineligible for a low-income prescription drug
subsidy under section 1860D-14 of the Social Security Act for
use in outreach efforts under section 1144 of the Social
Security Act.''.
(b) Safeguards.--Paragraph (4) of section 6103(p) of such
Code is amended--
(1) by striking ``(19),'' each place it appears, and
(2) by striking ``or (17)'' each place it appears and
inserting ``(17), or (19)''.
(c) Conforming Amendment.--Paragraph (3) of section 6103(a)
of such Code is amended by striking ``(19),''.
(d) Effective Date.--The amendments made by this section
shall apply to disclosures made after the date which is 12
months after the date of the enactment of this Act.

SEC. 1802. COMPARATIVE EFFECTIVENESS RESEARCH TRUST FUND;
FINANCING FOR TRUST FUND.

(a) Establishment of Trust Fund.--
(1) In general.--Subchapter A of chapter 98 of the Internal
Revenue Code of 1986 (relating to trust fund code) is amended
by adding at the end the following new section:

``SEC. 9511. HEALTH CARE COMPARATIVE EFFECTIVENESS RESEARCH
TRUST FUND.

``(a) Creation of Trust Fund.--There is established in the
Treasury of the United States a trust fund to be known as the
`Health Care Comparative Effectiveness Research Trust Fund'
(hereinafter in this section referred to as the `CERTF'),
consisting of such amounts as may be appropriated or credited
to such Trust Fund as provided in this section and section
9602(b).
``(b) Transfers to Fund.--
``(1) In general.--There are hereby appropriated to the
Trust Fund the following:
``(A) For fiscal year 2010, $90,000,000.
``(B) For fiscal year 2011, $100,000,000.
``(C) For fiscal year 2012, $110,000,000.
``(D) For each fiscal year beginning with fiscal year
2013--
``(i) an amount equivalent to the net revenues received in
the Treasury from the fees imposed under subchapter B of
chapter 34 (relating to fees on health insurance and self-
insured plans) for such fiscal year; and
``(ii) subject to subsection (c)(2), amounts determined by
the Secretary of Health and Human Services to be equivalent
to the fair share per capita amount computed under subsection
(c)(1) for the fiscal year multiplied by the average number
of individuals entitled to benefits under part A, or enrolled
under part B, of title XVIII of the Social Security Act
during such fiscal year.
``(2) Administrative provisions.--
``(A) Transfers from other trust funds.--The amounts
appropriated by subparagraphs (A), (B), (C), and (D)(ii) of
paragraph (1) shall be transferred from the Federal Hospital
Insurance Trust Fund and from the Federal Supplementary
Medical Insurance Trust Fund (established under section 1841
of such Act), and from the Medicare Prescription Drug Account
within such Trust Fund, in proportion (as estimated by the
Secretary) to the total expenditures during such fiscal year
that are made under title XVIII of such Act from the
respective trust fund or account.
``(B) Appropriations not subject to fiscal year
limitation.--The amounts appropriated by paragraph (1) shall
not be subject to any fiscal year limitation.
``(C) Periodic transfers, estimates, and adjustments.--
Except as provided in subparagraph (A), the provisions of
section 9601 shall apply to the amounts appropriated by
paragraph (1).
``(c) Fair Share Per Capita Amount.--
``(1) Computation.--
``(A) In general.--Subject to subparagraph (B), the fair
share per capita amount under this paragraph for a fiscal
year (beginning with fiscal year 2013) is an amount computed
by the Secretary of Health and Human Services for such fiscal
year that, when applied under this section and subchapter B
of chapter 34 of the Internal Revenue Code of 1986, will
result in revenues to the CERTF of $375,000,000 for the
fiscal year.
``(B) Alternative computation.--
``(i) In general.--If the Secretary is unable to compute
the fair share per capita amount under subparagraph (A) for a
fiscal year, the fair share per capita amount under this
paragraph for the fiscal year shall be the default amount
determined under clause (ii) for the fiscal year.
``(ii) Default amount.--The default amount under this
clause for--

``(I) fiscal year 2013 is equal to $2; or
``(II) a subsequent year is equal to the default amount
under this clause for the preceding fiscal year increased by
the annual percentage increase in the medical care component
of the consumer price index (United States city average) for
the 12-month period ending with April of the preceding fiscal
year.

Any amount determined under subclause (II) shall be rounded
to the nearest penny.
``(2) Limitation on medicare funding.--In no case shall the
amount transferred under subsection (b)(4)(B) for any fiscal
year exceed $90,000,000.
``(d) Expenditures From Fund.--
``(1) In general.--Subject to paragraph (2), amounts in the
CERTF are available, without the need for further
appropriations and without fiscal year limitation, to the
Secretary of Health and Human Services to carry out section
1181 of the Social Security Act.
``(2) Allocation for commission.--The following amounts in
the CERTF shall be available, without the need for further
appropriations and without fiscal year limitation, to the
Commission to carry out the activities of the Comparative
Effectiveness Research Commission established under section
1181(b) of the Social Security Act:
``(A) For fiscal year 2010, $7,000,000.
``(B) For fiscal year 2011, $9,000,000.
``(C) For each fiscal year beginning with 2012, 2.6 percent
of the total amount appropriated to the CERTF under
subsection (b) for the fiscal year.
``(e) Net Revenues.--For purposes of this section, the term
`net revenues' means the amount estimated by the Secretary
based on the excess of--
``(1) the fees received in the Treasury under subchapter B
of chapter 34, over
``(2) the decrease in the tax imposed by chapter 1
resulting from the fees imposed by such subchapter.''.
(2) Clerical amendment.--The table of sections for such
subchapter A is amended by adding at the end thereof the
following new item:

``Sec. 9511. Health Care Comparative Effectiveness Research Trust
Fund.''.

(b) Financing for Fund From Fees on Insured and Self-
Insured Health Plans.--
(1) General rule.--Chapter 34 of the Internal Revenue Code
of 1986 is amended by adding at the end the following new
subchapter:

``Subchapter B--Insured and Self-Insured Health Plans

``Sec. 4375. Health insurance.
``Sec. 4376. Self-insured health plans.
``Sec. 4377. Definitions and special rules.

``SEC. 4375. HEALTH INSURANCE.

``(a) Imposition of Fee.--There is hereby imposed on each
specified health insurance policy for each policy year a fee
equal to the fair share per capita amount determined under
section 9511(c)(1) multiplied by the average number of lives
covered under the policy.
``(b) Liability for Fee.--The fee imposed by subsection (a)
shall be paid by the issuer of the policy.
``(c) Specified Health Insurance Policy.--For purposes of
this section:
``(1) In general.--Except as otherwise provided in this
section, the term `specified health insurance policy' means
any accident or health insurance policy issued with respect
to individuals residing in the United States.
``(2) Exemption for certain policies.--The term `specified
health insurance policy' does not include any insurance if
substantially all of its coverage is of excepted benefits
described in section 9832(c).
``(3) Treatment of prepaid health coverage arrangements.--
``(A) In general.--In the case of any arrangement described
in subparagraph (B)--
``(i) such arrangement shall be treated as a specified
health insurance policy, and
``(ii) the person referred to in such subparagraph shall be
treated as the issuer.
``(B) Description of arrangements.--An arrangement is
described in this subparagraph if under such arrangement
fixed payments or premiums are received as consideration for
any person's agreement to provide or arrange for the
provision of accident or health coverage to residents of the
United States, regardless of how such coverage is provided or
arranged to be provided.

``SEC. 4376. SELF-INSURED HEALTH PLANS.

``(a) Imposition of Fee.--In the case of any applicable
self-insured health plan for each plan year, there is hereby
imposed a fee equal to the fair share per capita amount
determined under section 9511(c)(1) multiplied by the average
number of lives covered under the plan.
``(b) Liability for Fee.--
``(1) In general.--The fee imposed by subsection (a) shall
be paid by the plan sponsor.
``(2) Plan sponsor.--For purposes of paragraph (1) the term
`plan sponsor' means--

[[Page H12746]]

``(A) the employer in the case of a plan established or
maintained by a single employer,
``(B) the employee organization in the case of a plan
established or maintained by an employee organization,
``(C) in the case of--
``(i) a plan established or maintained by 2 or more
employers or jointly by 1 or more employers and 1 or more
employee organizations,
``(ii) a multiple employer welfare arrangement, or
``(iii) a voluntary employees' beneficiary association
described in section 501(c)(9),

the association, committee, joint board of trustees, or other
similar group of representatives of the parties who establish
or maintain the plan, or
``(D) the cooperative or association described in
subsection (c)(2)(F) in the case of a plan established or
maintained by such a cooperative or association.
``(c) Applicable Self-Insured Health Plan.--For purposes of
this section, the term `applicable self-insured health plan'
means any plan for providing accident or health coverage if--
``(1) any portion of such coverage is provided other than
through an insurance policy, and
``(2) such plan is established or maintained--
``(A) by one or more employers for the benefit of their
employees or former employees,
``(B) by one or more employee organizations for the benefit
of their members or former members,
``(C) jointly by 1 or more employers and 1 or more employee
organizations for the benefit of employees or former
employees,
``(D) by a voluntary employees' beneficiary association
described in section 501(c)(9),
``(E) by any organization described in section 501(c)(6),
or
``(F) in the case of a plan not described in the preceding
subparagraphs, by a multiple employer welfare arrangement (as
defined in section 3(40) of Employee Retirement Income
Security Act of 1974), a rural electric cooperative (as
defined in section 3(40)(B)(iv) of such Act), or a rural
telephone cooperative association (as defined in section
3(40)(B)(v) of such Act).

``SEC. 4377. DEFINITIONS AND SPECIAL RULES.

``(a) Definitions.--For purposes of this subchapter--
``(1) Accident and health coverage.--The term `accident and
health coverage' means any coverage which, if provided by an
insurance policy, would cause such policy to be a specified
health insurance policy (as defined in section 4375(c)).
``(2) Insurance policy.--The term `insurance policy' means
any policy or other instrument whereby a contract of
insurance is issued, renewed, or extended.
``(3) United states.--The term `United States' includes any
possession of the United States.
``(b) Treatment of Governmental Entities.--
``(1) In general.--For purposes of this subchapter--
``(A) the term `person' includes any governmental entity,
and
``(B) notwithstanding any other law or rule of law,
governmental entities shall not be exempt from the fees
imposed by this subchapter except as provided in paragraph
(2).
``(2) Treatment of exempt governmental programs.--In the
case of an exempt governmental program, no fee shall be
imposed under section 4375 or section 4376 on any covered
life under such program.
``(3) Exempt governmental program defined.--For purposes of
this subchapter, the term `exempt governmental program'
means--
``(A) any insurance program established under title XVIII
of the Social Security Act,
``(B) the medical assistance program established by title
XIX or XXI of the Social Security Act,
``(C) any program established by Federal law for providing
medical care (other than through insurance policies) to
individuals (or the spouses and dependents thereof) by reason
of such individuals being--
``(i) members of the Armed Forces of the United States, or
``(ii) veterans, and
``(D) any program established by Federal law for providing
medical care (other than through insurance policies) to
members of Indian tribes (as defined in section 4(d) of the
Indian Health Care Improvement Act).
``(c) Treatment as Tax.--For purposes of subtitle F, the
fees imposed by this subchapter shall be treated as if they
were taxes.
``(d) No Cover Over to Possessions.--Notwithstanding any
other provision of law, no amount collected under this
subchapter shall be covered over to any possession of the
United States.''.
(2) Clerical amendments.--
(A) Chapter 34 of such Code is amended by striking the
chapter heading and inserting the following:

``CHAPTER 34--TAXES ON CERTAIN INSURANCE POLICIES

``subchapter a. policies issued by foreign insurers

``subchapter b. insured and self-insured health plans

``Subchapter A--Policies Issued By Foreign Insurers''.

(B) The table of chapters for subtitle D of such Code is
amended by striking the item relating to chapter 34 and
inserting the following new item:

``Chapter 34--Taxes on Certain Insurance Policies''.

(3) Effective date.--The amendments made by this subsection
shall apply with respect to policies and plans for portions
of policy or plan years beginning on or after October 1,
2012.

TITLE IX--MISCELLANEOUS PROVISIONS

SEC. 1901. REPEAL OF TRIGGER PROVISION.

Subtitle A of title VIII of the Medicare Prescription Drug,
Improvement, and Modernization Act of 2003 (Public Law 108-
173) is repealed and the provisions of law amended by such
subtitle are restored as if such subtitle had never been
enacted.

SEC. 1902. REPEAL OF COMPARATIVE COST ADJUSTMENT (CCA)
PROGRAM.

Section 1860C-1 of the Social Security Act (42 U.S.C.
1395w-29), as added by section 241(a) of the Medicare
Prescription Drug, Improvement, and Modernization Act of 2003
(Public Law 108-173), is repealed.

SEC. 1903. EXTENSION OF GAINSHARING DEMONSTRATION.

(a) In General.--Subsection (d)(3) of section 5007 of the
Deficit Reduction Act of 2005 (Public Law 109-171) is amended
by inserting ``(or September 30, 2011, in the case of a
demonstration project in operation as of October 1, 2008)''
after ``December 31, 2009''.
(b) Funding.--
(1) In general.--Subsection (f)(1) of such section is
amended by inserting ``and for fiscal year 2010,
$1,600,000,'' after ``$6,000,000,''.
(2) Availability.--Subsection (f)(2) of such section is
amended by striking ``2010'' and inserting ``2014 or until
expended''.
(c) Reports.--
(1) Quality improvement and savings.--Subsection (e)(3) of
such section is amended by striking ``December 1, 2008'' and
inserting ``March 31, 2011''.
(2) Final report.--Subsection (e)(4) of such section is
amended by striking ``May 1, 2010'' and inserting ``March 31,
2013''.

SEC. 1904. GRANTS TO STATES FOR QUALITY HOME VISITATION
PROGRAMS FOR FAMILIES WITH YOUNG CHILDREN AND
FAMILIES EXPECTING CHILDREN.

Part B of title IV of the Social Security Act (42 U.S.C.
621-629i) is amended by adding at the end the following:

``Subpart 3--Support for Quality Home Visitation Programs

``SEC. 440. HOME VISITATION PROGRAMS FOR FAMILIES WITH YOUNG
CHILDREN AND FAMILIES EXPECTING CHILDREN.

``(a) Purpose.--The purpose of this section is to improve
the well-being, health, and development of children by
enabling the establishment and expansion of high quality
programs providing voluntary home visitation for families
with young children and families expecting children.
``(b) Grant Application.--A State that desires to receive a
grant under this section shall submit to the Secretary for
approval, at such time and in such manner as the Secretary
may require, an application for the grant that includes the
following:
``(1) Description of home visitation programs.--A
description of the high quality programs of home visitation
for families with young children and families expecting
children that will be supported by a grant made to the State
under this section, the outcomes the programs are intended to
achieve, and the evidence supporting the effectiveness of the
programs.
``(2) Results of needs assessment.--The results of a
statewide needs assessment that describes--
``(A) the number, quality, and capacity of home visitation
programs for families with young children and families
expecting children in the State;
``(B) the number and types of families who are receiving
services under the programs;
``(C) the sources and amount of funding provided to the
programs;
``(D) the gaps in home visitation in the State, including
identification of communities that are in high need of the
services; and
``(E) training and technical assistance activities designed
to achieve or support the goals of the programs.
``(3) Assurances.--Assurances from the State that--
``(A) in supporting home visitation programs using funds
provided under this section, the State shall identify and
prioritize serving communities that are in high need of such
services, especially communities with a high proportion of
low-income families or a high incidence of child
maltreatment;
``(B) the State will reserve 5 percent of the grant funds
for training and technical assistance to the home visitation
programs using such funds;
``(C) in supporting home visitation programs using funds
provided under this section, the State will promote
coordination and collaboration with other home visitation
programs (including programs funded under title XIX) and with
other child and family services, health services, income
supports, and other related assistance;
``(D) home visitation programs supported using such funds
will, when appropriate, provide referrals to other programs
serving children and families; and
``(E) the State will comply with subsection (i), and
cooperate with any evaluation conducted under subsection (j).
``(4) Other information.--Such other information as the
Secretary may require.

[[Page H12747]]

``(c) Allotments.--
``(1) Indian tribes.--From the amount reserved under
subsection (l)(2) for a fiscal year, the Secretary shall
allot to each Indian tribe that meets the requirement of
subsection (d), if applicable, for the fiscal year the amount
that bears the same ratio to the amount so reserved as the
number of children in the Indian tribe whose families have
income that does not exceed 200 percent of the poverty line
bears to the total number of children in such Indian tribes
whose families have income that does not exceed 200 percent
of the poverty line.
``(2) States and territories.--From the amount appropriated
under subsection (m) for a fiscal year that remains after
making the reservations required by subsection (l), the
Secretary shall allot to each State that is not an Indian
tribe and that meets the requirement of subsection (d), if
applicable, for the fiscal year the amount that bears the
same ratio to the remainder of the amount so appropriated as
the number of children in the State whose families have
income that does not exceed 200 percent of the poverty line
bears to the total number of children in such States whose
families have income that does not exceed 200 percent of the
poverty line.
``(3) Reallotments.--The amount of any allotment to a State
under a paragraph of this subsection for any fiscal year that
the State certifies to the Secretary will not be expended by
the State pursuant to this section shall be available for
reallotment using the allotment methodology specified in that
paragraph. Any amount so reallotted to a State is deemed part
of the allotment of the State under this subsection.
``(d) Maintenance of Effort.--Beginning with fiscal year
2011, a State meets the requirement of this subsection for a
fiscal year if the Secretary finds that the aggregate
expenditures by the State from State and local sources for
programs of home visitation for families with young children
and families expecting children for the then preceding fiscal
year was not less than 100 percent of such aggregate
expenditures for the then 2nd preceding fiscal year.
``(e) Payment of Grant.--
``(1) In general.--The Secretary shall make a grant to each
State that meets the requirements of subsections (b) and (d),
if applicable, for a fiscal year for which funds are
appropriated under subsection (m), in an amount equal to the
reimbursable percentage of the eligible expenditures of the
State for the fiscal year, but not more than the amount
allotted to the State under subsection (c) for the fiscal
year.
``(2) Reimbursable percentage defined.--In paragraph (1),
the term `reimbursable percentage' means, with respect to a
fiscal year--
``(A) 85 percent, in the case of fiscal year 2010;
``(B) 80 percent, in the case of fiscal year 2011; or
``(C) 75 percent, in the case of fiscal year 2012 and any
succeeding fiscal year.
``(f) Eligible Expenditures.--
``(1) In general.--In this section, the term `eligible
expenditures'--
``(A) means expenditures to provide voluntary home
visitation for as many families with young children (under
the age of school entry) and families expecting children as
practicable, through the implementation or expansion of high
quality home visitation programs that--
``(i) adhere to clear evidence-based models of home
visitation that have demonstrated positive effects on
important program-determined child and parenting outcomes,
such as reducing abuse and neglect and improving child health
and development;
``(ii) employ well-trained and competent staff, maintain
high quality supervision, provide for ongoing training and
professional development, and show strong organizational
capacity to implement such a program;
``(iii) establish appropriate linkages and referrals to
other community resources and supports;
``(iv) monitor fidelity of program implementation to ensure
that services are delivered according to the specified model;
and
``(v) provide parents with--

``(I) knowledge of age-appropriate child development in
cognitive, language, social, emotional, and motor domains
(including knowledge of second language acquisition, in the
case of English language learners);
``(II) knowledge of realistic expectations of age-
appropriate child behaviors;
``(III) knowledge of health and wellness issues for
children and parents;
``(IV) modeling, consulting, and coaching on parenting
practices;
``(V) skills to interact with their child to enhance age-
appropriate development;
``(VI) skills to recognize and seek help for issues related
to health, developmental delays, and social, emotional, and
behavioral skills; and
``(VII) activities designed to help parents become full
partners in the education of their children;

``(B) includes expenditures for training, technical
assistance, and evaluations related to the programs; and
``(C) does not include any expenditure with respect to
which a State has submitted a claim for payment under any
other provision of Federal law.
``(2) Priority funding for programs with strongest
evidence.--
``(A) In general.--The expenditures, described in paragraph
(1), of a State for a fiscal year that are attributable to
the cost of programs that do not adhere to a model of home
visitation with the strongest evidence of effectiveness shall
not be considered eligible expenditures for the fiscal year
to the extent that the total of the expenditures exceeds the
applicable percentage for the fiscal year of the allotment of
the State under subsection (c) for the fiscal year.
``(B) Applicable percentage defined.--In subparagraph (A),
the term `applicable percentage' means, with respect to a
fiscal year--
``(i) 60 percent for fiscal year 2010;
``(ii) 55 percent for fiscal year 2011;
``(iii) 50 percent for fiscal year 2012;
``(iv) 45 percent for fiscal year 2013; or
``(v) 40 percent for fiscal year 2014.
``(g) No Use of Other Federal Funds for State Match.--A
State to which a grant is made under this section may not
expend any Federal funds to meet the State share of the cost
of an eligible expenditure for which the State receives a
payment under this section.
``(h) Waiver Authority.--
``(1) In general.--The Secretary may waive or modify the
application of any provision of this section, other than
subsection (b) or (f), to an Indian tribe if the failure to
do so would impose an undue burden on the Indian tribe.
``(2) Special rule.--An Indian tribe is deemed to meet the
requirement of subsection (d) for purposes of subsections (c)
and (e) if--
``(A) the Secretary waives the requirement; or
``(B) the Secretary modifies the requirement, and the
Indian tribe meets the modified requirement.
``(i) State Reports.--Each State to which a grant is made
under this section shall submit to the Secretary an annual
report on the progress made by the State in addressing the
purposes of this section. Each such report shall include a
description of--
``(1) the services delivered by the programs that received
funds from the grant;
``(2) the characteristics of each such program, including
information on the service model used by the program and the
performance of the program;
``(3) the characteristics of the providers of services
through the program, including staff qualifications, work
experience, and demographic characteristics;
``(4) the characteristics of the recipients of services
provided through the program, including the number of the
recipients, the demographic characteristics of the
recipients, and family retention;
``(5) the annual cost of implementing the program,
including the cost per family served under the program;
``(6) the outcomes experienced by recipients of services
through the program;
``(7) the training and technical assistance provided to aid
implementation of the program, and how the training and
technical assistance contributed to the outcomes achieved
through the program;
``(8) the indicators and methods used to monitor whether
the program is being implemented as designed; and
``(9) other information as determined necessary by the
Secretary.
``(j) Evaluation.--
``(1) In general.--The Secretary shall, by grant or
contract, provide for the conduct of an independent
evaluation of the effectiveness of home visitation programs
receiving funds provided under this section, which shall
examine the following:
``(A) The effect of home visitation programs on child and
parent outcomes, including child maltreatment, child health
and development, school readiness, and links to community
services.
``(B) The effectiveness of home visitation programs on
different populations, including the extent to which the
ability of programs to improve outcomes varies across
programs and populations.
``(2) Reports to the congress.--
``(A) Interim report.--Within 3 years after the date of the
enactment of this section, the Secretary shall submit to the
Congress an interim report on the evaluation conducted
pursuant to paragraph (1).
``(B) Final report.--Within 5 years after the date of the
enactment of this section, the Secretary shall submit to the
Congress a final report on the evaluation conducted pursuant
to paragraph (1).
``(k) Annual Reports to the Congress.--The Secretary shall
submit annually to the Congress a report on the activities
carried out using funds made available under this section,
which shall include a description of the following:
``(1) The high need communities targeted by States for
programs carried out under this section.
``(2) The service delivery models used in the programs
receiving funds provided under this section.
``(3) The characteristics of the programs, including--
``(A) the qualifications and demographic characteristics of
program staff; and
``(B) recipient characteristics including the number of
families served, the demographic characteristics of the
families served, and family retention and duration of
services.
``(4) The outcomes reported by the programs.
``(5) The research-based instruction, materials, and
activities being used in the activities funded under the
grant.
``(6) The training and technical activities, including on-
going professional development, provided to the programs.

[[Page H12748]]

``(7) The annual costs of implementing the programs,
including the cost per family served under the programs.
``(8) The indicators and methods used by States to monitor
whether the programs are being been implemented as designed.
``(l) Reservations of Funds.--From the amounts appropriated
for a fiscal year under subsection (m), the Secretary shall
reserve--
``(1) an amount equal to 5 percent of the amounts to pay
the cost of the evaluation provided for in subsection (j),
and the provision to States of training and technical
assistance, including the dissemination of best practices in
early childhood home visitation; and
``(2) after making the reservation required by paragraph
(1), an amount equal to 3 percent of the amount so
appropriated, to pay for grants to Indian tribes under this
section.
``(m) Appropriations.--Out of any money in the Treasury of
the United States not otherwise appropriated, there is
appropriated to the Secretary to carry out this section--
``(1) $50,000,000 for fiscal year 2010;
``(2) $100,000,000 for fiscal year 2011;
``(3) $150,000,000 for fiscal year 2012;
``(4) $200,000,000 for fiscal year 2013; and
``(5) $250,000,000 for fiscal year 2014.
``(n) Indian Tribes Treated as States.--In this section,
paragraphs (4), (5), and (6) of section 431(a) shall
apply.''.

SEC. 1905. IMPROVED COORDINATION AND PROTECTION FOR DUAL
ELIGIBLES.

Title XI of the Social Security Act is amended by inserting
after section 1150 the following new section:

``improved coordination and protection for dual eligibles

``Sec. 1150A.  (a) In General.--The Secretary shall
provide, through an identifiable office or program within the
Centers for Medicare & Medicaid Services, for a focused
effort to provide for improved coordination between Medicare
and Medicaid and protection in the case of dual eligibles (as
defined in subsection (g)). The office or program shall--
``(1) review Medicare and Medicaid policies related to
enrollment, benefits, service delivery, payment, and
grievance and appeals processes under parts A and B of title
XVIII, under the Medicare Advantage program under part C of
such title, and under title XIX;
``(2) identify areas of such policies where better
coordination and protection could improve care and costs; and
``(3) issue guidance to States regarding improving such
coordination and protection.
``(b) Elements.--The improved coordination and protection
under this section shall include efforts--
``(1) to simplify access of dual eligibles to benefits and
services under Medicare and Medicaid;
``(2) to improve care continuity for dual eligibles and
ensure safe and effective care transitions;
``(3) to harmonize regulatory conflicts between Medicare
and Medicaid rules with regard to dual eligibles; and
``(4) to improve total cost and quality performance under
Medicare and Medicaid for dual eligibles.
``(c) Responsibilities.--In carrying out this section, the
Secretary shall provide for the following:
``(1) An examination of Medicare and Medicaid payment
systems to develop strategies to foster more integrated and
higher quality care.
``(2) Development of methods to facilitate access to post-
acute and community-based services and to identify actions
that could lead to better coordination of community-based
care.
``(3) A study of enrollment of dual eligibles in the
Medicare Savings Program (as defined in section 1144(c)(7)),
under Medicaid, and in the low-income subsidy program under
section 1860D-14 to identify methods to more efficiently and
effectively reach and enroll dual eligibles.
``(4) An assessment of communication strategies for dual
eligibles to determine whether additional informational
materials or outreach is needed, including an assessment of
the Medicare website, 1-800-MEDICARE, and the Medicare
handbook.
``(5) Research and evaluation of areas where service
utilization, quality, and access to cost sharing protection
could be improved and an assessment of factors related to
enrollee satisfaction with services and care delivery.
``(6) Collection (and making available to the public) of
data and a database that describe the eligibility, benefit
and cost-sharing assistance available to dual eligibles by
State.
``(7) Support for coordination of State and Federal
contracting and oversight for dual coordination programs
supportive of the goals described in subsection (b).
``(8) Support for State Medicaid agencies through the
provision of technical assistance for Medicare and Medicaid
coordination initiatives designed to improve acute and long-
term care for dual eligibles.
``(9) Monitoring total combined Medicare and Medicaid
program costs in serving dual eligibles and making
recommendations for optimizing total quality and cost
performance across both programs.
``(10) Coordination of activities relating to Medicare
Advantage plans under 1859(b)(6)(B)(ii) and Medicaid.
``(d) Reporting.--The Office or program shall work with
relevant State agencies and any appropriate quality
measurement entities to improve and coordinate reporting
requirements for Medicare and Medicaid. In addition, the
Office or program shall seek to minimize duplication in
reporting requirements, where appropriate, and to identify
opportunities to combine assessment requirements, where
appropriate. The Office or program shall seek to identify
quality metrics and assessment requirements that facilitate
comparisons of the quality of care received by beneficiaries
enrolled in or entitled to benefits under fee-for-service
Medicare, the Medicare Advantage program, fee-for-service
Medicaid, and Medicaid managed care, and combinations thereof
(including integrated Medicare-Medicaid programs for dual
eligibles).
``(e) Endorsement.--The Secretary shall seek endorsement by
the entity with a contract under section 1890(a) of quality
measures and benchmarks developed under this section.
``(f) Consultation With Stakeholders.--The Office or
program shall consult with relevant stakeholders, including
dual eligible beneficiaries representatives for dual eligible
beneficiaries, health plans, providers, and relevant State
agencies, in the development of policies related to
integrated Medicare-Medicaid programs for dual eligibles.
``(g) Periodic Reports.--Not later than 1 year after the
date of the enactment of this section and every 3 years
thereafter the Secretary shall submit to Congress a report on
progress in activities conducted under this section.
``(h) Definitions.--In this section:
``(1) Dual eligible.--The term `dual eligible' means an
individual who is dually eligible for benefits under title
XVIII, and medical assistance under title XIX, including such
individuals who are eligible for benefits under the Medicare
Savings Program (as defined in section 1144(c)(7)).
``(2) Medicare; medicaid.--The terms `Medicare' and
`Medicaid' mean the programs under titles XVIII and XIX,
respectively.''.

SEC. 1906. ASSESSMENT OF MEDICARE COST-INTENSIVE DISEASES AND
CONDITIONS.

(a) Initial Assessment.--
(1) In general.--The Secretary of Health and Human Services
shall conduct an assessment of the diseases and conditions
that are the most cost-intensive for the Medicare program
and, to the extent possible, assess the diseases and
conditions that could become cost-intensive for Medicare in
the future. In conducting the assessment, the Secretary shall
include the input of relevant research agencies, including
the National Institutes of Health, the Agency for Healthcare
Research and Quality, the Food and Drug Administration, and
the Centers for Medicare & Medicaid Services.
(2) Report.--Not later than January 1, 2011, the Secretary
shall transmit a report to the Committees on Energy and
Commerce, Ways and Means, and Appropriations of the House of
Representatives and the Committees on Health, Education,
Labor and Pensions, Finance, and Appropriations of the Senate
on the assessment conducted under paragraph (1). Such report
shall--
(A) include the assessment of current and future trends of
cost-intensive diseases and conditions described in such
paragraph;
(B) address whether current research priorities are
appropriately addressing current and future cost-intensive
conditions so identified; and
(C) include recommendations concerning research in the
Department of Health and Human Services that should be funded
to improve the prevention, treatment, or cure of such cost-
intensive diseases and conditions.
(b) Updates of Assessment.--Not later than January 1, 2013,
and biennially thereafter, the Secretary shall--
(1) review and update the assessment and recommendations
described in subsection (a)(1); and
(2) submit a report described in subsection (a)(2) to the
Committees specified in subsection (a)(2) on such updated
assessment and recommendations.

SEC. 1907. ESTABLISHMENT OF CENTER FOR MEDICARE AND MEDICAID
INNOVATION WITHIN CMS.

(a) In General.--Title XI of the Social Security Act is
amended by inserting after section 1115 the following new
section:

``center for medicare and medicaid innovation

``Sec. 1115A.  (a) Center for Medicare and Medicaid
Innovation Established.--
``(1) In general.--There is created within the Centers for
Medicare & Medicaid Services a Center for Medicare and
Medicaid Innovation (in this section referred to as the
`CMI') to carry out the duties described in this section. The
purpose of the CMI is to test innovative payment and service
delivery models to improve the coordination, quality, and
efficiency of health care services provided to applicable
individuals defined in paragraph (4)(A).
``(2) Deadline.--The Secretary shall ensure that the CMI is
carrying out the duties described in this section by not
later than January 1, 2011.
``(3) Consultation.--In carrying out the duties under this
section, the CMI shall consult representatives of relevant
Federal agencies, clinical and analytical experts with
expertise in medicine and health care management, and States.
The CMI shall use open door forums or other mechanisms to
seek input from interested parties.
``(4) Definitions.--In this section:

[[Page H12749]]

``(A) Applicable individual.--The term `applicable
individual' means--
``(i) an individual who is enrolled under part B and
entitled to benefits under part A of title XVIII;
``(ii) an individual who is eligible for medical assistance
under title XIX; or
``(iii) an individual who meets the criteria of both
clauses (i) and (ii).
``(B) Applicable title.--The term `applicable title' means
title XVIII, title XIX, or both.
``(b) Testing of Models (Phase I).--
``(1) In general.--The CMI shall test payment and service
delivery models in accordance with selection criteria under
paragraph (2) to determine the effect of applying such models
under the applicable title (as defined in subsection
(a)(4)(B)) on program expenditures under such titles and the
quality of care received by individuals receiving benefits
under such title.
``(2) Selection of models to be tested.--
``(A) In general.--The Secretary shall give preference to
testing models for which, as determined by the Administrator
of the Centers for Medicare & Medicaid Services and using
such input from outside the Centers as the Administrator
determines appropriate, there is evidence that the model
addresses a defined population for which there are deficits
in care leading to poor clinical outcomes or potentially
avoidable expenditures. The Administrator shall focus on
models expected to reduce program costs under the applicable
title while preserving or enhancing the quality of care
received by individuals receiving benefits under such title.
``(B) Application to other demonstrations.--The Secretary
shall operate the demonstration programs under sections 1222
and 1236 of the Affordable Health Care for America Act
through the CMI in accordance with the rules applicable under
this section, including those relating to evaluations,
terminations, and expansions.
``(3) Budget neutrality.--
``(A) Initial period.--The Secretary shall not require, as
a condition for testing a model under paragraph (1), that the
design of such model ensure that such model is budget neutral
initially with respect to expenditures under the applicable
title.
``(B) Termination.--The Secretary shall terminate or modify
the design and implementation of a model unless the Secretary
determines (and the Chief Actuary of the Centers for Medicare
& Medicaid Services, with respect to spending under the
applicable title, certifies), after testing has begun, that
the model is expected to--
``(i) improve the quality of care (as determined by the
Administrator of the Centers for Medicare & Medicaid
Services) without increasing spending under such title;
``(ii) reduce spending under such titles without reducing
the quality of care; or
``(iii) do both.

Such termination may occur at any time after such testing has
begun and before completion of the testing.
``(4) Evaluation.--
``(A) In general.--The Secretary shall conduct an
evaluation of each model tested under this subsection. Such
evaluation shall include an analysis of--
``(i) the quality of care furnished under the model,
including through the use of patient-level outcomes measures;
and
``(ii) the changes in spending under the applicable titles
by reason of the model.

The Secretary shall make the results of each evaluation under
this paragraph available to the public in a timely fashion.
``(B) Measure selection.--To the extent feasible, the
Secretary shall select measures under this paragraph that
reflect national priorities for quality improvement and
patient-centered care consistent with the measures developed
under section 1192(c)(1).
``(5) Testing period.--In no case shall a model be tested
under this subsection for more than a 7-year period.
``(c) Expansion of Models (Phase II).--The Secretary may
expand the duration and the scope of a model that is being
tested under subsection (b) (including implementation on a
nationwide basis), to the extent determined appropriate by
the Secretary, if--
``(1) the Secretary determines that such expansion is
expected--
``(A) to improve the quality of patient care without
increasing spending under the applicable titles;
``(B) to reduce spending under applicable titles without
reducing the quality of care; or
``(C) to do both;
``(2) the Chief Actuary of the Centers for Medicare &
Medicaid Services certifies that such expansion would reduce
(or not result in any increase in) net program spending under
applicable titles; and
``(3) the Secretary determines that such expansion would
not deny or limit the coverage or provision of benefits under
the applicable title for applicable individuals.
``(d) Implementation.--
``(1) Waiver authority.--The Secretary may waive such
requirements of titles XI and XVIII and of sections 1902 and
1903(m) as may be necessary solely for purposes of carrying
out this section with respect to testing models described in
subsection (b).
``(2) Limitations on review.--There shall be no
administrative or judicial review under section 1869, section
1878, or otherwise of--
``(A) the selection of models for testing or expansion
under this section;
``(B) the elements, parameters, scope, and duration of such
models for testing or dissemination;
``(C) the termination or modification of the design and
implementation of a model under subsection (b)(3)(B); and
``(D) determinations about expansion of the duration and
scope of a model under subsection (c) including the
determination that a model is not expected to meet criteria
described in paragraphs (1) or (2) of such subsection.
``(3) Administration.--Chapter 35 of title 44, United
States Code shall not apply to the testing and evaluation of
models or expansion of such models under this section.
``(4) Funding for testing items and services and
administrative costs.--
``(A) Additional benefits.--There shall be available until
expended, equally divided from the Federal Supplementary
Hospital Insurance Trust Fund and Federal Supplementary
Medical Insurance Trust Fund for payments for additional
benefits for items and services under models tested under
subsection (b) not otherwise covered under this title and
applicable to benefits under this title, and for researching,
designing, implementing, and evaluating such models,
$350,000,000 for fiscal year 2010, $440,000,000 for fiscal
year 2011, $550,000,000 for fiscal year 2012, and, for a
subsequent fiscal year, the amount determined under this
subparagraph for the preceding fiscal year increased by the
annual percentage rate of increase in total expenditures
under this title for the subsequent fiscal year as estimated
in the latest available Annual Report of the Board of
Trustees as described in section 1841(b)(2).
``(B) Medicaid.--For administrative costs of the Centers
for Medicare & Medicaid Services for administering this
section with respect to title XIX, from any amounts in the
Treasury not otherwise appropriated there are appropriated to
the Secretary for the Centers for Medicare & Medicaid
Services Program Management Account $25,000,000 for each
fiscal year beginning with fiscal year 2010. Amounts
appropriated under this subparagraph for a fiscal year shall
be available until expended.
``(e) Report to Congress.--Beginning in 2012, and not less
than once every other year thereafter, the Secretary shall
submit to Congress a report on activities under this section.
Each such report shall describe the payment models tested
under subsection (b), including the number of individuals
described in subsection (a)(4)(A)(i) and of individuals
described in subsection (a)(4)(A)(ii) participating in such
models and payments made under applicable titles for services
on behalf of such individuals, any models chosen for
expansion under subsection (c), and the results from
evaluations under subsection (b)(4). In addition, each such
report shall provide such recommendations as the Secretary
believes are appropriate for legislative action to facilitate
the development and expansion of successful payment
models.''.
(b) Medicaid Conforming Amendment.--Section 1902(a) of the
Social Security Act (42 U.S.C. 1396a(a)), as amended by
sections 1631(b), 1703(a), 1729, 1753, 1757(a), and 1759(a),
is amended--
(1) in paragraph (78), by striking ``and'' at the end;
(2) in paragraph (79), by striking the period at the end
and inserting ``; and''; and
(3) by inserting after paragraph (79) the following new
paragraph:
``(80) provide for implementation of the payment models
specified by the Secretary under section 1115A(c) for
implementation on a nationwide basis unless the State
demonstrates to the satisfaction of the Secretary that
implementation would not be administratively feasible or
appropriate to the health care delivery system of the
State.''.

SEC. 1908. APPLICATION OF EMERGENCY SERVICES LAWS.

Nothing in this Act shall be construed to relieve any
health care provider from providing emergency services as
required by State or Federal law, including section 1867 of
the Social Security Act (popularly known as ``EMTALA'').

SEC. 1909. DISREGARD UNDER THE SUPPLEMENTAL SECURITY INCOME
PROGRAM OF COMPENSATION FOR PARTICIPATION IN
CLINICAL TRIALS FOR RARE DISEASES OR
CONDITIONS.

(a) Income Disregard.--Section 1612(b) of the Social
Security Act (42 U.S.C. 1382a(b)) is amended--
(1) by striking ``and'' at the end of paragraph (24);
(2) by striking the period at the end of paragraph (25) and
inserting ``; and''; and
(3) by adding at the end the following:
``(26) The first $2,000 per year received by such
individual (or such spouse) for participation in a clinical
trial to test a treatment for a rare disease or condition
(within the meaning of section 5(b)(2) of the Orphan Drug Act
(Public Law 97-414)), that--
``(A) has been reviewed and approved by an institutional
review board that--
``(i) is established to protect the rights and welfare of
human subjects participating in research; and
``(ii) meet the standards for such bodies set forth in part
46 of title 45, Code of Federal Regulations; and
``(B) meets the standards for protection of human subjects
for clinical research (as set forth in such part).''.
(b) Resource Disregard.--Section 1613(a) of such Act (42
U.S.C. 1382b(a)) is amended--
(1) by striking ``and'' at the end of paragraph (15);
(2) by striking the period at the end of paragraph (16) and
inserting ``; and''; and

[[Page H12750]]

(3) by inserting after paragraph (16) the following:
``(17) the first $2,000 per year received by such
individual (or such spouse) for participation in a clinical
trial, as described in section 1612(b)(26).''.
(c) Effective Date.--The amendments made by this section
shall apply to benefits payable for calendar months beginning
after the earlier of--
(1) the date the Commissioner of Social Security
promulgates regulations to carry out the amendments; or
(2) the 180-day period that begins with the date of the
enactment of this Act.

DIVISION C--PUBLIC HEALTH AND WORKFORCE DEVELOPMENT

SEC. 2001. TABLE OF CONTENTS; REFERENCES.

(a) Table of Contents.--The table of contents of this
division is as follows:

Sec. 2001. Table of contents; references.
Sec. 2002. Public Health Investment Fund.
Sec. 2003. Deficit neutrality.

TITLE I--COMMUNITY HEALTH CENTERS

Sec. 2101. Increased funding.

TITLE II--WORKFORCE

Subtitle A--Primary Care Workforce

Part 1--National Health Service Corps

Sec. 2201. National Health Service Corps.
Sec. 2202. Authorizations of appropriations.

Part 2--Promotion of Primary Care and Dentistry

Sec. 2211. Frontline health providers.

``subpart xi--health professional needs areas

``Sec. 340H. In general.
``Sec. 340I. Loan repayments.
``Sec. 340J. Report.
``Sec. 340K. Allocation.
Sec. 2212. Primary care student loan funds.
Sec. 2213. Training in family medicine, general internal medicine,
general pediatrics, geriatrics, and physician assistants.
Sec. 2214. Training of medical residents in community-based settings.
Sec. 2215. Training for general, pediatric, and public health dentists
and dental hygienists.
Sec. 2216. Authorization of appropriations.
Sec. 2217. Study on effectiveness of scholarships and loan repayments.

Subtitle B--Nursing Workforce

Sec. 2221. Amendments to Public Health Service Act.

Subtitle C--Public Health Workforce

Sec. 2231. Public Health Workforce Corps.

``subpart xii--public health workforce

``Sec. 340L. Public Health Workforce Corps.
``Sec. 340M. Public Health Workforce Scholarship Program.
``Sec. 340N. Public Health Workforce Loan Repayment Program.
Sec. 2232. Enhancing the public health workforce.
Sec. 2233. Public health training centers.
Sec. 2234. Preventive medicine and public health training grant
program.
Sec. 2235. Authorization of appropriations.

Subtitle D--Adapting Workforce to Evolving Health System Needs

Part 1--Health Professions Training for Diversity

Sec. 2241. Scholarships for disadvantaged students, loan repayments and
fellowships regarding faculty positions, and educational
assistance in the health professions regarding
individuals from disadvantaged backgrounds.
Sec. 2242. Nursing workforce diversity grants.
Sec. 2243. Coordination of diversity and cultural competency programs.

Part 2--Interdisciplinary Training Programs

Sec. 2251. Cultural and linguistic competency training for health
professionals.
Sec. 2252. Innovations in interdisciplinary care training.

Part 3--Advisory Committee on Health Workforce Evaluation and
Assessment

Sec. 2261. Health workforce evaluation and assessment.

Part 4--Health Workforce Assessment

Sec. 2271. Health workforce assessment.

Part 5--Authorization of Appropriations

Sec. 2281. Authorization of appropriations.

TITLE III--PREVENTION AND WELLNESS

Sec. 2301. Prevention and wellness.

``TITLE XXXI--PREVENTION AND WELLNESS

``Subtitle A--Prevention and Wellness Trust

``Sec. 3111. Prevention and Wellness Trust.

``Subtitle B--National Prevention and Wellness Strategy

``Sec. 3121. National Prevention and Wellness Strategy.

``Subtitle C--Prevention Task Forces

``Sec. 3131. Task Force on Clinical Preventive Services.
``Sec. 3132. Task Force on Community Preventive Services.

``Subtitle D--Prevention and Wellness Research

``Sec. 3141. Prevention and wellness research activity coordination.
``Sec. 3142. Community prevention and wellness research grants.
``Sec. 3143. Research on subsidies and rewards to encourage wellness
and healthy behaviors.

``Subtitle E--Delivery of Community Prevention and Wellness Services

``Sec. 3151. Community prevention and wellness services grants.

``Subtitle F--Core Public Health Infrastructure

``Sec. 3161. Core public health infrastructure for State, local, and
tribal health departments.
``Sec. 3162. Core public health infrastructure and activities for CDC.

``Subtitle G--General Provisions

``Sec. 3171. Definitions.

TITLE IV--QUALITY AND SURVEILLANCE

Sec. 2401. Implementation of best practices in the delivery of health
care.
Sec. 2402. Assistant Secretary for Health Information.
Sec. 2403. Authorization of appropriations.

TITLE V--OTHER PROVISIONS

Subtitle A--Drug Discount for Rural and Other Hospitals; 340B Program
Integrity

Sec. 2501. Expanded participation in 340B program.
Sec. 2502. Improvements to 340B program integrity.
Sec. 2503. Effective date.

Subtitle B--Programs

Part 1--Grants for Clinics and Centers

Sec. 2511. School-based health clinics.
Sec. 2512. Nurse-Managed health centers.
Sec. 2513. Federally qualified behavioral health centers.

Part 2--Other Grant Programs

Sec. 2521. Comprehensive programs to provide education to nurses and
create a pipeline to nursing.
Sec. 2522. Mental and behavioral health training.
Sec. 2523. Reauthorization of telehealth and telemedicine grant
programs.
Sec. 2524. No child left unimmunized against influenza: demonstration
program using elementary and secondary schools as
influenza vaccination centers.
Sec. 2525. Extension of Wisewoman Program.
Sec. 2526. Healthy teen initiative to prevent teen pregnancy.
Sec. 2527. National training initiatives on autism spectrum disorders.
Sec. 2528. Implementation of medication management services in
treatment of chronic diseases.
Sec. 2529. Postpartum depression.
Sec. 2530. Grants to promote positive health behaviors and outcomes.
Sec. 2531. Medical liability alternatives.
Sec. 2532. Infant mortality pilot programs.
Sec. 2533. Secondary school health sciences training program.
Sec. 2534. Community-based collaborative care networks.
Sec. 2535. Community-based overweight and obesity prevention program.
Sec. 2536. Reducing student-to-school nurse ratios.
Sec. 2537. Medical-legal partnerships.
Sec. 2538. Screening, Brief Intervention, referral, and treatment for
mental health and substance abuse disorders.
Sec. 2539. Grants to assist in developing medical schools in federally-
designated health professional shortage areas.

Part 3--Emergency Care-Related Programs

Sec. 2551. Trauma care centers.
Sec. 2552. Emergency care coordination.
Sec. 2553. Pilot programs to improve emergency medical care.
Sec. 2554. Assisting veterans with military emergency medical training
to become State-licensed or certified emergency medical
technicians (EMTs).
Sec. 2555. Dental emergency responders: public health and medical
response.
Sec. 2556. Dental emergency responders: homeland security.

Part 4--Pain Care and Management Programs

Sec. 2561. Institute of Medicine Conference on Pain.
Sec. 2562. Pain research at National Institutes of Health.
Sec. 2563. Public awareness campaign on pain management.

Subtitle C--Food and Drug Administration

Part 1--In General

Sec. 2571. National medical device registry.
Sec. 2572. Nutrition labeling of standard menu items at chain
restaurants and of articles of food sold from vending
machines.
Sec. 2573. Protecting consumer access to generic drugs.

Part 2--Biosimilars

Sec. 2575. Licensure pathway for biosimilar biological products.
Sec. 2576. Fees relating to biosimilar biological products.
Sec. 2577. Amendments to certain patent provisions.

Subtitle D--Community Living Assistance Services and Supports

Sec. 2581. Establishment of national voluntary insurance program for
purchasing community living assistance services and
support (CLASS program).

[[Page H12751]]

``TITLE XXXII--COMMUNITY LIVING ASSISTANCE SERVICES AND SUPPORTS

``Sec. 3201. Purpose.
``Sec. 3202. Definitions.
``Sec. 3203. CLASS Independence Benefit Plan.
``Sec. 3204. Enrollment and disenrollment requirements.
``Sec. 3205. Benefits.
``Sec. 3206. CLASS Independence Fund.
``Sec. 3207. CLASS Independence Advisory Council.
``Sec. 3208. Regulations; annual report.
``Sec. 3209. Inspector General's report.

Subtitle E--Miscellaneous

Sec. 2585. States failing to adhere to certain employment obligations.
Sec. 2586. Health centers under Public Health Service Act; liability
protections for volunteer practitioners.
Sec. 2587. Report to Congress on the current state of parasitic
diseases that have been overlooked among the poorest
Americans.
Sec. 2588. Office of Women's Health.
Sec. 2588A. Offices of Minority Health.
Sec. 2589. Long-Term Care and Family Caregiver Support.
Sec. 2590. Web site on health care labor market and related educational
and training opportunities.
Sec. 2591. Online health workforce training programs.
Sec. 2592. Access for individuals with disabilities.
Sec. 2593. Duplicative Grant programs.
Sec. 2594. Diabetes screening collaboration and outreach program.
Sec. 2595. Improvement of vital statistics collection.
Sec. 2596. National health service corps demonstration on incentive
payments.

(b) References.--Except as otherwise specified, whenever in
this division an amendment is expressed in terms of an
amendment to a section or other provision, the reference
shall be considered to be made to a section or other
provision of the Public Health Service Act (42 U.S.C. 201 et
seq.).

SEC. 2002. PUBLIC HEALTH INVESTMENT FUND.

(a) Establishment of Funds.--
(1) In general.--Subject to section 2003, there is hereby
established in the Treasury a separate account to be known as
the ``Public Health Investment Fund'' (referred to in this
section and section 2003 as the ``Fund'').
(2) Funding.--
(A) There shall be deposited into the Fund--
(i) for fiscal year 2011, $4,600,000,000;
(ii) for fiscal year 2012, $5,600,000,000;
(iii) for fiscal year 2013, $6,900,000,000;
(iv) for fiscal year 2014, $7,800,000,000; and
(v) for fiscal year 2015, $9,000,000,000.
(B) Amounts deposited into the Fund shall be derived from
general revenues of the Treasury only for the fiscal years
set forth in this section, and amounts appropriated from the
Fund shall remain available until expended.
(b) Authorization of Appropriations From the Fund.--
(1) New funding.--
(A) In general.--Subject to section 2003, amounts in the
Fund are authorized to be appropriated for carrying out
activities under designated public health provisions.
(B) Designated provisions.--For purposes of this paragraph,
the term ``designated public health provisions'' means the
provisions for which amounts are authorized to be
appropriated under section 330(s), 338(c), 338H-1, 799C, 872,
or 3111 of the Public Health Service Act, as added by this
division.
(2) Baseline funding.--
(A) In general.--Amounts in the Fund are authorized to be
appropriated (as described in paragraph (1)) for a fiscal
year only if (excluding any amounts in or appropriated from
the Fund) the amounts specified in subparagraph (B) for the
fiscal year involved are equal to or greater than the amounts
specified in subparagraph (B) for fiscal year 2008.
(B) Amounts specified.--The amounts specified in this
subparagraph, with respect to a fiscal year are the amounts
appropriated (excluding any amounts in or appropriated from
the Fund) for the following:
(i) Community health centers (including funds appropriated
under the authority of section 330 of the Public Health
Service Act (42 U.S.C. 254b)).
(ii) The National Health Service Corps Program (including
funds appropriated under the authority of section 338 of such
Act (42 U.S.C. 254k)).
(iii) The National Health Service Corps Scholarship and
Loan Repayment Programs (including funds appropriated under
the authority of section 338H of such Act (42 U.S.C. 254q)).
(iv) Primary care education programs (including funds
appropriated under the authority of sections 736, 740, 741,
and 747 of such Act (42 U.S.C. 293, 293d, and 293k)).
(v) Sections 761 and 770 of such Act (42 U.S.C. 294n and
295e).
(vi) Nursing workforce development (including funds
appropriated under the authority of title VIII of such Act
(42 U.S.C. 296 et seq.)).
(vii) The National Center for Health Statistics (including
funds appropriated under the authority of sections 304, 306,
307, and 308 of such Act (42 U.S.C. 242b, 242k, 242l, and
242m)).
(viii) The Agency for Healthcare Research and Quality
(including funds made available under the authority of title
IX of such Act (42 U.S.C. 299 et seq.)).

SEC. 2003. DEFICIT NEUTRALITY.

(a) Availability.--Funds appropriated or made available
pursuant to sections 330(s), 338(c), 338H-1, 799C, 872, or
3111 of the Public Health Service Act, as added by this
division, are only available for the purposes set forth in
this Act. Appropriations shall not be available and are
precluded from obligation for any other purpose.
(b) Estimation of Budgetary Impact.--For the purposes of
estimating the spending effects of this Act, the
authorization of appropriations from the Fund, to the extent
amounts in the Fund are derived from the general revenues of
the Treasury, shall be treated as new direct spending and
attributed to this Act.
(c) Budgetary Treatment.--For the purposes of section 257
of the Balanced Budget and Emergency Deficit Control Act of
1985, the Fund, to the extent amounts in the Fund are derived
from the general revenues of the Treasury, and not in excess
of amounts subsequently appropriated from the Fund, shall be
deemed to be included on the list of appropriations
referenced under section 250(c)(17) of that Act.

TITLE I--COMMUNITY HEALTH CENTERS

SEC. 2101. INCREASED FUNDING.

Section 330 of the Public Health Service Act (42 U.S.C.
254b) is amended--
(1) in subsection (r)(1)--
(A) in subparagraph (D), by striking ``and'' at the end;
(B) in subparagraph (E), by striking the period at the end
and inserting ``; and''; and
(C) by inserting at the end the following:
``(F) such sums as may be necessary for each of fiscal
years 2013 through 2015.''; and
(2) by inserting after subsection (r) the following:
``(s) Additional Funding.--For the purpose of carrying out
this section, in addition to any other amounts authorized to
be appropriated for such purpose, there are authorized to be
appropriated, out of any monies in the Public Health
Investment Fund, the following:
``(1) For fiscal year 2011, $1,000,000,000.
``(2) For fiscal year 2012, $1,500,000,000.
``(3) For fiscal year 2013, $2,500,000,000.
``(4) For fiscal year 2014, $3,000,000,000.
``(5) For fiscal year 2015, $4,000,000,000.''.

TITLE II--WORKFORCE

Subtitle A--Primary Care Workforce

PART 1--NATIONAL HEALTH SERVICE CORPS

SEC. 2201. NATIONAL HEALTH SERVICE CORPS.

(a) Fulfillment of Obligated Service Requirement Through
Half-Time Service.--
(1) Waivers.--Subsection (i) of section 331 (42 U.S.C.
254d) is amended--
(A) in paragraph (1), by striking ``In carrying out subpart
III'' and all that follows through the period and inserting
``In carrying out subpart III, the Secretary may, in
accordance with this subsection, issue waivers to individuals
who have entered into a contract for obligated service under
the Scholarship Program or the Loan Repayment Program under
which the individuals are authorized to satisfy the
requirement of obligated service through providing clinical
practice that is half-time.'';
(B) in paragraph (2)--
(i) in subparagraphs (A)(ii) and (B), by striking ``less
than full time'' each place it appears and inserting ``half
time'';
(ii) in subparagraphs (C) and (F), by striking ``less than
full-time service'' each place it appears and inserting
``half-time service''; and
(iii) by amending subparagraphs (D) and (E) to read as
follows:
``(D) the entity and the Corps member agree in writing that
the Corps member will perform half-time clinical practice;
``(E) the Corps member agrees in writing to fulfill all of
the service obligations under section 338C through half-time
clinical practice and either--
``(i) double the period of obligated service that would
otherwise be required; or
``(ii) in the case of contracts entered into under section
338B, accept a minimum service obligation of 2 years with an
award amount equal to 50 percent of the amount that would
otherwise be payable for full-time service; and''; and
(C) in paragraph (3), by striking ``In evaluating a
demonstration project described in paragraph (1)'' and
inserting ``In evaluating waivers issued under paragraph
(1)''.
(2) Definitions.--Subsection (j) of section 331 (42 U.S.C.
254d) is amended by adding at the end the following:
``(5) The terms `full time' and `full-time' mean a minimum
of 40 hours per week in a clinical practice, for a minimum of
45 weeks per year.
``(6) The terms `half time' and `half-time' mean a minimum
of 20 hours per week (not to exceed 39 hours per week) in a
clinical practice, for a minimum of 45 weeks per year.''.
(b) Reappointment to National Advisory Council.--Section
337(b)(1) (42 U.S.C. 254j(b)(1)) is amended by striking
``Members may not be reappointed to the Council.''.
(c) Loan Repayment Amount.--Section 338B(g)(2)(A) (42
U.S.C. 254l-1(g)(2)(A)) is amended by striking ``$35,000''
and inserting ``$50,000, plus, beginning with fiscal year
2012, an amount determined by the Secretary on an annual
basis to reflect inflation,''.
(d) Treatment of Teaching as Obligated Service.--Subsection
(a) of section 338C (42

[[Page H12752]]

U.S.C. 254m) is amended by adding at the end the following:
``The Secretary may treat teaching as clinical practice for
up to 20 percent of such period of obligated service.''.

SEC. 2202. AUTHORIZATIONS OF APPROPRIATIONS.

(a) National Health Service Corps Program.--Section 338 (42
U.S.C. 254k) is amended--
(1) in subsection (a), by striking ``2012'' and inserting
``2015''; and
(2) by adding at the end the following:
``(c) For the purpose of carrying out this subpart, in
addition to any other amounts authorized to be appropriated
for such purpose, there are authorized to be appropriated,
out of any monies in the Public Health Investment Fund, the
following:
``(1) $63,000,000 for fiscal year 2011.
``(2) $66,000,000 for fiscal year 2012.
``(3) $70,000,000 for fiscal year 2013.
``(4) $73,000,000 for fiscal year 2014.
``(5) $77,000,000 for fiscal year 2015.''.
(b) Scholarship and Loan Repayment Programs.--Subpart III
of part D of title III of the Public Health Service Act (42
U.S.C. 254l et seq.) is amended--
(1) in section 338H(a)--
(A) in paragraph (4), by striking ``and'' at the end;
(B) in paragraph (5), by striking the period at the end and
inserting ``; and''; and
(C) by adding at the end the following:
``(6) for each of fiscal years 2013 through 2015, such sums
as may be necessary.''; and
(2) by inserting after section 338H the following:

``SEC. 338H-1. ADDITIONAL FUNDING.

``For the purpose of carrying out this subpart, in addition
to any other amounts authorized to be appropriated for such
purpose, there are authorized to be appropriated, out of any
monies in the Public Health Investment Fund, the following:
``(1) $254,000,000 for fiscal year 2011.
``(2) $266,000,000 for fiscal year 2012.
``(3) $278,000,000 for fiscal year 2013.
``(4) $292,000,000 for fiscal year 2014.
``(5) $306,000,000 for fiscal year 2015.''.

PART 2--PROMOTION OF PRIMARY CARE AND DENTISTRY

SEC. 2211. FRONTLINE HEALTH PROVIDERS.

Part D of title III (42 U.S.C. 254b et seq.) is amended by
adding at the end the following:

``Subpart XI--Health Professional Needs Areas

``SEC. 340H. IN GENERAL.

``(a) Program.--The Secretary, acting through the
Administrator of the Health Resources and Services
Administration, shall establish a program, to be known as the
Frontline Health Providers Loan Repayment Program, to address
unmet health care needs in health professional needs areas
through loan repayments under section 340I.
``(b) Designation of Health Professional Needs Areas.--
``(1) In general.--In this subpart, the term `health
professional needs area' means an area, population, or
facility that is designated by the Secretary in accordance
with paragraph (2).
``(2) Designation.--To be designated by the Secretary as a
health professional needs area under this subpart:
``(A) In the case of an area, the area must be a rational
area for the delivery of health services.
``(B) The area, population, or facility must have, in one
or more health disciplines, specialties, or subspecialties
for the population served, as determined by the Secretary--
``(i) insufficient capacity of health professionals; or
``(ii) high needs for health services, including services
to address health disparities.
``(C) With respect to the delivery of primary health
services, the area, population, or facility must not include
a health professional shortage area (as designated under
section 332), except that the area, population, or facility
may include such a health professional shortage area in which
there is an unmet need for such services.
``(c) Eligibility.--To be eligible to participate in the
Program, an individual shall--
``(1) hold a degree in a course of study or program
(approved by the Secretary) from a school defined in section
799B(1)(A) (other than a school of public health);
``(2) hold a degree in a course of study or program
(approved by the Secretary) from a school or program defined
in subparagraph (C), (D), or (E)(4) of section 799B(1), as
designated by the Secretary;
``(3) be enrolled as a full-time student--
``(A) in a school or program defined in subparagraph (C),
(D), or (E)(4) of section 799B(1), as designated by the
Secretary, or a school described in paragraph (1); and
``(B) in the final year of a course of study or program,
offered by such school or program and approved by the
Secretary, leading to a degree in a discipline referred to in
subparagraph (A) (other than a graduate degree in public
health), (C), (D), or (E)(4) of section 799B(1);
``(4) be a practitioner described in section 1842(b)(18)(C)
or 1848(k)(3)(B)(iii) or (iv) of the Social Security Act; or
``(5) be a practitioner in the field of respiratory
therapy, medical technology, or radiologic technology.
``(d) Definitions.--In this subpart:
``(1) The term `health disparities' has the meaning given
to the term in section 3171.
``(2) The term `primary health services' has the meaning
given to such term in section 331(a)(3)(D).

``SEC. 340I. LOAN REPAYMENTS.

``(a) Loan Repayments.--The Secretary, acting through the
Administrator of the Health Resources and Services
Administration, shall enter into contracts with individuals
under which--
``(1) the individual agrees--
``(A) to serve as a full-time primary health services
provider or as a full-time or part-time provider of other
health services for a period of time equal to 2 years or such
longer period as the individual may agree to;
``(B) to serve in a health professional needs area in a
health discipline, specialty, or a subspecialty for which the
area, population, or facility is designated as a health
professional needs area under section 340H; and
``(C) in the case of an individual described in section
340H(c)(3) who is in the final year of study and who has
accepted employment as a primary health services provider or
provider of other health services in accordance with
subparagraphs (A) and (B), to complete the education or
training and maintain an acceptable level of academic
standing (as determined by the educational institution
offering the course of study or training); and
``(2) the Secretary agrees to pay, for each year of such
service, an amount on the principal and interest of the
undergraduate or graduate educational loans (or both) of the
individual that is not more than 50 percent of the average
award made under the National Health Service Corps Loan
Repayment Program under subpart III in that year.
``(b) Practice Setting.--A contract entered into under this
section shall allow the individual receiving the loan
repayment to satisfy the service requirement described in
subsection (a)(1) through employment in a solo or group
practice, a clinic, an accredited public or private nonprofit
hospital, or any other health care entity, as deemed
appropriate by the Secretary.
``(c) Application of Certain Provisions.--The provisions of
subpart III of part D shall, except as inconsistent with this
section, apply to the loan repayment program under this
subpart in the same manner and to the same extent as such
provisions apply to the National Health Service Corps Loan
Repayment Program established under section 338B.
``(d) Insufficient Number of Applicants.--If there are an
insufficient number of applicants for loan repayments under
this section to obligate all appropriated funds, the
Secretary shall transfer the unobligated funds to the
National Health Service Corps for the purpose of recruiting
applicants and entering into contracts with individuals so as
to ensure a sufficient number of participants in the National
Health Service Corps for the following year.

``SEC. 340J. REPORT.

``The Secretary shall submit to the Congress an annual
report on the program carried out under this subpart.

``SEC. 340K. ALLOCATION.

``Of the amount of funds obligated under this subpart each
fiscal year for loan repayments--
``(1) 90 percent shall be for physicians and other health
professionals providing primary health services; and
``(2) 10 percent shall be for health professionals not
described in paragraph (1).''.

SEC. 2212. PRIMARY CARE STUDENT LOAN FUNDS.

(a) In General.--Section 735 (42 U.S.C. 292y) is amended--
(1) by redesignating subsection (f) as subsection (g); and
(2) by inserting after subsection (e) the following:
``(f) Determination of Financial Need.--The Secretary--
``(1) may require, or authorize a school or other entity to
require, the submission of financial information to determine
the financial resources available to any individual seeking
assistance under this subpart; and
``(2) shall take into account the extent to which such
individual is financially independent in determining whether
to require or authorize the submission of such information
regarding such individual's family members.''.
(b) Revised Guidelines.--The Secretary of Health and Human
Services shall--
(1) strike the second sentence of section 57.206(b)(1) of
title 42, Code of Federal Regulations; and
(2) make such other revisions to guidelines and regulations
in effect as of the date of the enactment of this Act as may
be necessary for consistency with the amendments made by
paragraph (1).

SEC. 2213. TRAINING IN FAMILY MEDICINE, GENERAL INTERNAL
MEDICINE, GENERAL PEDIATRICS, GERIATRICS, AND
PHYSICIAN ASSISTANTS.

Section 747 (42 U.S.C. 293k) is amended--
(1) by amending the section heading to read as follows:
``PRIMARY CARE TRAINING AND ENHANCEMENT'';
(2) by redesignating subsection (e) as subsection (g); and
(3) by striking subsections (a) through (d) and inserting
the following:
``(a) Program.--The Secretary shall establish a primary
care training and capacity building program consisting of
awarding grants and contracts under subsections (b) and (c).
``(b) Support and Development of Primary Care Training
Programs.--
``(1) In general.--The Secretary shall make grants to, or
enter into contracts with, eligible entities--
``(A) to plan, develop, operate, or participate in an
accredited professional training

[[Page H12753]]

program, including an accredited residency or internship
program, in the field of family medicine, general internal
medicine, general pediatrics, or geriatrics for medical
students, interns, residents, or practicing physicians;
``(B) to provide financial assistance in the form of
traineeships and fellowships to medical students, interns,
residents, or practicing physicians, who are participants in
any such program, and who plan to specialize or work in
family medicine, general internal medicine, general
pediatrics, or geriatrics;
``(C) to plan, develop, operate, or participate in an
accredited program for the training of physicians who plan to
teach in family medicine, general internal medicine, general
pediatrics, or geriatrics training programs including in
community-based settings;
``(D) to provide financial assistance in the form of
traineeships and fellowships to practicing physicians who are
participants in any such programs and who plan to teach in a
family medicine, general internal medicine, general
pediatrics, or geriatrics training program; and
``(E) to plan, develop, operate, or participate in an
accredited program for physician assistant education, and for
the training of individuals who plan to teach in programs to
provide such training.
``(2) Eligibility.--To be eligible for a grant or contract
under paragraph (1), an entity shall be--
``(A) an accredited school of medicine or osteopathic
medicine, public or nonprofit private hospital, or physician
assistant training program;
``(B) a public or private nonprofit entity; or
``(C) a consortium of 2 or more entities described in
subparagraphs (A) and (B).
``(c) Capacity Building in Primary Care.--
``(1) In general.--The Secretary shall make grants to or
enter into contracts with eligible entities to establish,
maintain, or improve--
``(A) academic administrative units (including departments,
divisions, or other appropriate units) in the specialties of
family medicine, general internal medicine, general
pediatrics, or geriatrics; or
``(B) programs that improve clinical teaching in such
specialties.
``(2) Eligibility.--To be eligible for a grant or contract
under paragraph (1), an entity shall be an accredited school
of medicine or osteopathic medicine.
``(d) Preference.--In awarding grants or contracts under
this section, the Secretary shall give preference to entities
that have a demonstrated record of at least one of the
following:
``(1) Training a high or significantly improved percentage
of health professionals who provide primary care.
``(2) Training individuals who are from disadvantaged
backgrounds (including racial and ethnic minorities
underrepresented among primary care professionals).
``(3) A high rate of placing graduates in practice settings
having the principal focus of serving in underserved areas or
populations experiencing health disparities (including
serving patients eligible for medical assistance under title
XIX of the Social Security Act or for child health assistance
under title XXI of such Act or those with special health care
needs).
``(4) Supporting teaching programs that address the health
care needs of vulnerable populations.
``(e) Report.--The Secretary shall submit to the Congress
an annual report on the program carried out under this
section.
``(f) Definition.--In this section, the term `health
disparities' has the meaning given the term in section
3171.''.

SEC. 2214. TRAINING OF MEDICAL RESIDENTS IN COMMUNITY-BASED
SETTINGS.

Title VII (42 U.S.C. 292 et seq.) is amended--
(1) by redesignating section 748 as 749A; and
(2) by inserting after section 747 the following:

``SEC. 748. TRAINING OF MEDICAL RESIDENTS IN COMMUNITY-BASED
SETTINGS.

``(a) Program.--The Secretary shall establish a program for
the training of medical residents in community-based settings
consisting of awarding grants and contracts under this
section.
``(b) Development and Operation of Community-Based
Programs.--The Secretary shall make grants to, or enter into
contracts with, eligible entities--
``(1) to plan and develop a new primary care residency
training program, which may include--
``(A) planning and developing curricula;
``(B) recruiting and training residents and faculty; and
``(C) other activities designated to result in
accreditation of such a program; or
``(2) to operate or participate in an established primary
care residency training program, which may include--
``(A) planning and developing curricula;
``(B) recruitment and training of residents; and
``(C) retention of faculty.
``(c) Eligible Entity.--To be eligible to receive a grant
or contract under subsection (b), an entity shall--
``(1) be designated as a recipient of payment for the
direct costs of medical education under section 1886(k) of
the Social Security Act;
``(2) be designated as an approved teaching health center
under section 1502(d) of the Affordable Health Care for
America Act and continuing to participate in the
demonstration project under such section;
``(3) be an applicant for designation described in
paragraph (1) or (2) and have demonstrated to the Secretary
appropriate involvement of an accredited teaching hospital to
carry out the inpatient responsibilities associated with a
primary care residency training program; or
``(4) be eligible to be designated as described in
paragraph (1) or (2), not be an applicant as described in
paragraph (3), and have demonstrated appropriate involvement
of an accredited teaching hospital to carry out the inpatient
responsibilities associated with a primary care residency
training program.
``(d) Preferences.--In awarding grants and contracts under
paragraph (1) or (2) of subsection (b), the Secretary shall
give preference to entities that--
``(1) support teaching programs that address the health
care needs of vulnerable populations; or
``(2) are a Federally qualified health center (as defined
in section 1861(aa)(4) of the Social Security Act) or a rural
health clinic (as defined in section 1861(aa)(2) of such
Act).
``(e) Additional Preferences for Established Programs.--In
awarding grants and contracts under subsection (b)(2), the
Secretary shall give preference to entities that have a
demonstrated record of training--
``(1) a high or significantly improved percentage of health
professionals who provide primary care;
``(2) individuals who are from disadvantaged backgrounds
(including racial and ethnic minorities underrepresented
among primary care professionals); or
``(3) individuals who practice in settings having the
principal focus of serving underserved areas or populations
experiencing health disparities (including serving patients
eligible for medical assistance under title XIX of the Social
Security Act or for child health assistance under title XXI
of such Act or those with special health care needs).
``(f) Period of Awards.--
``(1) In general.--The period of a grant or contract under
this section--
``(A) shall not exceed 3 years for awards under subsection
(b)(1); and
``(B) shall not exceed 5 years for awards under subsection
(b)(2).
``(2) Special rules.--
``(A) An award of a grant or contract under subsection
(b)(1) shall not be renewed.
``(B) The period of a grant or contract awarded to an
entity under subsection (b)(2) shall not overlap with the
period of any grant or contact awarded to the same entity
under subsection (b)(1).
``(g) Report.--The Secretary shall submit to the Congress
an annual report on the program carried out under this
section.
``(h) Definitions.--In this section:
``(1) Health disparities.--The term `health disparities'
has the meaning given the term in section 3171.
``(2) Primary care resident.--The term `primary care
resident' has the meaning given the term in section
1886(h)(5)(H) of the Social Security Act.
``(3) Primary care residency training program.--The term
`primary care residency training program' means an approved
medical residency training program described in section
1886(h)(5)(A) of the Social Security Act for primary care
residents that is--
``(A) in the case of entities seeking awards under
subsection (b)(1), actively applying to be accredited by the
Accreditation Council for Graduate Medical Education or the
American Osteopathic Association; or
``(B) in the case of entities seeking awards under
subsection (b)(2), so accredited.
``(i) Allocation of Funds.--Of the amount appropriated
pursuant to section 799C(a) for a fiscal year, not more than
17 percent of such amount shall be made available to carry
out this section.''.

SEC. 2215. TRAINING FOR GENERAL, PEDIATRIC, AND PUBLIC HEALTH
DENTISTS AND DENTAL HYGIENISTS.

Title VII (42 U.S.C. 292 et seq.) is amended--
(1) in section 791(a)(1), by striking ``747 and 750'' and
inserting ``747, 749, and 750''; and
(2) by inserting after section 748, as added, the
following:

``SEC. 749. TRAINING FOR GENERAL, PEDIATRIC, AND PUBLIC
HEALTH DENTISTS AND DENTAL HYGIENISTS.

``(a) Program.--The Secretary shall establish a training
program for oral health professionals consisting of awarding
grants and contracts under this section.
``(b) Support and Development of Oral Health Training
Programs.--The Secretary shall make grants to, or enter into
contracts with, eligible entities--
``(1) to plan, develop, operate, or participate in an
accredited professional training program for oral health
professionals;
``(2) to provide financial assistance to oral health
professionals who are in need thereof, who are participants
in any such program, and who plan to work in general,
pediatric, or public health dentistry, or dental hygiene;
``(3) to plan, develop, operate, or participate in a
program for the training of oral health professionals who
plan to teach in general, pediatric, or public health
dentistry, or dental hygiene;
``(4) to provide financial assistance in the form of
traineeships and fellowships to oral health professionals who
plan to teach in

[[Page H12754]]

general, pediatric, or public health dentistry or dental
hygiene;
``(5) to establish, maintain, or improve--
``(A) academic administrative units (including departments,
divisions, or other appropriate units) in the specialties of
general, pediatric, or public health dentistry; or
``(B) programs that improve clinical teaching in such
specialties;
``(6) to plan, develop, operate, or participate in
predoctoral and postdoctoral training in general, pediatric,
or public health dentistry programs;
``(7) to plan, develop, operate, or participate in a loan
repayment program for full-time faculty in a program of
general, pediatric, or public health dentistry; and
``(8) to provide technical assistance to pediatric dental
training programs in developing and implementing instruction
regarding the oral health status, dental care needs, and
risk-based clinical disease management of all pediatric
populations with an emphasis on underserved children.
``(c) Eligibility.--To be eligible for a grant or contract
under this section, an entity shall be--
``(1) an accredited school of dentistry, training program
in dental hygiene, or public or nonprofit private hospital;
``(2) a training program in dental hygiene at an accredited
institution of higher education;
``(3) a public or private nonprofit entity; or
``(4) a consortium of--
``(A) 1 or more of the entities described in paragraphs (1)
through (3); and
``(B) an accredited school of public health.
``(d) Preference.--In awarding grants or contracts under
this section, the Secretary shall give preference to entities
that have a demonstrated record of at least one of the
following:
``(1) Training a high or significantly improved percentage
of oral health professionals who practice general, pediatric,
or public health dentistry.
``(2) Training individuals who are from disadvantaged
backgrounds (including racial and ethnic minorities
underrepresented among oral health professionals).
``(3) A high rate of placing graduates in practice settings
having the principal focus of serving in underserved areas or
populations experiencing health disparities (including
serving patients eligible for medical assistance under title
XIX of the Social Security Act or for child health assistance
under title XXI of such Act or those with special health care
needs).
``(4) Supporting teaching programs that address the oral
health needs of vulnerable populations.
``(5) Providing instruction regarding the oral health
status, oral health care needs, and risk-based clinical
disease management of all pediatric populations with an
emphasis on underserved children.
``(e) Report.--The Secretary shall submit to the Congress
an annual report on the program carried out under this
section.
``(f) Definitions.--In this section:
``(1) The term `health disparities' has the meaning given
the term in section 3171.
``(2) The term `oral health professional' means an
individual training or practicing--
``(A) in general dentistry, pediatric dentistry, public
health dentistry, or dental hygiene; or
``(B) another oral health specialty, as deemed appropriate
by the Secretary.''.

SEC. 2216. AUTHORIZATION OF APPROPRIATIONS.

(a) In General.--Part F of title VII (42 U.S.C. 295j et
seq.) is amended by adding at the end the following:

``SEC. 799C. FUNDING THROUGH PUBLIC HEALTH INVESTMENT FUND.

``(a) Promotion of Primary Care and Dentistry.--For the
purpose of carrying out subpart XI of part D of title III and
sections 747, 748, and 749, in addition to any other amounts
authorized to be appropriated for such purpose, there are
authorized to be appropriated, out of any monies in the
Public Health Investment Fund, the following:
``(1) $240,000,000 for fiscal year 2011.
``(2) $253,000,000 for fiscal year 2012.
``(3) $265,000,000 for fiscal year 2013.
``(4) $278,000,000 for fiscal year 2014.
``(5) $292,000,000 for fiscal year 2015.''.
(b) Existing Authorization of Appropriations.--Subsection
(g)(1), as so redesignated, of section 747 (42 U.S.C. 293k)
is amended by striking ``2002'' and inserting ``2015''.

SEC. 2217. STUDY ON EFFECTIVENESS OF SCHOLARSHIPS AND LOAN
REPAYMENTS.

(a) Study.--The Comptroller General of the United States
shall conduct a study to determine the effectiveness of
scholarship and loan repayment programs under subparts III
and XI of part D of title III of the Public Health Service
Act, as amended or added by sections 2201 and 2211, including
whether scholarships or loan repayments are more effective
in--
(1) incentivizing physicians, and other providers, to
pursue careers in primary care specialties;
(2) retaining such primary care providers; and
(3) encouraging such primary care providers to practice in
underserved areas.
(b) Report.--Not later than 12 months after the date of the
enactment of this Act, the Comptroller General shall submit
to the Congress a report on the results of the study under
subsection (a).

Subtitle B--Nursing Workforce

SEC. 2221. AMENDMENTS TO PUBLIC HEALTH SERVICE ACT.

(a) Definitions.--Section 801 (42 U.S.C. 296 et seq.) is
amended--
(1) in paragraph (1), by inserting ``nurse-managed health
centers,'' after ``nursing centers,''; and
(2) by adding at the end the following:
``(16) Nurse-managed health center.--The term `nurse-
managed health center'--
``(A) means a nurse-practice arrangement, managed by one or
more advanced practice nurses, that provides primary care or
wellness services to underserved or vulnerable populations
and is associated with an accredited school of nursing,
Federally qualified health center, or independent nonprofit
health or social services agency; and
``(B) shall not be construed as changing State law
requirements applicable to an advanced practice nurse or the
authorized scope of practice of such a nurse.''.
(b) Grants for Health Professions Education.--Title VIII
(42 U.S.C. 296 et seq.) is amended by striking section 807.
(c) Reports.--Part A of title VIII (42 U.S.C. 296 et seq.)
is amended by adding at the end the following:

``SEC. 809. REPORTS.

``The Secretary shall submit to the Congress a separate
annual report on the activities carried out under each of
sections 811, 821, 836, 846A, and 861.''.
(d) Advanced Education Nursing Grants.--Section 811(f) (42
U.S.C. 296j(f)) is amended--
(1) by striking paragraph (2);
(2) by redesignating paragraph (3) as paragraph (2); and
(3) in paragraph (2), as so redesignated, by striking
``that agrees'' and all that follows through the end and
inserting: ``that agrees to expend the award--
``(A) to train advanced education nurses who will practice
in health professional shortage areas designated under
section 332; or
``(B) to increase diversity among advanced education
nurses.''.
(e) Nurse Education, Practice, and Retention Grants.--
Section 831 (42 U.S.C. 296p) is amended--
(1) in subsection (b), by amending paragraph (3) to read as
follows:
``(3) providing coordinated care, quality care, and other
skills needed to practice nursing; or''; and
(2) by striking subsection (e) and redesignating
subsections (f) through (h) as subsections (e) through (g),
respectively.
(f) Student Loans.--Subsection (a) of section 836 (42
U.S.C. 297b) is amended--
(1) by striking ``$2,500'' and inserting ``$3,300'';
(2) by striking ``$4,000'' and inserting ``$5,200'';
(3) by striking ``$13,000'' and inserting ``$17,000''; and
(4) by adding at the end the following: ``Beginning with
fiscal year 2012, the dollar amounts specified in this
subsection shall be adjusted by an amount determined by the
Secretary on an annual basis to reflect inflation.''.
(g) Loan Repayment.--Section 846 (42 U.S.C. 297n) is
amended--
(1) in subsection (a), by amending paragraph (3) to read as
follows:
``(3) who enters into an agreement with the Secretary to
serve for a period of not less than 2 years--
``(A) as a nurse at a health care facility with a critical
shortage of nurses; or
``(B) as a faculty member at an accredited school of
nursing;''; and
(2) in subsection (g)(1), by striking ``to provide health
services'' each place it appears and inserting ``to provide
health services or serve as a faculty member''.
(h) Nurse Faculty Loan Program.--Paragraph (2) of section
846A(c) (42 U.S.C. 297n-1(c)) is amended by striking
``$30,000'' and all that follows through the semicolon and
inserting ``$35,000, plus, beginning with fiscal year 2012,
an amount determined by the Secretary on an annual basis to
reflect inflation;''.
(i) Public Service Announcements.--Title VIII (42 U.S.C.
296 et seq.) is amended by striking part H.
(j) Technical and Conforming Amendments.--Title VIII (42
U.S.C. 296 et seq.) is amended--
(1) by moving section 810 (relating to prohibition against
discrimination by schools on the basis of sex) so that it
follows section 809, as added by subsection (c);
(2) in sections 835, 836, 838, 840, and 842, by striking
the term ``this subpart'' each place it appears and inserting
``this part'';
(3) in section 836(h), by striking the last sentence;
(4) in section 836, by redesignating subsection (l) as
subsection (k);
(5) in section 839, by striking ``839'' and all that
follows through ``(a)'' and inserting ``839. (a)'';
(6) in section 835(b), by striking ``841'' each place it
appears and inserting ``871'';
(7) by redesignating section 841 as section 871, moving
part F to the end of the title, and redesignating such part
as part H;
(8) in part G--
(A) by redesignating section 845 as section 851; and
(B) by redesignating part G as part F; and
(9) in part I--
(A) by redesignating section 855 as section 861; and
(B) by redesignating part I as part G.
(k) Funding.--
(1) In general.--Part H, as redesignated, of title VIII is
amended by adding at the end the following:

[[Page H12755]]

``SEC. 872. FUNDING THROUGH PUBLIC HEALTH INVESTMENT FUND.

``For the purpose of carrying out this title, in addition
to any other amounts authorized to be appropriated for such
purpose, there are authorized to be appropriated, out of any
monies in the Public Health Investment Fund, the following:
``(1) $115,000,000 for fiscal year 2011.
``(2) $122,000,000 for fiscal year 2012.
``(3) $127,000,000 for fiscal year 2013.
``(4) $134,000,000 for fiscal year 2014.
``(5) $140,000,000 for fiscal year 2015.''.
(2) Existing authorizations of appropriations.--
(A) Sections 831, 846, 846a, and 861.--Sections 831(g) (as
so redesignated), 846(i)(1) (42 U.S.C. 297n(i)(1)), 846A(f)
(42 U.S.C. 297n-1(f)), and 861(e) (as so redesignated) are
amended by striking ``2007'' each place it appears and
inserting ``2015''.
(B) Section 871.--Section 871, as so redesignated by
subsection (j), is amended to read as follows:

``SEC. 871. FUNDING.

``For the purpose of carrying out parts B, C, and D
(subject to section 851(g)), there are authorized to be
appropriated such sums as may be necessary for each fiscal
year through fiscal year 2015.''.

Subtitle C--Public Health Workforce

SEC. 2231. PUBLIC HEALTH WORKFORCE CORPS.

Part D of title III (42 U.S.C. 254b et seq.), as amended by
section 2211, is amended by adding at the end the following:

``Subpart XII--Public Health Workforce

``SEC. 340L. PUBLIC HEALTH WORKFORCE CORPS.

``(a) Establishment.--There is established, within the
Service, the Public Health Workforce Corps (in this subpart
referred to as the `Corps'), for the purpose of ensuring an
adequate supply of public health professionals throughout the
Nation. The Corps shall consist of--
``(1) such officers of the Regular and Reserve Corps of the
Service as the Secretary may designate;
``(2) such civilian employees of the United States as the
Secretary may appoint; and
``(3) such other individuals who are not employees of the
United States.
``(b) Administration.--Except as provided in subsection
(c), the Secretary shall carry out this subpart acting
through the Administrator of the Health Resources and
Services Administration.
``(c) Placement and Assignment.--The Secretary, acting
through the Director of the Centers for Disease Control and
Prevention, shall develop a methodology for placing and
assigning Corps participants as public health professionals.
Such methodology may allow for placing and assigning such
participants in State, local, and tribal health departments
and Federally qualified health centers (as defined in section
1861(aa)(4) of the Social Security Act).
``(d) Application of Certain Provisions.--The provisions of
subpart II shall, except as inconsistent with this subpart,
apply to the Public Health Workforce Corps in the same manner
and to the same extent as such provisions apply to the
National Health Service Corps established under section 331.
``(e) Report.--The Secretary shall submit to the Congress
an annual report on the programs carried out under this
subpart.

``SEC. 340M. PUBLIC HEALTH WORKFORCE SCHOLARSHIP PROGRAM.

``(a) Establishment.--The Secretary shall establish the
Public Health Workforce Scholarship Program (referred to in
this section as the `Program') for the purpose described in
section 340L(a).
``(b) Eligibility.--To be eligible to participate in the
Program, an individual shall--
``(1)(A) be accepted for enrollment, or be enrolled, as a
full-time or part-time student in a course of study or
program (approved by the Secretary) at an accredited graduate
school or program of public health; or
``(B) have demonstrated expertise in public health and be
accepted for enrollment, or be enrolled, as a full-time or
part-time student in a course of study or program (approved
by the Secretary) at--
``(i) an accredited graduate school or program of nursing;
health administration, management, or policy; preventive
medicine; laboratory science; veterinary medicine; or dental
medicine; or
``(ii) another accredited graduate school or program, as
deemed appropriate by the Secretary;
``(2) be eligible for, or hold, an appointment as a
commissioned officer in the Regular or Reserve Corps of the
Service or be eligible for selection for civilian service in
the Corps; and
``(3) sign and submit to the Secretary a written contract
(described in subsection (c)) to serve full-time as a public
health professional, upon the completion of the course of
study or program involved, for the period of obligated
service described in subsection (c)(2)(E).
``(c) Contract.--The written contract between the Secretary
and an individual under subsection (b)(3) shall contain--
``(1) an agreement on the part of the Secretary that the
Secretary will--
``(A) provide the individual with a scholarship for a
period of years (not to exceed 4 academic years) during which
the individual shall pursue an approved course of study or
program to prepare the individual to serve in the public
health workforce; and
``(B) accept (subject to the availability of appropriated
funds) the individual into the Corps;
``(2) an agreement on the part of the individual that the
individual will--
``(A) accept provision of such scholarship to the
individual;
``(B) maintain full-time or part-time enrollment in the
approved course of study or program described in subsection
(b)(1) until the individual completes that course of study or
program;
``(C) while enrolled in the approved course of study or
program, maintain an acceptable level of academic standing
(as determined by the educational institution offering such
course of study or program);
``(D) if applicable, complete a residency or internship;
and
``(E) serve full-time as a public health professional for a
period of time equal to the greater of--
``(i) 1 year for each academic year for which the
individual was provided a scholarship under the Program; or
``(ii) 2 years; and
``(3) an agreement by both parties as to the nature and
extent of the scholarship assistance, which may include--
``(A) payment of reasonable educational expenses of the
individual, including tuition, fees, books, equipment, and
laboratory expenses; and
``(B) payment of a stipend of not more than $1,269 (plus,
beginning with fiscal year 2012, an amount determined by the
Secretary on an annual basis to reflect inflation) per month
for each month of the academic year involved, with the dollar
amount of such a stipend determined by the Secretary taking
into consideration whether the individual is enrolled full-
time or part-time.
``(d) Application of Certain Provisions.--The provisions of
subpart III shall, except as inconsistent with this subpart,
apply to the scholarship program under this section in the
same manner and to the same extent as such provisions apply
to the National Health Service Corps Scholarship Program
established under section 338A.

``SEC. 340N. PUBLIC HEALTH WORKFORCE LOAN REPAYMENT PROGRAM.

``(a) Establishment.--The Secretary shall establish the
Public Health Workforce Loan Repayment Program (referred to
in this section as the `Program') for the purpose described
in section 340L(a).
``(b) Eligibility.--To be eligible to participate in the
Program, an individual shall--
``(1)(A) have a graduate degree from an accredited school
or program of public health;
``(B) have demonstrated expertise in public health and have
a graduate degree in a course of study or program (approved
by the Secretary) from--
``(i) an accredited school or program of nursing; health
administration, management, or policy; preventive medicine;
laboratory science; veterinary medicine; or dental medicine;
or
``(ii) another accredited school or program approved by the
Secretary; or
``(C) be enrolled as a full-time or part-time student in
the final year of a course of study or program (approved by
the Secretary) offered by a school or program described in
subparagraph (A) or (B), leading to a graduate degree;
``(2) be eligible for, or hold, an appointment as a
commissioned officer in the Regular or Reserve Corps of the
Service or be eligible for selection for civilian service in
the Corps;
``(3) if applicable, complete a residency or internship;
and
``(4) sign and submit to the Secretary a written contract
(described in subsection (c)) to serve full-time as a public
health professional for the period of obligated service
described in subsection (c)(2).
``(c) Contract.--The written contract between the Secretary
and an individual under subsection (b)(4) shall contain--
``(1) an agreement by the Secretary to repay on behalf of
the individual loans incurred by the individual in the
pursuit of the relevant public health workforce educational
degree in accordance with the terms of the contract;
``(2) an agreement by the individual to serve full-time as
a public health professional for a period of time equal to 2
years or such longer period as the individual may agree to;
and
``(3) in the case of an individual described in subsection
(b)(1)(C) who is in the final year of study and who has
accepted employment as a public health professional, in
accordance with section 340L(c), an agreement on the part of
the individual to complete the education or training,
maintain an acceptable level of academic standing (as
determined by the educational institution offering the course
of study or training), and serve the period of obligated
service described in paragraph (2).
``(d) Payments.--
``(1) In general.--A loan repayment provided for an
individual under a written contract under the Program shall
consist of payment, in accordance with paragraph (2), on
behalf of the individual of the principal, interest, and
related expenses on government and commercial loans received
by the individual regarding the undergraduate or graduate
education of the individual (or both), which loans were made
for reasonable educational expenses, including tuition, fees,
books, equipment, and laboratory expenses, incurred by the
individual.
``(2) Payments for years served.--
``(A) In general.--For each year of obligated service that
an individual contracts to serve under subsection (c), the
Secretary may pay up to $35,000 (plus, beginning with fiscal
year 2012, an amount determined by

[[Page H12756]]

the Secretary on an annual basis to reflect inflation) on
behalf of the individual for loans described in paragraph
(1).
``(B) Repayment schedule.--Any arrangement made by the
Secretary for the making of loan repayments in accordance
with this subsection shall provide that any repayments for a
year of obligated service shall be made no later than the end
of the fiscal year in which the individual completes such
year of service.
``(e) Application of Certain Provisions.--The provisions of
subpart III shall, except as inconsistent with this subpart,
apply to the loan repayment program under this section in the
same manner and to the same extent as such provisions apply
to the National Health Service Corps Loan Repayment Program
established under section 338B.''.

SEC. 2232. ENHANCING THE PUBLIC HEALTH WORKFORCE.

Section 765 (42 U.S.C. 295) is amended to read as follows:

``SEC. 765. ENHANCING THE PUBLIC HEALTH WORKFORCE.

``(a) Program.--The Secretary, acting through the
Administrator of the Health Resources and Services
Administration and in consultation with the Director of the
Centers for Disease Control and Prevention, shall establish a
public health workforce training and enhancement program
consisting of awarding grants and contracts under subsection
(b).
``(b) Grants and Contracts.--The Secretary shall award
grants to, or enter into contracts with, eligible entities--
``(1) to plan, develop, operate, or participate in, an
accredited professional training program in the field of
public health (including such a program in nursing; health
administration, management, or policy; preventive medicine;
laboratory science; veterinary medicine; or dental medicine)
for members of the public health workforce, including
midcareer professionals;
``(2) to provide financial assistance in the form of
traineeships and fellowships to students who are participants
in any such program and who plan to specialize or work in the
field of public health;
``(3) to plan, develop, operate, or participate in a
program for the training of public health professionals who
plan to teach in any program described in paragraph (1); and
``(4) to provide financial assistance in the form of
traineeships and fellowships to public health professionals
who are participants in any program described in paragraph
(1) and who plan to teach in the field of public health,
including nursing; health administration, management, or
policy; preventive medicine; laboratory science; veterinary
medicine; or dental medicine.
``(c) Eligibility.--To be eligible for a grant or contract
under this section, an entity shall be--
``(1) an accredited health professions school, including an
accredited school or program of public health; nursing;
health administration, management, or policy; preventive
medicine; laboratory science; veterinary medicine; or dental
medicine;
``(2) a State, local, or tribal health department;
``(3) a public or private nonprofit entity; or
``(4) a consortium of 2 or more entities described in
paragraphs (1) through (3).
``(d) Preference.--In awarding grants or contracts under
this section, the Secretary shall give preference to entities
that have a demonstrated record of at least one of the
following:
``(1) Training a high or significantly improved percentage
of public health professionals who serve in underserved
communities.
``(2) Training individuals who are from disadvantaged
backgrounds (including racial and ethnic minorities
underrepresented among public health professionals).
``(3) Training individuals in public health specialties
experiencing a significant shortage of public health
professionals (as determined by the Secretary).
``(4) Training a high or significantly improved percentage
of public health professionals serving in the Federal
Government or a State, local, or tribal government.
``(e) Report.--The Secretary shall submit to the Congress
an annual report on the program carried out under this
section.''.

SEC. 2233. PUBLIC HEALTH TRAINING CENTERS.

Section 766 (42 U.S.C. 295a) is amended--
(1) in subsection (b)(1), by striking ``in furtherance of
the goals established by the Secretary for the year 2000''
and inserting ``in furtherance of the goals established by
the Secretary in the national prevention and wellness
strategy under section 3121''; and
(2) by adding at the end the following:
``(d) Report.--The Secretary shall submit to the Congress
an annual report on the program carried out under this
section.''.

SEC. 2234. PREVENTIVE MEDICINE AND PUBLIC HEALTH TRAINING
GRANT PROGRAM.

Section 768 (42 U.S.C. 295c) is amended to read as follows:

``SEC. 768. PREVENTIVE MEDICINE AND PUBLIC HEALTH TRAINING
GRANT PROGRAM.

``(a) Grants.--The Secretary, acting through the
Administrator of the Health Resources and Services
Administration and in consultation with the Director of the
Centers for Disease Control and Prevention, shall award
grants to, or enter into contracts with, eligible entities to
provide training to graduate medical residents in preventive
medicine specialties.
``(b) Eligibility.--To be eligible for a grant or contract
under subsection (a), an entity shall be--
``(1) an accredited school of public health or school of
medicine or osteopathic medicine;
``(2) an accredited public or private nonprofit hospital;
``(3) a State, local, or tribal health department; or
``(4) a consortium of 2 or more entities described in
paragraphs (1) through (3).
``(c) Use of Funds.--Amounts received under a grant or
contract under this section shall be used to--
``(1) plan, develop (including the development of
curricula), operate, or participate in an accredited
residency or internship program in preventive medicine or
public health;
``(2) defray the costs of practicum experiences, as
required in such a program; and
``(3) establish, maintain, or improve--
``(A) academic administrative units (including departments,
divisions, or other appropriate units) in preventive medicine
and public health; or
``(B) programs that improve clinical teaching in preventive
medicine and public health.
``(d) Report.--The Secretary shall submit to the Congress
an annual report on the program carried out under this
section.''.

SEC. 2235. AUTHORIZATION OF APPROPRIATIONS.

(a) In General.--Section 799C, as added by section 2216 of
this Act, is amended by adding at the end the following:
``(b) Public Health Workforce.--For the purpose of carrying
out subpart XII of part D of title III and sections 765, 766,
and 768, in addition to any other amounts authorized to be
appropriated for such purpose, there are authorized to be
appropriated, out of any monies in the Public Health
Investment Fund, the following:
``(1) $51,000,000 for fiscal year 2011.
``(2) $54,000,000 for fiscal year 2012.
``(3) $57,000,000 for fiscal year 2013.
``(4) $59,000,000 for fiscal year 2014.
``(5) $62,000,000 for fiscal year 2015.''.
(b) Existing Authorization of Appropriations.--Subsection
(a) of section 770 (42 U.S.C. 295e) is amended by striking
``2002'' and inserting ``2015''.

Subtitle D--Adapting Workforce to Evolving Health System Needs

PART 1--HEALTH PROFESSIONS TRAINING FOR DIVERSITY

SEC. 2241. SCHOLARSHIPS FOR DISADVANTAGED STUDENTS, LOAN
REPAYMENTS AND FELLOWSHIPS REGARDING FACULTY
POSITIONS, AND EDUCATIONAL ASSISTANCE IN THE
HEALTH PROFESSIONS REGARDING INDIVIDUALS FROM
DISADVANTAGED BACKGROUNDS.

Paragraph (1) of section 738(a) (42 U.S.C. 293b(a)) is
amended by striking ``not more than $20,000'' and all that
follows through the end of the paragraph and inserting: ``not
more than $35,000 (plus, beginning with fiscal year 2012, an
amount determined by the Secretary on an annual basis to
reflect inflation) of the principal and interest of the
educational loans of such individuals.''.

SEC. 2242. NURSING WORKFORCE DIVERSITY GRANTS.

Subsection (b) of section 821 (42 U.S.C. 296m) is amended--
(1) in the heading, by striking ``Guidance'' and inserting
``Consultation''; and
(2) by striking ``shall take into consideration'' and all
that follows through ``consult with nursing associations''
and inserting ``shall, as appropriate, consult with nursing
associations''.

SEC. 2243. COORDINATION OF DIVERSITY AND CULTURAL COMPETENCY
PROGRAMS.

(a) In General.--Title VII (42 U.S.C. 292 et seq.) is
amended by inserting after section 739 the following:

``SEC. 739A. COORDINATION OF DIVERSITY AND CULTURAL
COMPETENCY PROGRAMS.

``The Secretary shall, to the extent practicable,
coordinate the activities carried out under this part and
section 821 in order to enhance the effectiveness of such
activities and avoid duplication of effort.''.
(b) Report.--Section 736 (42 U.S.C. 293) is amended--
(1) by redesignating subsection (h) as subsection (i); and
(2) by inserting after subsection (g) the following:
``(h) Report.--The Secretary shall submit to the Congress
an annual report on the activities carried out under this
section.''.

PART 2--INTERDISCIPLINARY TRAINING PROGRAMS

SEC. 2251. CULTURAL AND LINGUISTIC COMPETENCY TRAINING FOR
HEALTH PROFESSIONALS.

Section 741 (42 U.S.C. 293e) is amended--
(1) in the section heading, by striking ``GRANTS FOR HEALTH
PROFESSIONS EDUCATION'' and inserting ``CULTURAL AND
LINGUISTIC COMPETENCY TRAINING FOR HEALTH PROFESSIONALS'';
(2) by redesignating subsection (b) as subsection (h); and
(3) by striking subsection (a) and inserting the following:
``(a) Program.--The Secretary shall establish a cultural
and linguistic competency training program for health
professionals, including nurse professionals, consisting of
awarding grants and contracts under subsection (b).
``(b) Cultural and Linguistic Competency Training.--The
Secretary shall award grants

[[Page H12757]]

to, or enter into contracts with, eligible entities--
``(1) to test, develop, and evaluate models of cultural and
linguistic competency training (including continuing
education) for health professionals; and
``(2) to implement cultural and linguistic competency
training programs for health professionals developed under
paragraph (1) or otherwise.
``(c) Eligibility.--To be eligible for a grant or contract
under subsection (b), an entity shall be--
``(1) an accredited health professions school or program;
``(2) an academic health center;
``(3) a public or private nonprofit entity; or
``(4) a consortium of 2 or more entities described in
paragraphs (1) through (3).
``(d) Preference.--In awarding grants and contracts under
this section, the Secretary shall give preference to entities
that have a demonstrated record of at least one of the
following:
``(1) Addressing, or partnering with an entity with
experience addressing, the cultural and linguistic competency
needs of the population to be served through the grant or
contract.
``(2) Addressing health disparities.
``(3) Placing health professionals in regions experiencing
significant changes in the cultural and linguistic
demographics of populations, including communities along the
United States-Mexico border.
``(4) Carrying out activities described in subsection (b)
with respect to more than one health profession discipline,
specialty, or subspecialty.
``(e) Consultation.--The Secretary shall carry out this
section in consultation with the heads of appropriate health
agencies and offices in the Department of Health and Human
Services, including the Office of Minority Health and the
National Center on Minority Health and Health Disparities.
``(f) Definition.--In this section, the term `health
disparities' has the meaning given to the term in section
3171.
``(g) Report.--The Secretary shall submit to the Congress
an annual report on the program carried out under this
section.''.

SEC. 2252. INNOVATIONS IN INTERDISCIPLINARY CARE TRAINING.

Part D of title VII (42 U.S.C. 294 et seq.) is amended by
adding at the end the following:

``SEC. 759. INNOVATIONS IN INTERDISCIPLINARY CARE TRAINING.

``(a) Program.--The Secretary shall establish an
innovations in interdisciplinary care training program
consisting of awarding grants and contracts under subsection
(b).
``(b) Training Programs.--The Secretary shall award grants
to, or enter into contracts with, eligible entities--
``(1) to test, develop, and evaluate health professional
training programs (including continuing education) designed
to promote--
``(A) the delivery of health services through
interdisciplinary and team-based models, which may include
patient-centered medical home models, medication therapy
management models, and models integrating physical, mental,
or oral health services; and
``(B) coordination of the delivery of health care within
and across settings, including health care institutions,
community-based settings, and the patient's home; and
``(2) to implement such training programs developed under
paragraph (1) or otherwise.
``(c) Eligibility.--To be eligible for a grant or contract
under subsection (b), an entity shall be--
``(1) an accredited health professions school or program;
``(2) an academic health center;
``(3) a public or private nonprofit entity (including an
area health education center or a geriatric education
center); or
``(4) a consortium of 2 or more entities described in
paragraphs (1) through (3).
``(d) Preferences.--In awarding grants and contracts under
this section, the Secretary shall give preference to entities
that have a demonstrated record of at least one of the
following:
``(1) Training a high or significantly improved percentage
of health professionals who serve in underserved communities.
``(2) Broad interdisciplinary team-based collaborations.
``(3) Addressing health disparities.
``(e) Report.--The Secretary shall submit to the Congress
an annual report on the program carried out under this
section.
``(f) Definitions.--In this section:
``(1) The term `health disparities' has the meaning given
the term in section 3171.
``(2) The term `interdisciplinary' means collaboration
across health professions and specialties, which may include
public health, nursing, allied health, dietetics or
nutrition, and appropriate health specialties.''.

PART 3--ADVISORY COMMITTEE ON HEALTH WORKFORCE EVALUATION AND
ASSESSMENT

SEC. 2261. HEALTH WORKFORCE EVALUATION AND ASSESSMENT.

Subpart 1 of part E of title VII (42 U.S.C. 294n et seq.)
is amended by adding at the end the following:

``SEC. 764. HEALTH WORKFORCE EVALUATION AND ASSESSMENT.

``(a) Advisory Committee.--The Secretary, acting through
the Assistant Secretary for Health, shall establish a
permanent advisory committee to be known as the Advisory
Committee on Health Workforce Evaluation and Assessment
(referred to in this section as the `Advisory Committee') to
develop and implement an integrated, coordinated, and
strategic national health workforce policy reflective of
current and evolving health workforce needs.
``(b) Responsibilities.--The Advisory Committee shall--
``(1) not later than 1 year after the date of the
establishment of the Advisory Committee, submit
recommendations to the Secretary on--
``(A) classifications of the health workforce to ensure
consistency of data collection on the health workforce; and
``(B) based on such classifications, standardized
methodologies and procedures to enumerate the health
workforce;
``(2) not later than 2 years after the date of the
establishment of the Advisory Committee, submit
recommendations to the Secretary on--
``(A) the supply, diversity, and geographic distribution of
the health workforce;
``(B) the retention and expansion of the health workforce
(on a short- and long-term basis) to ensure quality and
adequacy of such workforce; and
``(C) policies to carry out the recommendations made
pursuant to subparagraphs (A) and (B); and
``(3) not later than 4 years after the date of the
establishment of the Advisory Committee, and every 2 years
thereafter, submit updated recommendations to the Secretary
under paragraphs (1) and (2).
``(c) Role of Agency.--The Secretary shall provide ongoing
administrative, research, and technical support for the
operations of the Advisory Committee, including coordinating
and supporting the dissemination of the recommendations of
the Advisory Committee.
``(d) Membership.--
``(1) Number; appointment.--The Secretary shall appoint 15
members to serve on the Advisory Committee.
``(2) Terms.--
``(A) In general.--The Secretary shall appoint members of
the Advisory Committee for a term of 3 years and may
reappoint such members, but the Secretary may not appoint any
member to serve more than a total of 6 years.
``(B) Staggered terms.--Notwithstanding subparagraph (A),
of the members first appointed to the Advisory Committee
under paragraph (1)--
``(i) 5 shall be appointed for a term of 1 year;
``(ii) 5 shall be appointed for a term of 2 years; and
``(iii) 5 shall be appointed for a term of 3 years.
``(3) Qualifications.--Members of the Advisory Committee
shall be appointed from among individuals who possess
expertise in at least one of the following areas:
``(A) Conducting and interpreting health workforce market
analysis, including health care labor workforce analysis.
``(B) Conducting and interpreting health finance and
economics research.
``(C) Delivering and administering health care services.
``(D) Delivering and administering health workforce
education and training.
``(4) Representation.--In appointing members of the
Advisory Committee, the Secretary shall--
``(A) include no less than one representative of each of--
``(i) health professionals within the health workforce;
``(ii) health care patients and consumers;
``(iii) employers;
``(iv) labor unions; and
``(v) third-party health payors; and
``(B) ensure that--
``(i) all areas of expertise described in paragraph (3) are
represented;
``(ii) the members of the Advisory Committee include
members who, collectively, have significant experience
working with--

``(I) populations in urban and federally designated rural
and nonmetropolitan areas; and
``(II) populations who are underrepresented in the health
professions, including underrepresented minority groups; and

``(iii) individuals who are directly involved in health
professions education or practice do not constitute a
majority of the members of the Advisory Committee.
``(5) Disclosure and conflicts of interest.--Members of the
Advisory Committee shall not be considered employees of the
Federal Government by reason of service on the Advisory
Committee, except members of the Advisory Committee shall be
considered to be special Government employees within the
meaning of section 107 of the Ethics in Government Act of
1978 (5 U.S.C. App.) and section 208 of title 18, United
States Code, for the purposes of disclosure and management of
conflicts of interest under those sections.
``(6) No pay; receipt of travel expenses.--Members of the
Advisory Committee shall not receive any pay for service on
the Committee, but may receive travel expenses, including a
per diem, in accordance with applicable provisions of
subchapter I of chapter 57 of title 5, United States Code.
``(e) Consultation.--In carrying out this section, the
Secretary shall consult with the Secretary of Education and
the Secretary of Labor.
``(f) Collaboration.--The Advisory Committee shall
collaborate with the advisory bodies at the Health Resources
and Services Administration, the National Advisory Council
(as authorized in section 337), the Advisory Committee on
Training in Primary Care Medicine and Dentistry (as
authorized in section 749A), the Advisory Committee on

[[Page H12758]]

Interdisciplinary, Community-Based Linkages (as authorized in
section 756), the Advisory Council on Graduate Medical
Education (as authorized in section 762), and the National
Advisory Council on Nurse Education and Practice (as
authorized in section 851).
``(g) FACA.--The Federal Advisory Committee Act (5 U.S.C.
App.) except for section 14 of such Act shall apply to the
Advisory Committee under this section only to the extent that
the provisions of such Act do not conflict with the
requirements of this section.
``(h) Report.--The Secretary shall submit to the Congress
an annual report on the activities of the Advisory Committee.
``(i) Definition.--In this section, the term `health
workforce' includes all health care providers with direct
patient care and support responsibilities, including
physicians, nurses, physician assistants, pharmacists, oral
health professionals (as defined in section 749(f)(2)),
allied health professionals, mental and behavioral health
professionals (as defined in section 775(f)(2)), and public
health professionals (including veterinarians engaged in
public health practice).''.

PART 4--HEALTH WORKFORCE ASSESSMENT

SEC. 2271. HEALTH WORKFORCE ASSESSMENT.

(a) In General.--Section 761 (42 U.S.C. 294n) is amended--
(1) by redesignating subsection (c) as subsection (e); and
(2) by striking subsections (a) and (b) and inserting the
following:
``(a) In General.--The Secretary shall, based upon the
classifications and standardized methodologies and procedures
developed by the Advisory Committee on Health Workforce
Evaluation and Assessment under section 764(b)--
``(1) collect data on the health workforce (as defined in
section 764(i)), disaggregated by field, discipline, and
specialty, with respect to--
``(A) the supply (including retention) of health
professionals relative to the demand for such professionals;
``(B) the diversity of health professionals (including with
respect to race, ethnic background, and sex); and
``(C) the geographic distribution of health professionals;
and
``(2) collect such data on individuals participating in the
programs authorized by subtitles A, B, and C and part 1 of
subtitle D of title II of division C of the Affordable Health
Care for America Act.
``(b) Grants and Contracts for Health Workforce Analysis.--
``(1) In general.--The Secretary may award grants to, or
enter into contracts with, eligible entities to carry out
subsection (a).
``(2) Eligibility.--To be eligible for a grant or contract
under this subsection, an entity shall be--
``(A) an accredited health professions school or program;
``(B) an academic health center;
``(C) a State, local, or tribal government;
``(D) a public or private entity; or
``(E) a consortium of 2 or more entities described in
subparagraphs (A) through (D).
``(c) Collaboration and Data Sharing.--The Secretary shall
collaborate with Federal departments and agencies, health
professions organizations (including health professions
education organizations), and professional medical societies
for the purpose of carrying out subsection (a).
``(d) Report.--The Secretary shall submit to the Congress
an annual report on the data collected under subsection
(a).''.
(b) Period Before Completion of National Strategy.--Pending
completion of the classifications and standardized
methodologies and procedures developed by the Advisory
Committee on Health Workforce Evaluation and Assessment under
section 764(b) of the Public Health Service Act, as added by
section 2261, the Secretary of Health and Human Services,
acting through the Administrator of the Health Resources and
Services Administration and in consultation with such
Advisory Committee, may make a judgment about the
classifications, methodologies, and procedures to be used for
collection of data under section 761(a) of the Public Health
Service Act, as amended by this section.

PART 5--AUTHORIZATION OF APPROPRIATIONS

SEC. 2281. AUTHORIZATION OF APPROPRIATIONS.

(a) In General.--Section 799C, as added and amended, is
further amended by adding at the end the following:
``(c) Health Professions Training for Diversity.--For the
purpose of carrying out sections 736, 737, 738, 739, and
739A, in addition to any other amounts authorized to be
appropriated for such purpose, there are authorized to be
appropriated, out of any monies in the Public Health
Investment Fund, the following:
``(1) $90,000,000 for fiscal year 2011.
``(2) $97,000,000 for fiscal year 2012.
``(3) $100,000,000 for fiscal year 2013.
``(4) $104,000,000 for fiscal year 2014.
``(5) $110,000,000 for fiscal year 2015.
``(d) Interdisciplinary Training Programs, Advisory
Committee on Health Workforce Evaluation and Assessment, and
Health Workforce Assessment.--For the purpose of carrying out
sections 741, 759, 761, and 764, in addition to any other
amounts authorized to be appropriated for such purpose, there
are authorized to be appropriated, out of any monies in the
Public Health Investment Fund, the following:
``(1) $87,000,000 for fiscal year 2011.
``(2) $97,000,000 for fiscal year 2012.
``(3) $103,000,000 for fiscal year 2013.
``(4) $105,000,000 for fiscal year 2014.
``(5) $113,000,000 for fiscal year 2015.''.
(b) Existing Authorizations of Appropriations.--
(1) Section 736.--Paragraph (1) of section 736(i) (42
U.S.C. 293(h)), as redesignated, is amended by striking
``2002'' and inserting ``2015''.
(2) Sections 737, 738, and 739.--Subsections (a), (b), and
(c) of section 740 are amended by striking ``2002'' each
place it appears and inserting ``2015''.
(3) Section 741.--Subsection (h), as so redesignated, of
section 741 is amended--
(A) by striking ``and'' after ``fiscal year 2003,''; and
(B) by inserting ``, and such sums as may be necessary for
each subsequent fiscal year through the end of fiscal year
2015'' before the period at the end.
(4) Section 761.--Subsection (e)(1), as so redesignated, of
section 761 is amended by striking ``2002'' and inserting
``2015''.

TITLE III--PREVENTION AND WELLNESS

SEC. 2301. PREVENTION AND WELLNESS.

(a) In General.--The Public Health Service Act (42 U.S.C.
201 et seq.) is amended by inserting after title XXX the
following:

``TITLE XXXI--PREVENTION AND WELLNESS

``Subtitle A--Prevention and Wellness Trust

``SEC. 3111. PREVENTION AND WELLNESS TRUST.

(a) ``Deposits Into Trust.--There is established a
Prevention and Wellness Trust. There are authorized to be
appropriated to the Trust, out of any monies in the Public
Health Investment Fund--
``(1) for fiscal year 2011, $2,400,000,000;
``(2) for fiscal year 2012, $2,845,000,000;
``(3) for fiscal year 2013, $3,100,000,000;
``(4) for fiscal year 2014, $3,455,000,000; and
``(5) for fiscal year 2015, $3,600,000,000.
``(b) Availability of Funds.--Amounts in the Prevention and
Wellness Trust shall be available, as provided in advance in
appropriation Acts, for carrying out this title.
``(c) Allocation.--Of the amounts authorized to be
appropriated in subsection (a), there are authorized to be
appropriated--
``(1) for carrying out subtitle C (Prevention Task Forces),
$30,000,000 for each of fiscal years 2011 through 2015;
``(2) for carrying out subtitle D (Prevention and Wellness
Research)--
``(A) for fiscal year 2011, $155,000,000;
``(B) for fiscal year 2012, $205,000,000;
``(C) for fiscal year 2013, $255,000,000;
``(D) for fiscal year 2014, $305,000,000; and
``(E) for fiscal year 2015, $355,000,000;
``(3) for carrying out subtitle E (Delivery of Community
Preventive and Wellness Services)--
``(A) for fiscal year 2011, $1,065,000,000;
``(B) for fiscal year 2012, $1,260,000,000;
``(C) for fiscal year 2013, $1,365,000,000;
``(D) for fiscal year 2014, $1,570,000,000; and
``(E) for fiscal year 2015, $1,600,000,000;
``(4) for carrying out section 3161 (Core Public Health
Infrastructure for State, Local, and Tribal Health
Departments)--
``(A) for fiscal year 2011, $800,000,000;
``(B) for fiscal year 2012, $1,000,000,000;
``(C) for fiscal year 2013, $1,100,000,000;
``(D) for fiscal year 2014, $1,200,000,000; and
``(E) for fiscal year 2015, $1,265,000,000; and
``(5) for carrying out section 3162 (Core Public Health
Infrastructure and Activities for CDC), $350,000,000 for each
of fiscal years 2011 through 2015.

``Subtitle B--National Prevention and Wellness Strategy

``SEC. 3121. NATIONAL PREVENTION AND WELLNESS STRATEGY.

``(a) In General.--The Secretary shall submit to the
Congress within one year after the date of the enactment of
this section, and at least every 2 years thereafter, a
national strategy that is designed to improve the Nation's
health through evidence-based clinical and community
prevention and wellness activities (in this section referred
to as `prevention and wellness activities'), including core
public health infrastructure improvement activities.
``(b) Contents.--The strategy under subsection (a) shall
include each of the following:
``(1) Identification of specific national goals and
objectives in prevention and wellness activities that take
into account appropriate public health measures and
standards, including departmental measures and standards
(including Healthy People and National Public Health
Performance Standards).
``(2) Establishment of national priorities for prevention
and wellness, taking into account unmet prevention and
wellness needs.
``(3) Establishment of national priorities for research on
prevention and wellness, taking into account unanswered
research questions on prevention and wellness.
``(4) Identification of health disparities in prevention
and wellness.
``(5) Review of prevention payment incentives, the
prevention workforce, and prevention delivery system
capacity.
``(6) A plan for addressing and implementing paragraphs (1)
through (5).
``(c) Consultation.--In developing or revising the strategy
under subsection (a), the Secretary shall consult with the
following:
``(1) The heads of appropriate health agencies and offices
in the Department, including the Office of the Surgeon
General of the Public Health Service, the Office of Minority

[[Page H12759]]

Health, the Office on Women's Health, and the Substance Abuse
and Mental Health Services Administration.
``(2) As appropriate, the heads of other Federal
departments and agencies whose programs have a significant
impact upon health (as determined by the Secretary).
``(3) As appropriate, nonprofit and for-profit entities.
``(4) The Association of State and Territorial Health
Officials and the National Association of County and City
Health Officials.
``(5) The Task Force on Community Preventive Services and
the Task Force on Clinical Preventive Services.

``Subtitle C--Prevention Task Forces

``SEC. 3131. TASK FORCE ON CLINICAL PREVENTIVE SERVICES.

``(a) In General.--The Secretary, acting through the
Director of the Agency for Healthcare Research and Quality,
shall establish a permanent task force to be known as the
Task Force on Clinical Preventive Services (in this section
referred to as the `Task Force').
``(b) Responsibilities.--The Task Force shall--
``(1) identify clinical preventive services for review;
``(2) review the scientific evidence related to the
benefits, effectiveness, appropriateness, and costs of
clinical preventive services identified under paragraph (1)
for the purpose of developing, updating, publishing, and
disseminating evidence-based recommendations on the use of
such services;
``(3) as appropriate, take into account health disparities
in developing, updating, publishing, and disseminating
evidence-based recommendations on the use of such services;
``(4) identify gaps in clinical preventive services
research and evaluation and recommend priority areas for such
research and evaluation;
``(5) pursuant to section 3143(c), determine whether
subsidies and rewards meet the Task Force's standards for a
grade of A or B;
``(6) as appropriate, consult with the clinical prevention
stakeholders board in accordance with subsection (f);
``(7) consult with the Task Force on Community Preventive
Services established under section 3132; and
``(8) as appropriate, in carrying out this section,
consider the national strategy under section 3121.
``(c) Role of Agency.--The Secretary shall provide ongoing
administrative, research, and technical support for the
operations of the Task Force, including coordinating and
supporting the dissemination of the recommendations of the
Task Force.
``(d) Membership.--
``(1) Number; appointment.--The Task Force shall be
composed of 30 members, appointed by the Secretary.
``(2) Terms.--
``(A) In general.--The Secretary shall appoint members of
the Task Force for a term of 6 years and may reappoint such
members, but the Secretary may not appoint any member to
serve more than a total of 12 years.
``(B) Staggered terms.--Notwithstanding subparagraph (A),
of the members first appointed to serve on the Task Force
after the enactment of this title--
``(i) 10 shall be appointed for a term of 2 years;
``(ii) 10 shall be appointed for a term of 4 years; and
``(iii) 10 shall be appointed for a term of 6 years.
``(3) Qualifications.--Members of the Task Force shall be
appointed from among individuals who possess expertise in at
least one of the following areas:
``(A) Health promotion and disease prevention.
``(B) Evaluation of research and systematic evidence
reviews.
``(C) Application of systematic evidence reviews to
clinical decisionmaking or health policy.
``(D) Clinical primary care in child and adolescent health.
``(E) Clinical primary care in adult health, including
women's health.
``(F) Clinical primary care in geriatrics.
``(G) Clinical counseling and behavioral services for
primary care patients.
``(4) Representation.--In appointing members of the Task
Force, the Secretary shall ensure that--
``(A) all areas of expertise described in paragraph (3) are
represented; and
``(B) the members of the Task Force include individuals
with expertise in health disparities.
``(e) Subgroups.--As appropriate to maximize efficiency,
the Task Force may delegate authority for conducting reviews
and making recommendations to subgroups consisting of Task
Force members, subject to final approval by the Task Force.
``(f) Clinical Prevention Stakeholders Board.--
``(1) In general.--The Task Force shall convene a clinical
prevention stakeholders board composed of representatives of
appropriate public and private entities with an interest in
clinical preventive services to advise the Task Force on
developing, updating, publishing, and disseminating evidence-
based recommendations on the use of clinical preventive
services.
``(2) Membership.--The members of the clinical prevention
stakeholders board shall include representatives of the
following:
``(A) Health care consumers and patient groups.
``(B) Providers of clinical preventive services, including
community-based providers.
``(C) Federal departments and agencies, including--
``(i) appropriate health agencies and offices in the
Department, including the Office of the Surgeon General of
the Public Health Service, the Office of Minority Health, the
National Center on Minority Health and Health Disparities,
and the Office on Women's Health; and
``(ii) as appropriate, other Federal departments and
agencies whose programs have a significant impact upon health
(as determined by the Secretary).
``(D) Private health care payors.
``(3) Responsibilities.--In accordance with subsection
(b)(6), the clinical prevention stakeholders board shall--
``(A) recommend clinical preventive services for review by
the Task Force;
``(B) suggest scientific evidence for consideration by the
Task Force related to reviews undertaken by the Task Force;
``(C) provide feedback regarding draft recommendations by
the Task Force; and
``(D) assist with efforts regarding dissemination of
recommendations by the Director of the Agency for Healthcare
Research and Quality.
``(g) Disclosure and Conflicts of Interest.--Members of the
Task Force or the clinical prevention stakeholders board
shall not be considered employees of the Federal Government
by reason of service on the Task Force or the clinical
prevention stakeholders board, except members of the Task
Force or the clinical prevention stakeholders board shall be
considered to be special Government employees within the
meaning of section 107 of the Ethics in Government Act of
1978 (5 U.S.C. App.) and section 208 of title 18, United
States Code, for the purposes of disclosure and management of
conflicts of interest under those sections.
``(h) No Pay; Receipt of Travel Expenses.--Members of the
Task Force or the clinical prevention stakeholders board
shall not receive any pay for service on the Task Force, but
may receive travel expenses, including a per diem, in
accordance with applicable provisions of subchapter I of
chapter 57 of title 5, United States Code.
``(i) Application of FACA.--The Federal Advisory Committee
Act (5 U.S.C. App.) except for section 14 of such Act shall
apply to the Task Force to the extent that the provisions of
such Act do not conflict with the provisions of this title.
``(j) Report.--The Secretary shall submit to the Congress
an annual report on the Task Force, including with respect to
gaps identified and recommendations made under subsection
(b)(4).

``SEC. 3132. TASK FORCE ON COMMUNITY PREVENTIVE SERVICES.

``(a) In General.--The Secretary, acting through the
Director of the Centers for Disease Control and Prevention,
shall establish a permanent task force to be known as the
Task Force on Community Preventive Services (in this section
referred to as the `Task Force').
``(b) Responsibilities.--The Task Force shall--
``(1) identify community preventive services for review;
``(2) review the scientific evidence related to the
benefits, effectiveness, appropriateness, and costs of
community preventive services identified under paragraph (1)
for the purpose of developing, updating, publishing, and
disseminating evidence-based recommendations on the use of
such services;
``(3) as appropriate, take into account health disparities
in developing, updating, publishing, and disseminating
evidence-based recommendations on the use of such services;
``(4) identify gaps in community preventive services
research and evaluation and recommend priority areas for such
research and evaluation;
``(5) pursuant to section 3143(d), determine whether
subsidies and rewards are effective;
``(6) as appropriate, consult with the community prevention
stakeholders board in accordance with subsection (f);
``(7) consult with the Task Force on Clinical Preventive
Services established under section 3131; and
``(8) as appropriate, in carrying out this section,
consider the national strategy under section 3121.
``(c) Role of Agency.--The Secretary shall provide ongoing
administrative, research, and technical support for the
operations of the Task Force, including coordinating and
supporting the dissemination of the recommendations of the
Task Force.
``(d) Membership.--
``(1) Number; appointment.--The Task Force shall be
composed of 30 members, appointed by the Secretary.
``(2) Terms.--
``(A) In general.--The Secretary shall appoint members of
the Task Force for a term of 6 years and may reappoint such
members, but the Secretary may not appoint any member to
serve more than a total of 12 years.
``(B) Staggered terms.--Notwithstanding subparagraph (A),
of the members first appointed to serve on the Task Force
after the enactment of this section--
``(i) 10 shall be appointed for a term of 2 years;
``(ii) 10 shall be appointed for a term of 4 years; and

[[Page H12760]]

``(iii) 10 shall be appointed for a term of 6 years.
``(3) Qualifications.--Members of the Task Force shall be
appointed from among individuals who possess expertise in at
least one of the following areas:
``(A) Public health.
``(B) Evaluation of research and systematic evidence
reviews.
``(C) Disciplines relevant to community preventive
services, including health promotion; disease prevention;
chronic disease; worksite health; school-site health;
qualitative and quantitative analysis; and health economics,
policy, law, and statistics.
``(4) Representation.--In appointing members of the Task
Force, the Secretary--
``(A) shall ensure that all areas of expertise described in
paragraph (3) are represented;
``(B) shall ensure that such members include sufficient
representatives of each of--
``(i) State health officers;
``(ii) local health officers;
``(iii) health care practitioners; and
``(iv) public health practitioners; and
``(C) shall appoint individuals who have expertise in
health disparities.
``(e) Subgroups.--As appropriate to maximize efficiency,
the Task Force may delegate authority for conducting reviews
and making recommendations to subgroups consisting of Task
Force members, subject to final approval by the Task Force.
``(f) Community Prevention Stakeholders Board.--
``(1) In general.--The Task Force shall convene a community
prevention stakeholders board composed of representatives of
appropriate public and private entities with an interest in
community preventive services to advise the Task Force on
developing, updating, publishing, and disseminating evidence-
based recommendations on the use of community preventive
services.
``(2) Membership.--The members of the community prevention
stakeholders board shall include representatives of the
following:
``(A) Health care consumers and patient groups.
``(B) Providers of community preventive services, including
community-based providers.
``(C) Federal departments and agencies, including--
``(i) appropriate health agencies and offices in the
Department, including the Office of the Surgeon General of
the Public Health Service, the Office of Minority Health, the
National Center on Minority Health and Health Disparities,
and the Office on Women's Health; and
``(ii) as appropriate, other Federal departments and
agencies whose programs have a significant impact upon health
(as determined by the Secretary).
``(D) Private health care payors.
``(3) Responsibilities.--In accordance with subsection
(b)(6), the community prevention stakeholders board shall--
``(A) recommend community preventive services for review by
the Task Force;
``(B) suggest scientific evidence for consideration by the
Task Force related to reviews undertaken by the Task Force;
``(C) provide feedback regarding draft recommendations by
the Task Force; and
``(D) assist with efforts regarding dissemination of
recommendations by the Director of the Centers for Disease
Control and Prevention.
``(g) Disclosure and Conflicts of Interest.--Members of the
Task Force or the community prevention stakeholders board
shall not be considered employees of the Federal Government
by reason of service on the Task Force or the community
prevention stakeholders board, except members of the Task
Force or the community prevention stakeholders board shall be
considered to be special Government employees within the
meaning of section 107 of the Ethics in Government Act of
1978 (5 U.S.C. App.) and section 208 of title 18, United
States Code, for the purposes of disclosure and management of
conflicts of interest under those sections.
``(h) No Pay; Receipt of Travel Expenses.--Members of the
Task Force or the community prevention stakeholders board
shall not receive any pay for service on the Task Force, but
may receive travel expenses, including a per diem, in
accordance with applicable provisions of subchapter I of
chapter 57 of title 5, United States Code.
``(i) Application of FACA.--The Federal Advisory Committee
Act (5 U.S.C. App.) except for section 14 of such Act shall
apply to the Task Force to the extent that the provisions of
such Act do not conflict with the provisions of this title.
``(j) Report.--The Secretary shall submit to the Congress
an annual report on the Task Force, including with respect to
gaps identified and recommendations made under subsection
(b)(4).

``Subtitle D--Prevention and Wellness Research

``SEC. 3141. PREVENTION AND WELLNESS RESEARCH ACTIVITY
COORDINATION.

``In conducting or supporting research on prevention and
wellness, the Director of the Centers for Disease Control and
Prevention, the Director of the National Institutes of
Health, and the heads of other agencies within the Department
of Health and Human Services conducting or supporting such
research, shall take into consideration the national strategy
under section 3121 and the recommendations of the Task Force
on Clinical Preventive Services under section 3131 and the
Task Force on Community Preventive Services under section
3132.

``SEC. 3142. COMMUNITY PREVENTION AND WELLNESS RESEARCH
GRANTS.

``(a) In General.--The Secretary, acting through the
Director of the Centers for Disease Control and Prevention,
shall conduct, or award grants to eligible entities to
conduct, research in priority areas identified by the
Secretary in the national strategy under section 3121 or by
the Task Force on Community Preventive Services as required
by section 3132.
``(b) Eligibility.--To be eligible for a grant under this
section, an entity shall be--
``(1) a State, local, or tribal department of health;
``(2) a public or private nonprofit entity; or
``(3) a consortium of 2 or more entities described in
paragraphs (1) and (2).
``(c) Report.--The Secretary shall submit to the Congress
an annual report on the program of research under this
section.

``SEC. 3143. RESEARCH ON SUBSIDIES AND REWARDS TO ENCOURAGE
WELLNESS AND HEALTHY BEHAVIORS.

``(a) Research and Demonstration Projects.--
``(1) In general.--The Secretary shall conduct, or award
grants to public or nonprofit private entities to conduct,
research and demonstration projects on the use of financial
and in-kind subsidies and rewards to encourage individuals
and communities to promote wellness, adopt healthy behaviors,
and use evidence-based preventive health services.
``(2) Focus.--Research and demonstration projects under
paragraph (1) shall focus on--
``(A) tobacco use, obesity, and other prevention and
wellness priorities identified by the Secretary in the
national strategy under section 3121;
``(B) the initiation, maintenance, and long-term
sustainability of wellness promotion; adoption of healthy
behaviors; and use of evidence-based preventive health
services; and
``(C) populations at high risk of preventable diseases and
conditions.
``(b) Findings; Report.--
``(1) Submission of findings.--The Secretary shall submit
the findings of research and demonstration projects under
subsection (a) to--
``(A) the Task Force on Clinical Preventive Services
established under section 3131 or the Task Force on Community
Preventive Services established under section 3132, as
appropriate; and
``(B) the Health Benefits Advisory Committee established by
section 223 of the Affordable Health Care for America Act.
``(2) Report to congress.--Not later than 18 months after
the initiation of research and demonstration projects under
subsection (a), the Secretary shall submit a report to the
Congress on the progress of such research and projects,
including any preliminary findings.
``(c) Inclusion in Essential Benefits Package.--If, on the
basis of the findings of research and demonstration projects
under subsection (a) or other sources consistent with section
3131, the Task Force on Clinical Preventive Services
determines that a subsidy or reward meets the Task Force's
standards for a grade A or B, the Secretary shall ensure that
the subsidy or reward is included in the essential benefits
package under section 222.
``(d) Inclusion as Allowable Use of Community Prevention
and Wellness Services Grants.--If, on the basis of the
findings of research and demonstration projects under
subsection (a) or other sources consistent with section 3132,
the Task Force on Community Preventive Services determines
that a subsidy or reward is effective, the Secretary shall
ensure that the subsidy or reward becomes an allowable use of
grant funds under section 3151.
``(e) Nondiscrimination; No Tie to Premium or Cost
Sharing.--In carrying out this section, the Secretary shall
ensure that any subsidy or reward--
``(1) does not have a discriminatory effect on the basis of
any personal characteristic extraneous to the provision of
high-quality health care or related services; and
``(2) is not tied to the premium or cost sharing of an
individual under any qualified health benefits plan (as
defined in section 100(c)).

``Subtitle E--Delivery of Community Prevention and Wellness Services

``SEC. 3151. COMMUNITY PREVENTION AND WELLNESS SERVICES
GRANTS.

``(a) In General.--The Secretary, acting through the
Director of the Centers for Disease Control and Prevention,
shall establish a program for the delivery of community
prevention and wellness services consisting of awarding
grants to eligible entities--
``(1) to provide evidence-based, community prevention and
wellness services in priority areas identified by the
Secretary in the national strategy under section 3121; or
``(2) to plan such services.
``(b) Eligibility.--
``(1) Definition.--To be eligible for a grant under this
section, an entity shall be--
``(A) a State, local, or tribal department of health;
``(B) a public or private entity; or
``(C) a consortium that--
``(i) consists of 2 or more entities described in
subparagraph (A) or (B); and
``(ii) may be a community partnership representing a Health
Empowerment Zone.
``(2) Health empowerment zone.--In this subsection, the
term `Health Empowerment Zone' means an area--

[[Page H12761]]

``(A) in which multiple community prevention and wellness
services are implemented in order to address one or more
health disparities, including those identified by the
Secretary in the national strategy under section 3121; and
``(B) which is represented by a community partnership that
demonstrates community support and coordination with State,
local, or tribal health departments and includes--
``(i) a broad cross section of stakeholders;
``(ii) residents of the community; and
``(iii) representatives of entities that have a history of
working within and serving the community.
``(c) Preferences.--In awarding grants under this section,
the Secretary shall give preference to entities that--
``(1) will address one or more goals or objectives
identified by the Secretary in the national strategy under
section 3121;
``(2) will address significant health disparities,
including those identified by the Secretary in the national
strategy under section 3121;
``(3) will address unmet community prevention and wellness
needs and avoid duplication of effort;
``(4) have been demonstrated to be effective in communities
comparable to the proposed target community;
``(5) will contribute to the evidence base for community
prevention and wellness services;
``(6) demonstrate that the community prevention and
wellness services to be funded will be sustainable; and
``(7) demonstrate coordination or collaboration across
governmental and nongovernmental partners.
``(d) Health Disparities.--Of the funds awarded under this
section for a fiscal year, the Secretary shall award not less
than 50 percent for planning or implementing community
prevention and wellness services whose primary purpose is to
achieve a measurable reduction in one or more health
disparities, including those identified by the Secretary in
the national strategy under section 3121.
``(e) Emphasis on Recommended Services.--For fiscal year
2014 and subsequent fiscal years, the Secretary shall award
grants under this section only for planning or implementing
services recommended by the Task Force on Community
Preventive Services under section 3132 or deemed effective
based on a review of comparable rigor (as determined by the
Director of the Centers for Disease Control and Prevention).
``(f) Prohibited Uses of Funds.--An entity that receives a
grant under this section may not use funds provided through
the grant--
``(1) to build or acquire real property or for
construction; or
``(2) for services or planning to the extent that payment
has been made, or can reasonably be expected to be made--
``(A) under any insurance policy;
``(B) under any Federal or State health benefits program
(including titles XIX and XXI of the Social Security Act); or
``(C) by an entity which provides health services on a
prepaid basis.
``(g) Report.--The Secretary shall submit to the Congress
an annual report on the program of grants awarded under this
section.
``(h) Definitions.--In this section, the term `evidence-
based' means that methodologically sound research has
demonstrated a beneficial health effect, in the judgment of
the Director of the Centers for Disease Control and
Prevention.

``Subtitle F--Core Public Health Infrastructure

``SEC. 3161. CORE PUBLIC HEALTH INFRASTRUCTURE FOR STATE,
LOCAL, AND TRIBAL HEALTH DEPARTMENTS.

``(a) Program.--The Secretary, acting through the Director
of the Centers for Disease Control and Prevention, shall
establish a core public health infrastructure program
consisting of awarding grants under subsection (b).
``(b) Grants.--
``(1) Award.--For the purpose of addressing core public
health infrastructure needs, the Secretary--
``(A) shall award a grant to each State health department;
and
``(B) may award grants on a competitive basis to State,
local, or tribal health departments.
``(2) Allocation.--Of the total amount of funds awarded as
grants under this subsection for a fiscal year--
``(A) not less than 50 percent shall be for grants to State
health departments under paragraph (1)(A); and
``(B) not less than 30 percent shall be for grants to
State, local, or tribal health departments under paragraph
(1)(B).
``(c) Use of Funds.--The Secretary may award a grant to an
entity under subsection (b)(1) only if the entity agrees to
use the grant to address core public health infrastructure
needs, including those identified in the accreditation
process under subsection (g).
``(d) Formula Grants to State Health Departments.--In
making grants under subsection (b)(1)(A), the Secretary shall
award funds to each State health department in accordance
with--
``(1) a formula based on population size; burden of
preventable disease and disability; and core public health
infrastructure gaps, including those identified in the
accreditation process under subsection (g); and
``(2) application requirements established by the
Secretary, including a requirement that the State submit a
plan that demonstrates to the satisfaction of the Secretary
that the State's health department will--
``(A) address its highest priority core public health
infrastructure needs; and
``(B) as appropriate, allocate funds to local health
departments within the State.
``(e) Competitive Grants to State, Local, and Tribal Health
Departments.--In making grants under subsection (b)(1)(B),
the Secretary shall give priority to applicants demonstrating
core public health infrastructure needs identified in the
accreditation process under subsection (g).
``(f) Maintenance of Effort.--The Secretary may award a
grant to an entity under subsection (b) only if the entity
demonstrates to the satisfaction of the Secretary that--
``(1) funds received through the grant will be expended
only to supplement, and not supplant, non-Federal and Federal
funds otherwise available to the entity for the purpose of
addressing core public health infrastructure needs; and
``(2) with respect to activities for which the grant is
awarded, the entity will maintain expenditures of non-Federal
amounts for such activities at a level not less than the
level of such expenditures maintained by the entity for the
fiscal year preceding the fiscal year for which the entity
receives the grant.
``(g) Establishment of a Public Health Accreditation
Program.--
``(1) In general.--The Secretary, acting through the
Director of the Centers for Disease Control and Prevention,
shall--
``(A) develop, and periodically review and update,
standards for voluntary accreditation of State, local, or
tribal health departments and public health laboratories for
the purpose of advancing the quality and performance of such
departments and laboratories; and
``(B) implement a program to accredit such health
departments and laboratories in accordance with such
standards.
``(2) Cooperative agreement.--The Secretary may enter into
a cooperative agreement with a private nonprofit entity to
carry out paragraph (1).
``(h) Report.--The Secretary shall submit to the Congress
an annual report on progress being made to accredit entities
under subsection (g), including--
``(1) a strategy, including goals and objectives, for
accrediting entities under subsection (g) and achieving the
purpose described in subsection (g)(1); and
``(2) identification of gaps in research related to core
public health infrastructure and recommendations of priority
areas for such research.

``SEC. 3162. CORE PUBLIC HEALTH INFRASTRUCTURE AND ACTIVITIES
FOR CDC.

``(a) In General.--The Secretary, acting through the
Director of the Centers for Disease Control and Prevention,
shall expand and improve the core public health
infrastructure and activities of the Centers for Disease
Control and Prevention to address unmet and emerging public
health needs.
``(b) Report.--The Secretary shall submit to the Congress
an annual report on the activities funded through this
section.

``Subtitle G--General Provisions

``SEC. 3171. DEFINITIONS.

``In this title:
``(1) The term `core public health infrastructure' includes
workforce capacity and competency; laboratory systems; health
information, health information systems, and health
information analysis; communications; financing; other
relevant components of organizational capacity; and other
related activities.
``(2) The terms `Department' and `departmental' refer to
the Department of Health and Human Services.
``(3) The term `health disparities' includes health and
health care disparities and means population-specific
differences in the presence of disease, health outcomes, or
access to health care. For purposes of the preceding
sentence, a population may be delineated by race, ethnicity,
primary language, sex, sexual orientation, gender identity,
disability, socioeconomic status, or rural, urban, or other
geographic setting, and any other population or subpopulation
determined by the Secretary to experience significant gaps in
disease, health outcomes, or access to health care.
``(4) The term `tribal' refers to an Indian tribe, a Tribal
organization, or an Urban Indian organization, as such terms
are defined in section 4 of the Indian Health Care
Improvement Act.''.
(b) Transition Provisions Applicable to Task Forces.--
(1) Functions, personnel, assets, liabilities, and
administrative actions.--All functions, personnel, assets,
and liabilities of, and administrative actions applicable to,
the Preventive Services Task Force convened under section
915(a) of the Public Health Service Act and the Task Force on
Community Preventive Services (as such section and Task
Forces were in existence on the day before the date of the
enactment of this Act) shall be transferred to the Task Force
on Clinical Preventive Services and the Task Force on
Community Preventive Services, respectively, established
under sections 3131 and 3132 of the Public Health Service
Act, as added by subsection (a).
(2) Recommendations.--All recommendations of the Preventive
Services Task Force

[[Page H12762]]

and the Task Force on Community Preventive Services, as in
existence on the day before the date of the enactment of this
Act, shall be considered to be recommendations of the Task
Force on Clinical Preventive Services and the Task Force on
Community Preventive Services, respectively, established
under sections 3131 and 3132 of the Public Health Service
Act, as added by subsection (a).
(3) Members already serving.--
(A) Initial members.--The Secretary of Health and Human
Services may select those individuals already serving on the
Preventive Services Task Force and the Task Force on
Community Preventive Services, as in existence on the day
before the date of the enactment of this Act, to be among the
first members appointed to the Task Force on Clinical
Preventive Services and the Task Force on Community
Preventive Services, respectively, under sections 3131 and
3132 of the Public Health Service Act, as added by subsection
(a).
(B) Calculation of total service.--In calculating the total
years of service of a member of a task force for purposes of
section 3131(d)(2)(A) or 3132(d)(2)(A) of the Public Health
Service Act, as added by subsection (a), the Secretary of
Health and Human Services shall not include any period of
service by the member on the Preventive Services Task Force
or the Task Force on Community Preventive Services,
respectively, as in existence on the day before the date of
the enactment of this Act.
(c) Period Before Completion of National Strategy.--Pending
completion of the national strategy under section 3121 of the
Public Health Service Act, as added by subsection (a), the
Secretary of Health and Human Services, acting through the
relevant agency head, may make a judgment about how the
strategy will address an issue and rely on such judgment in
carrying out any provision of subtitle C, D, E, or F of title
XXXI of such Act, as added by subsection (a), that requires
the Secretary--
(1) to take into consideration such strategy;
(2) to conduct or support research or provide services in
priority areas identified in such strategy; or
(3) to take any other action in reliance on such strategy.
(d) Conforming Amendments.--
(1) Paragraph (61) of section 3(b) of the Indian Health
Care Improvement Act (25 U.S.C. 1602) is amended by striking
``United States Preventive Services Task Force'' and
inserting ``Task Force on Clinical Preventive Services''.
(2) Section 126 of the Medicare, Medicaid, and SCHIP
Benefits Improvement and Protection Act of 2000 (Appendix F
of Public Law 106-554) is amended by striking ``United States
Preventive Services Task Force'' each place it appears and
inserting ``Task Force on Clinical Preventive Services''.
(3) Paragraph (7) of section 317D(a) of the Public Health
Service Act (42 U.S.C. 247b-5(a)) is amended by striking
``United States Preventive Services Task Force'' and
inserting ``Task Force on Clinical Preventive Services''.
(4) Section 915 of the Public Health Service Act (42 U.S.C.
299b-4) is amended by striking subsection (a).
(5) Subsections (s)(2)(AA)(iii)(II), (xx)(1), and
(ddd)(1)(B) of section 1861 of the Social Security Act (42
U.S.C. 1395x) are amended by striking ``United States
Preventive Services Task Force'' each place it appears and
inserting ``Task Force on Clinical Preventive Services''.

TITLE IV--QUALITY AND SURVEILLANCE

SEC. 2401. IMPLEMENTATION OF BEST PRACTICES IN THE DELIVERY
OF HEALTH CARE.

(a) In General.--Title IX of the Public Health Service Act
(42 U.S.C. 299 et seq.) is amended--
(1) by redesignating part D as part E;
(2) by redesignating sections 931 through 938 as sections
941 through 948, respectively;
(3) in section 948(1), as redesignated, by striking ``931''
and inserting ``941''; and
(4) by inserting after part C the following:

``PART D--IMPLEMENTATION OF BEST PRACTICES IN THE DELIVERY OF HEALTH
CARE

``SEC. 931. CENTER FOR QUALITY IMPROVEMENT.

``(a) In General.--There is established the Center for
Quality Improvement (referred to in this part as the
`Center'), to be headed by the Director.
``(b) Prioritization.--
``(1) In general.--The Director shall prioritize areas for
the identification, development, evaluation, and
implementation of best practices (including innovative
methodologies and strategies) for quality improvement
activities in the delivery of health care services (in this
section referred to as `best practices').
``(2) Considerations.--In prioritizing areas under
paragraph (1), the Director shall consider--
``(A) the priorities established under section 1191 of the
Social Security Act; and
``(B) the key health indicators identified by the Assistant
Secretary for Health Information under section 1709.
``(3) Limitations.--In conducting its duties under this
subsection, the Center for Quality Improvement shall not
develop quality-adjusted life year measures or any other
methodologies that can be used to deny benefits to a
beneficiary against the beneficiary's wishes on the basis of
the beneficiary's age, life expectancy, present or predicted
disability, or expected quality of life.
``(c) Other Responsibilities.--The Director, acting
directly or by awarding a grant or contract to an eligible
entity, shall--
``(1) identify existing best practices under subsection
(e);
``(2) develop new best practices under subsection (f);
``(3) evaluate best practices under subsection (g);
``(4) implement best practices under subsection (h);
``(5) ensure that best practices are identified, developed,
evaluated, and implemented under this section consistent with
standards adopted by the Secretary under section 3004 for
health information technology used in the collection and
reporting of quality information (including for purposes of
the demonstration of meaningful use of certified electronic
health record (EHR) technology by physicians and hospitals
under the Medicare program (under sections 1848(o)(2) and
1886(n)(3), respectively, of the Social Security Act)); and
``(6) provide for dissemination of information and
reporting under subsections (i) and (j).
``(d) Eligibility.--To be eligible for a grant or contract
under subsection (c), an entity shall--
``(1) be a nonprofit entity;
``(2) agree to work with a variety of institutional health
care providers, physicians, nurses, and other health care
practitioners; and
``(3) if the entity is not the organization holding a
contract under section 1153 of the Social Security Act for
the area to be served, agree to cooperate with and avoid
duplication of the activities of such organization.
``(e) Identifying Existing Best Practices.--The Director
shall identify best practices that are--
``(1) currently utilized by health care providers
(including hospitals, physician and other clinician
practices, community cooperatives, and other health care
entities) that deliver consistently high-quality, efficient
health care services; and
``(2) easily adapted for use by other health care providers
and for use across a variety of health care settings.
``(f) Developing New Best Practices.--The Director shall
develop best practices that are--
``(1) based on a review of existing scientific evidence;
``(2) sufficiently detailed for implementation and
incorporation into the workflow of health care providers; and
``(3) designed to be easily adapted for use by health care
providers across a variety of health care settings.
``(g) Evaluation of Best Practices.--The Director shall
evaluate best practices identified or developed under this
section. Such evaluation--
``(1) shall include determinations of which best
practices--
``(A) most reliably and effectively achieve significant
progress in improving the quality of patient care; and
``(B) are easily adapted for use by health care providers
across a variety of health care settings;
``(2) shall include regular review, updating, and
improvement of such best practices; and
``(3) may include in-depth case studies or empirical
assessments of health care providers (including hospitals,
physician and other clinician practices, community
cooperatives, and other health care entities) and simulations
of such best practices for determinations under paragraph
(1).
``(h) Implementation of Best Practices.--
``(1) In general.--The Director shall enter into
arrangements with entities in a State or region to implement
best practices identified or developed under this section.
Such implementation--
``(A) may include forming collaborative multi-institutional
teams; and
``(B) shall include an evaluation of the best practices
being implemented, including the measurement of patient
outcomes before, during, and after implementation of such
best practices.
``(2) Preferences.--In carrying out this subsection, the
Director shall give priority to health care providers
implementing best practices that--
``(A) have the greatest impact on patient outcomes and
satisfaction;
``(B) are the most easily adapted for use by health care
providers across a variety of health care settings;
``(C) promote coordination of health care practitioners
across the continuum of care; and
``(D) engage patients and their families in improving
patient care and outcomes.
``(i) Public Dissemination of Information.--The Director
shall provide for the public dissemination of information
with respect to best practices and activities under this
section. Such information shall be made available in
appropriate formats and languages to reflect the varying
needs of consumers and diverse levels of health literacy.
``(j) Report.--
``(1) In general.--The Director shall submit an annual
report to the Congress and the Secretary on activities under
this section.
``(2) Content.--Each report under paragraph (1) shall
include--
``(A) information on activities conducted pursuant to
grants and contracts awarded;

[[Page H12763]]

``(B) summary data on patient outcomes before, during, and
after implementation of best practices; and
``(C) recommendations on the adaptability of best practices
for use by health providers.''.
(b) Initial Quality Improvement Activities and Initiatives
To Be Implemented.--Until the Director of the Agency for
Healthcare Research and Quality has established initial
priorities under section 931(b) of the Public Health Service
Act, as added by subsection (a), the Director shall, for
purposes of such section, prioritize the following:
(1) Health care-associated infections.--Reducing health
care-associated infections, including infections in nursing
homes and outpatient settings.
(2) Surgery.--Increasing hospital and outpatient
perioperative patient safety, including reducing surgical-
site infections and surgical errors (such as wrong-site
surgery and retained foreign bodies).
(3) Emergency room.--Improving care in hospital emergency
rooms, including through the use of principles of efficiency
of design and delivery to improve patient flow.
(4) Obstetrics.--Improving the provision of obstetrical and
neonatal care, including the identification of interventions
that are effective in reducing the risk of preterm and
premature labor and the implementation of best practices for
labor and delivery care.
(5) Pediatrics.--Improving the provision of preventive and
developmental child health services, including interventions
that can reduce child health disparities (as defined in
section 3171 of the Public Health Service Act, as added by
section 2301) and reduce the risk of developing chronic
health-threatening conditions that affect an individual's
life course development.
(c) Report.--Not later than 18 months after the date of the
enactment of this Act, the Director of the Agency for
Healthcare Research and Quality shall submit a report to the
Congress on the impact of the nurse-to-patient ratio on the
quality of care and patient outcomes, including
recommendations for further integration into quality
measurement and quality improvement activities.

SEC. 2402. ASSISTANT SECRETARY FOR HEALTH INFORMATION.

(a) Establishment.--Title XVII (42 U.S.C. 300u et seq.) is
amended--
(1) by redesignating sections 1709 and 1710 as sections
1710 and 1711, respectively; and
(2) by inserting after section 1708 the following:

``SEC. 1709. ASSISTANT SECRETARY FOR HEALTH INFORMATION.

``(a) In General.--There is established within the
Department an Assistant Secretary for Health Information (in
this section referred to as the `Assistant Secretary'), to be
appointed by the Secretary.
``(b) Responsibilities.--The Assistant Secretary shall--
``(1) ensure the collection, collation, reporting, and
publishing of information (including full and complete
statistics) on key health indicators regarding the Nation's
health and the performance of the Nation's health care;
``(2) facilitate and coordinate the collection, collation,
reporting, and publishing of information regarding the
Nation's health and the performance of the Nation's health
care (other than information described in paragraph (1));
``(3)(A) develop standards for the collection of data
regarding the Nation's health and the performance of the
Nation's health care; and
``(B) in carrying out subparagraph (A)--
``(i) ensure appropriate specificity and standardization
for data collection at the national, regional, State, and
local levels;
``(ii) include standards, as appropriate, for the
collection of accurate data on health disparities;
``(iii) ensure, with respect to data on race and ethnicity,
consistency with the 1997 Office of Management and Budget
Standards for Maintaining, Collecting and Presenting Federal
Data on Race and Ethnicity (or any successor standards); and
``(iv) in consultation with the Director of the Office of
Minority Health, and the Director of the Office of Civil
Rights of the Department, develop standards for the
collection of data on health and health care with respect to
primary language;
``(4) provide support to Federal departments and agencies
whose programs have a significant impact upon health (as
determined by the Secretary) for the collection and collation
of information described in paragraphs (1) and (2);
``(5) ensure the sharing of information described in
paragraphs (1) and (2) among the agencies of the Department;
``(6) facilitate the sharing of information described in
paragraphs (1) and (2) by Federal departments and agencies
whose programs have a significant impact upon health (as
determined by the Secretary);
``(7) identify gaps in information described in paragraphs
(1) and (2) and the appropriate agency or entity to address
such gaps;
``(8) facilitate and coordinate identification and
monitoring of health disparities by the agencies of the
Department to inform program and policy efforts to reduce
such disparities, including facilitating and funding analyses
conducted in cooperation with the Social Security
Administration, the Bureau of the Census, and other
appropriate agencies and entities;
``(9) consistent with privacy, proprietary, and other
appropriate safeguards, facilitate public accessibility of
datasets (such as de-identified Medicare datasets or publicly
available data on key health indicators) by means of the
Internet; and
``(10) award grants or contracts for the collection and
collation of information described in paragraphs (1) and (2)
(including through statewide surveys that provide
standardized information).
``(c) Key Health Indicators.--
``(1) In general.--In carrying out subsection (b)(1), the
Assistant Secretary shall--
``(A) identify, and reassess at least once every 3 years,
key health indicators described in such subsection;
``(B) publish statistics on such key health indicators for
the public--
``(i) not less than annually; and
``(ii) on a supplemental basis whenever warranted by--

``(I) the rate of change for a key health indicator; or
``(II) the need to inform policy regarding the Nation's
health and the performance of the Nation's health care; and

``(C) ensure consistency with the national strategy
developed by the Secretary under section 3121 and
consideration of the indicators specified in the reports
under sections 308, 903(a)(6), and 913(b)(2).
``(2) Release of key health indicators.--The regulations,
rules, processes, and procedures of the Office of Management
and Budget governing the review, release, and dissemination
of key health indicators shall be the same as the
regulations, rules, processes, and procedures of the Office
of Management and Budget governing the review, release, and
dissemination of Principal Federal Economic Indicators (or
equivalent statistical data) by the Bureau of Labor
Statistics.
``(d) Coordination.--In carrying out this section, the
Assistant Secretary shall coordinate with--
``(1) public and private entities that collect and
disseminate information on health and health care, including
foundations; and
``(2) the head of the Office of the National Coordinator
for Health Information Technology to ensure optimal use of
health information technology.
``(e) Request for Information From Departments and
Agencies.--Consistent with applicable law, the Assistant
Secretary may secure directly from any Federal department or
agency information necessary to enable the Assistant
Secretary to carry out this section.
``(f) Report.--
``(1) Submission.--The Assistant Secretary shall submit to
the Secretary and the Congress an annual report containing--
``(A) a description of national, regional, or State changes
in health or health care, as reflected by the key health
indicators identified under subsection (c)(1);
``(B) a description of gaps in the collection, collation,
reporting, and publishing of information regarding the
Nation's health and the performance of the Nation's health
care;
``(C) recommendations for addressing such gaps and
identification of the appropriate agency within the
Department or other entity to address such gaps;
``(D) a description of analyses of health disparities,
including the results of completed analyses, the status of
ongoing longitudinal studies, and proposed or planned
research; and
``(E) a plan for actions to be taken by the Assistant
Secretary to address gaps described in subparagraph (B).
``(2) Consideration.--In preparing a report under paragraph
(1), the Assistant Secretary shall take into consideration
the findings and conclusions in the reports under sections
308, 903(a)(6), and 913(b)(2).
``(g) Proprietary and Privacy Protections.--Nothing in this
section shall be construed to affect applicable proprietary
or privacy protections.
``(h) Consultation.--In carrying out this section, the
Assistant Secretary shall consult with--
``(1) the heads of appropriate health agencies and offices
in the Department, including the Office of the Surgeon
General of the Public Health Service, the Office of Minority
Health, and the Office on Women's Health; and
``(2) as appropriate, the heads of other Federal
departments and agencies whose programs have a significant
impact upon health (as determined by the Secretary).
``(i) Definition.--In this section:
``(1) The terms `agency' and `agencies' include an
epidemiology center established under section 214 of the
Indian Health Care Improvement Act.
``(2) The term `Department' means the Department of Health
and Human Services.
``(3) The term `health disparities' has the meaning given
to such term in section 3171.''.
(b) Other Coordination Responsibilities.--Title III (42
U.S.C. 241 et seq.) is amended--
(1) in paragraphs (1) and (2) of section 304(c) (42 U.S.C.
242b(c)), by inserting ``, acting through the Assistant
Secretary for Health Information,'' after ``The Secretary''
each place it appears; and
(2) in section 306(j) (42 U.S.C. 242k(j)), by inserting ``,
acting through the Assistant Secretary for Health
Information,'' after ``of this section, the Secretary''.

SEC. 2403. AUTHORIZATION OF APPROPRIATIONS.

Section 799C, as added and amended, is further amended by
adding at the end the following:
``(e) Quality and Surveillance.--For the purpose of
carrying out part D of title IX and

[[Page H12764]]

section 1709, in addition to any other amounts authorized to
be appropriated for such purpose, there are authorized to be
appropriated, out of any monies in the Public Health
Investment Fund, $300,000,000 for each of fiscal years 2011
through 2015.''.

TITLE V--OTHER PROVISIONS

Subtitle A--Drug Discount for Rural and Other Hospitals; 340B Program
Integrity

SEC. 2501. EXPANDED PARTICIPATION IN 340B PROGRAM.

(a) Expansion of Covered Entities Receiving Discounted
Prices.--Section 340B(a)(4) (42 U.S.C. 256b(a)(4)) is amended
by adding at the end the following:
``(M) A children's hospital excluded from the Medicare
prospective payment system pursuant to section
1886(d)(1)(B)(iii) of the Social Security Act, or a free-
standing cancer hospital excluded from the Medicare
prospective payment system pursuant to section
1886(d)(1)(B)(v) of the Social Security Act that would meet
the requirements of subparagraph (L), including the
disproportionate share adjustment percentage requirement
under clause (ii) of such subparagraph, if the hospital were
a subsection (d) hospital as defined by section 1886(d)(1)(B)
of the Social Security Act.
``(N) An entity that is a critical access hospital (as
determined under section 1820(c)(2) of the Social Security
Act).
``(O) An entity receiving funds under title V of the Social
Security Act (relating to maternal and child health) for the
provision of health services.
``(P) An entity receiving funds under subpart I of part B
of title XIX of the Public Health Service Act (relating to
comprehensive mental health services) for the provision of
community mental health services.
``(Q) An entity receiving funds under subpart II of such
part B (relating to the prevention and treatment of substance
abuse) for the provision of treatment services for substance
abuse.
``(R) An entity that is a Medicare-dependent, small rural
hospital (as defined in section 1886(d)(5)(G)(iv) of the
Social Security Act).
``(S) An entity that is a sole community hospital (as
defined in section 1886(d)(5)(D)(iii) of the Social Security
Act).
``(T) An entity that is classified as a rural referral
center under section 1886(d)(5)(C) of the Social Security
Act.''.
(b) Prohibition on Group Purchasing Arrangements.--Section
340B(a) (42 U.S.C. 256b(a)) is amended--
(1) in paragraph (4)(L)--
(A) by adding ``and'' at the end of clause (i);
(B) by striking ``; and'' at the end of clause (ii) and
inserting a period; and
(C) by striking clause (iii); and
(2) in paragraph (5), by redesignating subparagraphs (C)
and (D) as subparagraphs (D) and (E), respectively, and by
inserting after subparagraph (B) the following:
``(C) Prohibiting use of group purchasing arrangements.--A
hospital described in subparagraph (L), (M), (N), (R), (S),
or (T) of paragraph (4) shall not obtain covered outpatient
drugs through a group purchasing organization or other group
purchasing arrangement.''.

SEC. 2502. IMPROVEMENTS TO 340B PROGRAM INTEGRITY.

(a) Integrity Improvements.--Section 340B (42 U.S.C. 256b)
is amended--
(1) by striking subsections (c) and (d); and
(2) by inserting after subsection (b) the following:
``(c) Improvements in Program Integrity.--
``(1) Manufacturer compliance.--
``(A) In general.--From amounts appropriated under
paragraph (4), the Secretary shall provide for improvements
in compliance by manufacturers with the requirements of this
section in order to prevent overcharges and other violations
of the discounted pricing requirements specified in this
section.
``(B) Improvements.--The improvements described in
subparagraph (A) shall include the following:
``(i) The establishment of a process to enable the
Secretary to verify the accuracy of ceiling prices calculated
by manufacturers under subsection (a)(1) and charged to
covered entities, which shall include the following:

``(I) Developing and publishing, through an appropriate
policy or regulatory issuance, standards and methodology for
the calculation of ceiling prices under such subsection.
``(II) Comparing regularly the ceiling prices calculated by
the Secretary with the quarterly pricing data that is
reported by manufacturers to the Secretary.
``(III) Conducting periodic monitoring of sales
transactions to covered entities.
``(IV) Inquiring into any discrepancies between ceiling
prices and manufacturer pricing data that may be identified
and taking, or requiring manufacturers to take, corrective
action in response to such discrepancies, including the
issuance of refunds pursuant to the procedures set forth in
clause (ii).

``(ii) The establishment of procedures for the issuance of
refunds to covered entities by manufacturers in the event
that the Secretary finds there has been an overcharge,
including the following:

``(I) Submission to the Secretary by manufacturers of an
explanation of why and how the overcharge occurred, how the
refunds will be calculated, and to whom the refunds will be
issued.
``(II) Oversight by the Secretary to ensure that the
refunds are issued accurately and within a reasonable period
of time.

``(iii) Notwithstanding any other provision of law
prohibiting the disclosure of ceiling prices or data used to
calculate the ceiling price, the provision of access to
covered entities and State Medicaid agencies through an
Internet website of the Department of Health and Human
Services or contractor to the applicable ceiling prices for
covered drugs as calculated and verified by the Secretary in
a manner that ensures protection of privileged pricing data
from unauthorized disclosure.
``(iv) The development of a mechanism by which--

``(I) rebates, discounts, or other price concessions
provided by manufacturers to other purchasers subsequent to
the sale of covered drugs to covered entities are reported to
the Secretary; and
``(II) appropriate credits and refunds are issued to
covered entities if such rebates, discounts, or other price
concessions have the effect of lowering the applicable
ceiling price for the relevant quarter for the drugs
involved.

``(v) In addition to authorities under section 1927(b)(3)
of the Social Security Act, the Secretary may conduct audits
of manufacturers and wholesalers to ensure the integrity of
the program under this section, including audits on the
market price of covered drugs.
``(vi) The establishment of a requirement that
manufacturers and wholesalers use the identification system
developed by the Secretary for purposes of facilitating the
ordering, purchasing, and delivery of covered drugs under
this section, including the processing of chargebacks for
such drugs.
``(vii) The imposition of sanctions in the form of civil
monetary penalties, which--

``(I) shall be assessed according to standards and
procedures established in regulations to be promulgated by
the Secretary within one year of the date of the enactment of
the Affordable Health Care for America Act; and
``(II) shall apply to any manufacturer with an agreement
under this section and shall not exceed $100,000 for each
instance where a manufacturer knowingly charges a covered
entity a price for purchase of a drug that exceeds the
maximum applicable price under subsection (a)(1) or that
knowingly violates any other provision of this section, or
withholds or provides false information to the Secretary or
to covered entities under this section.

``(2) Covered entity compliance.--
``(A) In general.--From amounts appropriated under
paragraph (4), the Secretary shall provide for improvements
in compliance by covered entities with the requirements of
this section in order to prevent diversion and violations of
the duplicate discount provision and other requirements under
subsection (a)(5).
``(B) Improvements.--The improvements described in
subparagraph (A) shall include the following:
``(i) The development of procedures to enable and require
covered entities to update at least annually the information
on the Internet Web site of the Department of Health and
Human Services relating to this section.
``(ii) The development of procedures for the Secretary to
verify the accuracy of information regarding covered entities
that is listed on the Web site described in clause (i).
``(iii) The development of more detailed guidance
describing methodologies and options available to covered
entities for billing covered drugs to State Medicaid agencies
in a manner that avoids duplicate discounts pursuant to
subsection (a)(5)(A).
``(iv) The establishment of a single, universal, and
standardized identification system by which each covered
entity site can be identified by manufacturers, distributors,
covered entities, and the Secretary for purposes of
facilitating the ordering, purchasing, and delivery of
covered drugs under this section, including the processing of
chargebacks for such drugs.
``(v) The imposition of sanctions in the form of civil
monetary penalties, which--

``(I) shall be assessed according to standards and
procedures established in regulations promulgated by the
Secretary;
``(II) shall not exceed $5,000 for each violation; and
``(III) shall apply to any covered entity that knowingly
violates subparagraph (a)(5)(B) or knowingly violates any
other provision of this section.

``(vi) The exclusion of a covered entity from participation
in the program under this section, for a period of time to be
determined by the Secretary, in cases in which the Secretary
determines, in accordance with standards and procedures
established in regulations, that--

``(I) a violation of a requirement of this section was
repeated and knowing; and
``(II) imposition of a monetary penalty would be
insufficient to reasonably ensure compliance.

``(vii) The referral of matters as appropriate to the Food
and Drug Administration, the Office of Inspector General of
Department of Health and Human Services, or other Federal
agencies.
``(3) Administrative dispute resolution process.--From
amounts appropriated under paragraph (4), the Secretary may
establish and implement an administrative process for the
resolution of the following:
``(A) Claims by covered entities that manufacturers have
violated the terms of their

[[Page H12765]]

agreement with the Secretary under subsection (a)(1).
``(B) Claims by manufacturers that covered entities have
violated subsection (a)(5)(A) or (a)(5)(B).
``(4) Authorization of appropriations.--There are
authorized to be appropriated to carry out this subsection,
such sums as may be necessary for fiscal year 2011 and each
succeeding fiscal year.''.
(b) Conforming Amendments.--
(1) Section 340B(a) (42 U.S.C. 256b(a)) is amended--
(A) by adding at the end of paragraph (1) the following:
``Such agreement shall require that the manufacturer offer
each covered entity covered drugs for purchase at or below
the applicable ceiling price if such drug is made available
to any other purchaser at any price. Such agreement shall
require that, if the supply of a covered drug is insufficient
to meet demand, then the manufacturer may utilize an
allocation method that is reported in writing to the
Secretary and does not discriminate on the basis of the price
paid by covered entities or on any other basis related to an
entity's participation in the program under this section.
Notwithstanding any other provision of law, if the Secretary
requests a manufacturer to enter into a new or amended
agreement under this section that complies with current law
and if the manufacturer opts not to sign the new or amended
agreement, then any existing agreement between the
manufacturer and the Secretary under this section is deemed
to no longer meet the requirements of this section for
purposes of this section and section 1927 of the Social
Security Act.''; and
(B) by adding at the end the following paragraph:
``(11) Quarterly reports.--An agreement described in
paragraph (1) shall require that the manufacturer furnish the
Secretary with reports on a quarterly basis that include the
following information:
``(A) The price for each covered drug subject to the
agreement that, according to the manufacturer, represents the
maximum price that covered entities may permissibly be
required to pay for the drug (referred to in this section as
the `ceiling price').
``(B) The component information used to calculate the
ceiling price as determined necessary to administer the
requirements of the program under this section.
``(C) Rebates, discounts, and other price concessions
provided by manufacturers to other purchasers subsequent to
the sale of covered drugs to covered entities.''.
(2) Section 1927(a)(5) of the Social Security Act (42
U.S.C. 1396r-8(a)(5)) is amended by striking subparagraph
(D).

SEC. 2503. EFFECTIVE DATE.

(a) In General.--The amendments made by this subtitle shall
take effect on the date of the enactment of this Act, and
sections 2501, 2502(a)(1), and 2502(b)(2) shall apply to
drugs dispensed on or after such date.
(b) Effectiveness.--The amendments made by this subtitle
shall be effective, and shall be taken into account in
determining whether a manufacturer is deemed to meet the
requirements of section 340B(a) of the Public Health Service
Act (42 U.S.C. 256b(a)), and of section 1927(a)(5) of the
Social Security Act (42 U.S.C. 1396r-8(a)(5)),
notwithstanding any other provision of law.

Subtitle B--Programs

PART 1--GRANTS FOR CLINICS AND CENTERS

SEC. 2511. SCHOOL-BASED HEALTH CLINICS.

(a) In General.--Part Q of title III (42 U.S.C. 280h et
seq.) is amended by adding at the end the following:

``SEC. 399Z-1. SCHOOL-BASED HEALTH CLINICS.

``(a) Program.--The Secretary shall establish a school-
based health clinic program consisting of awarding grants to
eligible entities to support the operation of school-based
health clinics (referred to in this section as `SBHCs').
``(b) Eligibility.--To be eligible for a grant under this
section, an entity shall--
``(1) be an SBHC (as defined in subsection (l)(3)); and
``(2) submit an application at such time, in such manner,
and containing such information as the Secretary may require,
including at a minimum--
``(A) evidence that the applicant meets all criteria
necessary to be designated as an SBHC;
``(B) evidence of local need for the services to be
provided by the SBHC;
``(C) an assurance that--
``(i) SBHC services will be provided in accordance with
Federal, State, and local laws;
``(ii) the SBHC has established and maintains collaborative
relationships with other health care providers in the
catchment area of the SBHC;
``(iii) the SBHC will provide onsite access during the
academic day when school is in session and has an established
network of support and access to services with backup health
providers when the school or SBHC is closed;
``(iv) the SBHC will be integrated into the school
environment and will coordinate health services with
appropriate school personnel and other community providers
co-located at the school; and
``(v) the SBHC sponsoring facility assumes all
responsibility for the SBHC administration, operations, and
oversight; and
``(D) such other information as the Secretary may require.
``(c) Use of Funds.--Funds awarded under a grant under this
section--
``(1) may be used for--
``(A) providing training related to the provision of
comprehensive primary health services and additional health
services;
``(B) the management and operation of SBHC programs,
including through subcontracts; and
``(C) the payment of salaries for health professionals and
other appropriate SBHC personnel; and
``(2) may not be used to provide abortions.
``(d) Consideration of Need.--In determining the amount of
a grant under this section, the Secretary shall take into
consideration--
``(1) the financial need of the SBHC;
``(2) State, local, or other sources of funding provided to
the SBHC; and
``(3) other factors as determined appropriate by the
Secretary.
``(e) Preferences.--In awarding grants under this section,
the Secretary shall give preference to SBHCs that have a
demonstrated record of service to at least one of the
following:
``(1) A high percentage of medically underserved children
and adolescents.
``(2) Communities or populations in which children and
adolescents have difficulty accessing health and mental
health services.
``(3) Communities with high percentages of children and
adolescents who are uninsured, underinsured, or eligible for
medical assistance under Federal or State health benefits
programs (including titles XIX and XXI of the Social Security
Act).
``(f) Matching Requirement.--The Secretary may award a
grant to an SBHC under this section only if the SBHC agrees
to provide, from non-Federal sources, an amount equal to 20
percent of the amount of the grant (which may be provided in
cash or in kind) to carry out the activities supported by the
grant.
``(g) Supplement, Not Supplant.--The Secretary may award a
grant to an SBHC under this section only if the SBHC
demonstrates to the satisfaction of the Secretary that funds
received through the grant will be expended only to
supplement, and not supplant, non-Federal and Federal funds
otherwise available to the SBHC for operation of the SBHC
(including each activity described in paragraph (1) or (2) of
subsection (c)).
``(h) Payor of Last Resort.--The Secretary may award a
grant to an SBHC under this section only if the SBHC
demonstrates to the satisfaction of the Secretary that funds
received through the grant will not be expended for any
activity to the extent that payment has been made, or can
reasonably be expected to be made--
``(1) under any insurance policy;
``(2) under any Federal or State health benefits program
(including titles XIX and XXI of the Social Security Act); or
``(3) by an entity which provides health services on a
prepaid basis.
``(i) Regulations Regarding Reimbursement for Health
Services.--The Secretary shall issue regulations regarding
the reimbursement for health services provided by SBHCs to
individuals eligible to receive such services through the
program under this section, including reimbursement under any
insurance policy or any Federal or State health benefits
program (including titles XIX and XXI of the Social Security
Act).
``(j) Technical Assistance.--The Secretary shall provide
(either directly or by grant or contract) technical and other
assistance to SBHCs to assist such SBHCs to meet the
requirements of this section. Such assistance may include
fiscal and program management assistance, training in fiscal
and program management, operational and administrative
support, and the provision of information to the SBHCs of the
variety of resources available under this title and how those
resources can be best used to meet the health needs of the
communities served by the SBHCs.
``(k) Evaluation; Report.--The Secretary shall--
``(1) develop and implement a plan for evaluating SBHCs and
monitoring quality performances under the awards made under
this section; and
``(2) submit to the Congress on an annual basis a report on
the program under this section.
``(l) Definitions.--In this section:
``(1) Comprehensive primary health services.--The term
`comprehensive primary health services' means the core
services offered by SBHCs, which--
``(A) shall include--
``(i) comprehensive health assessments, diagnosis, and
treatment of minor, acute, and chronic medical conditions and
referrals to, and followup for, specialty care; and
``(ii) mental health assessments, crisis intervention,
counseling, treatment, and referral to a continuum of
services including emergency psychiatric care, community
support programs, inpatient care, and outpatient programs;
and
``(B) may include additional services, such as oral health,
social, and age-appropriate health education services,
including nutritional counseling.
``(2) Medically underserved children and adolescents.--The
term `medically underserved children and adolescents' means a
population of children and adolescents who are residents of
an area designated by the Secretary as an area with a
shortage of personal health services and health
infrastructure for such children and adolescents.
``(3) School-based health clinic.--The term `school-based
health clinic' means a health clinic that--

[[Page H12766]]

``(A) is located in, or is adjacent to, a school facility
of a local educational agency;
``(B) is organized through school, community, and health
provider relationships;
``(C) is administered by a sponsoring facility;
``(D) provides comprehensive primary health services during
school hours to children and adolescents by health
professionals in accordance with State and local laws and
regulations, established standards, and community practice;
and
``(E) does not perform abortion services.
``(4) Sponsoring facility.--The term `sponsoring facility'
is--
``(A) a hospital;
``(B) a public health department;
``(C) a community health center;
``(D) a nonprofit health care entity whose mission is to
provide access to comprehensive primary health care services;
``(E) a local educational agency; or
``(F) a program administered by the Indian Health Service
or the Bureau of Indian Affairs or operated by an Indian
tribe or a tribal organization under the Indian Self-
Determination and Education Assistance Act, a Native Hawaiian
entity, or an urban Indian program under title V of the
Indian Health Care Improvement Act.
``(m) Authorization of Appropriations.--For purposes of
carrying out this section, there are authorized to be
appropriated $50,000,000 for fiscal year 2011 and such sums
as may be necessary for each of fiscal years 2012 through
2015.''.
(b) Effective Date.--The Secretary of Health and Human
Services shall begin awarding grants under section 399Z-1 of
the Public Health Service Act, as added by subsection (a),
not later than July 1, 2010, without regard to whether or not
final regulations have been issued under section 399Z-1(i) of
such Act.
(c) Termination of Study.--Section 2(b) of the Health Care
Safety Net Act of 2008 (42 U.S.C. 254b note) is amended by
striking paragraph (2) (relating to a school-based health
center study).

SEC. 2512. NURSE-MANAGED HEALTH CENTERS.

Title III (42 U.S.C. 241 et seq.) is amended by adding at
the end the following:

``PART S--NURSE-MANAGED HEALTH CENTERS

``SEC. 399FF. NURSE-MANAGED HEALTH CENTERS.

``(a) Program.--The Secretary, acting through the
Administrator of the Health Resources and Services
Administration, shall establish a nurse-managed health center
program consisting of awarding grants to entities under
subsection (b).
``(b) Grant.--The Secretary shall award grants to
entities--
``(1) to plan and develop a nurse-managed health center; or
``(2) to operate a nurse-managed health center.
``(c) Use of Funds.--Amounts received as a grant under
subsection (b) may be used for activities including the
following:
``(1) Purchasing or leasing equipment.
``(2) Training and technical assistance related to the
provision of comprehensive primary care services and wellness
services.
``(3) Other activities for planning, developing, or
operating, as applicable, a nurse-managed health center.
``(d) Assurances Applicable to Both Planning and Operation
Grants.--
``(1) In general.--The Secretary may award a grant under
this section to an entity only if the entity demonstrates to
the Secretary's satisfaction that--
``(A) nurses, in addition to managing the center, will be
adequately represented as providers at the center; and
``(B) not later than 90 days after receiving the grant, the
entity will establish a community advisory committee composed
of individuals, a majority of whom are being served by the
center, to provide input into the nurse-managed health
center's operations.
``(2) Matching requirement.--The Secretary may award a
grant under this section to an entity only if the entity
agrees to provide, from non-Federal sources, an amount equal
to 20 percent of the amount of the grant (which may be
provided in cash or in kind) to carry out the activities
supported by the grant.
``(3) Payor of last resort.--The Secretary may award a
grant under this section to an entity only if the entity
demonstrates to the satisfaction of the Secretary that funds
received through the grant will not be expended for any
activity to the extent that payment has been made, or can
reasonably be expected to be made--
``(A) under any insurance policy;
``(B) under any Federal or State health benefits program
(including titles XIX and XXI of the Social Security Act); or
``(C) by an entity which provides health services on a
prepaid basis.
``(4) Maintenance of effort.--The Secretary may award a
grant under this section to an entity only if the entity
demonstrates to the satisfaction of the Secretary that--
``(A) funds received through the grant will be expended
only to supplement, and not supplant, non-Federal and Federal
funds otherwise available to the entity for the activities to
be funded through the grant; and
``(B) with respect to such activities, the entity will
maintain expenditures of non-Federal amounts for such
activities at a level not less than the lesser of such
expenditures maintained by the entity for the fiscal year
preceding the fiscal year for which the entity receives the
grant.
``(e) Additional Assurance for Planning Grants.--The
Secretary may award a grant under subsection (b)(1) to an
entity only if the entity agrees--
``(1) to assess the needs of the medically underserved
populations proposed to be served by the nurse-managed health
center; and
``(2) to design services and operations of the nurse-
managed health center for such populations based on such
assessment.
``(f) Additional Assurance for Operation Grants.--The
Secretary may award a grant under subsection (b)(2) to an
entity only if the entity assures that the nurse-managed
health center will provide--
``(1) comprehensive primary care services, wellness
services, and other health care services deemed appropriate
by the Secretary;
``(2) care without respect to insurance status or income of
the patient; and
``(3) direct access to client-centered services offered by
advanced practice nurses, other nurses, physicians, physician
assistants, or other qualified health professionals.
``(g) Technical Assistance.--The Secretary shall provide
(either directly or by grant or contract) technical and other
assistance to nurse-managed health centers to assist such
centers in meeting the requirements of this section. Such
assistance may include fiscal and program management
assistance, training in fiscal and program management,
operational and administrative support, and the provision of
information to nurse-managed health centers regarding the
various resources available under this section and how those
resources can best be used to meet the health needs of the
communities served by nurse-managed health centers.
``(h) Report.--The Secretary shall submit to the Congress
an annual report on the program under this section.
``(i) Definitions.--In this section:
``(1) Comprehensive primary care services.--The term
`comprehensive primary care services' has the meaning given
to the term `required primary health services' in section
330(b)(1).
``(2) Medically underserved population.--The term
`medically underserved population' has the meaning given to
such term in section 330(b)(3).
``(3) Nurse-managed health center.--The term `nurse-managed
health center' has the meaning given to such term in section
801.
``(4) Wellness services.--The term `wellness services'
means any health-related service or intervention, not
including primary care, which is designed to reduce
identifiable health risks and increase healthy behaviors
intended to prevent the onset of disease or lessen the impact
of existing chronic conditions by teaching more effective
management techniques that focus on individual self-care and
patient-driven decisionmaking.
``(j) Authorization of Appropriations.--To carry out this
section, there are authorized to be appropriated such sums as
may be necessary for each of fiscal years 2011 through
2015.''.

SEC. 2513. FEDERALLY QUALIFIED BEHAVIORAL HEALTH CENTERS.

Section 1913 (42 U.S.C. 300x-3) is amended--
(1) in subsection (a)(2)(A), by striking ``community mental
health services'' and inserting ``behavioral health services
(of the type offered by federally qualified behavioral health
centers consistent with subsection (c)(3))'';
(2) in subsection (b)--
(A) by striking paragraph (1) and inserting the following:
``(1) services under the plan will be provided only through
appropriate, qualified community programs (which may include
federally qualified behavioral health centers, child mental
health programs, psychosocial rehabilitation programs, mental
health peer-support programs, and mental health primary
consumer-directed programs); and''; and
(B) in paragraph (2), by striking ``community mental health
centers'' and inserting ``federally qualified behavioral
health centers''; and
(3) by striking subsection (c) and inserting the following:
``(c) Criteria for Federally Qualified Behavioral Health
Centers.--
``(1) In general.--The Administrator shall certify, and
recertify at least every 5 years, federally qualified
behavioral health centers as meeting the criteria specified
in this subsection.
``(2) Regulations.--Not later than 18 months after the date
of the enactment of the Affordable Health Care for America
Act, the Administrator shall issue final regulations for
certifying centers under paragraph (1).
``(3) Criteria.--The criteria referred to in subsection
(b)(2) are that the center performs each of the following:
``(A) Provide services in locations that ensure services
will be available and accessible promptly and in a manner
which preserves human dignity and assures continuity of care.
``(B) Provide services in a mode of service delivery
appropriate for the target population.
``(C) Provide individuals with a choice of service options
where there is more than one efficacious treatment.
``(D) Employ a core staff of clinical staff that is
multidisciplinary and culturally and linguistically
competent.

[[Page H12767]]

``(E) Provide services, within the limits of the capacities
of the center, to any individual residing or employed in the
service area of the center.
``(F) Provide, directly or through contract, to the extent
covered for adults in the State Medicaid plan and for
children in accordance with section 1905(r) of the Social
Security Act regarding early and periodic screening,
diagnosis, and treatment, each of the following services:
``(i) Screening, assessment, and diagnosis, including risk
assessment.
``(ii) Person-centered treatment planning or similar
processes, including risk assessment and crisis planning.
``(iii) Outpatient clinic mental health services, including
screening, assessment, diagnosis, psychotherapy, substance
abuse counseling, medication management, and integrated
treatment for mental illness and substance abuse which shall
be evidence-based (including cognitive behavioral therapy,
dialectical behavioral therapy, motivational interviewing,
and other such therapies which are evidence-based).
``(iv) Outpatient clinic primary care services, including
screening and monitoring of key health indicators and health
risk (including screening for diabetes, hypertension, and
cardiovascular disease and monitoring of weight, height, body
mass index (BMI), blood pressure, blood glucose or HbA1C, and
lipid profile).
``(v) Crisis mental health services, including 24-hour
mobile crisis teams, emergency crisis intervention services,
and crisis stabilization.
``(vi) Targeted case management (services to assist
individuals gaining access to needed medical, social,
educational, and other services and applying for income
security and other benefits to which they may be entitled).
``(vii) Psychiatric rehabilitation services including
skills training, assertive community treatment, family
psychoeducation, disability self-management, supported
employment, supported housing services, therapeutic foster
care services, multisystemic therapy, and such other
evidence-based practices as the Secretary may require.
``(viii) Peer support and counselor services and family
supports.
``(G) Maintain linkages, and where possible enter into
formal contracts with, inpatient psychiatric facilities and
substance abuse detoxification and residential programs.
``(H) Make available to individuals served by the center,
directly, through contract, or through linkages with other
programs, each of the following:
``(i) Adult and youth peer support and counselor services.
``(ii) Family support services for families of children
with serious mental disorders.
``(iii) Other community or regional services, supports, and
providers, including schools, child welfare agencies,
juvenile and criminal justice agencies and facilities,
housing agencies and programs, employers, and other social
services.
``(iv) Onsite or offsite access to primary care services.
``(v) Enabling services, including outreach,
transportation, and translation.
``(vi) Health and wellness services, including services for
tobacco cessation.''.

PART 2--OTHER GRANT PROGRAMS

SEC. 2521. COMPREHENSIVE PROGRAMS TO PROVIDE EDUCATION TO
NURSES AND CREATE A PIPELINE TO NURSING.

(a) Purposes.--It is the purpose of this section to
authorize grants to--
(1) address the projected shortage of nurses by funding
comprehensive programs to create a career ladder to nursing
(including certified nurse assistants, licensed practical
nurses, licensed vocational nurses, and registered nurses)
for incumbent ancillary health care workers;
(2) increase the capacity for educating nurses by
increasing both nurse faculty and clinical opportunities
through collaborative programs between staff nurse
organizations, health care providers, and accredited schools
of nursing; and
(3) provide training programs through education and
training organizations jointly administered by health care
providers and health care labor organizations or other
organizations representing staff nurses and frontline health
care workers, working in collaboration with accredited
schools of nursing and academic institutions.
(b) Grants.--Not later than 6 months after the date of the
enactment of this Act, the Secretary of Labor (referred to in
this section as the ``Secretary'') shall establish a
partnership grant program to award grants to eligible
entities to carry out comprehensive programs to provide
education to nurses and create a pipeline to nursing for
incumbent ancillary health care workers who wish to advance
their careers, and to otherwise carry out the purposes of
this section.
(c) Eligibility.--To be eligible for a grant under this
section, an entity shall be--
(1) a health care entity that is jointly administered by a
health care employer and a labor union representing the
health care employees of the employer and that carries out
activities using labor-management training funds as provided
for under section 302(c)(6) of the Labor Management Relations
Act, 1947 (29 U.S.C. 186(c)(6));
(2) an entity that operates a training program that is
jointly administered by--
(A) one or more health care providers or facilities, or a
trade association of health care providers; and
(B) one or more organizations which represent the interests
of direct care health care workers or staff nurses and in
which the direct care health care workers or staff nurses
have direct input as to the leadership of the organization;
(3) a State training partnership program that consists of
nonprofit organizations that include equal participation from
industry, including public or private employers, and labor
organizations including joint labor-management training
programs, and which may include representatives from local
governments, worker investment agency one-stop career
centers, community-based organizations, community colleges,
and accredited schools of nursing; or
(4) a school of nursing (as defined in section 801 of the
Public Health Service Act (42 U.S.C. 296)).
(d) Additional Requirements for Health Care Employer
Described in Subsection (c).--To be eligible for a grant
under this section, a health care employer described in
subsection (c) shall demonstrate that it--
(1) has an established program within its facility to
encourage the retention of existing nurses;
(2) provides wages and benefits to its nurses that are
competitive for its market or that have been collectively
bargained with a labor organization; and
(3) supports programs funded under this section through 1
or more of the following:
(A) The provision of paid leave time and continued health
coverage to incumbent health care workers to allow their
participation in nursing career ladder programs, including
certified nurse assistants, licensed practical nurses,
licensed vocational nurses, and registered nurses.
(B) Contributions to a joint labor-management training fund
which administers the program involved.
(C) The provision of paid release time, incentive
compensation, or continued health coverage to staff nurses
who desire to work full- or part-time in a faculty position.
(D) The provision of paid release time for staff nurses to
enable them to obtain a bachelor of science in nursing
degree, other advanced nursing degrees, specialty training,
or certification program.
(E) The payment of tuition assistance which is managed by a
joint labor-management training fund or other jointly
administered program.
(e) Other Requirements.--
(1) Matching requirement.--
(A) In general.--The Secretary may not make a grant under
this section unless the applicant involved agrees, with
respect to the costs to be incurred by the applicant in
carrying out the program under the grant, to make available
non-Federal contributions (in cash or in kind under
subparagraph (B)) toward such costs in an amount equal to not
less than $1 for each $1 of Federal funds provided in the
grant. Such contributions may be made directly or through
donations from public or private entities, or may be provided
through the cash equivalent of paid release time provided to
incumbent worker students.
(B) Determination of amount of non-federal contribution.--
Non-Federal contributions required in subparagraph (A) may be
in cash or in kind (including paid release time), fairly
evaluated, including equipment or services (and excluding
indirect or overhead costs). Amounts provided by the Federal
Government, or services assisted or subsidized to any
significant extent by the Federal Government, may not be
included in determining the amount of such non-Federal
contributions.
(2) Required collaboration.--Entities carrying out or
overseeing programs carried out with assistance provided
under this section shall demonstrate collaboration with
accredited schools of nursing which may include community
colleges and other academic institutions providing
associate's, bachelor's, or advanced nursing degree programs
or specialty training or certification programs.
(f) Use of Funds.--Amounts awarded to an entity under a
grant under this section shall be used for the following:
(1) To carry out programs that provide education and
training to establish nursing career ladders to educate
incumbent health care workers to become nurses (including
certified nurse assistants, licensed practical nurses,
licensed vocational nurses, and registered nurses). Such
programs shall include one or more of the following:
(A) Preparing incumbent workers to return to the classroom
through English-as-a-second-language education, GED
education, precollege counseling, college preparation
classes, and support with entry level college classes that
are a prerequisite to nursing.
(B) Providing tuition assistance with preference for
dedicated cohort classes in community colleges, universities,
and accredited schools of nursing with supportive services
including tutoring and counseling.
(C) Providing assistance in preparing for and meeting all
nursing licensure tests and requirements.
(D) Carrying out orientation and mentorship programs that
assist newly graduated nurses in adjusting to working at the
bedside to ensure their retention postgraduation, and ongoing
programs to support nurse retention.
(E) Providing stipends for release time and continued
health care coverage to enable incumbent health care workers
to participate in these programs.
(2) To carry out programs that assist nurses in obtaining
advanced degrees and

[[Page H12768]]

completing specialty training or certification programs and
to establish incentives for nurses to assume nurse faculty
positions on a part-time or full-time basis. Such programs
shall include one or more of the following:
(A) Increasing the pool of nurses with advanced degrees who
are interested in teaching by funding programs that enable
incumbent nurses to return to school.
(B) Establishing incentives for advanced degree bedside
nurses who wish to teach in nursing programs so they can
obtain a leave from their bedside position to assume a full-
or part-time position as adjunct or full-time faculty without
the loss of salary or benefits.
(C) Collaboration with accredited schools of nursing which
may include community colleges and other academic
institutions providing associate's, bachelor's, or advanced
nursing degree programs, or specialty training or
certification programs, for nurses to carry out innovative
nursing programs which meet the needs of bedside nursing and
health care providers.
(g) Preference.--In awarding grants under this section the
Secretary shall give preference to programs that--
(1) provide for improving nurse retention;
(2) provide for improving the diversity of the new nurse
graduates to reflect changes in the demographics of the
patient population;
(3) provide for improving the quality of nursing education
to improve patient care and safety;
(4) have demonstrated success in upgrading incumbent health
care workers to become nurses or which have established
effective programs or pilots to increase nurse faculty; or
(5) are modeled after or affiliated with such programs
described in paragraph (4).
(h) Evaluation.--
(1) Program evaluations.--An entity that receives a grant
under this section shall annually evaluate, and submit to the
Secretary a report on, the activities carried out under the
grant and the outcomes of such activities. Such outcomes may
include--
(A) an increased number of incumbent workers entering an
accredited school of nursing and in the pipeline for nursing
programs;
(B) an increasing number of graduating nurses and improved
nurse graduation and licensure rates;
(C) improved nurse retention;
(D) an increase in the number of staff nurses at the health
care facility involved;
(E) an increase in the number of nurses with advanced
degrees in nursing;
(F) an increase in the number of nurse faculty;
(G) improved measures of patient quality (which may include
staffing ratios of nurses, patient satisfaction rates, and
patient safety measures); and
(H) an increase in the diversity of new nurse graduates
relative to the patient population.
(2) General report.--Not later than 2 years after the date
of the enactment of this Act, and annually thereafter, the
Secretary of Labor shall, using data and information from the
reports received under paragraph (1), submit to the Congress
a report concerning the overall effectiveness of the grant
program carried out under this section.
(i) Authorization of Appropriations.--There are authorized
to be appropriated to carry out this section such sums as may
be necessary for each of fiscal years 2011 through 2015.

SEC. 2522. MENTAL AND BEHAVIORAL HEALTH TRAINING.

Part E of title VII (42 U.S.C. 294n et seq.) is amended by
adding at the end the following:

``Subpart 3--Mental and Behavioral Health Training

``SEC. 775. MENTAL AND BEHAVIORAL HEALTH TRAINING PROGRAM.

``(a) Program.--The Secretary, acting through the
Administrator of the Health Resources and Services
Administration and in consultation with the Administrator of
the Substance Abuse and Mental Health Services
Administration, shall establish an interdisciplinary mental
and behavioral health training program consisting of awarding
grants and contracts under subsection (b).
``(b) Support and Development of Mental and Behavioral
Health Training Programs.--The Secretary shall make grants
to, or enter into contracts with, eligible entities--
``(1) to plan, develop, operate, or participate in an
accredited professional training program for mental and
behavioral health professionals to promote--
``(A) interdisciplinary training; and
``(B) coordination of the delivery of health care within
and across settings, including health care institutions,
community-based settings, and the patient's home;
``(2) to provide financial assistance to mental and
behavioral health professionals, who are participants in any
such program, and who plan to work in the field of mental and
behavioral health;
``(3) to plan, develop, operate, or participate in an
accredited program for the training of mental and behavioral
health professionals who plan to teach in the field of mental
and behavioral health; and
``(4) to provide financial assistance in the form of
traineeships and fellowships to mental and behavioral health
professionals who are participants in any such program and
who plan to teach in the field of mental and behavioral
health.
``(c) Eligibility.--To be eligible for a grant or contract
under subsection (b), an entity shall be--
``(1) an accredited health professions school, including an
accredited school or program of psychology, psychiatry,
social work, marriage and family therapy, professional mental
health or substance abuse counseling, or addiction medicine;
``(2) an accredited public or nonprofit private hospital;
``(3) a public or private nonprofit entity; or
``(4) a consortium of 2 or more entities described in
paragraphs (1) through (3).
``(d) Preference.--In awarding grants or contracts under
this section, the Secretary shall give preference to entities
that have a demonstrated record of at least one of the
following:
``(1) Training a high or significantly improved percentage
of health professionals who serve in underserved communities.
``(2) Supporting teaching programs that address the health
care needs of vulnerable populations.
``(3) Training individuals who are from disadvantaged
backgrounds (including racial and ethnic minorities
underrepresented among mental and behavioral health
professionals).
``(4) Training individuals who serve geriatric populations
with an emphasis on underserved elderly.
``(5) Training individuals who serve pediatric populations
with an emphasis on underserved children.
``(e) Report.--The Secretary shall submit to the Congress
an annual report on the program under this section.
``(f) Definition.--In this section:
``(1) The term `interdisciplinary' means collaboration
across health professions, specialties, and subspecialties,
which may include public health, nursing, allied health,
dietetics or nutrition, and appropriate health specialties.
``(2) The term `mental and behavioral health professional'
means an individual training or practicing--
``(A) in psychology; general, geriatric, child or
adolescent psychiatry; social work; marriage and family
therapy; professional mental health or substance abuse
counseling; or addiction medicine; or
``(B) another mental and behavioral health specialty, as
deemed appropriate by the Secretary.
``(g) Authorization of Appropriations.--To carry out this
section, there is authorized to be appropriated $60,000,000
for each of fiscal years 2011 through 2015. Of the amounts
appropriated to carry out this section for a fiscal year, not
less than 15 percent shall be used for training programs in
psychology.''.

SEC. 2523. REAUTHORIZATION OF TELEHEALTH AND TELEMEDICINE
GRANT PROGRAMS.

(a) Telehealth Network and Telehealth Resource Centers
Grant Programs.--Section 330I (42 U.S.C. 254c-14) is
amended--
(1) in subsection (a)--
(A) by striking paragraph (3) (relating to frontier
communities); and
(B) by inserting after paragraph (2) the following:
``(3) Health disparities.--The term `health disparities'
has the meaning given such term in section 3171.'';
(2) in subsection (d)(1)--
(A) in subparagraph (B), by striking ``and'' at the end;
(B) in subparagraph (C), by striking the period at the end
and inserting ``; and''; and
(C) by adding at the end the following:
``(D) reduce health disparities.'';
(3) in subsection (f)(1)(B)(iii)--
(A) in subclause (VII), by inserting ``, including skilled
nursing facilities'' before the period at the end;
(B) in subclause (IX), by inserting ``, including county
mental health and public mental health facilities'' before
the period at the end; and
(C) by adding at the end the following:

``(XIII) Renal dialysis facilities.'';

(4) by amending subsection (i) to read as follows:
``(i) Preferences.--
``(1) Telehealth networks.--In awarding grants under
subsection (d)(1) for projects involving telehealth networks,
the Secretary shall give preference to eligible entities
meeting at least one of the following:
``(A) Network.--The eligible entity is a health care
provider in, or proposing to form, a health care network that
furnishes services in a medically underserved area or a
health professional shortage area.
``(B) Broad geographic coverage.--The eligible entity
demonstrates broad geographic coverage in the rural or
medically underserved areas of the State or States in which
the entity is located.
``(C) Health disparities.--The eligible entity demonstrates
how the project to be funded through the grant will address
health disparities.
``(D) Linkages.--The eligible entity agrees to use the
grant to establish or develop plans for telehealth systems
that will link rural hospitals and rural health care
providers to other hospitals, health care providers, and
patients.
``(E) Efficiency.--The eligible entity agrees to use the
grant to promote greater efficiency in the use of health care
resources.

[[Page H12769]]

``(F) Viability.--The eligible entity demonstrates the
long-term viability of projects through--
``(i) availability of non-Federal funding sources; or
``(ii) institutional and community support for the
telehealth network.
``(G) Services.--The eligible entity provides a plan for
coordinating system use by eligible entities and prioritizes
use of grant funds for health care services over nonclinical
uses.
``(2) Telehealth resource centers.--In awarding grants
under subsection (d)(2) for projects involving telehealth
resource centers, the Secretary shall give preference to
eligible entities meeting at least one of the following:
``(A) Provision of a broad range of services.--The eligible
entity has a record of success in the provision of a broad
range of telehealth services to medically underserved areas
or populations.
``(B) Provision of telehealth technical assistance.--The
eligible entity has a record of success in the provision of
technical assistance to providers serving medically
underserved communities or populations in the establishment
and implementation of telehealth services.
``(C) Collaboration and sharing of expertise.--The eligible
entity has a demonstrated record of collaborating and sharing
expertise with providers of telehealth services at the
national, regional, State, and local levels.'';
(5) in subsection (j)(2)(B), by striking ``such projects
for fiscal year 2001'' and all that follows through the
period and inserting ``such projects for fiscal year 2010.'';
(6) in subsection (k)(1)--
(A) in subparagraph (E)(i), by striking ``transmission of
medical data'' and inserting ``transmission and electronic
archival of medical data''; and
(B) by amending subparagraph (F) to read as follows:
``(F) developing projects to use telehealth technology to--
``(i) facilitate collaboration between health care
providers;
``(ii) promote telenursing services; or
``(iii) promote patient understanding and adherence to
national guidelines for chronic disease and self-management
of such conditions;'';
(7) in subsection (q), by striking ``Not later than
September 30, 2005'' and inserting ``Not later than 1 year
after the date of the enactment of the Affordable Health Care
for America Act, and annually thereafter'';
(8) by striking subsection (r);
(9) by redesignating subsection (s) as subsection (r); and
(10) in subsection (r) (as so redesignated)--
(A) in paragraph (1)--
(i) by striking ``and'' before ``such sums''; and
(ii) by inserting ``, $10,000,000 for fiscal year 2011, and
such sums as may be necessary for each of fiscal years 2012
through 2015'' before the semicolon; and
(B) in paragraph (2)--
(i) by striking ``and'' before ``such sums''; and
(ii) by inserting ``, $10,000,000 for fiscal year 2011, and
such sums as may be necessary for each of fiscal years 2012
through 2015'' before the period.
(b) Telemedicine; Incentive Grants Regarding Coordination
Among States.--Subsection (b) of section 330L (42 U.S.C.
254c-18) is amended by inserting ``, $10,000,000 for fiscal
year 2011, and such sums as may be necessary for each of
fiscal years 2012 through 2015'' before the period at the
end.

SEC. 2524. NO CHILD LEFT UNIMMUNIZED AGAINST INFLUENZA:
DEMONSTRATION PROGRAM USING ELEMENTARY AND
SECONDARY SCHOOLS AS INFLUENZA VACCINATION
CENTERS.

(a) Purpose.--The Secretary of Health and Human Services in
consultation with the Secretary of Education, shall award
grants to eligible partnerships to carry out demonstration
programs designed to test the feasibility of using the
Nation's elementary schools and secondary schools as
influenza vaccination centers.
(b) In General.--The Secretary shall coordinate with the
Secretary of Labor, the Secretary of Education, State
Medicaid agencies, State insurance agencies, and private
insurers to carry out a program consisting of awarding grants
under subsection (c) to ensure that children have coverage
for all reasonable and customary expenses related to
influenza vaccinations, including the costs of purchasing and
administering the vaccine incurred when influenza vaccine is
administered outside of the physician's office in a school or
other related setting.
(c) Program Description.--
(1) Grants.--From amounts appropriated pursuant to
subsection (l), the Secretary shall award grants to eligible
partnerships to be used to provide influenza vaccinations to
children in elementary and secondary schools, in coordination
with school nurses, school health care programs, community
health care providers, State insurance agencies, or private
insurers.
(2) ACIP recommendations.--The program under this section
shall be designed to administer vaccines consistent with the
recommendations of the Centers for Disease Control and
Prevention's Advisory Committee on Immunization Practices
(ACIP) for the annual vaccination of all children 5 through
19 years of age.
(3) Participation voluntary.--Participation by a school or
an individual shall be voluntary.
(d) Use of Funds.--Eligible partnerships receiving a grant
under this section shall ensure the maximum number of
children access influenza vaccinations as follows:
(1) Covered children.--To the extent to which payment of
the costs of purchasing or administering the influenza
vaccine for children is not covered through other federally
funded programs or through private insurance, eligible
partnerships receiving a grant shall use funds to purchase
and administer influenza vaccinations.
(2) Children covered by other federal programs.--For
children who are eligible under other federally funded
programs for payment of the costs of purchasing or
administering the influenza vaccine, eligible partnerships
receiving a grant shall not use funds provided under this
section for such costs.
(3) Children covered by private health insurance.--For
children who have private insurance, eligible partnerships
receiving a grant shall offer assistance in accessing
coverage for vaccinations administered through the program
under this section.
(e) Privacy.--The Secretary shall ensure that the program
under this section adheres to confidentiality and privacy
requirements of section 264 of the Health Insurance
Portability and Accountability Act of 1996 (42 U.S.C. 1320d-2
note) and section 444 of the General Education Provisions Act
(20 U.S.C. 1232g; commonly referred to as the ``Family
Educational Rights and Privacy Act of 1974'').
(f) Application.--An eligible partnership desiring a grant
under this section shall submit an application to the
Secretary at such time, in such manner, and containing such
information as the Secretary may require.
(g) Duration.--Eligible partnerships receiving a grant
shall administer a demonstration program funded through this
section over a period of 2 consecutive school years.
(h) Choice of Vaccine.--The program under this section
shall not restrict the discretion of a health care provider
to administer any influenza vaccine approved by the Food and
Drug Administration for use in pediatric populations.
(i) Awards.--The Secretary shall award--
(1) a minimum of 10 grants in 10 different States to
eligible partnerships that each include one or more public
schools serving primarily low-income students; and
(2) a minimum of 5 grants in 5 different States to eligible
partnerships that each include one or more public schools
located in a rural local educational agency.
(j) Report.--Not later than 90 days following the
completion of the program under this section, the Secretary
shall submit to the Committees on Education and Labor, Energy
and Commerce, and Appropriations of the House of
Representatives and to the Committees on Health, Education,
Labor, and Pensions and Appropriations of the Senate a report
on the results of the program. The report shall include--
(1) an assessment of the influenza vaccination rates of
school-age children in localities where the program is
implemented, compared to the national average influenza
vaccination rates for school-aged children, including whether
school-based vaccination assists in achieving the
recommendations of the Advisory Committee on Immunization
Practices;
(2) an assessment of the utility of employing elementary
schools and secondary schools as a part of a multistate,
community-based pandemic response program that is consistent
with existing Federal and State pandemic response plans;
(3) an assessment of the feasibility of using existing
Federal and private insurance funding in establishing a
multistate, school-based vaccination program for seasonal
influenza vaccination;
(4) an assessment of the number of education days gained by
students as a result of seasonal vaccinations based on
absenteeism rates;
(5) a determination of whether the program under this
section--
(A) increased vaccination rates in the participating
localities; and
(B) was implemented for sufficient time for gathering
enough valid data; and
(6) a recommendation on whether the program should be
continued, expanded, or terminated.
(k) Definitions.--In this section:
(1) Eligible partnership.--The term ``eligible
partnership'' means a local public health department, or
another health organization defined by the Secretary as
eligible to submit an application, and one or more elementary
and secondary schools.
(2) Elementary school.--The terms ``elementary school'' and
``secondary school'' have the meanings given such terms in
section 9101 of the Elementary and Secondary Education Act of
1965 (20 U.S.C. 7801).
(3) Low-income.--The term ``low-income'' means a student,
age 5 through 19, eligible for free or reduced-price lunch
under the National School Lunch Act (42 U.S.C. 1751 et seq.).
(4) Rural local educational agency.--The term ``rural local
educational agency'' means an eligible local educational
agency described in section 6211(b)(1) of the Elementary and
Secondary Education Act of 1965 (20 U.S.C. 7345(b)(1)).

[[Page H12770]]

(5) Secretary.--Except as otherwise specified, the term
``Secretary'' means the Secretary of Health and Human
Services.
(l) Authorization of Appropriations.--To carry out this
section, there are authorized to be appropriated such sums as
may be necessary for each of fiscal years 2011 through 2015.

SEC. 2525. EXTENSION OF WISEWOMAN PROGRAM.

Section 1509 of the Public Health Service Act (42 U.S.C.
300n-4a) is amended--
(1) in subsection (a)--
(A) by striking the heading and inserting ``In General.--
''; and
(B) in the matter preceding paragraph (1), by striking
``may make grants'' and all that follows through ``purpose''
and inserting the following: ``may make grants to such States
for the purpose''; and
(2) in subsection (d)(1), by striking ``there are
authorized'' and all that follows through the period and
inserting ``there are authorized to be appropriated
$70,000,000 for fiscal year 2011, $73,500,000 for fiscal year
2012, $77,000,000 for fiscal year 2013, $81,000,000 for
fiscal year 2014, and $85,000,000 for fiscal year 2015.''.

SEC. 2526. HEALTHY TEEN INITIATIVE TO PREVENT TEEN PREGNANCY.

Part B of title III (42 U.S.C. 243 et seq.) is amended by
inserting after section 317T the following:

``SEC. 317U. HEALTHY TEEN INITIATIVE TO PREVENT TEEN
PREGNANCY.

``(a) Program.--To the extent and in the amount of
appropriations made in advance in appropriations Acts, the
Secretary, acting through the Director of the Centers for
Disease Control and Prevention, shall establish a program
consisting of making grants, in amounts determined under
subsection (c), to each State that submits an application in
accordance with subsection (d) for an evidence-based
education program described in subsection (b).
``(b) Use of Funds.--Amounts received by a State under this
section shall be used to conduct or support evidence-based
education programs (directly or through grants or contracts
to public or private nonprofit entities, including schools
and community-based and faith-based organizations) to reduce
teen pregnancy or sexually transmitted diseases.
``(c) Distribution of Funds.--The Director shall, for
fiscal year 2011 and each subsequent fiscal year, make a
grant to each State described in subsection (a) in an amount
equal to the product of--
``(1) the amount appropriated to carry out this section for
the fiscal year; and
``(2) the percentage determined for the State under section
502(c)(1)(B)(ii) of the Social Security Act.
``(d) Application.--To seek a grant under this section, a
State shall submit an application at such time, in such
manner, and containing such information and assurance of
compliance with this section as the Secretary may require. At
a minimum, an application shall to the satisfaction of the
Secretary--
``(1) describe how the State's proposal will address the
needs of at-risk teens in the State;
``(2) identify the evidence-based education program or
programs selected from the registry developed under
subsection (g) that will be used to address risks in priority
populations;
``(3) describe how the program or programs will be
implemented and any adaptations to the evidence-based model
that will be made;
``(4) list any private and public entities with whom the
State proposes to work, including schools and community-based
and faith-based organizations, and demonstrate their capacity
to implement the proposed program or programs; and
``(5) identify an independent entity that will evaluate the
impact of the program or programs.
``(e) Evaluation.--
``(1) Requirement.--As a condition on receipt of a grant
under this section, a State shall agree--
``(A) to arrange for an independent evaluation of the
impact of the programs to be conducted or supported through
the grant; and
``(B) submit reports to the Secretary on such programs and
the results of evaluation of such programs.
``(2) Funding limitation.--Of the amounts made available to
a State through a grant under this section for any fiscal
year, not more than 10 percent may be used for such
evaluation.
``(f) Rule of Construction.--This section shall not be
construed to preempt or limit any State law regarding
parental involvement and decisionmaking in children's
education.
``(g) Registry of Eligible Programs.--The Secretary shall
develop not later than 180 days after the date of the
enactment of the Affordable Health Care for America Act, and
periodically update thereafter, a publicly available registry
of programs described in subsection (b) that, as determined
by the Secretary--
``(1) meet the definition of the term `evidence-based' in
subsection (i);
``(2) are medically and scientifically accurate; and
``(3) provide age-appropriate information.
``(h) Matching Funds.--The Secretary may award a grant to a
State under this section for a fiscal year only if the State
agrees to provide, from non-Federal sources, an amount equal
to $1 (in cash or in kind) for each $4 provided through the
grant to carry out the activities supported by the grant.
``(i) Definition.--In this section, the term `evidence-
based' means based on a model that has been found, in
methodologically sound research--
``(1) to delay initiation of sex;
``(2) to decrease number of partners;
``(3) to reduce teen pregnancy;
``(4) to reduce sexually transmitted infection rates; or
``(5) to improve rates of contraceptive use.
``(j) Authorization of Appropriations.--To carry out this
section, there is authorized to be appropriated $50,000,000
for each of fiscal years 2011 through 2015.''.

SEC. 2527. NATIONAL TRAINING INITIATIVES ON AUTISM SPECTRUM
DISORDERS.

Title I of the Developmental Disabilities Assistance and
Bill of Rights Act of 2000 (42 U.S.C. 15001 et seq.) is
amended by adding at the end the following:

``Subtitle F--National Training Initiative on Autism Spectrum Disorders

``SEC. 171. NATIONAL TRAINING INITIATIVE.

``(a) Grants and Technical Assistance.--
``(1) Grants.--
``(A) In general.--The Secretary, in consultation with the
Interagency Autism Coordinating Committee, shall award
multiyear grants to eligible entities to provide individuals
(including parents and health, allied health, vocational, and
educational professionals) with interdisciplinary training,
continuing education, technical assistance, and information
for the purpose of improving services rendered to children
and adults with autism, and their families, to address unmet
needs related to autism.
``(B) Eligible entity.--To be eligible to receive a grant
under this subsection, an entity shall be--
``(i) a University Center for Excellence in Developmental
Disabilities Education, Research, and Service; or
``(ii) a comparable interdisciplinary education, research,
and service entity.
``(C) Application requirements.--An entity that desires to
receive a grant for a program under this paragraph shall
submit to the Secretary an application--
``(i) demonstrating that the entity has capacity to--

``(I) provide training and technical assistance in
evidence-based practices to evaluate, and provide effective
interventions, services, treatments, and supports to,
children and adults with autism and their families;
``(II) include individuals with autism and their families
as part of the program to ensure that an individual- and
family-centered approach is used;
``(III) share and disseminate materials and practices that
are developed for, and evaluated to be effective in, the
provision of training and technical assistance; and
``(IV) provide training, technical assistance,
interventions, services, treatments, and supports under this
subsection statewide.

``(ii) providing assurances that the entity will--

``(I) provide trainees under this subsection with an
appropriate balance of interdisciplinary academic and
community-based experiences; and
``(II) provide to the Secretary, in the manner prescribed
by the Secretary, data regarding the number of individuals
who have benefitted from, and outcomes of, the provision of
training and technical assistance under this subsection;

``(iii) providing assurances that training, technical
assistance, dissemination of information, and services under
this subsection will be--

``(I) consistent with the goals of this Act, the Americans
with Disabilities Act of 1990, the Individuals with
Disabilities Education Act, and the Elementary and Secondary
Education Act of 1965; and
``(II) conducted in coordination with relevant State
agencies, institutions of higher education, and service
providers; and

``(iv) containing such other information and assurances as
the Secretary may require.
``(D) Use of funds.--A grant received under this subsection
shall be used to provide individuals (including parents and
health, allied health, vocational, and educational
professionals) with interdisciplinary training, continuing
education, technical assistance, and information for the
purpose of improving services rendered to children and adults
with autism, and their families, to address unmet needs
related to autism. Such training, education, assistance, and
information shall include each of the following:
``(i) Training health, allied health, vocational, and
educational professionals to identify, evaluate the needs of,
and develop interventions, services, treatments, and supports
for, children and adults with autism.
``(ii) Developing model services and supports that
demonstrate evidence-based practices.
``(iii) Developing systems and products that allow for the
interventions, services, treatments, and supports to be
evaluated for fidelity of implementation.
``(iv) Working to expand the availability of evidence-
based, lifelong interventions; educational, employment, and
transition services; and community supports.
``(v) Providing statewide technical assistance in
collaboration with relevant State agencies, institutions of
higher education, autism advocacy groups, and community-based
service providers.

[[Page H12771]]

``(vi) Working to develop comprehensive systems of supports
and services for individuals with autism and their families,
including seamless transitions between education and health
systems across the lifespan.
``(vii) Promoting training, technical assistance,
dissemination of information, supports, and services.
``(viii) Developing mechanisms to provide training and
technical assistance, including for-credit courses, intensive
summer institutes, continuing education programs, distance
based programs, and Web-based information dissemination
strategies.
``(ix) Promoting activities that support community-based
family and individual services and enable individuals with
autism and related developmental disabilities to fully
participate in society and achieve good quality-of-life
outcomes.
``(x) Collecting data on the outcomes of training and
technical assistance programs to meet statewide needs for the
expansion of services to children and adults with autism.
``(E) Amount of grants.--The amount of a grant to any
entity for a fiscal year under this section shall be not less
than $250,000.
``(2) Technical assistance.--The Secretary shall reserve 2
percent of the amount appropriated to carry out this
subsection for a fiscal year to make a grant to a national
organization with demonstrated capacity for providing
training and technical assistance to--
``(A) assist in national dissemination of specific
information, including evidence-based best practices, from
interdisciplinary training programs, and when appropriate,
other entities whose findings would inform the work performed
by entities awarded grants;
``(B) compile and disseminate strategies and materials that
prove to be effective in the provision of training and
technical assistance so that the entire network can benefit
from the models, materials, and practices developed in
individual centers;
``(C) assist in the coordination of activities of grantees
under this subsection;
``(D) develop a Web portal that will provide linkages to
each of the individual training initiatives and provide
access to training modules, promising training, and technical
assistance practices and other materials developed by
grantees;
``(E) serve as a research-based resource for Federal and
State policymakers on information concerning the provision of
training and technical assistance for the assessment, and
provision of supports and services for, children and adults
with autism;
``(F) convene experts from multiple interdisciplinary
training programs, individuals with autism, and the families
of such individuals to discuss and make recommendations with
regard to training issues related to assessment,
interventions, services, treatment, and supports for children
and adults with autism; and
``(G) undertake any other functions that the Secretary
determines to be appropriate.
``(3) Authorization of appropriations.--To carry out this
subsection, there are authorized to be appropriated
$17,000,000 for fiscal year 2011 and such sums as may be
necessary for each of fiscal years 2012 through 2015.
``(b) Expansion of the Number of University Centers for
Excellence in Developmental Disabilities Education, Research,
and Service.--
``(1) Grants.--To provide for the establishment of up to 4
new University Centers for Excellence in Developmental
Disabilities Education, Research, and Service, the Secretary
shall award up to 4 grants to institutions of higher
education.
``(2) Applicable provisions.--Except for subsection (a)(3),
the provisions of subsection (a) shall apply with respect to
grants under this subsection to the same extent and in the
same manner as such provisions apply with respect to grants
under subsection (a).
``(3) Priority.--In awarding grants under this subsection,
the Secretary shall give priority to applicants that--
``(A) are minority institutions that have demonstrated
capacity to meet the requirements of this section and provide
services to individuals with autism and their families; or
``(B) are located in a State with one or more underserved
populations.
``(4) Authorization of appropriations.--To carry out this
subsection, there is authorized to be appropriated $2,000,000
for each of fiscal years 2011 through 2015.
``(c) Definitions.--In this section:
``(1) The term `autism' means an autism spectrum disorder
or a related developmental disability.
``(2) The term `interventions' means educational methods
and positive behavioral support strategies designed to
improve or ameliorate symptoms associated with autism.
``(3) The term `minority institution' has the meaning given
to such term in section 365 of the Higher Education Act of
1965.
``(4) The term `services' means services to assist
individuals with autism to live more independently in their
communities.
``(5) The term `treatments' means health services,
including mental health services, designed to improve or
ameliorate symptoms associated with autism.
``(6) The term `University Center for Excellence in
Developmental Disabilities Education, Research, and Service'
means a University Center for Excellence in Development
Disabilities Education, Research, and Service that has been
or is funded through subtitle D or subsection (b).''.

SEC. 2528. IMPLEMENTATION OF MEDICATION MANAGEMENT SERVICES
IN TREATMENT OF CHRONIC DISEASES.

(a) In General.--The Secretary of Health and Human Services
(referred to in this section as the ``Secretary''), acting
through the Director of the Agency for Health Care Research
and Quality, shall establish a program to provide grants to
eligible entities to implement medication management services
(referred to in this section as ``MTM services'') provided by
licensed pharmacists, as a part of a collaborative,
multidisciplinary, interprofessional approach to the
treatment of chronic diseases for targeted individuals, to
improve the quality of care and reduce overall cost in the
treatment of such diseases. The Secretary shall commence the
grant program not later than May 1, 2011.
(b) Eligible Entities.--To be eligible to receive a grant
under subsection (a), an entity shall--
(1) provide a setting appropriate for MTM services, as
recommended by the experts described in subsection (e);
(2) submit to the Secretary a plan for achieving long-term
financial sustainability;
(3) where applicable, submit a plan for coordinating MTM
services with other local providers and where applicable,
through or in collaboration with the Medicare Medical Home
Pilot program as established by section 1866F of the Social
Security Act, as added by section 1302(a) of this Act;
(4) submit a plan for meeting the requirements under
subsection (c); and
(5) submit to the Secretary such other information as the
Secretary may require.
(c) MTM Services to Targeted Individuals.--The MTM services
provided with the assistance of a grant awarded under
subsection (a) shall, as allowed by State law (including
applicable collaborative pharmacy practice agreements),
include--
(1) performing or obtaining necessary assessments of the
health and functional status of each patient receiving such
MTM services;
(2) formulating a medication treatment plan according to
therapeutic goals agreed upon by the prescriber and the
patient or caregiver or authorized representative of the
patient;
(3) selecting, initiating, modifying, recommending changes
to, or administering medication therapy;
(4) monitoring, which may include access to, ordering, or
performing laboratory assessments, and evaluating the
response of the patient to therapy, including safety and
effectiveness;
(5) performing an initial comprehensive medication review
to identify, resolve, and prevent medication-related
problems, including adverse drug events, quarterly targeted
medication reviews for ongoing monitoring, and additional
followup interventions on a schedule developed
collaboratively with the prescriber;
(6) documenting the care delivered and communicating
essential information about such care (including a summary of
the medication review) and the recommendations of the
pharmacist to other appropriate health care providers of the
patient in a timely fashion;
(7) providing education and training designed to enhance
the understanding and appropriate use of the medications by
the patient, caregiver, and other authorized representative;
(8) providing information, support services, and resources
and strategies designed to enhance patient adherence with
therapeutic regimens;
(9) coordinating and integrating MTM services within the
broader health care management services provided to the
patient; and
(10) such other patient care services as are allowed under
the scopes of practice for pharmacists for purposes of other
Federal programs.
(d) Targeted Individuals.--MTM services provided by
licensed pharmacists under a grant awarded under subsection
(a) shall be offered to targeted individuals who--
(1) take 4 or more prescribed medications (including over-
the-counter and dietary supplements);
(2) take any high-risk medications;
(3) have 2 or more chronic diseases, as identified by the
Secretary; or
(4) have undergone a transition of care, or other factors,
as determined by the Secretary, that are likely to create a
high risk of medication-related problems.
(e) Consultation With Experts.--In designing and
implementing MTM services provided under grants awarded under
subsection (a), the Secretary shall consult with Federal,
State, private, public-private, and academic entities,
pharmacy and pharmacist organizations, health care
organizations, consumer advocates, chronic disease groups,
and other stakeholders involved with the research,
dissemination, and implementation of pharmacist-delivered MTM
services, as the Secretary determines appropriate. The
Secretary, in collaboration with this group, shall determine
whether it is possible to incorporate rapid cycle process
improvement concepts in use in other Federal programs that
have implemented MTM services.
(f) Reporting to the Secretary.--An entity that receives a
grant under subsection (a) shall submit to the Secretary a
report that describes and evaluates, as requested by the
Secretary, the activities carried out under subsection (c),
including quality measures, as determined by the Secretary.
(g) Evaluation and Report.--The Secretary shall submit to
the relevant committees of Congress a report which shall--

[[Page H12772]]

(1) assess the clinical effectiveness of pharmacist-
provided services under the MTM services program, as compared
to usual care, including an evaluation of whether enrollees
maintained better health with fewer hospitalizations and
emergency room visits than similar patients not enrolled in
the program;
(2) assess changes in overall health care resource of
targeted individuals;
(3) assess patient and prescriber satisfaction with MTM
services;
(4) assess the impact of patient-cost-sharing requirements
on medication adherence and recommendations for
modifications;
(5) identify and evaluate other factors that may impact
clinical and economic outcomes, including demographic
characteristics, clinical characteristics, and health
services use of the patient, as well as characteristics of
the regimen, pharmacy benefit, and MTM services provided; and
(6) evaluate the extent to which participating pharmacists
who maintain a dispensing role have a conflict of interest in
the provision of MTM services, and if such conflict is found,
provide recommendations on how such a conflict might be
appropriately addressed.
(h) Grant To Fund Development of Performance Measures.--The
Secretary may award grants or contracts to eligible entities
for the purpose of funding the development of performance
measures that assess the use and effectiveness of medication
therapy management services.

SEC. 2529. POSTPARTUM DEPRESSION.

(a) Expansion and Intensification of Activities.--
(1) Continuation of activities.--The Secretary is
encouraged to expand and intensify activities on postpartum
conditions.
(2) Programs for postpartum conditions.--In carrying out
paragraph (1), the Secretary is encouraged to continue
research to expand the understanding of the causes of, and
treatments for, postpartum conditions, including conducting
and supporting the following:
(A) Basic research concerning the etiology and causes of
the conditions.
(B) Epidemiological studies to address the frequency and
natural history of the conditions and the differences among
racial and ethnic groups with respect to the conditions.
(C) The development of improved screening and diagnostic
techniques.
(D) Clinical research for the development and evaluation of
new treatments.
(E) Information and education programs for health
professionals and the public, which may include a coordinated
national campaign that--
(i) is designed to increase the awareness and knowledge of
postpartum conditions;
(ii) may include public service announcements through
television, radio, and other means; and
(iii) may focus on--

(I) raising awareness about screening;
(II) educating new mothers and their families about
postpartum conditions to promote earlier diagnosis and
treatment; and
(III) ensuring that such education includes complete
information concerning postpartum conditions, including its
symptoms, methods of coping with the illness, and treatment
resources.

(b) Report by the Secretary.--
(1) Study.--The Secretary shall conduct a study on the
benefits of screening for postpartum conditions.
(2) Report.--Not later than 2 years after the date of the
enactment of this Act, the Secretary shall complete the study
required by paragraph (1) and submit a report to the Congress
on the results of such study.
(c) Sense of Congress Regarding Longitudinal Study of
Relative Mental Health Consequences for Women of Resolving a
Pregnancy.--
(1) Sense of congress.--It is the sense of the Congress
that the Director of the National Institute of Mental Health
may conduct a nationally representative longitudinal study
(during the period of fiscal years 2011 through 2020) on the
relative mental health consequences for women of resolving a
pregnancy (intended and unintended) in various ways,
including carrying the pregnancy to term and parenting the
child, carrying the pregnancy to term and placing the child
for adoption, miscarriage, and having an abortion. This study
may assess the incidence, timing, magnitude, and duration of
the immediate and long-term mental health consequences
(positive or negative) of these pregnancy outcomes.
(2) Report.--Beginning not later than 3 years after the
date of the enactment of this Act, and periodically
thereafter for the duration of the study, such Director may
prepare and submit to the Congress reports on the findings of
the study.
(d) Definitions.--In this section:
(1) The term ``postpartum condition'' means postpartum
depression or postpartum psychosis.
(2) The term ``Secretary'' means the Secretary of Health
and Human Services.
(e) Authorization of Appropriations.--For the purpose of
carrying out this section, in addition to any other amounts
authorized to be appropriated for such purpose, there are
authorized to be appropriated such sums as may be necessary
for each of fiscal years 2011 through 2013.

SEC. 2530. GRANTS TO PROMOTE POSITIVE HEALTH BEHAVIORS AND
OUTCOMES.

Part P of title III (42 U.S.C. 280g et seq.) is amended by
adding at the end the following:

``SEC. 399V. GRANTS TO PROMOTE POSITIVE HEALTH BEHAVIORS AND
OUTCOMES.

``(a) Grants Authorized.--The Secretary, in collaboration
with the Director of the Centers for Disease Control and
Prevention and other Federal officials determined appropriate
by the Secretary, is authorized to award grants to eligible
entities to promote positive health behaviors for populations
in medically underserved communities through the use of
community health workers.
``(b) Use of Funds.--Grants awarded under subsection (a)
shall be used to support community health workers--
``(1) to educate, guide, and provide outreach in a
community setting regarding health problems prevalent in
medically underserved communities, especially racial and
ethnic minority populations;
``(2) to educate, guide, and provide experiential learning
opportunities that target behavioral risk factors including--
``(A) poor nutrition;
``(B) physical inactivity;
``(C) being overweight or obese;
``(D) tobacco use;
``(E) alcohol and substance use;
``(F) injury and violence;
``(G) risky sexual behavior;
``(H) untreated mental health problems;
``(I) untreated dental and oral health problems; and
``(J) understanding informed consent;
``(3) to educate and provide guidance regarding effective
strategies to promote positive health behaviors within the
family;
``(4) to educate and provide outreach regarding enrollment
in health insurance including the State Children's Health
Insurance Program under title XXI of the Social Security Act,
Medicare under title XVIII of such Act, and Medicaid under
title XIX of such Act;
``(5) to educate and refer underserved populations to
appropriate health care agencies and community-based programs
and organizations in order to increase access to quality
health care services, including preventive health services,
and to eliminate duplicative care; or
``(6) to educate, guide, and provide home visitation
services regarding maternal health and prenatal care.
``(c) Application.--
``(1) In general.--Each eligible entity that desires to
receive a grant under subsection (a) shall submit an
application to the Secretary, at such time, in such manner,
and accompanied by such information as the Secretary may
require.
``(2) Contents.--Each application submitted pursuant to
paragraph (1) shall--
``(A) describe the activities for which assistance is
sought under this section;
``(B) contain an assurance that, with respect to each
community health worker program receiving funds under the
grant, such program will provide training and supervision to
community health workers to enable such workers to provide
authorized program services;
``(C) contain an assurance that the applicant will evaluate
the effectiveness of community health worker programs
receiving funds under the grant;
``(D) contain an assurance that each community health
worker program receiving funds under the grant will provide
services in the cultural context most appropriate for the
individuals served by the program;
``(E) contain a plan to document and disseminate project
descriptions and results to other States and organizations as
identified by the Secretary; and
``(F) describe plans to enhance the capacity of individuals
to utilize health services and health-related social services
under Federal, State, and local programs by--
``(i) assisting individuals in establishing eligibility
under the programs and in receiving the services or other
benefits of the programs; and
``(ii) providing other services as the Secretary determines
to be appropriate, that may include transportation and
translation services.
``(d) Priority.--In awarding grants under subsection (a),
the Secretary shall give priority to applicants that--
``(1) propose to target geographic areas--
``(A) with a high percentage of residents who are eligible
for health insurance but are uninsured or underinsured;
``(B) with a high percentage of residents who suffer from
chronic diseases including pulmonary conditions,
hypertension, heart disease, mental disorders, diabetes, and
asthma; and
``(C) with a high infant mortality rate;
``(2) have experience in providing health or health-related
social services to individuals who are underserved with
respect to such services; and
``(3) have documented community activity and experience
with community health workers.
``(e) Collaboration With Academic Institutions.--The
Secretary shall encourage community health worker programs
receiving funds under this section to collaborate with
academic institutions, especially those that graduate a
disproportionate number of health and health care students
from underrepresented racial and ethnic minority backgrounds.
Nothing in this section shall be construed to require such
collaboration.
``(f) Evidence-Based Interventions.--The Secretary shall
encourage community health worker programs receiving funding
under this section to implement an outcome-based payment
system that rewards community

[[Page H12773]]

health workers for connecting underserved populations with
the most appropriate services at the most appropriate time.
Nothing in this section shall be construed to require such
payment.
``(g) Quality Assurance and Cost Effectiveness.--The
Secretary shall establish guidelines for assuring the quality
of the training and supervision of community health workers
under the programs funded under this section and for assuring
the cost-effectiveness of such programs.
``(h) Monitoring.--The Secretary shall monitor community
health worker programs identified in approved applications
under this section and shall determine whether such programs
are in compliance with the guidelines established under
subsection (g).
``(i) Technical Assistance.--The Secretary may provide
technical assistance to community health worker programs
identified in approved applications under this section with
respect to planning, developing, and operating programs under
the grant.
``(j) Report to Congress.--
``(1) In general.--Not later than 4 years after the date on
which the Secretary first awards grants under subsection (a),
the Secretary shall submit to Congress a report regarding the
grant project.
``(2) Contents.--The report required under paragraph (1)
shall include the following:
``(A) A description of the programs for which grant funds
were used.
``(B) The number of individuals served under such programs.
``(C) An evaluation of--
``(i) the effectiveness of such programs;
``(ii) the cost of such programs; and
``(iii) the impact of the programs on the health outcomes
of the community residents.
``(D) Recommendations for sustaining the community health
worker programs developed or assisted under this section.
``(E) Recommendations regarding training to enhance career
opportunities for community health workers.
``(k) Definitions.--In this section:
``(1) Community health worker.--The term `community health
worker' means an individual who promotes health or nutrition
within the community in which the individual resides--
``(A) by serving as a liaison between communities and
health care agencies;
``(B) by providing guidance and social assistance to
community residents;
``(C) by enhancing community residents' ability to
effectively communicate with health care providers;
``(D) by providing culturally and linguistically
appropriate health or nutrition education;
``(E) by advocating for individual and community health,
including oral and mental, or nutrition needs; and
``(F) by providing referral and followup services or
otherwise coordinating care.
``(2) Community setting.--The term `community setting'
means a home or a community organization located in the
neighborhood in which a participant resides.
``(3) Medically underserved community.--The term `medically
underserved community' means a community identified by a
State, United States territory or possession, or federally
recognized Indian tribe--
``(A) that has a substantial number of individuals who are
members of a medically underserved population, as defined by
section 330(b)(3); and
``(B) a significant portion of which is a health
professional shortage area as designated under section 332.
``(4) Support.--The term `support' means the provision of
training, supervision, and materials needed to effectively
deliver the services described in subsection (b),
reimbursement for services, and other benefits.
``(5) Eligible entity.--The term `eligible entity' means a
public or private nonprofit entity (including a State or
public subdivision of a State, a public health department, or
a federally qualified health center), or a consortium of any
of such entities, located in the United States or territory
thereof.
``(l) Authorization of Appropriations.--There is authorized
to be appropriated to carry out this section $30,000,000 for
each of fiscal years 2011 through 2015.''.

SEC. 2531. MEDICAL LIABILITY ALTERNATIVES.

(a) Incentive Payments for Medical Liability Reform.--
(1) In general.--To the extent and in the amounts made
available in advance in appropriations Acts, the Secretary
shall make an incentive payment, in an amount determined by
the Secretary, to each State that has an alternative medical
liability law in compliance with this section.
(2) Determination by secretary.--The Secretary shall
determine that a State has an alternative medical liability
law in compliance with this section if the Secretary is
satisfied that--
(A) the State enacted the law after the date of the
enactment of this Act and is implementing the law;
(B) the law is effective; and
(C) the contents of the law are in accordance with
paragraph (4).
(3) Considerations for determining effectiveness.--In
determining whether an alternative medical liability law is
effective under paragraph (2)(B), the Secretary shall
consider whether the law--
(A) makes the medical liability system more reliable
through prevention of, or prompt and fair resolution of,
disputes;
(B) encourages the disclosure of health care errors; and
(C) maintains access to affordable liability insurance.
(4) Contents of alternative medical liability law.--The
contents of an alternative liability law are in accordance
with this paragraph if--
(A) the litigation alternatives contained in the law
consist of certificate of merit, early offer, or both; and
(B) the law does not limit attorneys' fees or impose caps
on damages.
(5) No limitation on other state laws.--Nothing in this
section shall be construed to--
(A) preempt or modify the application of any existing State
law that limits attorneys' fees or imposes caps on damages;
(B) impair the authority of a State to establish or
implement a law limiting attorneys' fees or imposing caps on
damages; or
(C) restrict the eligibility of a State for an incentive
payment under this section on the basis of a law described in
subparagraph (A) or (B) so long as any such law is not
established or implemented as part of the law described in
paragraph (4), as determined by the Secretary.
(b) Use of Incentive Payments.--Amounts received by a State
as an incentive payment under this section shall be used to
improve health care in that State.
(c) Technical Assistance.--The Secretary may provide
technical assistance to the States applying for or receiving
an incentive payment under this section.
(d) Reports.--Beginning not later than one year after the
date of the enactment of this Act, the Secretary shall submit
to the Congress an annual report on the progress States have
made in enacting and implementing alternative medical
liability laws in compliance with this section. Such reports
shall contain sufficient documentation regarding the
effectiveness of such laws to enable an objective comparative
analysis of such laws.
(e) Definition.--In this section--
(1) the term ``Secretary'' means the Secretary of Health
and Human Services; and
(2) the term ``State'' includes the several States,
District of Columbia, the Commonwealth of Puerto Rico, and
each other territory or possession of the United States.
(f) Authorization of Appropriations.--There are authorized
to be appropriated to carry out this section such sums as may
be necessary, to remain available until expended.

SEC. 2532. INFANT MORTALITY PILOT PROGRAMS.

(a) In General.--The Secretary of Health and Human Services
(in this section referred to as the ``Secretary''), acting
through the Director, shall award grants to eligible entities
to create, implement, and oversee infant mortality pilot
programs.
(b) Period of a Grant.--The period of a grant under this
section shall be 5 consecutive fiscal years.
(c) Preference.--In awarding grants under this section, the
Secretary shall give preference to eligible entities
proposing to serve any of the 15 counties or groups of
counties with the highest rates of infant mortality in the
United States in the past 3 years.
(d) Use of Funds.--Any infant mortality pilot program
funded under this section may--
(1) include the development of a plan that identifies the
individual needs of each community to be served and
strategies to address those needs;
(2) provide outreach to at-risk mothers through programs
deemed appropriate by the Director;
(3) develop and implement standardized systems for improved
access, utilization, and quality of social, educational, and
clinical services to promote healthy pregnancies, full term
births, and healthy infancies delivered to women and their
infants, such as--
(A) counseling on infant care, feeding, and parenting;
(B) postpartum care;
(C) prevention of premature delivery; and
(D) additional counseling for at-risk mothers, including
smoking cessation programs, drug treatment programs, alcohol
treatment programs, nutrition and physical activity programs,
postpartum depression and domestic violence programs, social
and psychological services, dental care, and parenting
programs;
(4) establish a rural outreach program to provide care to
at-risk mothers in rural areas;
(5) establish a regional public education campaign,
including a campaign to--
(A) prevent preterm births; and
(B) educate the public about infant mortality; and
(6) provide for any other activities, programs, or
strategies as identified by the community plan.
(e) Limitation.--Of the funds received through a grant
under this section for a fiscal year, an eligible entity
shall not use more than 10 percent for program evaluation.
(f) Reports on Pilot Programs.--
(1) In general.--Not later than 1 year after receiving a
grant, and annually thereafter for the duration of the grant
period, each entity that receives a grant under subsection
(a) shall submit a report to the Secretary detailing its
infant mortality pilot program.
(2) Contents of report.--The reports required under
paragraph (1) shall include information such as the
methodology of, and outcomes and statistics from, the
grantee's infant mortality pilot program.
(3) Evaluation.--The Secretary shall use the reports
required under paragraph (1) to

[[Page H12774]]

evaluate, and conduct statistical research on, infant
mortality pilot programs funded through this section.
(g) Definitions.--For the purposes of this section:
(1) Director.--The term ``Director'' means the Director of
the Centers for Disease Control and Prevention.
(2) Eligible entity.--The term ``eligible entity'' means a
State, county, city, territorial, or tribal health department
that has submitted a proposal to the Secretary that the
Secretary deems likely to reduce infant mortality rates
within the standard metropolitan statistical area involved.
(3) Tribal.--The term ``tribal'' refers to an Indian tribe,
a Tribal organization, or an Urban Indian organization, as
such terms are defined in section 4 of the Indian Health Care
Improvement Act.
(h) Authorization of Appropriations.--To carry out this
section, there are authorized to be appropriated $10,000,000
for each of fiscal years 2011 through 2015.

SEC. 2533. SECONDARY SCHOOL HEALTH SCIENCES TRAINING PROGRAM.

(a) Program.--The Secretary of Health and Human Services,
acting through the Administrator of the Health Resources and
Services Administration, and in consultation with the
Secretary of Education, may establish a health sciences
training program consisting of awarding grants and contracts
under subsection (b) to prepare secondary school students for
careers in health professions.
(b) Development and Implementation of Health Sciences
Curricula.--The Secretary may make grants to, or enter into
contracts with, eligible entities--
(1) to plan, develop, or implement secondary school health
sciences curricula, including curricula in biology,
chemistry, physiology, mathematics, nutrition, and other
courses deemed appropriate by the Secretary to prepare
students for associate's or bachelor's degree programs in
health professions or bachelor's degree programs in health
professions-related majors; and
(2) to increase the interest of secondary school students
in applying to, and enrolling in, accredited associate's or
bachelor's degree programs in health professions or
bachelor's degree programs in health professions-related
majors, including through--
(A) work-study programs;
(B) programs to increase awareness of careers in health
professions; and
(C) other activities to increase such interest.
(c) Eligibility.--To be eligible for a grant or contract
under subsection (b), an entity shall--
(1) be a local educational agency; and
(2) provide assurances that activities under the grant or
contract will be carried out in partnership with an
accredited health professions school or program, public or
private nonprofit hospital, or public or private nonprofit
entity.
(d) Preference.--In awarding grants and contracts under
subsection (b), the Secretary shall give preference to
entities that have a demonstrated record of at least one of
the following:
(1) Graduating a high or significantly improved percentage
of students who have exhibited mastery in secondary school
State science standards.
(2) Graduating students from disadvantaged backgrounds,
including racial and ethnic minorities who are
underrepresented in--
(A) associate's or bachelor's degree programs in health
professions or bachelor's degree programs in health
professions-related majors; or
(B) health professions.
(e) Report.--The Secretary shall submit to the Congress an
annual report on the program carried out under this section.
(f) Definitions.--In this section:
(1) The term ``health profession'' means the profession of
any member of the health workforce, as defined in section
764(i) of the Public Health Service Act, as added by section
2261.
(2) The term ``local educational agency'' has the meaning
given to the term in section 9101 of the Elementary and
Secondary Education Act of 1965 (20 U.S.C. 7801).
(3) The term ``secondary school''--
(A) means a secondary school, as defined in section 9101 of
the Elementary and Secondary Education Act of 1965 (20 U.S.C.
7801); and
(B) includes any such school that is a middle school.
(4) The term ``Secretary'' means the Secretary of Health
and Human Services except as otherwise specified.
(g) Authorization of Appropriations.--To carry out this
section, there are authorized to be appropriated such sums as
may be necessary for each of fiscal years 2011 through 2015.

SEC. 2534. COMMUNITY-BASED COLLABORATIVE CARE NETWORKS.

(a) Purpose.--The purpose of this subtitle is to establish
and provide assistance to community-based collaborative care
networks--
(1) to develop or strengthen coordination of services to
allow all individuals, including the uninsured and low-
income, to receive efficient and higher quality care and to
gain entry into and receive services from a comprehensive
system of care;
(2) to develop efficient and sustainable infrastructure for
a health care delivery system characterized by effective
collaboration, information sharing, and clinical and
financial coordination among providers of care in the
community;
(3) to develop or strengthen activities related to
providing coordinated care for individuals with chronic
conditions; and
(4) to reduce the use of emergency departments, inpatient
and other expensive resources of hospitals and other
providers.
(b) Creation of the Community-Based Collaborative Care
Network Program.--Part D of title III (42 U.S.C. 254b et
seq.), as amended, is further amended by inserting after
subpart XII the following new subpart:

``Subpart XIII--Community-Based Collaborative Care Network Program

``SEC. 340O. COMMUNITY-BASED COLLABORATIVE CARE NETWORK
PROGRAM.

``(a) In General.--The Secretary may award grants to
eligible entities for the purpose of establishing model
projects to accomplish the following goals:
``(1) To reduce unnecessary use of items and services
furnished in emergency departments of hospitals (especially
to ensure that individuals without health insurance coverage
or with inadequate health insurance coverage do not use the
services of such department instead of the services of a
primary care provider) through methods such as--
``(A) screening individuals who seek emergency department
services for possible eligibility under relevant governmental
health programs or for subsidies under such programs; and
``(B) providing such individuals referrals for followup
care and chronic condition care.
``(2) To manage chronic conditions to reduce their
severity, negative health outcomes, and expense.
``(3) To encourage health care providers to coordinate
their efforts so that the most vulnerable patient populations
seek and obtain primary care.
``(4) To provide more comprehensive and coordinated care to
vulnerable low-income individuals and individuals without
health insurance coverage or with inadequate coverage.
``(5) To provide mechanisms for improving both quality and
efficiency of care for low-income individuals and families,
with an emphasis on those most likely to remain uninsured
despite the existence of government programs to make health
insurance more affordable.
``(6) To increase preventive services, including screening
and counseling, to those who would otherwise not receive such
screening, in order to improve health status and reduce long-
term complications and costs.
``(7) To ensure the availability of community-wide safety
net services, including emergency and trauma care.
``(b) Eligibility and Grantee Selection.--
``(1) Application.--A community-based collaborative care
network described in subsection (d) shall submit to the
Secretary an application in such form and manner and
containing such information as specified by the Secretary.
Such information shall at least--
``(A) identify the health care providers participating in
the community-based collaborative care network proposed by
the applicant and, if a provider designated in paragraph
(d)(1)(B) is not included, the reason such provider is not so
included;
``(B) include a description of how the providers plan to
collaborate to provide comprehensive and integrated care for
low-income individuals, including uninsured and underinsured
individuals;
``(C) include a description of the organizational and joint
governance structure of the community-based collaborative
care network in a manner so that it is clear how decisions
will be made, and how the decisionmaking process of the
network will include appropriate representation of the
participating entities;
``(D) define the geographic areas and populations that the
network intends to serve;
``(E) define the scope of services that the network intends
to provide and identify any reasons why such services would
not include a suggested core service identified by the
Secretary under paragraph (3);
``(F) demonstrate the network's ability to meet the
requirements of this section; and
``(G) provide assurances that grant funds received shall be
used to support the entire community-based collaborative care
network.
``(2) Selection of grantees.--
``(A) In general.--The Secretary shall select community-
based collaborative care networks to receive grants from
applications submitted under paragraph (1) on the basis of
quality of the proposal involved, geographic diversity
(including different States and regions served and urban and
rural diversity), and the number of low-income and uninsured
individuals that the proposal intends to serve.
``(B) Priority.--The Secretary shall give priority to
proposals from community-based collaborative care networks
that--
``(i) include the capability to provide the broadest range
of services to low-income individuals; and
``(ii) include providers that currently serve a high volume
of low-income individuals.
``(C) Renewal.--In subsequent years, based on the
performance of grantees, the Secretary may provide renewal
grants to prior year grant recipients.
``(3) Suggested core services.--For purposes of paragraph
(1)(E), the Secretary shall develop a list of suggested core
patient and core network services to be provided by a

[[Page H12775]]

community-based collaborative care network. The Secretary may
select a community-based collaborative care network under
paragraph (2), the application of which does not include all
such services, if such application provides a reasonable
explanation why such services are not proposed to be
included, and the Secretary determines that the application
is otherwise high quality.
``(4) Termination authority.--The Secretary may terminate
selection of a community-based collaborative care network
under this section for good cause. Such good cause shall
include a determination that the network--
``(A) has failed to provide a comprehensive range of
coordinated and integrated health care services as required
under subsection (d)(2);
``(B) has failed to meet reasonable quality standards;
``(C) has misappropriated funds provided under this
section; or
``(D) has failed to make progress toward accomplishing
goals set out in subsection (a).
``(c) Use of Funds.--
``(1) Use by grantees.--Grant funds are provided to
community-based collaborative care networks to carry out the
following activities:
``(A) Assist low-income individuals without adequate health
care coverage to--
``(i) access and appropriately use health services;
``(ii) enroll in applicable public or private health
insurance programs;
``(iii) obtain referrals to and see a primary care provider
in case such an individual does not have a primary care
provider; and
``(iv) obtain appropriate care for chronic conditions.
``(B) Improve heath care by providing case management,
application assistance, and appropriate referrals such as
through methods to--
``(i) create and meaningfully use a health information
technology network to track patients across collaborative
providers;
``(ii) perform health outreach, such as by using
neighborhood health workers who may inform individuals about
the availability of safety net and primary care providers
available through the community-based collaborative care
network;
``(iii) provide for followup outreach to remind patients of
appointments or follow-up care instructions;
``(iv) provide transportation to individuals to and from
the site of care;
``(v) expand the capacity to provide care at any provider
participating in the community-based collaborative care
network, including telehealth, hiring new clinical or
administrative staff, providing access to services after-
hours, on weekends, or otherwise providing an urgent care
alternative to an emergency department; and
``(vi) provide a primary care provider or medical home for
each network patient.
``(C) Provide direct patient care services as described in
their application and approved by the Secretary.
``(2) Grant funds to hrsa grantees.--The Secretary may
limit the percent of grant funding that may be spent on
direct care services provided by grantees of programs
administered by the Health Resources and Services
Administration (in this section referred to as `HRSA') or
impose other requirements on HRSA grantees participating in a
community-based collaborative care network as may be
necessary for consistency with the requirements of such
programs.
``(3) Reservation of funds for national program purposes.--
The Secretary may use not more than 7 percent of funds
appropriated to carry out this section for providing
technical assistance to grantees, obtaining assistance of
experts and consultants, holding meetings, developing of
tools, disseminating of information, and evaluation.
``(d) Community-Based Collaborative Care Networks.--
``(1) In general.--
``(A) Description.--A community-based collaborative care
network described in this subsection is a consortium of
health care providers with a joint governance structure that
provides a comprehensive range of coordinated and integrated
health care services for low-income patient populations or
medically underserved communities (whether or not such
individuals receive benefits under title XVIII, XIX, or XXI
of the Social Security Act, private or other health insurance
or are uninsured or underinsured) and that complies with any
applicable minimum eligibility requirements that the
Secretary may determine appropriate.
``(B) Required inclusion.--Each such network shall include
the following providers that serve the community (unless such
provider does not exist within the community, declines or
refuses to participate, or places unreasonable conditions on
their participation)--
``(i) A safety net hospital that provides services to a
high volume of low-income patients, as demonstrated by
meeting the criteria in section 1923(b)(1) of the Social
Security Act, or other similar criteria determined by the
Secretary; and
``(ii) All Federally qualified health centers (as defined
in section 1861(aa) of the Social Security Act (42 U.S.C.
1395x(aa))) located in the geographic area served by the
Coordinated Care Network;
``(C) Additional inclusions.--Each such network may include
any of the following additional providers:
``(i) A hospital, including a critical access hospital (as
defined in section 1820(c)(2) of the Social Security Act (42
U.S.C. 1395i-4(c)(2))).
``(ii) A county or municipal department of health.
``(iii) A rural health clinic or a rural health network (as
defined in sections 1861(aa) and 1820(d) of the Social
Security Act, respectively (42 U.S.C. 1395x(aa), 1395i-
4(d))).
``(iv) A community clinic, including a mental health
clinic, substance abuse clinic, or a reproductive health
clinic.
``(v) A health center controlled network as defined by
section 330(e)(1)(C) of the Public Health Service Act
``(vi) A private practice physician or group practice.
``(vii) A nurse or physician assistant or group practice.
``(viii) An adult day care center.
``(ix) A home health provider.
``(x) Any other type of provider specified by the
Secretary, which has a desire to serve low-income and
uninsured patients.
``(D) Construction.--
``(i) Nothing in this section shall prohibit a single
entity from qualifying as community-based collaborative care
network so long as such single entity meets the criteria of a
community-based collaborative care network. If the network
does not include the providers referenced in clauses (i) and
(ii) of subparagraph (B) of this paragraph, the application
must explain the reason pursuant to subsection (b)(1)(A).
``(ii) Participation in a community-based collaborative
care network shall not affect Federally qualified health
centers' obligation to comply with the governance
requirements under section 330 of the Public Health Service
Act (42 U.S.C. 254b).
``(iii) Federally qualified health centers participating in
a community-based collaborative care network may not be
required to provide services beyond their Federal Health
Center scope of project approved by HRSA.
``(iv) Nothing in this section shall be construed to expand
medical malpractice liability protection under the Federal
Tort Claims Act for Section 330-funded Federally qualified
health centers.
``(2) Comprehensive range of coordinated and integrated
health care services.--The Secretary shall define criteria
for evaluating whether the services offered by a community-
based collaborative care network qualify as a comprehensive
range of coordinated and integrated health care services.
Such criteria may vary based on the needs of the geographic
areas and populations to be served by the network and may
include the following:
``(A) Requiring community-based collaborative care networks
to include at least the suggested core services identified
under subsection (b)(3), or whichever subset of the suggested
core services is applicable to a particular network.
``(B) Requiring such networks to assign each patient of the
network to a primary care provider responsible for managing
that patient's care.
``(C) Requiring the services provided by a community-based
collaborative care network to include support services
appropriate to meet the health needs of low-income
populations in the network's community, which may include
chronic care management, nutritional counseling,
transportation, language services, enrollment counselors,
social services and other services as proposed by the
network.
``(D) Providing that the services provided by a community-
based collaborative care network may also include long-term
care services and other services not specified in this
subsection.
``(E) Providing for the approval by the Secretary of a
scope of community-based collaborative care network services
for each network that addresses an appropriate minimum scope
of work consistent with the setting of the network and the
health professionals available in the community the network
serves.
``(3) Clarification.--Participation in a community-based
collaborative care network shall not disqualify a health care
provider from reimbursement under title XVIII, XIX, or XXI of
the Social Security Act with respect to services otherwise
reimbursable under such title. Nothing in this section shall
prevent a community-based collaborative care network that is
otherwise eligible to contract with Medicare, a private
health insurer, or any other appropriate entity to provide
care under Medicare, under health insurance coverage offered
by the insurer, or otherwise.
``(e) Evaluations.--
``(1) Grantee reports.--Beginning in the third year
following an initial grant, each community-based
collaborative care network shall submit to the Secretary,
with respect to each year the grantee has received a grant,
an evaluation on the activities carried out by the community-
based collaborative care network under the community-based
collaborative care network program and shall include--
``(A) the number of people served;
``(B) the most common health problems treated;
``(C) any reductions in emergency department use;
``(D) any improvements in access to primary care;
``(E) an accounting of how amounts received were used,
including identification of amounts used for patient care
services as may be required for HRSA grantees; and

[[Page H12776]]

``(F) to the extent requested by the Secretary, any quality
measures or any other measures specified by the Secretary.
``(2) Program reports.--The Secretary shall submit to
Congress an annual evaluation (beginning not later than 6
months after the first reports under paragraph (1) are
submitted) on the extent to which emergency department use
was reduced as a result of the activities carried out by the
community-based collaborative care network under the program.
Each such evaluation shall also include information on--
``(A) the prevalence of certain chronic conditions in
various populations, including a comparison of such
prevalence in the general population versus in the population
of individuals with inadequate health insurance coverage;
``(B) demographic characteristics of the population of
uninsured and underinsured individuals served by the
community-based collaborative care network involved; and
``(C) the conditions of such individuals for whom services
were requested at such emergency departments of participating
hospitals.
``(3) Audit authority.--The Secretary may conduct periodic
audits and request periodic spending reports of community-
based collaborative care networks under the community-based
collaborative care network program.
``(f) Clarification.--Nothing in this section requires a
provider to report individually identifiable information of
an individual to government agencies, unless the individual
consents, consistent with HIPAA privacy and security law, as
defined in section 3009(a)(2).
``(g) Authorization of Appropriations.--There are
authorized to be appropriated to carry out this section such
sums as may be necessary for each of fiscal years 2011
through 2015.''.

SEC. 2535. COMMUNITY-BASED OVERWEIGHT AND OBESITY PREVENTION
PROGRAM.

Part Q of title III (42 U.S.C. 280h et seq.) is amended by
inserting after section 399W the following:

``SEC. 399W-1. COMMUNITY-BASED OVERWEIGHT AND OBESITY
PREVENTION PROGRAM.

``(a) Program.--The Secretary shall establish a community-
based overweight and obesity prevention program consisting of
awarding grants and contracts under subsection (b).
``(b) Grants.--The Secretary shall award grants to, or
enter into contracts with, eligible entities--
``(1) to plan evidence-based programs for the prevention of
overweight and obesity among children and their families
through improved nutrition and increased physical activity;
or
``(2) to implement such programs.
``(c) Eligibility.--To be eligible for a grant or contract
under subsection (b), an entity shall be a community
partnership that demonstrates community support and
includes--
``(1) a broad cross section of stakeholders, such as--
``(A) hospitals, health care systems, community health
centers, or other health care providers;
``(B) universities, local educational agencies, or
childcare providers;
``(C) State, local, and tribal health departments;
``(D) State, local, and tribal park and recreation
departments;
``(E) employers; and
``(F) health insurance companies;
``(2) residents of the community; and
``(3) representatives of public and private entities that
have a history of working within and serving the community.
``(d) Period of Awards.--
``(1) In general.--The period of a grant or contract under
this section shall be 5 years, subject to renewal under
paragraph (2).
``(2) Renewal.--At the end of each fiscal year, the
Secretary may renew a grant or contract award under this
section only if the grant or contract recipient demonstrates
to the Secretary's satisfaction that the recipient has made
appropriate, measurable progress in preventing overweight and
obesity.
``(e) Requirements.--
``(1) In general.--The Secretary may award a grant or
contract under this section to an entity only if the entity
demonstrates to the Secretary's satisfaction that--
``(A) not later than 90 days after receiving the grant or
contract, the entity will establish a steering committee to
provide input on the assessment of, and recommendations on
improvements to, the entity's program funded through the
grant or contract; and
``(B) the entity has conducted or will conduct an
assessment of the overweight and obesity problem in its
community, including the extent of the problem and factors
contributing to the problem.
``(2) Matching requirement.--The Secretary may award a
grant or contract to an eligible entity under this section
only if the entity agrees to provide, from non-Federal
sources, an amount equal to $1 (in cash or in kind) for each
$9 provided through the grant or contract to carry out the
activities supported by the grant or contract.
``(3) Payor of last resort.--The Secretary may award a
grant or contract under this section to an entity only if the
entity demonstrates to the satisfaction of the Secretary that
funds received through the grant or contract will not be
expended for any activity to the extent that payment has been
made, or can reasonably be expected to be made--
``(A) under any insurance policy;
``(B) under any Federal or State health benefits program
(including titles XIX and XXI of the Social Security Act); or
``(C) by an entity which provides health services on a
prepaid basis.
``(4) Maintenance of effort.--The Secretary may award a
grant or contract under this section to an entity only if the
entity demonstrates to the satisfaction of the Secretary
that--
``(A) funds received through the grant or contract will be
expended only to supplement, and not supplant, non-Federal
and Federal funds otherwise available to the entity for the
activities to be funded through the grant or contract; and
``(B) with respect to such activities, the entity will
maintain expenditures of non-Federal amounts for such
activities at a level not less than the lesser of such
expenditures maintained by the entity for the fiscal year
preceding the fiscal year for which the entity receives the
grant or contract.
``(f) Preferences.--In awarding grants and contracts under
this section, the Secretary shall give preference to eligible
entities that--
``(1) will serve communities with high levels of overweight
and obesity and related chronic diseases; or
``(2) will plan or implement activities for the prevention
of overweight and obesity in school or workplace settings.
``(g) Report.--The Secretary shall submit to the Congress
an annual report on the program of grants and contracts
awarded under this section.
``(h) Definitions.--In this section:
``(1) The term `evidence-based' means that methodologically
sound research has demonstrated a beneficial health effect in
the judgment of the Secretary and includes the Ways to
Enhance Children's Activity and Nutrition (We Can) program
and curriculum of the National Institutes of Health.
``(2) The term `local educational agency' has the meaning
given to the term in section 9101 of the Elementary and
Secondary Education Act of 1965.
``(i) Authorization of Appropriations.--To carry out this
section, there are authorized to be appropriated $10,000,000
for fiscal year 2011 and such sums as may be necessary for
each of fiscal years 2012 through 2015.''.

SEC. 2536. REDUCING STUDENT-TO-SCHOOL NURSE RATIOS.

(a) Demonstration Grants.--
(1) In general.--The Secretary of Education, in
consultation with the Secretary of Health and Human Services
and the Director of the Centers for Disease Control and
Prevention, may make demonstration grants to eligible local
educational agencies for the purpose of reducing the student-
to-school nurse ratio in public elementary and secondary
schools.
(2) Special consideration.--In awarding grants under this
section, the Secretary of Education shall give special
consideration to applications submitted by high-need local
educational agencies that demonstrate the greatest need for
new or additional nursing services among children in the
public elementary and secondary schools served by the agency,
in part by providing information on current ratios of
students to school nurses.
(3) Matching funds.--The Secretary of Education may require
recipients of grants under this subsection to provide
matching funds from non-Federal sources, and shall permit the
recipients to match funds in whole or in part with in-kind
contributions.
(b) Report.--Not later than 24 months after the date on
which assistance is first made available to local educational
agencies under this section, the Secretary of Education shall
submit to the Congress a report on the results of the
demonstration grant program carried out under this section,
including an evaluation of the effectiveness of the program
in improving the student-to-school nurse ratios described in
subsection (a) and an evaluation of the impact of any
resulting enhanced health of students on learning.
(c) Definitions.--For purposes of this section:
(1) The terms ``elementary school'', ``local educational
agency'', and ``secondary school'' have the meanings given to
those terms in section 9101 of the Elementary and Secondary
Education Act of 1965 (20 U.S.C. 7801).
(2) The term ``eligible local educational agency'' means a
local educational agency in which the student-to-school nurse
ratio in the public elementary and secondary schools served
by the agency is 750 or more students to every school nurse.
(3) The term ``high-need local educational agency'' means a
local educational agency--
(A) that serves not fewer than 10,000 children from
families with incomes below the poverty line; or
(B) for which not less than 20 percent of the children
served by the agency are from families with incomes below the
poverty line.
(4) The term ``nurse'' means a licensed nurse, as defined
under State law.
(d) Authorization of Appropriations.--To carry out this
section, there are authorized to be appropriated such sums as
may be necessary for each of fiscal years 2011 through 2015.

SEC. 2537. MEDICAL-LEGAL PARTNERSHIPS.

(a) In General.--The Secretary shall establish a nationwide
demonstration project consisting of--

[[Page H12777]]

(1) awarding grants to, and entering into contracts with,
medical-legal partnerships to assist patients and their
families to navigate health-related programs and activities;
and
(2) evaluating the effectiveness of such partnerships.
(b) Use of Funds.--Amounts received as a grant or contract
under this section shall be used to assist patients and their
families to navigate health care-related programs and
activities and thereby achieve one or more of the following
goals:
(1) Enhancing access to health care services.
(2) Improving health outcomes for low-income individuals.
(3) Reducing health disparities.
(4) Enhancing wellness and prevention of chronic
conditions.
(c) Prohibition.--No funds under this section may be used--
(1) for any medical malpractice or other civil action or
proceeding; or
(2) to assist individuals who are not lawfully present in
the United States.
(d) Report.--Not later than 5 years after the date of the
enactment of this Act, the Secretary shall submit a report to
the Congress on the results of the demonstration project
under this section. Such report shall include the following:
(1) A description of the extent to which medical-legal
partnerships funded through this section achieved the goals
described in subsection (b).
(2) Recommendations on the possibility of extending or
expanding the demonstration project.
(e) Definitions.--In this section:
(1) The term ``health disparities'' has the meaning given
to the term in section 3171 of the Public Health Service Act,
as added by section 2301.
(2) The term ``medical-legal partnership'' means an
entity--
(A) that is a collaboration between--
(i) a community health center, public hospital, children's
hospital, or other provider of health care services to a
significant number of low-income beneficiaries; and
(ii) one or more attorneys; and
(B) whose primary mission is to assist patients and their
families navigate health care-related programs and
activities.
(3) The term ``Secretary'' means the Secretary of Health
and Human Services.
(f) Authorization of Appropriations.--To carry out this
section, there are authorized to be appropriated such sums as
may be necessary for each of fiscal years 2011 through 2015.

SEC. 2538. SCREENING, BRIEF INTERVENTION, REFERRAL, AND
TREATMENT FOR MENTAL HEALTH AND SUBSTANCE ABUSE
DISORDERS.

Part D of title V (42 U.S.C. 290dd et seq.) is amended by
adding at the end the following:

``SEC. 544. SCREENING, BRIEF INTERVENTION, REFERRAL, AND
TREATMENT FOR MENTAL HEALTH AND SUBSTANCE ABUSE
DISORDERS.

``(a) Program.--The Secretary, acting through the
Administrator, shall establish a program (consisting of
awarding grants, contracts, and cooperative agreements under
subsection (b)) on mental health and substance abuse
screening, brief intervention, referral, and recovery
services for individuals in primary health care settings.
``(b) Use of Funds.--The Secretary may award grants to, or
enter into contracts or cooperative agreements with,
entities--
``(1) to provide mental health and substance abuse
screening, brief interventions, referral, and recovery
services;
``(2) to coordinate these services with primary health care
services in the same program and setting;
``(3) to develop a network of facilities to which patients
may be referred if needed;
``(4) to purchase needed screening and other tools that
are--
``(A) necessary for providing these services; and
``(B) supported by evidence-based research; and
``(5) to maintain communication with appropriate State
mental health and substance abuse agencies.
``(c) Eligibility.--To be eligible for a grant, contract,
or cooperative agreement under this section, an entity shall
be a public or private nonprofit entity that--
``(1) provides primary health services;
``(2) seeks to integrate mental health and substance abuse
services into its service system;
``(3) has developed a working relationship with providers
of mental health and substance abuse services;
``(4) demonstrates a need for the inclusion of mental
health and substance abuse services in its service system;
and
``(5) agrees--
``(A) to prepare and submit to the Secretary at the end of
the grant, contract, or cooperative agreement period an
evaluation of all activities funded through the grant,
contract, or cooperative agreement; and
``(B) to use such performance measures as may be stipulated
by the Secretary for purposes of such evaluation.
``(d) Preference.--In awarding grants, contracts, and
cooperative agreements under this section, the Secretary
shall give preference to entities that--
``(1) provide services in rural or frontier areas of the
Nation;
``(2) provide services to special needs populations,
including American Indian or Alaska Native populations; or
``(3) provide services in school-based health clinics or on
university and college campuses.
``(e) Duration.--The period of a grant, contract, or
cooperative agreement under this section may not exceed 5
years.
``(f) Report.--Not later than 4 years after the first
appropriation of funds to carry out this section, the
Secretary shall submit a report to the Congress on the
program under this section--
``(1) including an evaluation of the benefits of
integrating mental health and substance abuse care within
primary health care; and
``(2) focusing on the performance measures stipulated by
the Secretary under subsection (c)(5).
``(g) Authorization of Appropriations.--
``(1) In general.--To carry out this section, there are
authorized to be appropriated $30,000,000 for fiscal year
2011 and such sums as may be necessary for each of fiscal
years 2012 through 2015.
``(2) Program management.--Of the funds appropriated to
carry out this section for a fiscal year, the Secretary may
use not more than 5 percent to manage the program under this
section.''.

SEC. 2539. GRANTS TO ASSIST IN DEVELOPING MEDICAL SCHOOLS IN
FEDERALLY-DESIGNATED HEALTH PROFESSIONAL
SHORTAGE AREAS.

(a) Grants Authorized.--The Secretary of Health and Human
Services may make grants to nonprofit organizations or
institutions of higher education for the purpose of assisting
the organization or institution involved to develop a medical
school if--
(1) the medical school will be located in an area that is
designated (under section 332 of the Public Health Service
Act (42 U.S.C. 254(e)) as a health professional shortage
area;
(2) the organization or institution provides assurances
satisfactory to the Secretary of substantial private or
public funding from non-Federal sources for the development
of the medical school; and
(3) the organization or institution provides assurances
satisfactory to the Secretary that accreditation will be
achieved for the medical school.
(b) Use of Grant Funds.--Grants awarded under this section
may be used for the acquisition and building of the medical
school campus in a health professional shortage area and the
purchase of equipment, curriculum and faculty development,
and general operations related to the development and
establishment of the medical school.
(c) Authorization of Appropriations.--For the purpose of
carrying out this section, there is authorized to be
appropriated $100,000,000 for each of fiscal years 2011
through 2015.
Page 1523, strike lines 5 through 17 and insert the
following:
``(i) In general.--A violation of subparagraph (A) shall be
subject to enforcement by the Federal Trade Commission in the
same manner, by the same means, and with the same
jurisdiction as would an unfair and deceptive act or practice
in or affecting interstate commerce or an unfair method of
competition in or affecting interstate commerce prohibited
under section 5 of the Federal Trade Commission Act, as
though all applicable terms and provisions of the Federal
Trade Commission Act were incorporated into and made a part
of this subsection.

PART 3--EMERGENCY CARE-RELATED PROGRAMS

SEC. 2551. TRAUMA CARE CENTERS.

(a) Grants for Trauma Care Centers.--Section 1241 (42
U.S.C. 300d-41) is amended to read as follows:

``SEC. 1241. GRANTS FOR CERTAIN TRAUMA CENTERS.

``(a) In General.--The Secretary shall establish a trauma
center program consisting of awarding grants under section
(b).
``(b) Grants.--The Secretary shall award grants as follows:
``(1) Existing centers.--Grants to public, private
nonprofit, Indian Health Service, Indian tribal, and urban
Indian trauma centers--
``(A) to further the core missions of such centers; or
``(B) to provide emergency relief to ensure the continued
and future availability of trauma services by trauma
centers--
``(i) at risk of closing or operating in an area where a
closing has occurred within their primary service area; or
``(ii) in need of financial assistance following a natural
disaster or other catastrophic event, such as a terrorist
attack.
``(2) New centers.--Grants to local governments and public
or private nonprofit entities to establish new trauma centers
in urban areas with a substantial degree of trauma resulting
from violent crimes.
``(c) Minimum Qualifications of Trauma Centers.--
``(1) Participation in trauma care system operating under
certain professional guidelines.--
``(A) Limitation.--Subject to subparagraph (B), the
Secretary may not award a grant to an existing trauma center
under this section unless the center is a participant in a
trauma care system that substantially complies with section
1213.
``(B) Exemption.--Subparagraph (A) shall not apply to
trauma centers that are located in States with no existing
trauma care system.
``(2) Designation.--The Secretary may not award a grant
under this section to an existing trauma center unless the
center is--
``(A) verified as a trauma center by the American College
of Surgeons; or

[[Page H12778]]

``(B) designated as a trauma center by the applicable State
health or emergency medical services authority.''.
(b) Considerations in Making Grants.--Section 1242 (42
U.S.C. 300d-42) is amended to read as follows:

``SEC. 1242. CONSIDERATIONS IN MAKING GRANTS.

``(a) Core Mission Awards.--
``(1) In general.--In awarding grants under section
1241(b)(1)(A), the Secretary shall--
``(A) reserve a minimum of 25 percent of the amount
allocated for such grants for level III and level IV trauma
centers in rural or underserved areas;
``(B) reserve a minimum of 25 percent of the amount
allocated for such grants for level I and level II trauma
centers in urban areas; and
``(C) give preference to any application made by a trauma
center--
``(i) in a geographic area where growth in demand for
trauma services exceeds capacity;
``(ii) that demonstrates the financial support of the State
or political subdivision involved;
``(iii) that has at least 1 graduate medical education
fellowship in trauma or trauma-related specialties, including
neurological surgery, surgical critical care, vascular
surgery, and spinal cord injury, for which demand is
exceeding supply; or
``(iv) that demonstrates a substantial commitment to
serving vulnerable populations.
``(2) Financial support.--For purposes of paragraph
(1)(C)(ii), financial support may be demonstrated by State or
political subdivision funding for the trauma center's capital
or operating expenses (including through State trauma
regional advisory coordination activities, Medicaid funding
designated for trauma services, or other governmental
funding). State funding derived from Federal support shall
not constitute State or local financial support for purposes
of preferential treatment under this subsection.
``(3) Use of funds.--The recipient of a grant under section
1241(b)(1)(A) shall carry out, consistent with furthering the
core missions of the center, one or more of the following
activities:
``(A) Providing 24-hour-a-day, 7-day-a-week trauma care
availability.
``(B) Reducing overcrowding related to throughput of trauma
patients.
``(C) Enhancing trauma surge capacity.
``(D) Ensuring physician and essential personnel
availability.
``(E) Trauma education and outreach.
``(F) Coordination with local and regional trauma care
systems.
``(G) Such other activities as the Secretary may deem
appropriate.
``(b) Emergency Awards; New Centers.--In awarding grants
under paragraphs (1)(B) and (2) of section 1241(b), the
Secretary shall--
``(1) give preference to any application submitted by an
applicant that demonstrates the financial support (in
accordance with subsection (a)(2)) of the State or political
subdivision involved for the activities to be funded through
the grant for each fiscal year during which payments are made
to the center under the grant; and
``(2) give preference to any application submitted for a
trauma center that--
``(A) is providing or will provide trauma care in a
geographic area in which the availability of trauma care has
either significantly decreased as a result of a trauma center
in the area permanently ceasing participation in a system
described in section 1241(c)(1) as of a date occurring during
the 2-year period preceding the fiscal year for which the
trauma center is applying to receive a grant, or in
geographic areas where growth in demand for trauma services
exceeds capacity;
``(B) will, in providing trauma care during the 1-year
period beginning on the date on which the application for the
grant is submitted, incur substantial uncompensated care
costs in an amount that renders the center unable to continue
participation in such system and results in a significant
decrease in the availability of trauma care in the geographic
area;
``(C) operates or will operate in rural areas where trauma
care availability will significantly decrease if the center
is forced to close or downgrade service and substantial costs
are contributing to a likelihood of such closure or
downgradation;
``(D) is in a geographic location substantially affected by
a natural disaster or other catastrophic event such as a
terrorist attack; or
``(E) will establish a new trauma service in an urban area
with a substantial degree of trauma resulting from violent
crimes.
``(c) Designations of Levels of Trauma Centers in Certain
States.--In the case of a State which has not designated 4
levels of trauma centers, any reference in this section to--
``(1) a level I or level II trauma center is deemed to be a
reference to a trauma center within the highest 2 levels of
trauma centers designated under State guidelines; and
``(2) a level III or IV trauma center is deemed to be a
reference to a trauma center not within such highest 2
levels.''.
(c) Certain Agreements.--Section 1243 (42 U.S.C. 300d-43)
is amended to read as follows:

``SEC. 1243. CERTAIN AGREEMENTS.

``(a) Commitment Regarding Continued Participation in
Trauma Care System.--The Secretary may not award a grant to
an applicant under section 1241(b) unless the applicant
agrees that--
``(1) the trauma center involved will continue
participation, or in the case of a new center will
participate, in the system described in section 1241(c)(1),
except as provided in section 1241(c)(1)(B), throughout the
grant period beginning on the date that the center first
receives payments under the grant; and
``(2) if the agreement made pursuant to paragraph (1) is
violated by the center, the center will be liable to the
United States for an amount equal to the sum of--
``(A) the amount of assistance provided to the center under
section 1241; and
``(B) an amount representing interest on the amount
specified in subparagraph (A).
``(b) Maintenance of Financial Support.--With respect to
activities for which funds awarded through a grant under
section 1241 are authorized to be expended, the Secretary may
not award such a grant unless the applicant agrees that,
during the period in which the trauma center involved is
receiving payments under the grant, the center will maintain
access to trauma services at levels not less than the levels
for the prior year, taking into account--
``(1) reasonable volume fluctuation that is not caused by
intentional trauma boundary reduction;
``(2) downgrading of the level of services; and
``(3) whether such center diverts its incoming patients
away from such center 5 percent or more of the time during
which the center is in operation over the course of the year.
``(c) Trauma Care Registry.--The Secretary may not award a
grant to a trauma center under section 1241(b)(1) unless the
center agrees that--
``(1) not later than 6 months after the date on which the
center submits a grant application to the Secretary, the
center will establish and operate a registry of trauma cases
in accordance with guidelines developed by the American
College of Surgeons; and
``(2) in carrying out paragraph (1), the center will
maintain information on the number of trauma cases treated by
the center and, for each such case, the extent to which the
center incurs uncompensated costs in providing trauma
care.''.
(d) General Provisions.--Section 1244 (42 U.S.C. 300d-44)
is amended to read as follows:

``SEC. 1244. GENERAL PROVISIONS.

``(a) Limitation on Duration of Support.--The period during
which a trauma center receives payments under a grant under
section 1241(b)(1) shall be for 3 fiscal years, except that
the Secretary may waive such requirement for the center and
authorize the center to receive such payments for 1
additional fiscal year.
``(b) Eligibility.--The acquisition of, or eligibility for,
a grant under section 1241(b) shall not preclude a trauma
center's eligibility for another grant described in such
section.
``(c) Funding Distribution.--Of the total amount
appropriated for a fiscal year under section 1245--
``(1) 90 percent shall be used for grants under paragraph
(1)(A) of section 1241(b); and
``(2) 10 percent shall be used for grants under paragraphs
(1)(B) and (2) of section 1241(b).
``(d) Report.--Beginning 2 years after the date of the
enactment of the Affordable Health Care for America Act, and
every 2 years thereafter, the Secretary shall biennially--
``(1) report to Congress on the status of the grants made
pursuant to section 1241;
``(2) evaluate and report to Congress on the overall
financial stability of trauma centers in the United States;
``(3) report on the populations using trauma care centers
and include aggregate patient data on income, race,
ethnicity, and geography; and
``(4) evaluate the effectiveness and efficiency of trauma
care center activities using standard public health measures
and evaluation methodologies.''.
(e) Authorization of Appropriations.--Section 1245 (42
U.S.C. 300d-45) is amended to read as follows:

``SEC. 1245. AUTHORIZATION OF APPROPRIATIONS.

``(a) In General.--For the purpose of carrying out this
part, there are authorized to be appropriated $100,000,000
for fiscal year 2011, and such sums as may be necessary for
each of fiscal years 2012 through 2015. Such authorization of
appropriations is in addition to any other authorization of
appropriations or amounts that are available for such
purpose.
``(b) Reallocation.--The Secretary shall reallocate for
grants under section 1241(b)(1)(A) any funds appropriated for
grants under paragraph (1)(B) or (2) of section 1241(b), but
not obligated due to insufficient applications eligible for
funding.''.

SEC. 2552. EMERGENCY CARE COORDINATION.

(a) In General.--Subtitle B of title XXVIII (42 U.S.C.
300hh-10 et seq.) is amended by adding at the end the
following:

``SEC. 2816. EMERGENCY CARE COORDINATION.

``(a) Emergency Care Coordination Center.--
``(1) Establishment.--The Secretary shall establish, within
the Office of the Assistant Secretary for Preparedness and
Response, an Emergency Care Coordination Center (in this
section referred to as the `Center'), to be headed by a
director.
``(2) Duties.--The Secretary, acting through the Director
of the Center, in coordination with the Federal Interagency

[[Page H12779]]

Committee on Emergency Medical Services, shall--
``(A) promote and fund research in emergency medicine and
trauma health care;
``(B) promote regional partnerships and more effective
emergency medical systems in order to enhance appropriate
triage, distribution, and care of routine community patients;
and
``(C) promote local, regional, and State emergency medical
systems' preparedness for and response to public health
events.
``(b) Council of Emergency Care.--
``(1) Establishment.--The Secretary, acting through the
Director of the Center, shall establish a Council of
Emergency Care to provide advice and recommendations to the
Director on carrying out this section.
``(2) Composition.--The Council shall be comprised of
employees of the departments and agencies of the Federal
Government who are experts in emergency care and management.
``(c) Report.--
``(1) Submission.--Not later than 12 months after the date
of the enactment of the Affordable Health Care for America
Act, the Secretary shall submit to the Congress an annual
report on the activities carried out under this section.
``(2) Considerations.--In preparing a report under
paragraph (1), the Secretary shall consider factors
including--
``(A) emergency department crowding and boarding; and
``(B) delays in care following presentation.
``(d) Authorization of Appropriations.--To carry out this
section, there are authorized to be appropriated such sums as
may be necessary for each of fiscal years 2011 through
2015.''.
(b) Functions, Personnel, Assets, Liabilities, and
Administrative Actions.--All functions, personnel, assets,
and liabilities of, and administrative actions applicable to,
the Emergency Care Coordination Center, as in existence on
the day before the date of the enactment of this Act, shall
be transferred to the Emergency Care Coordination Center
established under section 2816(a) of the Public Health
Service Act, as added by subsection (a).

SEC. 2553. PILOT PROGRAMS TO IMPROVE EMERGENCY MEDICAL CARE.

Part B of title III (42 U.S.C. 243 et seq.) is amended by
inserting after section 314 the following:

``SEC. 315. REGIONALIZED COMMUNICATION SYSTEMS FOR EMERGENCY
CARE RESPONSE.

``(a) In General.--The Secretary, acting through the
Assistant Secretary for Preparedness and Response, shall
award not fewer than 4 multiyear contracts or competitive
grants to eligible entities to support demonstration programs
that design, implement, and evaluate innovative models of
regionalized, comprehensive, and accountable emergency care
systems.
``(b) Eligible Entity; Region.--
``(1) Eligible entity.--In this section, the term `eligible
entity' means a State or a partnership of 1 or more States
and 1 or more local governments.
``(2) Region.--In this section, the term `region' means an
area within a State, an area that lies within multiple
States, or a similar area (such as a multicounty area), as
determined by the Secretary.
``(c) Demonstration Program.--The Secretary shall award a
contract or grant under subsection (a) to an eligible entity
that proposes a demonstration program to design, implement,
and evaluate an emergency medical system that--
``(1) coordinates with public safety services, public
health services, emergency medical services, medical
facilities, and other entities within a region;
``(2) coordinates an approach to emergency medical system
access throughout the region, including 9-1-1 public safety
answering points and emergency medical dispatch;
``(3) includes a mechanism, such as a regional medical
direction or transport communications system, that operates
throughout the region to ensure that the correct patient is
taken to the medically appropriate facility (whether an
initial facility or a higher level facility) in a timely
fashion;
``(4) allows for the tracking of prehospital and hospital
resources, including inpatient bed capacity, emergency
department capacity, on-call specialist coverage, ambulance
diversion status, and the coordination of such tracking with
regional communications and hospital destination decisions;
and
``(5) includes a consistent regionwide prehospital,
hospital, and interfacility data management system that--
``(A) complies with the National EMS Information System,
the National Trauma Data Bank, and others;
``(B) reports data to appropriate Federal and State
databanks and registries; and
``(C) contains information sufficient to evaluate key
elements of prehospital care, hospital destination decisions,
including initial hospital and interfacility decisions, and
relevant outcomes of hospital care.
``(d) Application.--
``(1) In general.--An eligible entity that seeks a contract
or grant described in subsection (a) shall submit to the
Secretary an application at such time and in such manner as
the Secretary may require.
``(2) Application information.--Each application shall
include--
``(A) an assurance from the eligible entity that the
proposed system--
``(i) has been coordinated with the applicable State office
of emergency medical services (or equivalent State office);
``(ii) is compatible with the applicable State emergency
medical services system;
``(iii) includes consistent indirect and direct medical
oversight of prehospital, hospital, and interfacility
transport throughout the region;
``(iv) coordinates prehospital treatment and triage,
hospital destination, and interfacility transport throughout
the region;
``(v) includes a categorization or designation system for
special medical facilities throughout the region that is--

``(I) consistent with State laws and regulations; and
``(II) integrated with the protocols for transport and
destination throughout the region; and

``(vi) includes a regional medical direction system, a
patient tracking system, and a resource allocation system
that--

``(I) support day-to-day emergency care system operation;
``(II) can manage surge capacity during a major event or
disaster; and
``(III) are integrated with other components of the
national and State emergency preparedness system;

``(B) an agreement to make available non-Federal
contributions in accordance with subsection (e); and
``(C) such other information as the Secretary may require.
``(e) Matching Funds.--
``(1) In general.--With respect to the costs of the
activities to be carried out each year with a contract or
grant under subsection (a), a condition for the receipt of
the contract or grant is that the eligible entity involved
agrees to make available (directly or through donations from
public or private entities) non-Federal contributions toward
such costs in an amount that is not less than 25 percent of
such costs.
``(2) Determination of amount contributed.--Non-Federal
contributions required in paragraph (1) may be in cash or in
kind, fairly evaluated, including plant, equipment, or
services. Amounts provided by the Federal Government, or
services assisted or subsidized to any significant extent by
the Federal Government, may not be included in determining
the amount of such non-Federal contributions.
``(f) Priority.--The Secretary shall give priority for the
award of the contracts or grants described in subsection (a)
to any eligible entity that serves a medically underserved
population (as defined in section 330(b)(3)).
``(g) Report.--Not later than 90 days after the completion
of a demonstration program under subsection (a), the
recipient of such contract or grant described in such
subsection shall submit to the Secretary a report containing
the results of an evaluation of the program, including an
identification of--
``(1) the impact of the regional, accountable emergency
care system on patient outcomes for various critical care
categories, such as trauma, stroke, cardiac emergencies, and
pediatric emergencies;
``(2) the system characteristics that contribute to the
effectiveness and efficiency of the program (or lack
thereof);
``(3) methods of assuring the long-term financial
sustainability of the emergency care system;
``(4) the State and local legislation necessary to
implement and to maintain the system; and
``(5) the barriers to developing regionalized, accountable
emergency care systems, as well as the methods to overcome
such barriers.
``(h) Evaluation.--The Secretary, acting through the
Assistant Secretary for Preparedness and Response, shall
enter into a contract with an academic institution or other
entity to conduct an independent evaluation of the
demonstration programs funded under subsection (a), including
an evaluation of--
``(1) the performance of the eligible entities receiving
the funds; and
``(2) the impact of the demonstration programs.
``(i) Dissemination of Findings.--The Secretary shall, as
appropriate, disseminate to the public and to the appropriate
committees of the Congress, the information contained in a
report made under subsection (h).
``(j) Authorization of Appropriations.--
``(1) In general.--There is authorized to be appropriated
to carry out this section $12,000,000 for each of fiscal
years 2011 through 2015.
``(2) Reservation.--Of the amount appropriated to carry out
this section for a fiscal year, the Secretary shall reserve 3
percent of such amount to carry out subsection (h) (relating
to an independent evaluation).''.

SEC. 2554. ASSISTING VETERANS WITH MILITARY EMERGENCY MEDICAL
TRAINING TO BECOME STATE-LICENSED OR CERTIFIED
EMERGENCY MEDICAL TECHNICIANS (EMTS).

(a) In General.--Part B of title III (42 U.S.C. 243 et
seq.), as amended, is amended by inserting after section 315
the following:

``SEC. 315A. ASSISTING VETERANS WITH MILITARY EMERGENCY
MEDICAL TRAINING TO BECOME STATE-LICENSED OR
CERTIFIED EMERGENCY MEDICAL TECHNICIANS (EMTS).

``(a) Program.--The Secretary shall establish a program
consisting of awarding grants to States to assist veterans
who received and completed military emergency medical
training while serving in the Armed Forces of the United
States to become, upon their

[[Page H12780]]

discharge or release from active duty service, State-licensed
or certified emergency medical technicians.
``(b) Use of Funds.--Amounts received as a grant under this
section may be used to assist veterans described in
subsection (a) to become State-licensed or certified
emergency medical technicians as follows:
``(1) Providing training.
``(2) Providing reimbursement for costs associated with--
``(A) training; or
``(B) applying for licensure or certification.
``(3) Expediting the licensing or certification process.
``(c) Eligibility.--To be eligible for a grant under this
section, a State shall demonstrate to the Secretary's
satisfaction that the State has a shortage of emergency
medical technicians.
``(d) Report.--The Secretary shall submit to the Congress
an annual report on the program under this section.
``(e) Authorization of Appropriations.--To carry out this
section, there are authorized to be appropriated such sums as
may be necessary for each of fiscal years 2011 through
2015.''.
(b) GAO Study and Report.--The Comptroller General of the
United States shall--
(1) conduct a study on the barriers experienced by veterans
who received training as medical personnel while serving in
the Armed Forces of the United States and, upon their
discharge or release from active duty service, seek to become
licensed or certified in a State as civilian health
professionals; and
(2) not later than 2 years after the date of the enactment
of this Act, submit to the Congress a report on the results
of such study, including recommendations on whether the
program established under section 315A of the Public Health
Service Act, as added by subsection (a), should be expanded
to assist veterans seeking to become licensed or certified in
a State as health providers other than emergency medical
technicians.

SEC. 2555. DENTAL EMERGENCY RESPONDERS: PUBLIC HEALTH AND
MEDICAL RESPONSE.

(a) National Health Security Strategy.--Section 2802(b)(3)
(42 U.S.C. 300hh-1(b)(3)) is amended--
(1) in the matter preceding subparagraph (A), by inserting
``dental and'' before ``mental health facilities''; and
(2) in subparagraph (D), by inserting ``and dental'' after
``medical''.
(b) All-Hazards Public Health and Medical Response
Curricula and Training.--Section 319F(a)(5)(B) (42 U.S.C.
247d-6(a)(5)(B)) is amended by striking ``public health or
medical'' and inserting ``public health, medical, or
dental''.

SEC. 2556. DENTAL EMERGENCY RESPONDERS: HOMELAND SECURITY.

(a) National Response Framework.--Paragraph (6) of section
2 of the Homeland Security Act of 2002 (6 U.S.C. 101) is
amended by inserting ``and dental'' after ``emergency
medical''.
(b) National Preparedness System.--Subparagraph (B) of
section 653(b)(4) of the Post-Katrina Emergency Management
Reform Act of 2006 (6 U.S.C. 753(b)(4)) is amended by
striking ``public health and medical'' and inserting ``public
health, medical, and dental''.
(c) Chief Medical Officer.--Paragraph (5) of section 516(c)
of the Homeland Security Act of 2002 (6 U.S.C. 321e(c)) is
amended by striking ``medical community'' and inserting
``medical and dental communities''.

PART 4--PAIN CARE AND MANAGEMENT PROGRAMS

SEC. 2561. INSTITUTE OF MEDICINE CONFERENCE ON PAIN.

(a) Convening.--Not later than June 30, 2011, the Secretary
of Health and Human Services shall seek to enter into an
agreement with the Institute of Medicine of the National
Academies to convene a Conference on Pain (in this section
referred to as ``the Conference'').
(b) Purposes.--The purposes of the Conference shall be to--
(1) increase the recognition of pain as a significant
public health problem in the United States;
(2) evaluate the adequacy of assessment, diagnosis,
treatment, and management of acute and chronic pain in the
general population, and in identified racial, ethnic, gender,
age, and other demographic groups that may be
disproportionately affected by inadequacies in the
assessment, diagnosis, treatment, and management of pain;
(3) identify barriers to appropriate pain care, including--
(A) lack of understanding and education among employers,
patients, health care providers, regulators, and third-party
payors;
(B) barriers to access to care at the primary, specialty,
and tertiary care levels, including barriers--
(i) specific to those populations that are
disproportionately undertreated for pain;
(ii) related to physician concerns over regulatory and law
enforcement policies applicable to some pain therapies; and
(iii) attributable to benefit, coverage, and payment
policies in both the public and private sectors; and
(C) gaps in basic and clinical research on the symptoms and
causes of pain, and potential assessment methods and new
treatments to improve pain care; and
(4) establish an agenda for action in both the public and
private sectors that will reduce such barriers and
significantly improve the state of pain care research,
education, and clinical care in the United States.
(c) Other Appropriate Entity.--If the Institute of Medicine
declines to enter into an agreement under subsection (a), the
Secretary of Health and Human Services may enter into such
agreement with another appropriate entity.
(d) Report.--A report summarizing the Conference's findings
and recommendations shall be submitted to the Congress not
later than June 30, 2012.
(e) Authorization of Appropriations.--For the purpose of
carrying out this section, there is authorized to be
appropriated $500,000 for each of fiscal years 2011 and 2012.

SEC. 2562. PAIN RESEARCH AT NATIONAL INSTITUTES OF HEALTH.

Part B of title IV (42 U.S.C. 284 et seq.) is amended by
adding at the end the following:

``SEC. 409J. PAIN RESEARCH.

``(a) Research Initiatives.--
``(1) In general.--The Director of NIH is encouraged to
continue and expand, through the Pain Consortium, an
aggressive program of basic and clinical research on the
causes of and potential treatments for pain.
``(2) Annual recommendations.--Not less than annually, the
Pain Consortium, in consultation with the Division of Program
Coordination, Planning, and Strategic Initiatives, shall
develop and submit to the Director of NIH recommendations on
appropriate pain research initiatives that could be
undertaken with funds reserved under section 402A(c)(1) for
the Common Fund or otherwise available for such initiatives.
``(3) Definition.--In this subsection, the term `Pain
Consortium' means the Pain Consortium of the National
Institutes of Health or a similar trans-National Institutes
of Health coordinating entity designated by the Secretary for
purposes of this subsection.
``(b) Interagency Pain Research Coordinating Committee.--
``(1) Establishment.--The Secretary shall establish not
later than 1 year after the date of the enactment of this
section and as necessary maintain a committee, to be known as
the Interagency Pain Research Coordinating Committee (in this
section referred to as the `Committee'), to coordinate all
efforts within the Department of Health and Human Services
and other Federal agencies that relate to pain research.
``(2) Membership.--
``(A) In general.--The Committee shall be composed of the
following voting members:
``(i) Not more than 7 voting Federal representatives as
follows:

``(I) The Director of the Centers for Disease Control and
Prevention.
``(II) The Director of the National Institutes of Health
and the directors of such national research institutes and
national centers as the Secretary determines appropriate.
``(III) The heads of such other agencies of the Department
of Health and Human Services as the Secretary determines
appropriate.
``(IV) Representatives of other Federal agencies that
conduct or support pain care research and treatment,
including the Department of Defense and the Department of
Veterans Affairs.

``(ii) Twelve additional voting members appointed under
subparagraph (B).
``(B) Additional members.--The Committee shall include
additional voting members appointed by the Secretary as
follows:
``(i) Six members shall be appointed from among scientists,
physicians, and other health professionals, who--

``(I) are not officers or employees of the United States;
``(II) represent multiple disciplines, including clinical,
basic, and public health sciences;
``(III) represent different geographical regions of the
United States; and
``(IV) are from practice settings, academia, manufacturers,
or other research settings.

``(ii) Six members shall be appointed from members of the
general public, who are representatives of leading research,
advocacy, and service organizations for individuals with
pain-related conditions.
``(C) Nonvoting members.--The Committee shall include such
nonvoting members as the Secretary determines to be
appropriate.
``(3) Chairperson.--The voting members of the Committee
shall select a chairperson from among such members. The
selection of a chairperson shall be subject to the approval
of the Director of NIH.
``(4) Meetings.--The Committee shall meet at the call of
the chairperson of the Committee or upon the request of the
Director of NIH, but in no case less often than once each
year.
``(5) Duties.--The Committee shall--
``(A) develop a summary of advances in pain care research
supported or conducted by the Federal agencies relevant to
the diagnosis, prevention, and treatment of pain and diseases
and disorders associated with pain;
``(B) identify critical gaps in basic and clinical research
on the symptoms and causes of pain;
``(C) make recommendations to ensure that the activities of
the National Institutes of Health and other Federal agencies,
including the Department of Defense and the Department of
Veteran Affairs, are free of unnecessary duplication of
effort;
``(D) make recommendations on how best to disseminate
information on pain care; and

[[Page H12781]]

``(E) make recommendations on how to expand partnerships
between public entities, including Federal agencies, and
private entities to expand collaborative, crosscutting
research.
``(6) Review.--The Secretary shall review the necessity of
the Committee at least once every 2 years.''.

SEC. 2563. PUBLIC AWARENESS CAMPAIGN ON PAIN MANAGEMENT.

Part B of title II (42 U.S.C. 238 et seq.) is amended by
adding at the end the following:

``SEC. 249. NATIONAL EDUCATION OUTREACH AND AWARENESS
CAMPAIGN ON PAIN MANAGEMENT.

``(a) Establishment.--Not later than 12 months after the
date of the enactment of this section, the Secretary shall
establish and implement a national pain care education
outreach and awareness campaign described in subsection (b).
``(b) Requirements.--The Secretary shall design the public
awareness campaign under this section to educate consumers,
patients, their families, and other caregivers with respect
to--
``(1) the incidence and importance of pain as a national
public health problem;
``(2) the adverse physical, psychological, emotional,
societal, and financial consequences that can result if pain
is not appropriately assessed, diagnosed, treated, or
managed;
``(3) the availability, benefits, and risks of all pain
treatment and management options;
``(4) having pain promptly assessed, appropriately
diagnosed, treated, and managed, and regularly reassessed
with treatment adjusted as needed;
``(5) the role of credentialed pain management specialists
and subspecialists, and of comprehensive interdisciplinary
centers of treatment expertise;
``(6) the availability in the public, nonprofit, and
private sectors of pain management-related information,
services, and resources for consumers, employers, third-party
payors, patients, their families, and caregivers, including
information on--
``(A) appropriate assessment, diagnosis, treatment, and
management options for all types of pain and pain-related
symptoms; and
``(B) conditions for which no treatment options are yet
recognized; and
``(7) other issues the Secretary deems appropriate.
``(c) Consultation.--In designing and implementing the
public awareness campaign required by this section, the
Secretary shall consult with organizations representing
patients in pain and other consumers, employers, physicians
including physicians specializing in pain care, other pain
management professionals, medical device manufacturers, and
pharmaceutical companies.
``(d) Coordination.--
``(1) Lead official.--The Secretary shall designate one
official in the Department of Health and Human Services to
oversee the campaign established under this section.
``(2) Agency coordination.--The Secretary shall ensure the
involvement in the public awareness campaign under this
section of the Surgeon General of the Public Health Service,
the Director of the Centers for Disease Control and
Prevention, and such other representatives of offices and
agencies of the Department of Health and Human Services as
the Secretary determines appropriate.
``(e) Underserved Areas and Populations.--In designing the
public awareness campaign under this section, the Secretary
shall--
``(1) take into account the special needs of geographic
areas and racial, ethnic, gender, age, and other demographic
groups that are currently underserved; and
``(2) provide resources that will reduce disparities in
access to appropriate diagnosis, assessment, and treatment.
``(f) Grants and Contracts.--The Secretary may make awards
of grants, cooperative agreements, and contracts to public
agencies and private nonprofit organizations to assist with
the development and implementation of the public awareness
campaign under this section.
``(g) Evaluation and Report.--Not later than the end of
fiscal year 2012, the Secretary shall prepare and submit to
the Congress a report evaluating the effectiveness of the
public awareness campaign under this section in educating the
general public with respect to the matters described in
subsection (b).
``(h) Authorization of Appropriations.--For purposes of
carrying out this section, there are authorized to be
appropriated $2,000,000 for fiscal year 2011 and $4,000,000
for each of fiscal years 2012 and 2015.''.

Subtitle C--Food and Drug Administration

PART 1--IN GENERAL

SEC. 2571. NATIONAL MEDICAL DEVICE REGISTRY.

(a) Registry.--
(1) In general.--Section 519 of the Federal Food, Drug, and
Cosmetic Act (21 U.S.C. 360i) is amended--
(A) by redesignating subsection (g) as subsection (h); and
(B) by inserting after subsection (f) the following:

``National Medical Device Registry

``(g)(1)(A) The Secretary shall establish a national
medical device registry (in this subsection referred to as
the `registry') to facilitate analysis of postmarket safety
and outcomes data on each covered device.
``(B) In this subsection, the term `covered device'--
``(i) shall include each class III device; and
``(ii) may include, as the Secretary determines appropriate
and specifies in regulation, a class II device that is life-
supporting or life-sustaining.
``(C) Notwithstanding subparagraph (B)(i), the Secretary
may by order exempt a class III device from the provisions of
this subsection if the Secretary concludes that inclusion of
information on the device in the registry will not provide
useful information on safety or effectiveness.
``(2) In developing the registry, the Secretary shall, in
consultation with the Commissioner of Food and Drugs, the
Administrator of the Centers for Medicare & Medicaid
Services, the Administrator of the Agency for Healthcare
Research and Quality, the head of the Office of the National
Coordinator for Health Information Technology, and the
Secretary of Veterans Affairs, determine the best methods
for--
``(A) including in the registry, in a manner consistent
with subsection (f), appropriate information to identify each
covered device by type, model, and serial number or other
unique identifier;
``(B) validating methods for analyzing patient safety and
outcomes data from multiple sources and for linking such data
with the information included in the registry as described in
subparagraph (A), including, to the extent feasible, use of--
``(i) data provided to the Secretary under other provisions
of this chapter; and
``(ii) information from public and private sources
identified under paragraph (3);
``(C) integrating the activities described in this
subsection (so as to avoid duplication) with--
``(i) activities under paragraph (3) of section 505(k)
(relating to active postmarket risk identification);
``(ii) activities under paragraph (4) of section 505(k)
(relating to advanced analysis of drug safety data);
``(iii) other postmarket device surveillance activities of
the Secretary authorized by this chapter; and
``(iv) registries carried out by or for the Agency for
Healthcare Research and Quality; and
``(D) providing public access to the data and analysis
collected or developed through the registry in a manner and
form that protects patient privacy and proprietary
information and is comprehensive, useful, and not misleading
to patients, physicians, and scientists.
``(3)(A) To facilitate analyses of postmarket safety and
patient outcomes for covered devices, the Secretary shall, in
collaboration with public, academic, and private entities,
develop methods to--
``(i) obtain access to disparate sources of patient safety
and outcomes data, including--
``(I) Federal health-related electronic data (such as data
from the Medicare program under title XVIII of the Social
Security Act or from the health systems of the Department of
Veterans Affairs);
``(II) private sector health-related electronic data (such
as pharmaceutical purchase data and health insurance claims
data); and
``(III) other data as the Secretary deems necessary to
permit postmarket assessment of device safety and
effectiveness; and
``(ii) link data obtained under clause (i) with information
in the registry.
``(B) In this paragraph, the term `data' refers to
information respecting a covered device, including claims
data, patient survey data, standardized analytic files that
allow for the pooling and analysis of data from disparate
data environments, electronic health records, and any other
data deemed appropriate by the Secretary.
``(4) The Secretary shall promulgate regulations for
establishment and operation of the registry under paragraph
(1). Such regulations--
``(A)(i) in the case of covered devices that are sold on or
after the date of the enactment of this subsection, shall
require manufacturers of such devices to submit information
to the registry, including, for each such device, the type,
model, and serial number or, if required under subsection
(f), other unique device identifier; and
``(ii) in the case of covered devices that are sold before
such date, may require manufacturers of such devices to
submit such information to the registry, if deemed necessary
by the Secretary to protect the public health;
``(B) shall establish procedures--
``(i) to permit linkage of information submitted pursuant
to subparagraph (A) with patient safety and outcomes data
obtained under paragraph (3); and
``(ii) to permit analyses of linked data;
``(C) may require covered device manufacturers to submit
such other information as is necessary to facilitate
postmarket assessments of device safety and effectiveness and
notification of device risks;
``(D) shall establish requirements for regular and timely
reports to the Secretary, which shall be included in the
registry, concerning adverse event trends, adverse event
patterns, incidence and prevalence of adverse events, and
other information the Secretary determines appropriate, which
may include data on comparative safety and outcomes trends;
and
``(E) shall establish procedures to permit public access to
the information in the registry in a manner and form that
protects patient privacy and proprietary information

[[Page H12782]]

and is comprehensive, useful, and not misleading to patients,
physicians, and scientists.
``(5)(A) The Secretary shall promulgate final regulations
under paragraph (4) not later than 36 months after the date
of the enactment of this subsection.
``(B) Before issuing the notice of proposed rulemaking
preceding the final regulations described in subparagraph
(A), the Secretary shall hold a public hearing before an
advisory committee on the issue of which class II devices to
include in the definition of covered devices.
``(C) The Secretary shall include in any regulation under
this subsection an explanation demonstrating that the
requirements of such regulation--
``(i) do not duplicate other Federal requirements; and
``(ii) do not impose an undue burden on device
manufacturers.
``(6) With respect to any entity that submits or is
required to submit a safety report or other information in
connection with the safety of a device under this section
(and any release by the Secretary of that report or
information), such report or information shall not be
construed to reflect necessarily a conclusion by the entity
or the Secretary that the report or information constitutes
an admission that the product involved malfunctioned, caused
or contributed to an adverse experience, or otherwise caused
or contributed to a death, serious injury, or serious
illness. Such an entity need not admit, and may deny, that
the report or information submitted by the entity constitutes
an admission that the product involved malfunctioned, caused
or contributed to an adverse experience, or caused or
contributed to a death, serious injury, or serious illness.
``(7) To carry out this subsection, there are authorized to
be appropriated such sums as may be necessary for each of
fiscal years 2011 and 2012.''.
(2) Effective date.--The Secretary of Health and Human
Services shall establish and begin implementation of the
registry under section 519(g) of the Federal Food, Drug, and
Cosmetic Act, as added by paragraph (1), by not later than
the date that is 36 months after the date of the enactment of
this Act, without regard to whether or not final regulations
to establish and operate the registry have been promulgated
by such date.
(3) Conforming amendment.--Section 303(f)(1)(B)(ii) of the
Federal Food, Drug, and Cosmetic Act (21 U.S.C.
333(f)(1)(B)(ii)) is amended by striking ``519(g)'' and
inserting ``519(h)''.
(b) Electronic Exchange and Use in Certified Electronic
Health Records of Unique Device Identifiers.--
(1) Recommendations.--The HIT Policy Committee established
under section 3002 of the Public Health Service Act (42
U.S.C. 300jj-12) shall recommend to the head of the Office of
the National Coordinator for Health Information Technology
standards, implementation specifications, and certification
criteria for the electronic exchange and use in certified
electronic health records of a unique device identifier for
each covered device (as defined under section 519(g)(1)(B) of
the Federal Food, Drug, and Cosmetic Act, as added by
subsection (a)).
(2) Standards, implementation criteria, and certification
criteria.--The Secretary of Health and Human Services, acting
through the head of the Office of the National Coordinator
for Health Information Technology, shall adopt standards,
implementation specifications, and certification criteria for
the electronic exchange and use in certified electronic
health records of a unique device identifier for each covered
device referred to in paragraph (1), if such an identifier is
required by section 519(f) of the Federal Food, Drug, and
Cosmetic Act (21 U.S.C. 360i(f)) for the device.
(c) Unique Device Identification System.--The Secretary of
Health and Human Services, acting through the Commissioner of
Food and Drugs, shall issue proposed regulations to implement
section 519(f) of the Federal Food, Drug, and Cosmetic Act
(21 U.S.C. 360i(f)) not later than 6 months after the date of
the enactment of this Act.

SEC. 2572. NUTRITION LABELING OF STANDARD MENU ITEMS AT CHAIN
RESTAURANTS AND OF ARTICLES OF FOOD SOLD FROM
VENDING MACHINES.

(a) Technical Amendments.--Section 403(q)(5)(A) of the
Federal Food, Drug, and Cosmetic Act (21 U.S.C. 343(q)(5)(A))
is amended--
(1) in subclause (i), by inserting ``except as provided in
clause (H)(ii)(III),'' after ``(i)'' ; and
(2) in subclause (ii), by inserting ``except as provided in
clause (H)(ii)(III),'' after ``(ii)''.
(b) Labeling Requirements.--Section 403(q)(5) of the
Federal Food, Drug, and Cosmetic Act (21 U.S.C. 343(q)(5)) is
amended by adding at the end the following:
``(H) Restaurants, Retail Food Establishments, and Vending
Machines.--
``(i) General requirements for restaurants and similar
retail food establishments.--Except for food described in
subclause (vii), in the case of food that is a standard menu
item that is offered for sale in a restaurant or similar
retail food establishment that is part of a chain with 20 or
more locations doing business under the same name (regardless
of the type of ownership of the locations) and offering for
sale substantially the same menu items, the restaurant or
similar retail food establishment shall disclose the
information described in subclauses (ii) and (iii).
``(ii) Information required to be disclosed by restaurants
and retail food establishments.--Except as provided in
subclause (vii), the restaurant or similar retail food
establishment shall disclose in a clear and conspicuous
manner--
``(I)(aa) in a nutrient content disclosure statement
adjacent to the name of the standard menu item, so as to be
clearly associated with the standard menu item, on the menu
listing the item for sale, the number of calories contained
in the standard menu item, as usually prepared and offered
for sale; and
``(bb) a succinct statement concerning suggested daily
caloric intake, as specified by the Secretary by regulation
and posted prominently on the menu and designed to enable the
public to understand, in the context of a total daily diet,
the significance of the caloric information that is provided
on the menu;
``(II)(aa) in a nutrient content disclosure statement
adjacent to the name of the standard menu item, so as to be
clearly associated with the standard menu item, on the menu
board, including a drive-through menu board, the number of
calories contained in the standard menu item, as usually
prepared and offered for sale; and
``(bb) a succinct statement concerning suggested daily
caloric intake, as specified by the Secretary by regulation
and posted prominently on the menu board, designed to enable
the public to understand, in the context of a total daily
diet, the significance of the nutrition information that is
provided on the menu board;
``(III) in a written form, available on the premises of the
restaurant or similar retail establishment and to the
consumer upon request, the nutrition information required
under clauses (C) and (D) of subparagraph (1); and
``(IV) on the menu or menu board, a prominent, clear, and
conspicuous statement regarding the availability of the
information described in item (III).
``(iii) Self-service food and food on display.--Except as
provided in subclause (vii), in the case of food sold at a
salad bar, buffet line, cafeteria line, or similar self-
service facility, and for self-service beverages or food that
is on display and that is visible to customers, a restaurant
or similar retail food establishment shall place adjacent to
each food offered a sign that lists calories per displayed
food item or per serving.
``(iv) Reasonable basis.--For the purposes of this clause,
a restaurant or similar retail food establishment shall have
a reasonable basis for its nutrient content disclosures,
including nutrient databases, cookbooks, laboratory analyses,
and other reasonable means, as described in section 101.10 of
title 21, Code of Federal Regulations (or any successor
regulation) or in a related guidance of the Food and Drug
Administration.
``(v) Menu variability and combination meals.--The
Secretary shall establish by regulation standards for
determining and disclosing the nutrient content for standard
menu items that come in different flavors, varieties, or
combinations, but which are listed as a single menu item,
such as soft drinks, ice cream, pizza, doughnuts, or
children's combination meals, through means determined by the
Secretary, including ranges, averages, or other methods.
``(vi) Additional information.--If the Secretary determines
that a nutrient, other than a nutrient required under
subclause (ii)(III), should be disclosed for the purpose of
providing information to assist consumers in maintaining
healthy dietary practices, the Secretary may require, by
regulation, disclosure of such nutrient in the written form
required under subclause (ii)(III).
``(vii) Nonapplicability to certain food.--
``(I) In general.--Subclauses (i) through (vi) do not apply
to--
``(aa) items that are not listed on a menu or menu board
(such as condiments and other items placed on the table or
counter for general use);
``(bb) daily specials, temporary menu items appearing on
the menu for less than 60 days per calendar year, or custom
orders; or
``(cc) such other food that is part of a customary market
test appearing on the menu for less than 90 days, under terms
and conditions established by the Secretary.
``(II) Written forms.--Clause (C) shall apply to any
regulations promulgated under subclauses (ii)(III) and (vi).
``(viii) Vending machines.--In the case of an article of
food sold from a vending machine that--
``(I) does not permit a prospective purchaser to examine
the Nutrition Facts Panel before purchasing the article or
does not otherwise provide visible nutrition information at
the point of purchase; and
``(II) is operated by a person who is engaged in the
business of owning or operating 20 or more vending machines,
the vending machine operator shall provide a sign in close
proximity to each article of food or the selection button
that includes a clear and conspicuous statement disclosing
the number of calories contained in the article.
``(ix) Voluntary provision of nutrition information.--
``(I) In general.--An authorized official of any restaurant
or similar retail food establishment or vending machine
operator not subject to the requirements of this clause may
elect to be subject to the requirements of such clause, by
registering biannually the

[[Page H12783]]

name and address of such restaurant or similar retail food
establishment or vending machine operator with the Secretary,
as specified by the Secretary by regulation.
``(II) Registration.--Within 120 days of the enactment of
this clause, the Secretary shall publish a notice in the
Federal Register specifying the terms and conditions for
implementation of item (I), pending promulgation of
regulations.
``(III) Rule of construction.--Nothing in this subclause
shall be construed to authorize the Secretary to require an
application, review, or licensing process for any entity to
register with the Secretary, as described in such item.
``(x) Regulations.--
``(I) Proposed regulation.--Not later than 1 year after the
date of the enactment of this clause, the Secretary shall
promulgate proposed regulations to carry out this clause.
``(II) Contents.--In promulgating regulations, the
Secretary shall--
``(aa) consider standardization of recipes and methods of
preparation, reasonable variation in serving size and
formulation of menu items, space on menus and menu boards,
inadvertent human error, training of food service workers,
variations in ingredients, and other factors, as the
Secretary determines; and
``(bb) specify the format and manner of the nutrient
content disclosure requirements under this subclause.
``(III) Reporting.--The Secretary shall submit to the
Committee on Health, Education, Labor, and Pensions of the
Senate and the Committee on Energy and Commerce of the House
of Representatives a quarterly report that describes the
Secretary's progress toward promulgating final regulations
under this subparagraph.
``(xi) Definition.--In this clause, the term `menu' or
`menu board' means the primary writing of the restaurant or
other similar retail food establishment from which a consumer
makes an order selection.''.
(c) National Uniformity.--Section 403A(a)(4) of the Federal
Food, Drug, and Cosmetic Act (21 U.S.C. 343-1(a)(4)) is
amended by striking ``except a requirement for nutrition
labeling of food which is exempt under subclause (i) or (ii)
of section 403(q)(5)(A)'' and inserting ``except that this
paragraph does not apply to food that is offered for sale in
a restaurant or similar retail food establishment that is not
part of a chain with 20 or more locations doing business
under the same name (regardless of the type of ownership of
the locations) and offering for sale substantially the same
menu items unless such restaurant or similar retail food
establishment complies with the voluntary provision of
nutrition information requirements under section
403(q)(5)(H)(ix)''.
(d) Rule of Construction.--Nothing in the amendments made
by this section shall be construed--
(1) to preempt any provision of State or local law, unless
such provision establishes or continues into effect nutrient
content disclosures of the type required under section
403(q)(5)(H) of the Federal Food, Drug, and Cosmetic Act (as
added by subsection (b)) and is expressly preempted under
section 403A(a)(4) of such Act;
(2) to apply to any State or local requirement respecting a
statement in the labeling of food that provides for a warning
concerning the safety of the food or component of the food;
or
(3) except as provided in section 403(q)(5)(H)(ix) of the
Federal Food, Drug, and Cosmetic Act (as added by subsection
(b)), to apply to any restaurant or similar retail food
establishment other than a restaurant or similar retail food
establishment described in section 403(q)(5)(H)(i) of such
Act.

SEC. 2573. PROTECTING CONSUMER ACCESS TO GENERIC DRUGS.

(a) Findings; Purpose.--
(1) Findings.--The Congress finds the following:
(A) In 1984, the Drug Price Competition and Patent Term
Restoration Act (Pub. L. 98-417; in this subsection referred
to as the ``1984 Act'') was enacted with the intent of
facilitating the early entry of generic drugs while
preserving incentives for innovation.
(B) Prescription drugs make up 10 percent of national
health care spending, but for the past decade have been one
of the fastest growing segments of health care expenditures.
(C) Until recently, the 1984 Act was successful in
facilitating generic competition to the benefit of consumers
and health care payers--although 67 percent of all
prescriptions dispensed in the United States are generic
drugs, they account for only 20 percent of all expenditures.
(D) In recent years, the intent of the 1984 Act has been
subverted by certain settlement agreements between brand
companies and their potential generic competitors that make
reverse payments, i.e., payments by the brand company to the
generic company.
(E) These settlement agreements have unduly delayed the
marketing of low-cost generic drugs contrary to free
competition and the interests of consumers.
(F) The state of antitrust law relating to such settlement
agreements is unsettled.
(2) Purpose.--The purpose of this section is to provide an
additional means to effectuate the intent of the 1984 Act by
enhancing competition in the pharmaceutical market by
stopping agreements between brand name and generic drug
manufacturers that limit, delay, or otherwise prevent
competition from generic drugs.
(b) In General.--Section 505 of the Federal Food, Drug, and
Cosmetic Act (21 U.S.C. 355) is amended by adding at the end
the following:
``(w) Protecting Consumer Access to Generic Drugs.--
``(1) Unfair and deceptive acts and practices related to
new drug applications.--
``(A) Conduct prohibited.--It shall be unlawful for any
person to directly or indirectly be a party to any agreement
resolving or settling a patent infringement claim in which--
``(i) an ANDA filer receives anything of value; and
``(ii) the ANDA filer agrees to limit or forego research,
development, manufacturing, marketing, or sales, for any
period of time, of the drug that is to be manufactured under
the ANDA involved and is the subject of the patent
infringement claim.
``(B) Exceptions.--Notwithstanding subparagraph (A)(i),
subparagraph (A) does not prohibit a resolution or settlement
of a patent infringement claim in which the value received by
the ANDA filer includes no more than--
``(i) the right to market the drug that is to be
manufactured under the ANDA involved and is the subject of
the patent infringement claim, before the expiration of--

``(I) the patent that is the basis for the patent
infringement claim; or
``(II) any other statutory exclusivity that would prevent
the marketing of such drug; and

``(ii) the waiver of a patent infringement claim for
damages based on prior marketing of such drug.
``(C) Enforcement.--
``(i) In general.--A violation of subparagraph (A) shall be
treated as an unfair and deceptive act or practice and an
unfair method of competition in or affecting interstate
commerce prohibited under section 5 of the Federal Trade
Commission Act and shall be enforced by the Federal Trade
Commission in the same manner, by the same means, and with
the same jurisdiction as though all applicable terms and
provisions of the Federal Trade Commission Act were
incorporated into and made a part of this subsection.
``(ii) Inapplicability.--Subchapter A of chapter VII shall
not apply with respect to this subsection.
``(D) Definitions.--In this subsection:
``(i) Agreement.--The term `agreement' means anything that
would constitute an agreement under section 5 of the Federal
Trade Commission Act.
``(ii) Agreement resolving or settling.--The term
`agreement resolving or settling', in reference to a patent
infringement claim, includes any agreement that is contingent
upon, provides a contingent condition for, or is otherwise
related to the resolution or settlement of the claim.
``(iii) ANDA.--The term `ANDA' means an abbreviated new
drug application for the approval of a new drug under section
(j).
``(iv) ANDA filer.--The term `ANDA filer' means a party
that has filed an ANDA with the Food and Drug Administration.
``(v) Patent infringement.--The term `patent infringement'
means infringement of any patent or of any filed patent
application, extension, reissuance, renewal, division,
continuation, continuation in part, reexamination, patent
term restoration, patent of addition, or extension thereof.
``(vi) Patent infringement claim.--The term `patent
infringement claim' means any allegation made to an ANDA
filer, whether or not included in a complaint filed with a
court of law, that its ANDA or drug to be manufactured under
such ANDA may infringe any patent.
``(2) FTC rulemaking.--The Federal Trade Commission may, by
rule promulgated under section 553 of title 5, United States
Code, exempt certain agreements described in paragraph (1)
from the requirements of this subsection if the Commission
finds such agreements to be in furtherance of market
competition and for the benefit of consumers. Consistent with
the authority of the Commission, such rules may include
interpretive rules and general statements of policy with
respect to the practices prohibited under paragraph (1).''.
(c) Notice and Certification of Agreements.--
(1) Notice of all agreements.--Section 1112(c)(2) of the
Medicare Prescription Drug, Improvement, and Modernization
Act of 2003 (21 U.S.C. 3155 note) is amended by--
(A) striking ``the Commission the'' and inserting the
following: ``the Commission--
``(A) the'';
(B) striking the period at the end and inserting ``; and'';
and
(C) adding at the end the following:
``(B) any other agreement the parties enter into within 30
days of entering into an agreement covered by subsection (a)
or (b).''.
(2) Certification of agreements.--Section 1112 of such Act
is amended by adding at the end the following:
``(d) Certification.--The chief executive officer or the
company official responsible for negotiating any agreement
required to be filed under subsection (a), (b), or (c) shall
execute and file with the Assistant Attorney General and the
Commission a certification as follows: `I declare under
penalty of perjury that the following is true and correct:
The materials filed with the Federal Trade Commission and the
Department of Justice under section 1112 of subtitle B of
title XI of the Medicare Prescription Drug, Improvement, and
Modernization Act of 2003, with

[[Page H12784]]

respect to the agreement referenced in this certification:
(1) represent the complete, final, and exclusive agreement
between the parties; (2) include any ancillary agreements
that are contingent upon, provide a contingent condition for,
or are otherwise related to, the referenced agreement; and
(3) include written descriptions of any oral agreements,
representations, commitments, or promises between the parties
that are responsive to subsection (a) or (b) of such section
1112 and have not been reduced to writing.'.''.
(d) GAO Study.--
(1) Study.--Beginning 2 years after the date of enactment
of this Act, and each year for a period of 4 years
thereafter, the Comptroller General shall conduct a study on
the litigation in United States courts during the period
beginning 5 years prior to the date of enactment of this Act
relating to patent infringement claims involving generic
drugs, the number of patent challenges initiated by
manufacturers of generic drugs, and the number of settlements
of such litigation. The Comptroller General shall transmit to
Congress a report of the findings of such a study and an
analysis of the effect of the amendments made by subsections
(b) and (c) on such litigation, whether such amendments have
had an effect on the number and frequency of claims settled,
and whether such amendments resulted in earlier or delayed
entry of generic drugs to market, including whether any harm
or benefit to consumers has resulted.
(2) Disclosure of agreements.--Notwithstanding any other
law, agreements filed under section 1112 of the Medicare
Prescription Drug, Improvement, and Modernization Act of 2003
(21 U.S.C. 355 note), or unaggregated information from such
agreements, shall be disclosed to the Comptroller General for
purposes of the study under paragraph (1) within 30 days of a
request by the Comptroller General.

PART 2--BIOSIMILARS

SEC. 2575. LICENSURE PATHWAY FOR BIOSIMILAR BIOLOGICAL
PRODUCTS.

(a) Licensure of Biological Products as Biosimilar or
Interchangeable.--Section 351 of the Public Health Service
Act (42 U.S.C. 262) is amended--
(1) in subsection (a)(1)(A), by inserting ``under this
subsection or subsection (k)'' after ``biologics license'';
and
(2) by adding at the end the following:
``(k) Licensure of Biological Products as Biosimilar or
Interchangeable.--
``(1) In general.--Any person may submit an application for
licensure of a biological product under this subsection.
``(2) Content.--
``(A) In general.--
``(i) Required information.--An application submitted under
this subsection shall include information demonstrating
that--

``(I) the biological product is biosimilar to a reference
product based upon data derived from--

``(aa) analytical studies that demonstrate that the
biological product is highly similar to the reference product
notwithstanding minor differences in clinically inactive
components;
``(bb) animal studies (including the assessment of
toxicity); and
``(cc) a clinical study or studies (including the
assessment of immunogenicity and pharmacokinetics or
pharmacodynamics) that are sufficient to demonstrate safety,
purity, and potency in 1 or more appropriate conditions of
use for which the reference product is licensed and intended
to be used and for which licensure is sought for the
biological product;

``(II) the biological product and reference product utilize
the same mechanism or mechanisms of action for the condition
or conditions of use prescribed, recommended, or suggested in
the proposed labeling, but only to the extent the mechanism
or mechanisms of action are known for the reference product;
``(III) the condition or conditions of use prescribed,
recommended, or suggested in the labeling proposed for the
biological product have been previously approved for the
reference product;
``(IV) the route of administration, the dosage form, and
the strength of the biological product are the same as those
of the reference product; and
``(V) the facility in which the biological product is
manufactured, processed, packed, or held meets standards
designed to assure that the biological product continues to
be safe, pure, and potent.

``(ii) Determination by secretary.--The Secretary may
determine, in the Secretary's discretion, that an element
described in clause (i)(I) is unnecessary in an application
submitted under this subsection.
``(iii) Additional information.--An application submitted
under this subsection--

``(I) shall include publicly available information
regarding the Secretary's previous determination that the
reference product is safe, pure, and potent; and
``(II) may include any additional information in support of
the application, including publicly available information
with respect to the reference product or another biological
product.

``(B) Interchangeability.--An application (or a supplement
to an application) submitted under this subsection may
include information demonstrating that the biological product
meets the standards described in paragraph (4).
``(3) Evaluation by secretary.--Upon review of an
application (or a supplement to an application) submitted
under this subsection, the Secretary shall license the
biological product under this subsection if--
``(A) the Secretary determines that the information
submitted in the application (or the supplement) is
sufficient to show that the biological product--
``(i) is biosimilar to the reference product; or
``(ii) meets the standards described in paragraph (4), and
therefore is interchangeable with the reference product; and
``(B) the applicant (or other appropriate person) consents
to the inspection of the facility that is the subject of the
application, in accordance with subsection (c).
``(4) Safety standards for determining
interchangeability.--Upon review of an application submitted
under this subsection or any supplement to such application,
the Secretary shall determine the biological product to be
interchangeable with the reference product if the Secretary
determines that the information submitted in the application
(or a supplement to such application) is sufficient to show
that--
``(A) the biological product--
``(i) is biosimilar to the reference product; and
``(ii) can be expected to produce the same clinical result
as the reference product in any given patient; and
``(B) for a biological product that is administered more
than once to an individual, the risk in terms of safety or
diminished efficacy of alternating or switching between use
of the biological product and the reference product is not
greater than the risk of using the reference product without
such alternation or switch.
``(5) General rules.--
``(A) One reference product per application.--A biological
product, in an application submitted under this subsection,
may not be evaluated against more than 1 reference product.
``(B) Review.--An application submitted under this
subsection shall be reviewed by the division within the Food
and Drug Administration that is responsible for the review
and approval of the application under which the reference
product is licensed.
``(C) Risk evaluation and mitigation strategies.--The
authority of the Secretary with respect to risk evaluation
and mitigation strategies under the Federal Food, Drug, and
Cosmetic Act shall apply to biological products licensed
under this subsection in the same manner as such authority
applies to biological products licensed under subsection (a).
``(D) Restrictions on biological products containing
dangerous ingredients.--If information in an application
submitted under this subsection, in a supplement to such an
application, or otherwise available to the Secretary shows
that a biological product--
``(i) is, bears, or contains a select agent or toxin listed
in section 73.3 or 73.4 of title 42, section 121.3 or 121.4
of title 9, or section 331.3 of title 7, Code of Federal
Regulations (or any successor regulations); or
``(ii) is, bears, or contains a controlled substance in
schedule I or II of section 202 of the Controlled Substances
Act, as listed in part 1308 of title 21, Code of Federal
Regulations (or any successor regulations);
the Secretary shall not license the biological product under
this subsection unless the Secretary determines, after
consultation with appropriate national security and drug
enforcement agencies, that there would be no increased risk
to the security or health of the public from licensing such
biological product under this subsection.
``(6) Exclusivity for first interchangeable biological
product.--Upon review of an application submitted under this
subsection relying on the same reference product for which a
prior biological product has received a determination of
interchangeability for any condition of use, the Secretary
shall not make a determination under paragraph (4) that the
second or subsequent biological product is interchangeable
for any condition of use until the earlier of--
``(A) 1 year after the first commercial marketing of the
first interchangeable biosimilar biological product to be
approved as interchangeable for that reference product;
``(B) 18 months after--
``(i) a final court decision on all patents in suit in an
action instituted under subsection (l)(5) against the
applicant that submitted the application for the first
approved interchangeable biosimilar biological product; or
``(ii) the dismissal with or without prejudice of an action
instituted under subsection (l)(5) against the applicant that
submitted the application for the first approved
interchangeable biosimilar biological product; or
``(C)(i) 42 months after approval of the first
interchangeable biosimilar biological product if the
applicant that submitted such application has been sued under
subsection (l)(5) and such litigation is still ongoing within
such 42-month period; or
``(ii) 18 months after approval of the first
interchangeable biosimilar biological product if the
applicant that submitted such application has not been sued
under subsection (l)(5).

For purposes of this paragraph, the term `final court
decision' means a final decision of a court from which no
appeal (other than a petition to the United States Supreme
Court for a writ of certiorari) has been or can be taken.
``(7) Exclusivity for reference product.--

[[Page H12785]]

``(A) Effective date of biosimilar application approval.--
Approval of an application under this subsection may not be
made effective by the Secretary until the date that is 12
years after the date on which the reference product was first
licensed under subsection (a).
``(B) Filing period.--An application under this subsection
may not be submitted to the Secretary until the date that is
4 years after the date on which the reference product was
first licensed under subsection (a).
``(C) First licensure.--Subparagraphs (A) and (B) shall not
apply to a license for or approval of--
``(i) a supplement for the biological product that is the
reference product; or
``(ii) a subsequent application filed by the same sponsor
or manufacturer of the biological product that is the
reference product (or a licensor, predecessor in interest, or
other related entity) for--

``(I) a change (not including a modification to the
structure of the biological product) that results in a new
indication, route of administration, dosing schedule, dosage
form, delivery system, delivery device, or strength; or
``(II) a modification to the structure of the biological
product that does not result in a change in safety, purity,
or potency.

``(8) Pediatric studies.--
``(A) Exclusivity.--If, before or after licensure of the
reference product under subsection (a) of this section, the
Secretary determines that information relating to the use of
such product in the pediatric population may produce health
benefits in that population, the Secretary makes a written
request for pediatric studies (which shall include a
timeframe for completing such studies), the applicant or
holder of the approved application agrees to the request,
such studies are completed using appropriate formulations for
each age group for which the study is requested within any
such timeframe, and the reports thereof are submitted and
accepted in accordance with section 505A(d)(3) of the Federal
Food, Drug, and Cosmetic Act the period referred to in
paragraph (7)(A) of this subsection is deemed to be 12 years
and 6 months rather than 12 years.
``(B) Exception.--The Secretary shall not extend the period
referred to in subparagraph (A) of this paragraph if the
determination under section 505A(d)(3) of the Federal Food,
Drug, and Cosmetic Act is made later than 9 months prior to
the expiration of such period.
``(C) Application of certain provisions.--The provisions of
subsections (a), (d), (e), (f), (h), (j), (k), and (l) of
section 505A of the Federal Food, Drug, and Cosmetic Act
shall apply with respect to the extension of a period under
subparagraph (A) of this paragraph to the same extent and in
the same manner as such provisions apply with respect to the
extension of a period under subsection (b) or (c) of section
505A of the Federal Food, Drug, and Cosmetic Act.
``(9) Guidance documents.--
``(A) In general.--The Secretary may, after opportunity for
public comment, issue guidance in accordance, except as
provided in subparagraph (B)(i), with section 701(h) of the
Federal Food, Drug, and Cosmetic Act with respect to the
licensure of a biological product under this subsection. Any
such guidance may be general or specific.
``(B) Public comment.--
``(i) In general.--The Secretary shall provide the public
an opportunity to comment on any proposed guidance issued
under subparagraph (A) before issuing final guidance.
``(ii) Input regarding most valuable guidance.--The
Secretary shall establish a process through which the public
may provide the Secretary with input regarding priorities for
issuing guidance.
``(C) No requirement for application consideration.--The
issuance (or non-issuance) of guidance under subparagraph (A)
shall not preclude the review of, or action on, an
application submitted under this subsection.
``(D) Requirement for product class-specific guidance.--If
the Secretary issues product class-specific guidance under
subparagraph (A), such guidance shall include a description
of--
``(i) the criteria that the Secretary will use to determine
whether a biological product is highly similar to a reference
product in such product class; and
``(ii) the criteria, if available, that the Secretary will
use to determine whether a biological product meets the
standards described in paragraph (4).
``(E) Certain product classes.--
``(i) Guidance.--The Secretary may indicate in a guidance
document that the science and experience, as of the date of
such guidance, with respect to a product or product class
(not including any recombinant protein) does not allow
approval of an application for a license as provided under
this subsection for such product or product class.
``(ii) Modification or reversal.--The Secretary may issue a
subsequent guidance document under subparagraph (A) to modify
or reverse a guidance document under clause (i).
``(iii) No effect on ability to deny license.--Clause (i)
shall not be construed to require the Secretary to approve a
product with respect to which the Secretary has not indicated
in a guidance document that the science and experience, as
described in clause (i), does not allow approval of such an
application.
``(10) Naming.--The Secretary shall ensure that the
labeling and packaging of each biological product licensed
under this subsection bears a name that uniquely identifies
the biological product and distinguishes it from the
reference product and any other biological products licensed
under this subsection following evaluation against such
reference product.
``(l) Patent Notices; Relationship to Final Approval.--
``(1) Definitions.--For the purposes of this subsection,
the term--
``(A) `biosimilar product' means the biological product
that is the subject of the application under subsection (k);
``(B) `relevant patent' means a patent that--
``(i) expires after the date specified in subsection
(k)(7)(A) that applies to the reference product; and
``(ii) could reasonably be asserted against the applicant
due to the unauthorized making, use, sale, or offer for sale
within the United States, or the importation into the United
States of the biosimilar product, or materials used in the
manufacture of the biosimilar product, or due to a use of the
biosimilar product in a method of treatment that is indicated
in the application;
``(C) `reference product sponsor' means the holder of an
approved application or license for the reference product;
and
``(D) `interested third party' means a person other than
the reference product sponsor that owns a relevant patent, or
has the right to commence or participate in an action for
infringement of a relevant patent.
``(2) Handling of confidential information.--Any entity
receiving confidential information pursuant to this
subsection shall designate one or more individuals to receive
such information. Each individual so designated shall execute
an agreement in accordance with regulations promulgated by
the Secretary. The regulations shall require each such
individual to take reasonable steps to maintain the
confidentiality of information received pursuant to this
subsection and use the information solely for purposes
authorized by this subsection. The obligations imposed on an
individual who has received confidential information pursuant
to this subsection shall continue until the individual
returns or destroys the confidential information, a court
imposes a protective order that governs the use or handling
of the confidential information, or the party providing the
confidential information agrees to other terms or conditions
regarding the handling or use of the confidential
information.
``(3) Public notice by secretary.--Within 30 days of
acceptance by the Secretary of an application filed under
subsection (k), the Secretary shall publish a notice
identifying--
``(A) the reference product identified in the application;
and
``(B) the name and address of an agent designated by the
applicant to receive notices pursuant to paragraph (4)(B).
``(4) Exchanges concerning patents.--
``(A) Exchanges with reference product sponsor.--
``(i) Within 30 days of the date of acceptance of the
application by the Secretary, the applicant shall provide the
reference product sponsor with a copy of the application and
information concerning the biosimilar product and its
production. This information shall include a detailed
description of the biosimilar product, its method of
manufacture, and the materials used in the manufacture of the
product.
``(ii) Within 60 days of the date of receipt of the
information required to be provided under clause (i), the
reference product sponsor shall provide to the applicant a
list of relevant patents owned by the reference product
sponsor, or in respect of which the reference product sponsor
has the right to commence an action of infringement or
otherwise has an interest in the patent as such patent
concerns the biosimilar product.
``(iii) If the reference product sponsor is issued or
acquires an interest in a relevant patent after the date on
which the reference product sponsor provides the list
required by clause (ii) to the applicant, the reference
product sponsor shall identify that patent to the applicant
within 30 days of the date of issue of the patent, or the
date of acquisition of the interest in the patent, as
applicable.
``(B) Exchanges with interested third parties.--
``(i) At any time after the date on which the Secretary
publishes a notice for an application under paragraph (3),
any interested third party may provide notice to the
designated agent of the applicant that the interested third
party owns or has rights under 1 or more patents that may be
relevant patents. The notice shall identify at least 1 patent
and shall designate an individual who has executed an
agreement in accordance with paragraph (2) to receive
confidential information from the applicant.
``(ii) Within 30 days of the date of receiving notice
pursuant to clause (i), the applicant shall send to the
individual designated by the interested third party the
information specified in subparagraph (A)(i), unless the
applicant and interested third party otherwise agree.
``(iii) Within 90 days of the date of receiving information
pursuant to clause (ii), the interested third party shall
provide to the applicant a list of relevant patents which the
interested third party owns, or in respect of which the
interested third party has the right to commence or
participate in an action for infringement.
``(iv) If the interested third party is issued or acquires
an interest in a relevant patent

[[Page H12786]]

after the date on which the interested third party provides
the list required by clause (iii), the interested third party
shall identify that patent within 30 days of the date of
issue of the patent, or the date of acquisition of the
interest in the patent, as applicable.
``(C) Identification of basis for infringement.--For any
patent identified under clause (ii) or (iii) of subparagraph
(A) or under clause (iii) or (iv) of subparagraph (B), the
reference product sponsor or the interested third party, as
applicable--
``(i) shall explain in writing why the sponsor or the
interested third party believes the relevant patent would be
infringed by the making, use, sale, or offer for sale within
the United States, or importation into the United States, of
the biosimilar product or by a use of the biosimilar product
in treatment that is indicated in the application;
``(ii) may specify whether the relevant patent is available
for licensing; and
``(iii) shall specify the number and date of expiration of
the relevant patent.
``(D) Certification by applicant concerning identified
relevant patents.--Not later than 45 days after the date on
which a patent is identified under clause (ii) or (iii) of
subparagraph (A) or under clause (iii) or (iv) of
subparagraph (B), the applicant shall send a written
statement regarding each identified patent to the party that
identified the patent. Such statement shall either--
``(i) state that the applicant will not commence marketing
of the biosimilar product and has requested the Secretary to
not grant final approval of the application before the date
of expiration of the noticed patent; or
``(ii) provide a detailed written explanation setting forth
the reasons why the applicant believes--

``(I) the making, use, sale, or offer for sale within the
United States, or the importation into the United States, of
the biosimilar product, or the use of the biosimilar product
in a treatment indicated in the application, would not
infringe the patent; or
``(II) the patent is invalid or unenforceable.

``(5) Action for infringement involving reference product
sponsor.--If an action for infringement concerning a relevant
patent identified by the reference product sponsor under
clause (ii) or (iii) of paragraph (4)(A), or by an interested
third party under clause (iii) or (iv) of paragraph (4)(B),
is brought within 60 days of the date of receipt of a
statement under paragraph (4)(D)(ii), and the court in which
such action has been commenced determines the patent is
infringed prior to the date applicable under subsection
(k)(7)(A) or (k)(8), the Secretary shall make approval of the
application effective on the day after the date of expiration
of the patent that has been found to be infringed. If more
than one such patent is found to be infringed by the court,
the approval of the application shall be made effective on
the day after the date that the last such patent expires.
``(6) Notification of agreements.--
``(A) Requirements.--
``(i) Agreement between biosimilar product applicant and
reference product sponsor.--If a biosimilar product applicant
under subsection (k) and the reference product sponsor enter
into an agreement described in subparagraph (B), the
applicant and sponsor shall each file the agreement in
accordance with subparagraph (C).
``(ii) Agreement between biosimilar product applicants.--If
2 or more biosimilar product applicants submit an application
under subsection (k) for biosimilar products with the same
reference product and enter into an agreement described in
subparagraph (B), the applicants shall each file the
agreement in accordance with subparagraph (C).
``(B) Subject matter of agreement.--An agreement described
in this subparagraph--
``(i) is an agreement between the biosimilar product
applicant under subsection (k) and the reference product
sponsor or between 2 or more biosimilar product applicants
under subsection (k) regarding the manufacture, marketing, or
sale of--

``(I) the biosimilar product (or biosimilar products) for
which an application was submitted; or
``(II) the reference product;

``(ii) includes any agreement between the biosimilar
product applicant under subsection (k) and the reference
product sponsor or between 2 or more biosimilar product
applicants under subsection (k) that is contingent upon,
provides a contingent condition for, or otherwise relates to
an agreement described in clause (i); and
``(iii) excludes any agreement that solely concerns--

``(I) purchase orders for raw material supplies;
``(II) equipment and facility contracts;
``(III) employment or consulting contracts; or
``(IV) packaging and labeling contracts.

``(C) Filing.--
``(i) In general.--The text of an agreement required to be
filed by subparagraph (A) shall be filed with the Assistant
Attorney General and the Federal Trade Commission not later
than--

``(I) 10 business days after the date on which the
agreement is executed; and
``(II) prior to the date of the first commercial marketing
of, for agreements described in subparagraph (A)(i), the
biosimilar product that is the subject of the application or,
for agreements described in subparagraph (A)(ii), any
biosimilar product that is the subject of an application
described in such subparagraph.

``(ii) If agreement not reduced to text.--If an agreement
required to be filed by subparagraph (A) has not been reduced
to text, the persons required to file the agreement shall
each file written descriptions of the agreement that are
sufficient to disclose all the terms and conditions of the
agreement.
``(iii) Certification.--The chief executive officer or the
company official responsible for negotiating any agreement
required to be filed by subparagraph (A) shall include in any
filing under this paragraph a certification as follows: `I
declare under penalty of perjury that the following is true
and correct: The materials filed with the Federal Trade
Commission and the Department of Justice under section
351(l)(6) of the Public Health Service Act, with respect to
the agreement referenced in this certification: (1) represent
the complete, final, and exclusive agreement between the
parties; (2) include any ancillary agreements that are
contingent upon, provide a contingent condition for, or are
otherwise related to, the referenced agreement; and (3)
include written descriptions of any oral agreements,
representations, commitments, or promises between the parties
that are responsive to such section and have not been reduced
to writing.'.
``(D) Disclosure exemption.--Any information or documentary
material filed with the Assistant Attorney General or the
Federal Trade Commission pursuant to this paragraph shall be
exempt from disclosure under section 552 of title 5, United
States Code, and no such information or documentary material
may be made public, except as may be relevant to any
administrative or judicial action or proceeding. Nothing in
this subparagraph prevents disclosure of information or
documentary material to either body of the Congress or to any
duly authorized committee or subcommittee of the Congress.
``(E) Enforcement.--
``(i) Civil penalty.--Any person that violates a provision
of this paragraph shall be liable for a civil penalty of not
more than $11,000 for each day on which the violation occurs.
Such penalty may be recovered in a civil action--

``(I) brought by the United States; or
``(II) brought by the Federal Trade Commission in
accordance with the procedures established in section
16(a)(1) of the Federal Trade Commission Act.

``(ii) Compliance and equitable relief.--If any person
violates any provision of this paragraph, the United States
district court may order compliance, and may grant such other
equitable relief as the court in its discretion determines
necessary or appropriate, upon application of the Assistant
Attorney General or the Federal Trade Commission.
``(F) Rulemaking.--The Federal Trade Commission, with the
concurrence of the Assistant Attorney General and by rule in
accordance with section 553 of title 5, United States Code,
consistent with the purposes of this paragraph--
``(i) may define the terms used in this paragraph;
``(ii) may exempt classes of persons or agreements from the
requirements of this paragraph; and
``(iii) may prescribe such other rules as may be necessary
and appropriate to carry out the purposes of this paragraph.
``(G) Savings clause.--Any action taken by the Assistant
Attorney General or the Federal Trade Commission, or any
failure of the Assistant Attorney General or the Commission
to take action, under this paragraph shall not at any time
bar any proceeding or any action with respect to any
agreement between a biosimilar product applicant under
subsection (k) and the reference product sponsor, or any
agreement between biosimilar product applicants under
subsection (k), under any other provision of law, nor shall
any filing under this paragraph constitute or create a
presumption of any violation of any competition laws.''.
(b) Definitions.--Section 351(i) of the Public Health
Service Act (42 U.S.C. 262(i)) is amended--
(1) by striking ``In this section, the term `biological
product' means'' and inserting the following: ``In this
section:
``(1) The term `biological product' means'';
(2) in paragraph (1), as so designated, by inserting
``protein (except any chemically synthesized polypeptide),''
after ``allergenic product,''; and
(3) by adding at the end the following:
``(2) The term `biosimilar' or `biosimilarity', in
reference to a biological product that is the subject of an
application under subsection (k), means--
``(A) that the biological product is highly similar to the
reference product notwithstanding minor differences in
clinically inactive components; and
``(B) there are no clinically meaningful differences
between the biological product and the reference product in
terms of the safety, purity, and potency of the product.
``(3) The term `interchangeable' or `interchangeability',
in reference to a biological product that is shown to meet
the standards described in subsection (k)(4), means that the
biological product may be substituted for the reference
product without the intervention of the health care provider
who prescribed the reference product.
``(4) The term `reference product' means the single
biological product licensed under subsection (a) against
which a biological product is evaluated in an application
submitted under subsection (k).''.
(c) Products Previously Approved Under Section 505.--

[[Page H12787]]

(1) Requirement to follow section 351.--Except as provided
in paragraph (2), an application for a biological product
shall be submitted under section 351 of the Public Health
Service Act (42 U.S.C. 262) (as amended by this Act).
(2) Exception.--An application for a biological product may
be submitted under section 505 of the Federal Food, Drug, and
Cosmetic Act (21 U.S.C. 355) if--
(A) such biological product is in a product class for which
a biological product in such product class is the subject of
an application approved under such section 505 not later than
the date of enactment of this Act; and
(B) such application--
(i) has been submitted to the Secretary of Health and Human
Services (referred to in this Act as the ``Secretary'')
before the date of enactment of this Act; or
(ii) is submitted to the Secretary not later than the date
that is 10 years after the date of enactment of this Act.
(3) Limitation.--Notwithstanding paragraph (2), an
application for a biological product may not be submitted
under section 505 of the Federal Food, Drug, and Cosmetic Act
(21 U.S.C. 355) if there is another biological product
approved under subsection (a) of section 351 of the Public
Health Service Act that could be a reference product with
respect to such application (within the meaning of such
section 351) if such application were submitted under
subsection (k) of such section 351.
(4) Deemed approved under section 351.--An approved
application for a biological product under section 505 of the
Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355) shall be
deemed to be a license for the biological product under such
section 351 on the date that is 10 years after the date of
enactment of this Act.
(5) Definitions.--For purposes of this subsection, the term
``biological product'' has the meaning given such term under
section 351 of the Public Health Service Act (42 U.S.C. 262)
(as amended by this Act).

SEC. 2576. FEES RELATING TO BIOSIMILAR BIOLOGICAL PRODUCTS.

Subparagraph (B) of section 735(1) of the Federal Food,
Drug, and Cosmetic Act (21 U.S.C. 379g(1)) is amended by
inserting ``, including licensure of a biological product
under section 351(k) of such Act'' before the period at the
end.

SEC. 2577. AMENDMENTS TO CERTAIN PATENT PROVISIONS.

(a) Section 271(e)(2) of title 35, United States Code is
amended--
(1) in subparagraph (A), by striking ``or'' after
``patent,'';
(2) in subparagraph (B), by adding ``or'' after the comma
at the end;
(3) by inserting the following after subparagraph (B):
``(C) a statement under section 351(l)(4)(D)(ii) of the
Public Health Service Act,''; and
(4) in the matter following subparagraph (C) (as added by
paragraph (3)), by inserting before the period the following:
``, or if the statement described in subparagraph (C) is
provided in connection with an application to obtain a
license to engage in the commercial manufacture, use, or sale
of a biological product claimed in a patent or the use of
which is claimed in a patent before the expiration of such
patent''.
(b) Section 271(e)(4) of title 35, United States Code, is
amended by striking ``in paragraph (2)'' in both places it
appears and inserting ``in paragraph (2)(A) or (2)(B)''.

Subtitle D--Community Living Assistance Services and Supports

SEC. 2581. ESTABLISHMENT OF NATIONAL VOLUNTARY INSURANCE
PROGRAM FOR PURCHASING COMMUNITY LIVING
ASSISTANCE SERVICES AND SUPPORT (CLASS
PROGRAM).

(a) Establishment of CLASS Program.--The Public Health
Service Act (42 U.S.C. 201 et seq.), as amended by section
2301, is amended by adding at the end the following:

``TITLE XXXII--COMMUNITY LIVING ASSISTANCE SERVICES AND SUPPORTS

``SEC. 3201. PURPOSE.

``The purpose of this title is to establish a national
voluntary insurance program for purchasing community living
assistance services and supports in order to--
``(1) provide individuals with functional limitations with
tools that will allow them to maintain their personal and
financial independence and live in the community through a
new financing strategy for community living assistance
services and supports;
``(2) establish an infrastructure that will help address
the Nation's community living assistance services and
supports needs;
``(3) alleviate burdens on family caregivers; and
``(4) address institutional bias by providing a financing
mechanism that supports personal choice and independence to
live in the community.

``SEC. 3202. DEFINITIONS.

``In this title:
``(1) Active enrollee.--The term `active enrollee' means an
individual who is enrolled in the CLASS program in accordance
with section 3204 and who has paid any premiums due to
maintain such enrollment.
``(2) Actively employed.--The term `actively employed'
means an individual who--
``(A) is reporting for work at the individual's usual place
of employment or at another location to which the individual
is required to travel because of the individual's employment
(or in the case of an individual who is a member of the
uniformed services, is on active duty and is physically able
to perform the duties of the individual's position); and
``(B) is able to perform all the usual and customary duties
of the individual's employment on the individual's regular
work schedule.
``(3) Activities of daily living.--The term `activities of
daily living' has the meaning given the term in section
7702B(c)(2)(B) of the Internal Revenue Code of 1986.
``(4) CLASS program.--The term `CLASS program' means the
program established under this title.
``(5) Eligibility assessment system.--The term `Eligibility
Assessment System' means the entity designated by the
Secretary under section 3205(a)(2)(A)(i).
``(6) Eligible beneficiary.--
``(A) In general.--The term `eligible beneficiary' means
any individual who is an active enrollee in the CLASS program
and, as of the date described in subparagraph (B)--
``(i) has paid premiums for enrollment in such program for
at least 60 months;
``(ii) has earned, for each calendar year that occurs
during the first 60 months for which the individual has paid
premiums for enrollment in the program, at least an amount
equal to the amount of wages and self-employment income which
an individual must have in order to be credited with a
quarter of coverage under section 213(d) of the Social
Security Act for that year; and
``(iii) has paid premiums for enrollment in such program
for at least 24 consecutive months, if a lapse in premium
payments of more than 3 months has occurred during the period
that begins on the date of the individual's enrollment and
ends on the date of such determination.
``(B) Date described.--For purposes of subparagraph (A),
the date described in this subparagraph is the date on which
the individual is determined to have a functional limitation
described in section 3203(a)(1)(C) that is expected to last
for a continuous period of more than 90 days.
``(C) Regulations.--The Secretary shall promulgate
regulations specifying exceptions to the minimum earnings
requirements under subparagraph (A)(ii) for purposes of being
considered an eligible beneficiary for certain populations.
``(7) Hospital; nursing facility; intermediate care
facility for the mentally retarded; institution for mental
diseases.--The terms `hospital', `nursing facility',
`intermediate care facility for the mentally retarded', and
`institution for mental diseases' have the meanings given
such terms for purposes of Medicaid.
``(8) CLASS independence advisory council.--The term `CLASS
Independence Advisory Council' or `Council' means the
Advisory Council established under section 3207 to advise the
Secretary.
``(9) CLASS independence benefit plan.--The term `CLASS
Independence Benefit Plan' means the benefit plan developed
and designated by the Secretary in accordance with section
3203.
``(10) CLASS independence fund.--The term `CLASS
Independence Fund' or `Fund' means the fund established under
section 3206.
``(11) Medicaid.--The term `Medicaid' means the program
established under title XIX of the Social Security Act.
``(12) Protection and advocacy system.--The term
`Protection and Advocacy System' means the system for each
State established under section 143 of the Developmental
Disabilities Assistance and Bill of Rights Act of 2000.

``SEC. 3203. CLASS INDEPENDENCE BENEFIT PLAN.

``(a) Process for Development.--
``(1) In general.--The Secretary, in consultation with
appropriate actuaries and other experts, shall develop at
least 3 actuarially sound benefit plans as alternatives for
consideration for designation by the Secretary as the CLASS
Independence Benefit Plan under which eligible beneficiaries
shall receive benefits under this title. Each of the plan
alternatives developed shall be designed to provide eligible
beneficiaries with the benefits described in section 3205
consistent with the following requirements:
``(A) Premiums.--Beginning with the first year of the CLASS
program, and for each year thereafter, the Secretary shall
establish all premiums to be paid by enrollees for the year
based on an actuarial analysis of the 75-year costs of the
program that ensures solvency throughout such 75-year period.
``(B) Vesting period.--A 5-year vesting period for
eligibility for benefits.
``(C) Benefit triggers.--A benefit trigger for provision of
benefits that requires a determination that an individual has
a functional limitation, as certified by a licensed health
care practitioner, described in any of the following clauses
that is expected to last for a continuous period of more than
90 days:
``(i) The individual is determined to be unable to perform
at least the minimum number (which may be 2 or 3) of
activities of daily living as are required under the plan for
the provision of benefits without substantial assistance (as
defined by the Secretary) from another individual.
``(ii) The individual requires substantial supervision to
protect the individual from

[[Page H12788]]

threats to health and safety due to substantial cognitive
impairment.
``(iii) The individual has a level of functional limitation
similar (as determined under regulations prescribed by the
Secretary) to the level of functional limitation described in
clause (i) or (ii).
``(D) Cash benefit.--Payment of a cash benefit that
satisfies the following requirements:
``(i) Minimum required amount.--The benefit amount provides
an eligible beneficiary with not less than an average of $50
per day (as determined based on the reasonably expected
distribution of beneficiaries receiving benefits at various
benefit levels).
``(ii) Amount scaled to functional ability.--The benefit
amount is varied based on a scale of functional ability, with
not less than 2, and not more than 6, benefit level amounts.
``(iii) Daily or weekly.--The benefit is paid on a daily or
weekly basis.
``(iv) No lifetime or aggregate limit.--The benefit is not
subject to any lifetime or aggregate limit.
``(2) Review and recommendation by the class independence
advisory council.--The CLASS Independence Advisory Council
shall--
``(A) evaluate the alternative benefit plans developed
under paragraph (1); and
``(B) recommend for designation as the CLASS Independence
Benefit Plan for offering to the public the plan that the
Council determines best balances price and benefits to meet
enrollees' needs in an actuarially sound manner, while
optimizing the probability of the long-term sustainability of
the CLASS program.
``(3) Designation by the secretary.--Not later than October
1, 2012, the Secretary, taking into consideration the
recommendation of the CLASS Independence Advisory Council
under paragraph (2)(B), shall designate a benefit plan as the
CLASS Independence Benefit Plan. The Secretary shall publish
such designation, along with details of the plan and the
reasons for the selection by the Secretary, in a final rule
that allows for a period of public comment.
``(b) Additional Premium Requirements.--
``(1) Adjustment of premiums.--
``(A) In general.--Except as provided in subparagraphs (B),
(C), (D), and (E), the amount of the monthly premium
determined for an individual upon such individual's
enrollment in the CLASS program shall remain the same for as
long as the individual is an active enrollee in the program.
``(B) Recalculated premium if required for program
solvency.--
``(i) In general.--Subject to clause (ii), if the Secretary
determines, based on the most recent report of the Board of
Trustees of the CLASS Independence Fund, the advice of the
CLASS Independence Advisory Council, and the annual report of
the Inspector General of the Department of Health and Human
Services, and waste, fraud, and abuse, or such other
information as the Secretary determines appropriate, that the
monthly premiums and income to the CLASS Independence Fund
for a year are projected to be insufficient with respect to
the 20-year period that begins with that year, the Secretary
shall adjust the monthly premiums for individuals enrolled in
the CLASS program as necessary.
``(ii) Exemption from increase.--Any increase in a monthly
premium imposed as result of a determination described in
clause (i) shall not apply with respect to the monthly
premium of any active enrollee who--

``(I) has attained age 65;
``(II) has paid premiums for enrollment in the program for
at least 20 years; and
``(III) is not actively employed.

``(C) Recalculated premium if reenrollment after more than
a 3-month lapse.--
``(i) In general.--The reenrollment of an individual after
a 90-day period during which the individual failed to pay the
monthly premium required to maintain the individual's
enrollment in the CLASS program shall be treated as an
initial enrollment for purposes of age-adjusting the premium
for enrollment in the program.
``(ii) Credit for prior months if reenrolled within 5
years.--An individual who reenrolls in the CLASS program
after such a 90-day period and before the end of the 5-year
period that begins with the first month for which the
individual failed to pay the monthly premium required to
maintain the individual's enrollment in the program shall
be--

``(I) credited with any months of paid premiums that
accrued prior to the individual's lapse in enrollment; and
``(II) notwithstanding the total amount of any such
credited months, required to satisfy section 3202(6)(A)(ii)
before being eligible to receive benefits.

``(D) Penalty for reenrollment after 5-year lapse.--In the
case of an individual who reenrolls in the CLASS program
after the end of the 5-year period described in subparagraph
(C)(ii), the monthly premium required for the individual
shall be the age-adjusted premium that would be applicable to
an initially enrolling individual who is the same age as the
reenrolling individual, increased by the greater of--
``(i) an amount that the Secretary determines is
actuarially sound for each month that occurs during the
period that begins with the first month for which the
individual failed to pay the monthly premium required to
maintain the individual's enrollment in the CLASS program and
ends with the month preceding the month in which the
reenrollment is effective; or
``(ii) 1 percent of the applicable age-adjusted premium for
each such month occurring in such period.
``(2) Administrative expenses.--In determining the monthly
premiums for the CLASS program, the Secretary may factor in
costs for administering the program, not to exceed--
``(A) in the case of the first 5 years in which the program
is in effect under this title, an amount equal to 3 percent
of all premiums paid during each such year; and
``(B) in the case of subsequent years, an amount equal to 5
percent of the total amount of all expenditures (including
benefits paid) under this title with respect to that year.
``(3) No underwriting requirements.--No underwriting (other
than on the basis of age in accordance with paragraph (2))
shall be used to--
``(A) determine the monthly premium for enrollment in the
CLASS program; or
``(B) prevent an individual from enrolling in the program.

``SEC. 3204. ENROLLMENT AND DISENROLLMENT REQUIREMENTS.

``(a) Automatic Enrollment.--
``(1) In general.--Subject to paragraph (2), the Secretary
shall establish procedures under which each individual
described in subsection (c) shall be automatically enrolled
in the CLASS program by an employer of such individual under
rules similar to the rules of sections 401(k)(13) and 414(w)
of the Internal Revenue Code of 1986.
``(2) Alternative enrollment procedures.--The procedures
established under paragraph (1) shall provide for an
alternative enrollment process for an individual described in
subsection (c) in the case of such an individual--
``(A) who is self-employed;
``(B) who has more than 1 employer;
``(C) whose employer does not elect to participate in the
automatic enrollment process established by the Secretary; or
``(D) who is a spouse described in subsection (c)(2) of who
is not subject to automatic enrollment.
``(3) Administration.--
``(A) In general.--The Secretary shall, by regulation,
establish procedures to--
``(i) ensure that an individual is not automatically
enrolled in the CLASS program by more than 1 employer; and
``(ii) allow for an individual's employer to deduct a
premium for a spouse described in subsection (c)(1)(B) who is
not subject to automatic enrollment.
``(B) Form.--Enrollment in the CLASS program shall be made
in such manner as the Secretary may prescribe in order to
ensure ease of administration.
``(b) Election To Opt-Out.--An individual described in
subsection (c) may elect to waive enrollment in the CLASS
program at any time in such form and manner as the Secretary
shall prescribe.
``(c) Individual Described.--For purposes of enrolling in
the CLASS program, an individual described in this paragraph
is--
``(1) an individual--
``(A) who has attained age 18;
``(B) who receives wages on which there is imposed a tax
under section 3101(a) or 3201(a) of the Internal Revenue Code
of 1986;
``(C) who is actively employed; and
``(D) who is not--
``(i) a patient in a hospital or nursing facility, an
intermediate care facility for the mentally retarded, or an
institution for mental diseases and receiving medical
assistance under Medicaid; or
``(ii) confined in a jail, prison, other penal institution
or correctional facility, or by court order pursuant to
conviction of a criminal offense or in connection with a
verdict or finding described in section 202(x)(1)(A)(ii) of
the Social Security Act; or
``(2) the spouse of an individual described in paragraph
(1) and who would be an individual so described but for
subparagraph (B) or (C) of that paragraph.
``(d) Rule of Construction.--Nothing in this title shall be
construed as requiring an active enrollee to continue to
satisfy subparagraph (B) or (C) of subsection (c)(1) in order
to maintain enrollment in the CLASS program.
``(e) Payment.--
``(1) Payroll deduction.--An amount equal to the monthly
premium for the enrollment in the CLASS program of an
individual shall be deducted from the wages of such
individual in accordance with such procedures as the
Secretary shall establish for employers who elect to deduct
and withhold such premiums on behalf of enrolled employees.
``(2) Alternative payment mechanism.--The Secretary shall
establish alternative procedures for the payment of monthly
premiums by an individual enrolled in the CLASS program who
does not have an employer who elects to deduct and withhold
premiums in accordance with subparagraph (A).
``(f) Transfer of Premiums Collected.--
``(1) In general.--During each calendar year the Secretary
of the Treasury shall deposit into the CLASS Independence
Fund a total amount equal, in the aggregate, to 100 percent
of the premiums collected during that year.
``(2) Transfers based on estimates.--The amount deposited
pursuant to paragraph (1) shall be transferred in at least
monthly payments to the CLASS Independence Fund on the basis
of estimates by the Secretary and certified to the Secretary
of the Treasury of

[[Page H12789]]

the amounts collected in accordance with this section. Proper
adjustments shall be made in amounts subsequently transferred
to the Fund to the extent prior estimates were in excess of,
or were less than, actual amounts collected.
``(g) Other Enrollment and Disenrollment Opportunities.--
The Secretary shall establish procedures under which--
``(1) an individual who, in the year of the individual's
initial eligibility to enroll in the CLASS program, has
elected to waive enrollment in the program, is eligible to
elect to enroll in the program, in such form and manner as
the Secretary shall establish, only during an open enrollment
period established by the Secretary that is specific to the
individual and that may not occur more frequently than
biennially after the date on which the individual first
elected to waive enrollment in the program; and
``(2) an individual shall only be permitted to disenroll
from the program during an annual disenrollment period
established by the Secretary and in such form and manner as
the Secretary shall establish.

``SEC. 3205. BENEFITS.

``(a) Determination of Eligibility.--
``(1) Application for receipt of benefits.--The Secretary
shall establish procedures under which an active enrollee
shall apply for receipt of benefits under the CLASS
Independence Benefit Plan.
``(2) Eligibility assessments.--
``(A) In general.--Not later than January 1, 2012, the
Secretary shall--
``(i) designate an entity (other than a service with which
the Commissioner of Social Security has entered into an
agreement, with respect to any State, to make disability
determinations for purposes of title II or XVI of the Social
Security Act) to serve as an Eligibility Assessment System by
providing for eligibility assessments of active enrollees who
apply for receipt of benefits;
``(ii) enter into an agreement with the Protection and
Advocacy System for each State to provide advocacy services
in accordance with subsection (d); and
``(iii) enter into an agreement with public and private
entities to provide advice and assistance counseling in
accordance with subsection (e).
``(B) Regulations.--The Secretary shall promulgate
regulations to develop an expedited nationally equitable
eligibility determination process, as certified by a licensed
health care practitioner, an appeals process, and a
redetermination process, as certified by a licensed health
care practitioner, including whether an applicant is eligible
for a cash benefit under the program and if so, the amount of
the cash benefit (in accordance the sliding scale established
under the plan).
``(C) Presumptive eligibility for certain institutionalized
enrollees planning to discharge.--An active enrollee shall be
deemed presumptively eligible if the enrollee--
``(i) has applied for, and attests is eligible for, the
maximum cash benefit available under the sliding scale
established under the CLASS Independence Benefit Plan;
``(ii) is a patient in a hospital (but only if the
hospitalization is for long-term care), nursing facility,
intermediate care facility for the mentally retarded, or an
institution for mental diseases; and
``(iii) is in the process of, or about to being the process
of, planning to discharge from the hospital, facility, or
institution, or within 60 days from the date of discharge
from the hospital, facility, or institution.
``(D) Appeals.--The Secretary shall establish procedures
under which an applicant for benefits under the CLASS
Independence Benefit Plan shall be guaranteed the right to
appeal an adverse determination.
``(b) Benefits.--An eligible beneficiary shall receive the
following benefits under the CLASS Independence Benefit Plan:
``(1) Cash benefit.--A cash benefit established by the
Secretary in accordance with the requirements of section
3203(a)(1)(D) that--
``(A) the first year in which beneficiaries receive the
benefits under the plan, is not less than the average dollar
amount specified in clause (i) of such section; and
``(B) for any subsequent year, is not less than the average
per day dollar limit applicable under this subparagraph for
the preceding year, increased by the percentage increase in
the consumer price index for all urban consumers (U.S. city
average) over the previous year.
``(2) Advocacy services.--Advocacy services in accordance
with subsection (d).
``(3) Advice and assistance counseling.--Advice and
assistance counseling in accordance with subsection (e).
``(4) Administrative expenses.--Advocacy services and
advise and assistance counseling services under paragraphs
(2) and (3) of this subsection shall be included as
administrative expenses under section 3203(b)(2).
``(c) Payment of Benefits.--
``(1) Life independence account.--
``(A) In general.--The Secretary shall establish procedures
for administering the provision of benefits to eligible
beneficiaries under the CLASS Independence Benefit Plan,
including the payment of the cash benefit for the beneficiary
into a Life Independence Account established by the Secretary
on behalf of each eligible beneficiary.
``(B) Use of cash benefits.--Cash benefits paid into a Life
Independence Account of an eligible beneficiary shall be used
to purchase nonmedical services and supports that the
beneficiary needs to maintain his or her independence at home
or in another residential setting of their choice in the
community, including (but not limited to) home modifications,
assistive technology, accessible transportation, homemaker
services, respite care, personal assistance services, home
care aides, and nursing support. Nothing in the preceding
sentence shall prevent an eligible beneficiary from using
cash benefits paid into a Life Independence Account for
obtaining assistance with decisionmaking concerning medical
care, including the right to accept or refuse medical or
surgical treatment and the right to formulate advance
directives or other written instructions recognized under
State law, such as a living will or durable power of attorney
for health care, in the case that an injury or illness causes
the individual to be unable to make health care decisions.
``(C) Electronic management of funds.--The Secretary shall
establish procedures for--
``(i) crediting an account established on behalf of a
beneficiary with the beneficiary's cash daily benefit;
``(ii) allowing the beneficiary to access such account
through debit cards; and
``(iii) accounting for withdrawals by the beneficiary from
such account.
``(D) Primary payor rules for beneficiaries who are
enrolled in medicaid.--In the case of an eligible beneficiary
who is enrolled in Medicaid, the following payment rules
shall apply:
``(i) Institutionalized beneficiary.--If the beneficiary is
a patient in a hospital, nursing facility, intermediate care
facility for the mentally retarded, or an institution for
mental diseases, the beneficiary shall retain an amount equal
to 5 percent of the beneficiary's daily or weekly cash
benefit (as applicable) (which shall be in addition to the
amount of the beneficiary's personal needs allowance provided
under Medicaid), and the remainder of such benefit shall be
applied toward the facility's cost of providing the
beneficiary's care, and Medicaid shall provide secondary
coverage for such care.
``(ii) Beneficiaries receiving home and community-based
services.--

``(I) 50 percent of benefit retained by beneficiary.--
Subject to subclause (II), if a beneficiary is receiving
medical assistance under Medicaid for home and community-
based services, the beneficiary shall retain an amount equal
to 50 percent of the beneficiary's daily or weekly cash
benefit (as applicable), and the remainder of the daily or
weekly cash benefit shall be applied toward the cost to the
State of providing such assistance (and shall not be used to
claim Federal matching funds under Medicaid), and Medicaid
shall provide secondary coverage for the remainder of any
costs incurred in providing such assistance.
``(II) Requirement for state offset.--A State shall be paid
the remainder of a beneficiary's daily or weekly cash benefit
under subclause (I) only if the State home and community-
based waiver under section 1115 of the Social Security Act or
subsection (c) or (d) of section 1915 of such Act, or the
State plan amendment under subsection (i) of such section
does not include a waiver of the requirements of section
1902(a)(1) of the Social Security Act (relating to
statewideness) or of section 1902(a)(10)(B) of such Act
(relating to comparability) and the State offers at a minimum
case management services, personal care services,
habilitation services, and respite care under such a waiver
or State plan amendment.
``(III) Definition of home and community-based services.--
In this clause, the term `home and community-based services'
means any services which may be offered under a home and
community-based waiver authorized for a State under section
1115 of the Social Security Act or subsection (c) or (d) of
section 1915 of such Act or under a State plan amendment
under subsection (i) of such section.

``(iii) Beneficiaries enrolled in programs of all-inclusive
care for the elderly (pace).--

``(I) In general.--Subject to subclause (II), if a
beneficiary is receiving medical assistance under Medicaid
for PACE program services under section 1934 of the Social
Security Act, the beneficiary shall retain an amount equal to
50 percent of the beneficiary's daily or weekly cash benefit
(as applicable), and the remainder of the daily or weekly
cash benefit shall be applied toward the cost to the State of
providing such assistance (and shall not be used to claim
Federal matching funds under Medicaid), and Medicaid shall
provide secondary coverage for the remainder of any costs
incurred in providing such assistance.
``(II) Institutionalized recipients of pace program
services.--If a beneficiary receiving assistance under
Medicaid for PACE program services is a patient in a
hospital, nursing facility, intermediate care facility for
the mentally retarded, or an institution for mental diseases,
the beneficiary shall be treated as in institutionalized
beneficiary under clause (i).

``(2) Authorized representatives.--
``(A) In general.--The Secretary shall establish procedures
to allow access to a beneficiary's cash benefits by an
authorized representative of the eligible beneficiary on
whose behalf such benefits are paid.
``(B) Quality assurance and protection against fraud and
abuse.--The procedures established under subparagraph (A)
shall ensure that authorized representatives of eligible
beneficiaries comply with standards of

[[Page H12790]]

conduct established by the Secretary, including standards
requiring that such representatives provide quality services
on behalf of such beneficiaries, do not have conflicts of
interest, and do not misuse benefits paid on behalf of such
beneficiaries or otherwise engage in fraud or abuse.
``(3) Commencement of benefits.--Benefits shall be paid to,
or on behalf of, an eligible beneficiary beginning with the
first month in which an application for such benefits is
approved.
``(4) Rollover option for lump-sum payment.--An eligible
beneficiary may elect to--
``(A) defer payment of their daily or weekly benefit and to
rollover any such deferred benefits from month-to-month, but
not from year-to-year; and
``(B) receive a lump-sum payment of such deferred benefits
in an amount that may not exceed the lesser of--
``(i) the total amount of the accrued deferred benefits; or
``(ii) the applicable annual benefit.
``(5) Period for determination of annual benefits.--
``(A) In general.--The applicable period for determining
with respect to an eligible beneficiary the applicable annual
benefit and the amount of any accrued deferred benefits is
the 12-month period that commences with the first month in
which the beneficiary began to receive such benefits, and
each 12-month period thereafter.
``(B) Inclusion of increased benefits.--The Secretary shall
establish procedures under which cash benefits paid to an
eligible beneficiary that increase or decrease as a result of
a change in the functional status of the beneficiary before
the end of a 12-month benefit period shall be included in the
determination of the applicable annual benefit paid to the
eligible beneficiary.
``(C) Recoupment of unpaid, accrued benefits.--
``(i) In general.--The Secretary, in coordination with the
Secretary of the Treasury, shall recoup any accrued benefits
in the event of--

``(I) the death of a beneficiary; or
``(II) the failure of a beneficiary to elect under
paragraph (4)(B) to receive such benefits as a lump-sum
payment before the end of the 12-month period in which such
benefits accrued.

``(ii) Payment into class independence fund.--Any benefits
recouped in accordance with clause (i) shall be paid into the
CLASS Independence Fund and used in accordance with section
3206.
``(6) Requirement to recertify eligibility for receipt of
benefits.--An eligible beneficiary shall periodically, as
determined by the Secretary--
``(A) recertify by submission of medical evidence the
beneficiary's continued eligibility for receipt of benefits;
and
``(B) submit records of expenditures attributable to the
aggregate cash benefit received by the beneficiary during the
preceding year.
``(7) Supplement, not supplant other health care
benefits.--Subject to the Medicaid payment rules under
paragraph (1)(D), benefits received by an eligible
beneficiary shall supplement, but not supplant, other health
care benefits for which the beneficiary is eligible under
Medicaid or any other Federally funded program that provides
health care benefits or assistance.
``(d) Advocacy Services.--An agreement entered into under
subsection (a)(2)(A)(ii) shall require the Protection and
Advocacy System for the State to--
``(1) assign, as needed, an advocacy counselor to each
eligible beneficiary that is covered by such agreement and
who shall provide an eligible beneficiary with--
``(A) information regarding how to access the appeals
process established for the program;
``(B) assistance with respect to the annual recertification
and notification required under subsection (c)(6); and
``(C) such other assistance with obtaining services as the
Secretary, by regulation, shall require; and
``(2) ensure that the System and such counselors comply
with the requirements of subsection (h).
``(e) Advice and Assistance Counseling.--An agreement
entered into under subsection (a)(2)(A)(iii) shall require
the entity to assign, as requested by an eligible beneficiary
that is covered by such agreement, an advice and assistance
counselor who shall provide an eligible beneficiary with
information regarding--
``(1) accessing and coordinating long-term services and
supports in the most integrated setting;
``(2) possible eligibility for other benefits and services;
``(3) development of a service and support plan;
``(4) information about programs established under the
Assistive Technology Act of 1998 and the services offered
under such programs;
``(5) available assistance with decisionmaking concerning
medical care, including the right to accept or refuse medical
or surgical treatment and the right to formulate advance
directives or other written instructions recognized under
State law, such as a living will or durable power of attorney
for health care, in the case that an injury or illness causes
the individual to be unable to make health care decisions;
and
``(6) such other services as the Secretary, by regulation,
may require.
``(f) No Effect on Eligibility for Other Benefits.--
Benefits paid to an eligible beneficiary under the CLASS
program shall be disregarded for purposes of determining or
continuing the beneficiary's eligibility for receipt of
benefits under any other Federal, State, or locally funded
assistance program, including benefits paid under titles II,
XVI, XVIII, XIX, or XXI of the Social Security Act, under the
laws administered by the Secretary of Veterans Affairs, under
low-income housing assistance programs, or under the
supplemental nutrition assistance program established under
the Food and Nutrition Act of 2008.
``(g) Rule of Construction.--Nothing in this title shall be
construed as prohibiting benefits paid under the CLASS
Independence Benefit Plan from being used to compensate a
family caregiver for providing community living assistance
services and supports to an eligible beneficiary.
``(h) Protection Against Conflicts of Interest.--The
Secretary shall establish procedures to ensure that the
Eligibility Assessment System, the Protection and Advocacy
System for a State, advocacy counselors for eligible
beneficiaries, and any other entities that provide services
to active enrollees and eligible beneficiaries under the
CLASS program comply with the following:
``(1) If the entity provides counseling or planning
services, such services are provided in a manner that fosters
the best interests of the active enrollee or beneficiary.
``(2) The entity has established operating procedures that
are designed to avoid or minimize conflicts of interest
between the entity and an active enrollee or beneficiary.
``(3) The entity provides information about all services
and options available to the active enrollee or beneficiary,
to the best of its knowledge, including services available
through other entities or providers.
``(4) The entity assists the active enrollee or beneficiary
to access desired services, regardless of the provider.
``(5) The entity reports the number of active enrollees and
beneficiaries provided with assistance by age, disability,
and whether such enrollees and beneficiaries received
services from the entity or another entity.
``(6) If the entity provides counseling or planning
services, the entity ensures that an active enrollee or
beneficiary is informed of any financial interest that the
entity has in a service provider.
``(7) The entity provides an active enrollee or beneficiary
with a list of available service providers that can meet the
needs of the active enrollee or beneficiary.

``SEC. 3206. CLASS INDEPENDENCE FUND.

``(a) Establishment of CLASS Independence Fund.--There is
established in the Treasury of the United States a trust fund
to be known as the `CLASS Independence Fund'. The Secretary
of the Treasury shall serve as Managing Trustee of such Fund.
The Fund shall consist of all amounts derived from payments
into the Fund under sections 3204(f) and 3205(c)(5)(C)(ii),
and remaining after investment of such amounts under
subsection (b), including additional amounts derived as
income from such investments. The amounts held in the Fund
are appropriated and shall remain available without fiscal
year limitation--
``(1) to be held for investment on behalf of individuals
enrolled in the CLASS program;
``(2) to pay the administrative expenses related to the
Fund and to investment under subsection (b); and
``(3) to pay cash benefits to eligible beneficiaries under
the CLASS Independence Benefit Plan.
``(b) Investment of Fund Balance.--The Secretary of the
Treasury shall invest and manage the CLASS Independence Fund
in the same manner, and to the same extent, as the Federal
Supplementary Medical Insurance Trust Fund may be invested
and managed under subsections (c), (d), and (e) of section
1841(d) of the Social Security Act.
``(c) Board of Trustees.--
``(1) In general.--With respect to the CLASS Independence
Fund, there is hereby created a body to be known as the Board
of Trustees of the CLASS Independence Fund (hereinafter in
this section referred to as the `Board of Trustees') composed
of the Secretary of the Treasury, the Secretary of Labor, and
the Secretary of Health and Human Services, all ex officio,
and of two members of the public (both of whom may not be
from the same political party), who shall be nominated by the
President for a term of 4 years and subject to confirmation
by the Senate. A member of the Board of Trustees serving as a
member of the public and nominated and confirmed to fill a
vacancy occurring during a term shall be nominated and
confirmed only for the remainder of such term. An individual
nominated and confirmed as a member of the public may serve
in such position after the expiration of such member's term
until the earlier of the time at which the member's successor
takes office or the time at which a report of the Board is
first issued under paragraph (2) after the expiration of the
member's term. The Secretary of the Treasury shall be the
Managing Trustee of the Board of Trustees. The Board of
Trustees shall meet not less frequently than once each
calendar year. A person serving on the Board of Trustees
shall not be considered to be a fiduciary and shall not be
personally liable for actions taken in such capacity with
respect to the Trust Fund.
``(2) Duties.--

[[Page H12791]]

``(A) In general.--It shall be the duty of the Board of
Trustees to do the following:
``(i) Hold the CLASS Independence Fund.
``(ii) Report to the Congress not later than the first day
of April of each year on the operation and status of the
CLASS Independence Fund during the preceding fiscal year and
on its expected operation and status during the current
fiscal year and the next 2 fiscal years.
``(iii) Report immediately to the Congress whenever the
Board is of the opinion that the amount of the CLASS
Independence Fund is not actuarially sound in regards to the
projections under section 3203(b)(1)(B)(i).
``(iv) Review the general policies followed in managing the
CLASS Independence Fund, and recommend changes in such
policies, including necessary changes in the provisions of
law which govern the way in which the CLASS Independence Fund
is to be managed.
``(B) Report.--The report provided for in subparagraph
(A)(ii) shall--
``(i) include--

``(I) a statement of the assets of, and the disbursements
made from, the CLASS Independence Fund during the preceding
fiscal year;
``(II) an estimate of the expected income to, and
disbursements to be made from, the CLASS Independence Fund
during the current fiscal year and each of the next 2 fiscal
years;
``(III) a statement of the actuarial status of the CLASS
Independence Fund for the current fiscal year, each of the
next 2 fiscal years, and as projected over the 75-year period
beginning with the current fiscal year; and
``(IV) an actuarial opinion certifying that the techniques
and methodologies used are generally accepted within the
actuarial profession and that the assumptions and cost
estimates used are reasonable; and

``(ii) be printed as a House document of the session of the
Congress to which the report is made.
``(C) Recommendations.--If the Board of Trustees determines
that enrollment trends and expected future benefit claims on
the CLASS Independence Fund are not actuarially sound in
regards to the projections under section 3203(b)(1)(B)(i) and
are unlikely to be resolved with reasonable premium increases
or through other means, the Board of Trustees shall include
in the report provided for in subparagraph (A)(ii)
recommendations for such legislative action as the Board of
Trustees determine to be appropriate, including whether to
adjust monthly premiums or impose a temporary moratorium on
new enrollments.

``SEC. 3207. CLASS INDEPENDENCE ADVISORY COUNCIL.

``(a) Establishment.--There is hereby created an Advisory
Committee to be known as the `CLASS Independence Advisory
Council'.
``(b) Membership.--
``(1) In general.--The CLASS Independence Advisory Council
shall be composed of not more than 15 individuals, not
otherwise in the employ of the United States--
``(A) who shall be appointed by the President without
regard to the civil service laws and regulations; and
``(B) a majority of whom shall be representatives of
individuals who participate or are likely to participate in
the CLASS program, and shall include representatives of older
and younger workers, individuals with disabilities, family
caregivers of individuals who require services and supports
to maintain their independence at home or in another
residential setting of their choice in the community,
individuals with expertise in long-term care or disability
insurance, actuarial science, economics, and other relevant
disciplines, as determined by the Secretary.
``(2) Terms.--
``(A) In general.--The members of the CLASS Independence
Advisory Council shall serve overlapping terms of 3 years
(unless appointed to fill a vacancy occurring prior to the
expiration of a term, in which case the individual shall
serve for the remainder of the term).
``(B) Limitation.--A member shall not be eligible to serve
for more than 2 consecutive terms.
``(3) Chair.--The President shall, from time to time,
appoint one of the members of the CLASS Independence Advisory
Council to serve as the Chair.
``(c) Duties.--The CLASS Independence Advisory Council
shall advise the Secretary on matters of general policy in
the administration of the CLASS program established under
this title and in the formulation of regulations under this
title including with respect to--
``(1) the development of the CLASS Independence Benefit
Plan under section 3203; and
``(2) the determination of monthly premiums under such
plan.
``(d) Application of FACA.--The Federal Advisory Committee
Act, other than section 14 of that Act, shall apply to the
CLASS Independence Advisory Council.
``(e) Authorization of Appropriations.--
``(1) In general.--There are authorized to be appropriated
to the CLASS Independence Advisory Council to carry out its
duties under this section, such sums as may be necessary for
fiscal year 2011 and for each fiscal year thereafter.
``(2) Availability.--Any sums appropriated under the
authorization contained in this section shall remain
available, without fiscal year limitation, until expended.

``SEC. 3208. REGULATIONS; ANNUAL REPORT.

``(a) Regulations.--The Secretary shall promulgate such
regulations as are necessary to carry out the CLASS program
in accordance with this title. Such regulations shall include
provisions to prevent fraud and abuse under the program.
``(b) Annual Report.--Beginning January 1, 2014, the
Secretary shall submit an annual report to Congress on the
CLASS program. Each report shall include the following:
``(1) The total number of enrollees in the program.
``(2) The total number of eligible beneficiaries during the
fiscal year.
``(3) The total amount of cash benefits provided during the
fiscal year.
``(4) A description of instances of fraud or abuse
identified during the fiscal year.
``(5) Recommendations for such administrative or
legislative action as the Secretary determines is necessary
to improve the program or to prevent the occurrence of fraud
or abuse.

``SEC. 3209. INSPECTOR GENERAL'S REPORT.

``The Inspector General of the Department of Health and
Human Services shall submit an annual report to the Secretary
and Congress relating to the overall progress of the CLASS
program and of the existence of waste, fraud, and abuse in
the CLASS program. Each such report shall include findings in
the following areas:
``(1) The eligibility determination process.
``(2) The provision of cash benefits.
``(3) Quality assurance and protection against waste,
fraud, and abuse.
``(4) Recouping of unpaid and accrued benefits.''.
(b) Conforming Amendments to Medicaid.--For conforming
provisions amending the Medicaid program, see section 1739.

Subtitle E--Miscellaneous

SEC. 2585. STATES FAILING TO ADHERE TO CERTAIN EMPLOYMENT
OBLIGATIONS.

A State is eligible for Federal funds under the provisions
of the Public Health Service Act (42 U.S.C. 201 et seq.) only
if the State--
(1) agrees to be subject in its capacity as an employer to
each obligation under division A of this Act and the
amendments made by such division applicable to persons in
their capacity as an employer; and
(2) assures that all political subdivisions in the State
will do the same.

SEC. 2586. HEALTH CENTERS UNDER PUBLIC HEALTH SERVICE ACT;
LIABILITY PROTECTIONS FOR VOLUNTEER
PRACTITIONERS.

(a) In General.--Section 224 (42 U.S.C. 233) is amended--
(1) in subsection (g)(1)(A)--
(A) in the first sentence, by striking ``or employee'' and
inserting ``employee, or (subject to subsection (k)(4))
volunteer practitioner''; and
(B) in the second sentence, by inserting ``and subsection
(k)(4)'' after ``subject to paragraph (5)''; and
(2) in each of subsections (g), (i), (j), (l), and (m), by
striking the term ``employee, or contractor'' each place such
term appears and inserting ``employee, volunteer
practitioner, or contractor'';
(3) in subsection (g)(1)(H), by striking the term
``employee, and contractor'' each place such term appears and
inserting ``employee, volunteer practitioner, and
contractor'';
(4) in subsection (l), by striking the term ``employee, or
any contractor'' and inserting ``employee, volunteer
practitioner, or contractor''; and
(5) in subsections (h)(3) and (k), by striking the term
``employees, or contractors'' each place such term appears
and inserting ``employees, volunteer practitioners, or
contractors''.
(b) Applicability; Definition.--Section 224(k) (42 U.S.C.
233(k)) is amended by adding at the end the following
paragraph:
``(4)(A) Subsections (g) through (m) apply with respect to
volunteer practitioners beginning with the first fiscal year
for which an appropriations Act provides that amounts in the
fund under paragraph (2) are available with respect to such
practitioners.
``(B) For purposes of subsections (g) through (m), the term
`volunteer practitioner' means a practitioner who, with
respect to an entity described in subsection (g)(4), meets
the following conditions:
``(i) The practitioner is a licensed physician, a licensed
clinical psychologist, or other licensed or certified health
care practitioner.
``(ii) At the request of such entity, the practitioner
provides services to patients of the entity, at a site at
which the entity operates or at a site designated by the
entity. The weekly number of hours of services provided to
the patients by the practitioner is not a factor with respect
to meeting conditions under this subparagraph.
``(iii) The practitioner does not for the provision of such
services receive any compensation from such patients, from
the entity, or from third-party payors (including
reimbursement under any insurance policy or health plan, or
under any Federal or State health benefits program).''.

SEC. 2587. REPORT TO CONGRESS ON THE CURRENT STATE OF
PARASITIC DISEASES THAT HAVE BEEN OVERLOOKED
AMONG THE POOREST AMERICANS.

Not later than 12 months after the date of the enactment of
this Act, the Secretary of Health and Human Services shall
report to Congress on the epidemiology of, impact of, and
appropriate funding required to address

[[Page H12792]]

neglected diseases of poverty, including neglected parasitic
diseases identified as Chagas disease, cysticercosis,
toxocariasis, toxoplasmosis, trichomoniasis, the soil-
transmitted helminths, and others. The report should provide
the information necessary to enhance health policy to
accurately evaluate and address the threat of these diseases.

SEC. 2588. OFFICE OF WOMEN'S HEALTH.

(a) Health and Human Services Office on Women's Health.--
(1) Establishment.--Part A of title II (42 U.S.C. 202 et
seq.) is amended by adding at the end the following:

``SEC. 229. HEALTH AND HUMAN SERVICES OFFICE ON WOMEN'S
HEALTH.

``(a) Establishment of Office.--There is established within
the Office of the Secretary, an Office on Women's Health
(referred to in this section as the `Office'). The Office
shall be headed by a Deputy Assistant Secretary for Women's
Health who may report to the Secretary.
``(b) Duties.--The Secretary, acting through the Office,
with respect to the health concerns of women, shall--
``(1) establish short-range and long-range goals and
objectives within the Department of Health and Human Services
and, as relevant and appropriate, coordinate with other
appropriate offices on activities within the Department that
relate to disease prevention, health promotion, service
delivery, research, and public and health care professional
education, for issues of particular concern to women
throughout their lifespan;
``(2) provide expert advice and consultation to the
Secretary concerning scientific, legal, ethical, and policy
issues relating to women's health;
``(3) monitor the Department of Health and Human Services'
offices, agencies, and regional activities regarding women's
health and identify needs regarding the coordination of
activities, including intramural and extramural
multidisciplinary activities;
``(4) establish a Department of Health and Human Services
Coordinating Committee on Women's Health, which shall be
chaired by the Deputy Assistant Secretary for Women's Health
and composed of senior level representatives from each of the
agencies and offices of the Department of Health and Human
Services;
``(5) establish a National Women's Health Information
Center to--
``(A) facilitate the exchange of information regarding
matters relating to health information, health promotion,
preventive health services, research advances, and education
in the appropriate use of health care;
``(B) facilitate access to such information;
``(C) assist in the analysis of issues and problems
relating to the matters described in this paragraph; and
``(D) provide technical assistance with respect to the
exchange of information (including facilitating the
development of materials for such technical assistance);
``(6) coordinate efforts to promote women's health programs
and policies with the private sector; and
``(7) through publications and any other means appropriate,
provide for the exchange of information between the Office
and recipients of grants, contracts, and agreements under
subsection (c), and between the Office and health
professionals and the general public.
``(c) Grants and Contracts Regarding Duties.--
``(1) Authority.--In carrying out subsection (b), the
Secretary may make grants to, and enter into cooperative
agreements, contracts, and interagency agreements with,
public and private entities, agencies, and organizations.
``(2) Evaluation and dissemination.--The Secretary shall
directly or through contracts with public and private
entities, agencies, and organizations, provide for
evaluations of projects carried out with financial assistance
provided under paragraph (1) and for the dissemination of
information developed as a result of such projects.
``(d) Reports.--Not later than 1 year after the date of
enactment of this section, and every second year thereafter,
the Secretary shall prepare and submit to the appropriate
committees of Congress a report describing the activities
carried out under this section during the period for which
the report is being prepared.''
``(e) References.--Except as otherwise specified, any
reference in Federal law to an Office on Women's Health (in
the Department of Health and Human Services) is deemed to be
a reference to the Office on Women's Health in the Office of
the Secretary.''.
(2) Transfer of functions.--There are transferred to the
Office on Women's Health (established under section 229 of
the Public Health Service Act, as added by this section), all
functions exercised by the Office on Women's Health of the
Public Health Service prior to the date of enactment of this
section, including all personnel and compensation authority,
all delegation and assignment authority, and all remaining
appropriations. All orders, determinations, rules,
regulations, permits, agreements, grants, contracts,
certificates, licenses, registrations, privileges, and other
administrative actions that--
(A) have been issued, made, granted, or allowed to become
effective by the President, any Federal agency or official
thereof, or by a court of competent jurisdiction, in the
performance of functions transferred under this paragraph;
and
(B) are in effect at the time this section takes effect, or
were final before the date of enactment of this section and
are to become effective on or after such date;
shall continue in effect according to their terms until
modified, terminated, superseded, set aside, or revoked in
accordance with law by the President, the Secretary, or other
authorized official, a court of competent jurisdiction, or by
operation of law.
(b) Centers for Disease Control and Prevention Office of
Women's Health.--Part A of title III (42 U.S.C. 241 et seq.)
is amended by adding at the end the following:

``SEC. 310A. CENTERS FOR DISEASE CONTROL AND PREVENTION
OFFICE OF WOMEN'S HEALTH.

``(a) Establishment.--There is established within the
Office of the Director of the Centers for Disease Control and
Prevention, an office to be known as the Office of Women's
Health (referred to in this section as the `Office'). The
Office shall be headed by a director who shall be appointed
by the Director of such Centers.
``(b) Purpose.--The Director of the Office shall--
``(1) report to the Director of the Centers for Disease
Control and Prevention on the current level of the Centers'
activity regarding women's health conditions across, where
appropriate, age, biological, and sociocultural contexts, in
all aspects of the Centers' work, including prevention
programs, public and professional education, services, and
treatment;
``(2) establish short-range and long-range goals and
objectives within the Centers for women's health and, as
relevant and appropriate, coordinate with other appropriate
offices on activities within the Centers that relate to
prevention, research, education and training, service
delivery, and policy development, for issues of particular
concern to women;
``(3) identify projects in women's health that should be
conducted or supported by the Centers;
``(4) consult with health professionals, nongovernmental
organizations, consumer organizations, women's health
professionals, and other individuals and groups, as
appropriate, on the policy of the Centers with regard to
women; and
``(5) serve as a member of the Department of Health and
Human Services Coordinating Committee on Women's Health
(established under section 229(b)(4)).
``(c) Definition.--As used in this section, the term
`women's health conditions', with respect to women of all
age, ethnic, and racial groups, means diseases, disorders,
and conditions--
``(1) unique to, significantly more serious for, or
significantly more prevalent in women; and
``(2) for which the factors of medical risk or type of
medical intervention are different for women, or for which
there is reasonable evidence that indicates that such factors
or types may be different for women.''.
(c) Office of Women's Health Research.--Section 486(a) (42
U.S.C. 287d(a)) is amended by inserting ``and who shall
report directly to the Director'' before the period at the
end thereof.
(d) Substance Abuse and Mental Health Services
Administration.--Section 501(f) (42 U.S.C. 290aa(f)) is
amended--
(1) in paragraph (1), by inserting ``who shall report
directly to the Administrator'' before the period;
(2) by redesignating paragraph (4) as paragraph (5); and
(3) by inserting after paragraph (3), the following:
``(4) Office.--Nothing in this subsection shall be
construed to preclude the Secretary from establishing within
the Substance Abuse and Mental Health Administration an
Office of Women's Health.''.
(e) Agency for Healthcare Research and Quality Activities
Regarding Women's Health.--Part C of title IX (42 U.S.C. 299c
et seq.) is amended--
(1) by redesignating sections 927 and 928 as sections 928
and 929, respectively;
(2) by inserting after section 926 the following:

``SEC. 927. ACTIVITIES REGARDING WOMEN'S HEALTH.

``(a) Establishment.--There is established within the
Office of the Director, an Office of Women's Health and
Gender-Based Research (referred to in this section as the
`Office'). The Office shall be headed by a director who shall
be appointed by the Director of Healthcare and Research
Quality.
``(b) Purpose.--The official designated under subsection
(a) shall--
``(1) report to the Director on the current Agency level of
activity regarding women's health, across, where appropriate,
age, biological, and sociocultural contexts, in all aspects
of Agency work, including the development of evidence reports
and clinical practice protocols and the conduct of research
into patient outcomes, delivery of health care services,
quality of care, and access to health care;
``(2) establish short-range and long-range goals and
objectives within the Agency for research important to
women's health and, as relevant and appropriate, coordinate
with other appropriate offices on activities within the
Agency that relate to health services and medical
effectiveness research, for issues of particular concern to
women;
``(3) identify projects in women's health that should be
conducted or supported by the Agency;
``(4) consult with health professionals, nongovernmental
organizations, consumer organizations, women's health
professionals, and

[[Page H12793]]

other individuals and groups, as appropriate, on Agency
policy with regard to women; and
``(5) serve as a member of the Department of Health and
Human Services Coordinating Committee on Women's Health
(established under section 229(b)(4)).''; and
(3) by adding at the end of section 928 (as redesignated by
paragraph (1)) the following:
``(e) Women's Health.--For the purpose of carrying out
section 927 regarding women's health, there are authorized to
be appropriated such sums as may be necessary for each of
fiscal years 2011 through 2015.''.
(f) Health Resources and Services Administration Office of
Women's Health.--Title VII of the Social Security Act (42
U.S.C. 901 et seq.) is amended by adding at the end the
following:

``SEC. 713. OFFICE OF WOMEN'S HEALTH.

``(a) Establishment.--The Secretary shall establish within
the Office of the Administrator of the Health Resources and
Services Administration, an office to be known as the Office
of Women's Health. The Office shall be headed by a director
who shall be appointed by the Administrator.
``(b) Purpose.--The Director of the Office shall--
``(1) report to the Administrator on the current
Administration level of activity regarding women's health
across, where appropriate, age, biological, and sociocultural
contexts;
``(2) establish short-range and long-range goals and
objectives within the Health Resources and Services
Administration for women's health and, as relevant and
appropriate, coordinate with other appropriate offices on
activities within the Administration that relate to health
care provider training, health service delivery, research,
and demonstration projects, for issues of particular concern
to women;
``(3) identify projects in women's health that should be
conducted or supported by the bureaus of the Administration;
``(4) consult with health professionals, nongovernmental
organizations, consumer organizations, women's health
professionals, and other individuals and groups, as
appropriate, on Administration policy with regard to women;
and
``(5) serve as a member of the Department of Health and
Human Services Coordinating Committee on Women's Health
(established under section 229(b)(4) of the Public Health
Service Act).
``(c) Continued Administration of Existing Programs.--The
Director of the Office shall assume the authority for the
development, implementation, administration, and evaluation
of any projects carried out through the Health Resources and
Services Administration relating to women's health on the
date of enactment of this section.
``(d) Definitions.--For purposes of this section:
``(1) Administration.--The term `Administration' means the
Health Resources and Services Administration.
``(2) Administrator.--The term `Administrator' means the
Administrator of the Health Resources and Services
Administration.
``(3) Office.--The term `Office' means the Office of
Women's Health established under this section in the
Administration.''.
(g) Food and Drug Administration Office of Women's
Health.--Chapter IX of the Federal Food, Drug, and Cosmetic
Act (21 U.S.C. 391 et seq.) is amended by adding at the end
the following:

``SEC. 911. OFFICE OF WOMEN'S HEALTH.

``(a) Establishment.--There is established within the
Office of the Commissioner, an office to be known as the
Office of Women's Health (referred to in this section as the
`Office'). The Office shall be headed by a director who shall
be appointed by the Commissioner of Food and Drugs.
``(b) Purpose.--The Director of the Office shall--
``(1) report to the Commissioner of Food and Drugs on
current Food and Drug Administration (referred to in this
section as the `Administration') levels of activity regarding
women's participation in clinical trials and the analysis of
data by sex in the testing of drugs, medical devices, and
biological products across, where appropriate, age,
biological, and sociocultural contexts;
``(2) establish short-range and long-range goals and
objectives within the Administration for issues of particular
concern to women's health within the jurisdiction of the
Administration, including, where relevant and appropriate,
adequate inclusion of women and analysis of data by sex in
Administration protocols and policies;
``(3) provide information to women and health care
providers on those areas in which differences between men and
women exist;
``(4) consult with pharmaceutical, biologics, and device
manufacturers, health professionals with expertise in women's
issues, consumer organizations, and women's health
professionals on Administration policy with regard to women;
``(5) make annual estimates of funds needed to monitor
clinical trials and analysis of data by sex in accordance
with needs that are identified; and
``(6) serve as a member of the Department of Health and
Human Services Coordinating Committee on Women's Health
(established under section 229(b)(4) of the Public Health
Service Act).''.
(h) No New Regulatory Authority.--Nothing in this section
and the amendments made by this section may be construed as
establishing regulatory authority or modifying any existing
regulatory authority.
(i) Limitation on Termination.--Notwithstanding any other
provision of law, a Federal office of women's health
(including the Office of Research on Women's Health of the
National Institutes of Health) or Federal appointive position
with primary responsibility over women's health issues
(including the Associate Administrator for Women's Services
under the Substance Abuse and Mental Health Services
Administration) that is in existence on the date of enactment
of this section shall not be terminated, reorganized, or have
any of its powers or duties transferred unless such
termination, reorganization, or transfer is approved by an
Act of Congress.
(j) Rule of Construction.--Nothing in this section (or the
amendments made by this section) shall be construed to limit
the authority of the Secretary of Health and Human Services
with respect to women's health, or with respect to activities
carried out through the Department of Health and Human
Services on the date of enactment of this section.

SEC. 2588A. OFFICES OF MINORITY HEALTH

(a) Existing Office.--Section 1707(a) (42 U.S.C. 300u-6(a))
is amended by striking ``within the Office of Public Health
and Science'' and inserting ``within the Office of the
Secretary''.
(b) Additional Offices.--Title XVII (42 U.S.C. 300u et
seq.) is amended by inserting after section 1707 the
following:

``SEC. 1707A. ADDITIONAL OFFICES OF MINORITY HEALTH.

``(a) Establishment.--In addition to the Office of Minority
Health established within the Office of the Secretary under
section 1707, the Secretary shall establish an Office of
Minority Health in each of the following agencies:
``(1) The Centers for Disease Control and Prevention.
``(2) The Substance Abuse and Mental Health Services
Administration.
``(3) The Agency for Healthcare Research and Quality.
``(4) The Health Resources and Services Administration.
``(5) The Food and Drug Administration.
``(b) Director; Appointment.--Each Office of Minority
Health established in an agency listed in subsection (a)
shall be headed by a director, who shall be appointed by and
report directly to the head of such agency.
``(c) References.--Except as otherwise specified, any
reference in Federal law to an Office of Minority Health (in
the Department of Health and Human Services) is deemed to be
a reference to the Office of Minority Health in the Office of
the Secretary.''.
(c) No New Regulatory Authority.--Nothing in this section
and the amendments made by this section may be construed as
establishing regulatory authority or modifying any existing
regulatory authority.
(d) Limitation on Termination.--Notwithstanding any other
provision of law, a Federal office of minority health or
Federal appointive position with primary responsibility over
minority health issues that is in existence in a office or
agency of the Department of Health and Human Services on the
date of enactment of this section shall not be terminated,
reorganized, or have any of its powers or duties transferred
unless such termination, reorganization, or transfer is
approved by an Act of Congress.

SEC. 2589. LONG-TERM CARE AND FAMILY CAREGIVER SUPPORT.

(a) Amendments to the Older Americans Act of 1965.--
(1) Promotion of direct care workforce.--Section 202(b)(1)
of the Older Americans Act of 1965 (42 U.S.C. 3012(b)(1)) is
amended by inserting before the semicolon the following: ``,
and, in carrying out the purposes of this paragraph, shall
make recommendations to other Federal entities regarding
appropriate and effective means of identifying, promoting,
and implementing investments in the direct care workforce
necessary to meet the growing demand for long-term health
services and supports and of assisting States in developing a
comprehensive State workforce development plan with respect
to such workforce, including assisting efforts to
systematically assess, track, and report on workforce
adequacy and capacity''.
(2) Personal care attendant workforce advisory panel.--
Section 202 of such Act (42 U.S.C. 3012) is amended by adding
at the end the following:
``(g)(1) Not later than 90 days after the date of the
enactment of this subsection, the Assistant Secretary shall
establish a Personal Care Attendant Workforce Advisory Panel
to examine and formulate recommendations on--
``(A) working conditions and training for workers providing
long-term services and supports, including home health aides,
certified nurse aides, and personal care attendants; and
``(B) other workforce issues related to such workers,
including with respect to the adequacy of the number of such
workers; the salaries, wages, and benefits of such workers;
and access to the services provided by such workers.
``(2) The Panel shall include representatives of--
``(A) relevant home- and community-based service providers,
health care agencies, and facilities (including personal or
home care agencies, home health care agencies, nursing homes,
assisted living facilities, and residential care facilities);

[[Page H12794]]

``(B) the disability community, including individuals with
disabilities and family caregivers;
``(C) the nursing community;
``(D) direct care workers (which may include unions and
national organizations);
``(E) older individuals, including senior individuals and
family caregivers;
``(F) State and Federal health care entities; and
``(G) experts in workforce development and adult learning.
``(3) Within one year after the establishment of the Panel,
the Panel shall submit a report to the Assistant Secretary
and the Congress on workforce issues related to providing
long-term services and supports, including information on
core competencies for eligible personal or home care aides
necessary to successfully provide long-term services and
supports to eligible consumers, as well as recommended
training curricula and resources.
``(4) Within 180 days after receipt by the Assistant
Secretary of the report under paragraph (3), the Assistant
Secretary shall establish a 3-year demonstration program in 4
States to pilot and evaluate the effectiveness of the
competencies articulated by the Panel and the training
curricula and training methods recommended by the Panel.
``(5) Not later than 1 year after the completion of the
demonstration program under paragraph (4), the Assistant
Secretary shall submit to the Congress a report containing
the results of the evaluations by the Assistant Secretary
pursuant to paragraph (4), together with such recommendations
for legislation or administrative action as the Assistant
Secretary determines appropriate.''.
(b) Authorization of Additional Appropriations for the
Family Caregiver Support Program Under the Older Americans
Act of 1965.--Section 303(e)(2) of the Older Americans Act of
1965 (42 U.S.C. 3023(e)(2)) is amended by striking ``,
$173,000,000'' and all that follows through ``2011'', and
inserting ``and $250,000,000 for each of fiscal years 2011,
2012, and 2013''.

SEC. 2590. WEB SITE ON HEALTH CARE LABOR MARKET AND RELATED
EDUCATIONAL AND TRAINING OPPORTUNITIES.

(a) In General.--The Secretary of Labor, in consultation
with the National Center for Health Workforce Analysis, shall
establish and maintain a Web site to serve as a comprehensive
source of information, searchable by workforce region, on the
health care labor market and related educational and training
opportunities.
(b) Contents.--The Web site maintained under this section
shall include the following:
(1) Information on the types of jobs that are currently or
are projected to be in high demand in the health care field,
including--
(A) salary information; and
(B) training requirements, such as requirements for
educational credentials, licensure, or certification.
(2) Information on training and educational opportunities
within each region for the type of jobs described in
paragraph (1), including by--
(A) type of provider or program (such as public, private
nonprofit, or private for-profit);
(B) duration;
(C) cost (such as tuition, fees, books, laboratory
expenses, and other mandatory costs);
(D) performance outcomes (such as graduation rates, job
placement, average salary, job retention, and wage
progression);
(E) Federal financial aid participation;
(F) average graduate loan debt;
(G) student loan default rates;
(H) average institutional grant aid provided;
(I) Federal and State accreditation information; and
(J) other information determined by the Secretary.
(3) A mechanism for searching and comparing training and
educational options for specific health care occupations to
facilitate informed career and education choices.
(4) Financial aid information, including with respect to
loan forgiveness, loan cancellation, loan repayment,
stipends, scholarships, and grants or other assistance
authorized by this Act or other Federal or State programs.
(c) Public Accessibility.--The Web site maintained under
this section shall--
(1) be publicly accessible;
(2) be user friendly and convey information in a manner
that is easily understandable; and
(3) be in English and the second most prevalent language
spoken based on the latest Census information.

SEC. 2591. ONLINE HEALTH WORKFORCE TRAINING PROGRAMS.

Section 171 of the Workforce Investment Act of 1998 (29
U.S.C. 2916) is amended by adding at the end the following:
``(f) Online Health Workforce Training Program.--
``(1) Grant program.--
``(A) In general.--The Secretary in consultation with the
Secretary of Health and Human Services, shall award National
Health Workforce Online Training Grants on a competitive
basis to eligible entities to enable such entities to carry
out training for individuals to attain or advance in health
care occupations. An entity may leverage such grant with
other Federal, State, local, and private resources, in order
to expand the participation of businesses, employees, and
individuals in such training programs.
``(B) Eligibility.--In order to receive a grant under the
program established under this paragraph--
``(i) an entity shall be an educational institution,
community-based organization, nonprofit organization,
workforce investment board, or local or county government;
and
``(ii) an entity shall provide online workforce training
for individuals seeking to attain or advance in health care
occupations, including nursing, nursing assistants,
dentistry, pharmacy, health care management and
administration, public health, health information systems
analysis, medical assistants, and other health care
practitioner and support occupations.
``(C) Priority.--Priority in awarding grants under this
paragraph shall be given to entities that--
``(i) have demonstrated experience in implementing and
operating online worker skills training and education
programs;
``(ii) have demonstrated experience coordinating
activities, where appropriate, with the workforce investment
system; and
``(iii) conduct training for occupations with national or
local shortages.
``(D) Data collection.--Grantees under this paragraph shall
collect and report information on--
``(i) the number of participants;
``(ii) the services received by the participants;
``(iii) program completion rates;
``(iv) factors determined as significantly interfering with
program participation or completion;
``(v) the rate of job placement; and
``(vi) other information as determined as needed by the
Secretary.
``(E) Outreach.--Grantees under this paragraph shall
conduct outreach activities to disseminate information about
their program and results to workforce investment boards,
local governments, educational institutions, and other
workforce training organizations.
``(F) Performance levels.--The Secretary shall establish
indicators of performance that will be used to evaluate the
performance of grantees under this paragraph in carrying out
the activities described in this paragraph. The Secretary
shall negotiate and reach agreement with each grantee
regarding the levels of performance expected to be achieved
by the grantee on the indicators of performance.
``(G) Authorization of appropriations.--There are
authorized to be appropriated to the Secretary to carry out
this subsection $50,000,000 for fiscal years 2011 through
2020.
``(2) Online health professions training program
clearinghouse.--
``(A) Description of grant.--The Secretary may award one or
more grants to eligible postsecondary educational
institutions to provide the services described in this
paragraph.
``(B) Eligibility.--To be eligible to receive a grant under
this paragraph, a postsecondary educational institution
shall--
``(i) have demonstrated the ability to disseminate research
on best practices for implementing workforce investment
programs; and
``(ii) be a national leader in producing cutting-edge
research on technology related to workforce investment
systems under subtitle B.
``(C) Services.--The postsecondary educational institution
that receives a grant under this paragraph shall use such
grant--
``(i) to provide technical assistance to entities that
receive grants under paragraph (1);
``(ii) to collect and nationally disseminate the data
gathered by entities that receive grants under paragraph (1);
and
``(iii) to disseminate the best practices identified by the
National Health Workforce Online Training Grant Program to
other workforce training organizations.
``(D) Authorization of appropriations.--There are
authorized to be appropriated to the Secretary to carry out
this subsection $1,000,000 for fiscal years 2011 through
2020.''.

SEC. 2592. ACCESS FOR INDIVIDUALS WITH DISABILITIES.

Title V of the Rehabilitation Act of 1973 (29 U.S.C. 791 et
seq.) is amended by adding at the end of the following:

``SEC. 510. STANDARDS FOR ACCESSIBILITY OF MEDICAL DIAGNOSTIC
EQUIPMENT.

``(a) Standards.--Not later than 9 months after the date of
enactment of the Affordable Health Care for America Act, the
Architectural and Transportation Barriers Compliance Board
(Access Board) shall issue guidelines setting forth the
minimum technical criteria for new medical diagnostic
equipment to be purchased for use in (or in conjunction with)
physician's offices, clinics, emergency rooms, hospitals, and
other medical settings. The guidelines shall ensure that such
equipment is accessible to, and usable by, individuals with
disabilities, including provisions to ensure independent
entry to, use of, and exit from the equipment by such
individuals to the maximum extent possible.
``(b) Medical Diagnostic Equipment Covered.--The guidelines
issued under subsection (a) for medical diagnostic equipment
shall apply to new purchases of equipment that includes
examination tables, examination chairs (including chairs used
for eye examinations or procedures, and dental examinations
or procedures), weight scales, mammography equipment, x-ray
machines, and other equipment commonly used for diagnostic or
examination purposes by health professionals.

[[Page H12795]]

``(c) Regulations.--Not later than 6 months after the date
of the issuance of the guidelines under subsection (a), each
appropriate Federal agency authorized to promulgate
regulations under this Act or under the Americans with
Disabilities Act shall--
``(1) prescribe regulations in an accessible format as
necessary to carry out the provisions of such Act and section
504 of this Act that include accessibility standards that are
consistent with the guidelines issued under subsection (a);
and
``(2) ensure that health care providers and health care
plans covered by the Affordable Health Care for America Act
meet the requirements of the Americans with Disabilities Act
and section 504, including provisions ensuring that
individuals with disabilities receive equal access to all
aspects of the health care delivery system.
``(d) Review and Amend.--The Architectural and
Transportation Barriers Compliance Board (Access Board) shall
periodically review and, as appropriate, amend the guidelines
as prescribed under subsection (a). Not later than 6 months
after the date of the issuance of such revised guidelines,
revised regulations consistent with such guidelines shall be
promulgated in an accessible format by the appropriate
Federal agencies described in subsection (c).''.

SEC. 2593. DUPLICATIVE GRANT PROGRAMS.

(a) Study.--The Secretary of Health and Human Services (in
this section referred to as the ``Secretary'') shall conduct
a study to determine if any new division C grant program is
duplicative of one or more other grant programs of the
Department of Health and Human Services that--
(1) are specifically authorized in the Public Health
Service Act (42 U.S.C. 201 et seq.); or
(2) are receiving appropriations.
(b) Duplicative Programs.--If the Secretary determines
under subsection (a) that a new division C grant program is
duplicative of one or more other grant programs described in
such subsection, the Secretary shall--
(1) attempt to integrate the new division C grant program
with the duplicative programs; and
(2) if the Secretary determines that such integration is
not appropriate or has not been successful, promulgate a rule
eliminating the duplication, including, if appropriate, by
terminating one or more programs.
(c) Continued Availability of Funds.--Any funds
appropriated to carry out a program that is terminated under
subsection (b)(2) shall remain available for obligation for
the one or more programs that--
(1) were determined under subsection (a) to be duplicative
of such program; and
(2) remain in effect.
(d) Report.--Not later than 1 year after the date of the
enactment of this Act, the Secretary shall submit to the
Congress and make available to the public a report that
contains the results of the study required under subsection
(a).
(e) Congressional Review.--Any rule under subsection (b)(2)
terminating a program is deemed to be a major rule for
purposes of chapter 8 of title 5, United States Code.
(f) Definition.--In this section, the term ``new division C
grant program''--
(1) means a grant program first established by this
division; and
(2) excludes any program whose statutory authorization was
in existence before the enactment of this division.

SEC. 2594. DIABETES SCREENING COLLABORATION AND OUTREACH
PROGRAM.

(a) Establishment.--With respect to diabetes screening
tests and for the purposes of reducing the number of
undiagnosed seniors with diabetes or prediabetes, the
Secretary of Health and Human Services (referred to in this
section as the ``Secretary''), in collaboration with the
Director of the Centers for Disease Control and Prevention
(referred to in this section as the ``Director''), shall--
(1) review uptake and utilization of diabetes screening
benefits, consistent with recommendations of the Task Force
on Clinical Preventive Services (established under section
3131 of the Public Health Service Act, as added by section
2301 of this Act), to identify and address any existing
problems, with regard to uptake and utilization and related
data collection mechanisms; and
(2) establish an outreach program to identify existing
efforts by agencies of the Department of Health and Human
Services and by the private and nonprofit sectors to increase
awareness among seniors and providers of diabetes screening
benefits.
(b) Consultation.--The Secretary shall carry out this
section in consultation with--
(1) the heads of appropriate health agencies and offices in
the Department of Health and Human Services, including the
Office of Minority Health; and
(2) entities with an interest in diabetes, including
industry, voluntary health organizations, trade associations,
and professional societies.
(c) Report.--The Secretary shall submit an annual report to
the Congress on the activities carried out under this
section.

SEC. 2595. IMPROVEMENT OF VITAL STATISTICS COLLECTION.

(a) In General.--The Secretary of Health and Human Services
(in this section referred to as the ``Secretary''), acting
through the Director of the Centers for Disease Control and
Prevention and in collaboration with appropriate agencies and
States, shall--
(1) promote the education and training of physicians on the
importance of birth and death certification data and how to
properly complete these documents in accordance with State
law, including the collection of such data for diabetes and
other chronic diseases as appropriate;
(2) encourage State adoption of the latest standard
revisions of birth and death certificates; and
(3) work with States to re-engineer their vital statistics
systems in order to provide cost-effective, timely, and
accurate vital systems data.
(b) Death Certificate Additional Language.--In carrying out
this section, the Secretary may promote improvements to the
collection of diabetes mortality data, including, as
appropriate, the addition by States of a question for the
individual certifying the cause of death regarding whether
the deceased had diabetes.

SEC. 2596. NATIONAL HEALTH SERVICES CORPS DEMONSTRATION ON
INCENTIVE PAYMENTS.

(a) In General.--The Secretary of Health and Human Services
may establish a demonstration program under which, in
addition to the salary and benefits otherwise owed to a
member of the National Health Services Corps, incentive
payments are awarded to any such member who is assigned to a
health professional shortage area with extreme need.
(b) Report.--The Secretary shall submit to the Congress an
annual report on the demonstration program under subsection
(a).
(c) Definitions.--In this section:
(1) The term ``health professional shortage area with
extreme need'' means a health professional shortage area
that--
(A) is described in section 333A(a)(1)(A) of the Public
Health Service Act (42 U.S.C. 254f-1(a)(1)(A));
(B) is described in section 333(a)(1)(D)(ii)(IV) of such
Act (42 U.S.C. 254f(a)(1)(D)(ii)(IV)); and
(C) has high rates of untreated disease, including chronic
conditions.
(3) The term ``Secretary'' means the Secretary of Health
and Human Services.
(d) Authorization of Appropriations.--To carry out this
section, there are authorized to be appropriated such sums as
may be necessary for each of fiscal years 2011 through 2015.

DIVISION D--INDIAN HEALTH CARE IMPROVEMENT

SEC. 3001. SHORT TITLE; TABLE OF CONTENTS.

(a) Short Title.--This division may be cited as the
``Indian Health Care Improvement Act Amendments of 2009''.
(b) Table of Contents.--The table of contents of this
division is as follows:
Sec. 3001. Short title; table of contents.

TITLE I--AMENDMENTS TO INDIAN LAWS

Sec. 3101. Indian Health Care Improvement Act amended.
Sec. 3102. Native American Health and Wellness Foundation.
Sec. 3103. GAO study and report on payments for contract health
services.

TITLE II--IMPROVEMENT OF INDIAN HEALTH CARE PROVIDED UNDER THE SOCIAL
SECURITY ACT

Sec. 3201. Expansion of payments under Medicare, Medicaid, and SCHIP
for all covered services furnished by Indian Health
Programs.
Sec. 3202. Additional provisions to increase outreach to, and
enrollment of, Indians in SCHIP and Medicaid.
Sec. 3203. Solicitation of proposals for safe harbors under the Social
Security Act for facilities of Indian Health Programs and
urban Indian organizations.
Sec. 3204. Annual report on Indians served by Social Security Act
health benefit programs.
Sec. 3205. Development of recommendations to improve interstate
coordination of Medicaid and SCHIP coverage of Indian
children and other children who are outside of their
State of residency because of educational or other needs.

TITLE I--AMENDMENTS TO INDIAN LAWS

SEC. 3101. INDIAN HEALTH CARE IMPROVEMENT ACT AMENDED.

(a) In General.--The Indian Health Care Improvement Act (25
U.S.C. 1601 et seq.) is amended to read as follows:

``SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

``(a) Short Title.--This Act may be cited as the `Indian
Health Care Improvement Act'.
``(b) Table of Contents.--The table of contents for this
Act is as follows:

``Sec. 1. Short title; table of contents.
``Sec. 2. Findings.
``Sec. 3. Declaration of national Indian health policy.
``Sec. 4. Definitions.

``TITLE I--INDIAN HEALTH, HUMAN RESOURCES, AND DEVELOPMENT

``Sec. 101. Purpose.
``Sec. 102. Health professions recruitment program for Indians.
``Sec. 103. Health professions preparatory scholarship program for
Indians.
``Sec. 104. Indian health professions scholarships.
``Sec. 105. American Indians Into Psychology Program.
``Sec. 106. Scholarship programs for Indian Tribes.
``Sec. 107. Indian Health Service extern programs.

[[Page H12796]]

``Sec. 108. Continuing education allowances.
``Sec. 109. Community Health Representative Program.
``Sec. 110. Indian Health Service Loan Repayment Program.
``Sec. 111. Scholarship and Loan Repayment Recovery Fund.
``Sec. 112. Recruitment activities.
``Sec. 113. Indian recruitment and retention program.
``Sec. 114. Advanced training and research.
``Sec. 115. Quentin N. Burdick American Indians Into Nursing Program.
``Sec. 116. Tribal cultural orientation.
``Sec. 117. INMED Program.
``Sec. 118. Health training programs of community colleges.
``Sec. 119. Retention bonus.
``Sec. 120. Nursing residency program.
``Sec. 121. Community Health Aide Program.
``Sec. 122. Tribal Health Program administration.
``Sec. 123. Health professional chronic shortage demonstration
programs.
``Sec. 124. National Health Service Corps.
``Sec. 125. Substance abuse counselor educational curricula
demonstration programs.
``Sec. 126. Behavioral health training and community education
programs.
``Sec. 127. Exemption from payment of certain fees.
``Sec. 128. Authorization of appropriations.

``TITLE II--HEALTH SERVICES

``Sec. 201. Indian Health Care Improvement Fund.
``Sec. 202. Health promotion and disease prevention services.
``Sec. 203. Diabetes prevention, treatment, and control.
``Sec. 204. Shared services for long-term care.
``Sec. 205. Health services research.
``Sec. 206. Mammography and other cancer screening.
``Sec. 207. Patient travel costs.
``Sec. 208. Epidemiology centers.
``Sec. 209. Comprehensive school health education programs.
``Sec. 210. Indian youth program.
``Sec. 211. Prevention, control, and elimination of communicable and
infectious diseases.
``Sec. 212. Other authority for provision of services.
``Sec. 213. Indian women's health care.
``Sec. 214. Environmental and nuclear health hazards.
``Sec. 215. Arizona as a contract health service delivery area.
``Sec. 216. North Dakota and South Dakota as contract health service
delivery area.
``Sec. 217. California contract health services program.
``Sec. 218. California as a contract health service delivery area.
``Sec. 219. Contract health services for the Trenton Service Area.
``Sec. 220. Programs operated by Indian Tribes and tribal
organizations.
``Sec. 221. Licensing.
``Sec. 222. Notification of provision of emergency contract health
services.
``Sec. 223. Prompt action on payment of claims.
``Sec. 224. Liability for payment.
``Sec. 225. Office of Indian Men's Health.
``Sec. 226. Catastrophic health emergency fund.
``Sec. 227. Authorization of appropriations.

``TITLE III--FACILITIES

``Sec. 301. Consultation; construction and renovation of facilities;
reports.
``Sec. 302. Sanitation facilities.
``Sec. 303. Preference to Indians and Indian firms.
``Sec. 304. Expenditure of non-Service funds for renovation.
``Sec. 305. Funding for the construction, expansion, and modernization
of small ambulatory care facilities.
``Sec. 306. Indian health care delivery demonstration project.
``Sec. 307. Land transfer.
``Sec. 308. Leases, contracts, and other agreements.
``Sec. 309. Study on loans, loan guarantees, and loan repayment.
``Sec. 310. Tribal leasing.
``Sec. 311. Indian Health Service/tribal facilities joint venture
program.
``Sec. 312. Location of facilities.
``Sec. 313. Maintenance and improvement of health care facilities.
``Sec. 314. Tribal management of federally owned quarters.
``Sec. 315. Applicability of Buy American Act requirement.
``Sec. 316. Other funding for facilities.
``Sec. 317. Authorization of appropriations.

``TITLE IV--ACCESS TO HEALTH SERVICES

``Sec. 401. Treatment of payments under Social Security Act health
benefits programs.
``Sec. 402. Grants to and contracts with the Service, Indian Tribes,
Tribal Organizations, and urban Indian organizations to
facilitate outreach, enrollment, and coverage of Indians
under Social Security Act health benefit programs.
``Sec. 403. Reimbursement from certain third parties of costs of health
services.
``Sec. 404. Crediting of reimbursements.
``Sec. 405. Purchasing health care coverage.
``Sec. 406. Sharing arrangements with Federal agencies.
``Sec. 407. Eligible indian veteran services.
``Sec. 408. Payor of last resort.
``Sec. 409. Consultation.
``Sec. 410. State Children's Health Insurance Program (SCHIP).
``Sec. 411. Premium and cost sharing protections and eligibility
determinations under Medicaid and SCHIP and protection of
certain Indian property from Medicaid estate recovery.
``Sec. 412. Treatment under Medicaid and SCHIP managed care.
``Sec. 413. Navajo Nation Medicaid Agency feasibility study.
``Sec. 414. Exception for excepted benefits.
``Sec. 415. Authorization of appropriations.

``TITLE V--HEALTH SERVICES FOR URBAN INDIANS

``Sec. 501. Purpose.
``Sec. 502. Contracts with, and grants to, urban Indian organizations.
``Sec. 503. Contracts and grants for the provision of health care and
referral services.
``Sec. 504. Use of Federal Government Facilities and Sources of Supply.
``Sec. 505. Contracts and grants for the determination of unmet health
care needs.
``Sec. 506. Evaluations; renewals.
``Sec. 507. Other contract and grant requirements.
``Sec. 508. Reports and records.
``Sec. 509. Limitation on contract authority.
``Sec. 510. Facilities.
``Sec. 511. Division of Urban Indian Health.
``Sec. 512. Grants for alcohol and substance abuse-related services.
``Sec. 513. Treatment of certain demonstration projects.
``Sec. 514. Urban NIAAA transferred programs.
``Sec. 515. Conferring with urban Indian organizations.
``Sec. 516. Urban youth treatment center demonstration.
``Sec. 517. Grants for diabetes prevention, treatment, and control.
``Sec. 518. Community health representatives.
``Sec. 519. Effective date.
``Sec. 520. Eligibility for services.
``Sec. 521. Authorization of appropriations.
``Sec. 522. Health information technology.

``TITLE VI--ORGANIZATIONAL IMPROVEMENTS

``Sec. 601. Establishment of the Indian Health Service as an agency of
the Public Health Service.
``Sec. 602. Automated management information system.
``Sec. 603. Authorization of appropriations.

``TITLE VII--BEHAVIORAL HEALTH PROGRAMS

``Sec. 701. Behavioral health prevention and treatment services.
``Sec. 702. Memoranda of agreement with the Department of the Interior.
``Sec. 703. Comprehensive behavioral health prevention and treatment
program.
``Sec. 704. Mental health technician program.
``Sec. 705. Licensing requirement for mental health care workers.
``Sec. 706. Indian women treatment programs.
``Sec. 707. Indian youth program.
``Sec. 708. Indian youth telemental health demonstration project.
``Sec. 709. Inpatient and community-based mental health facilities
design, construction, and staffing.
``Sec. 710. Training and community education.
``Sec. 711. Behavioral health program.
``Sec. 712. Fetal alcohol disorder programs.
``Sec. 713. Child sexual abuse and prevention treatment programs.
``Sec. 714. Domestic and sexual violence prevention and treatment.
``Sec. 715. Behavioral health research.
``Sec. 716. Definitions.
``Sec. 717. Authorization of appropriations.

``TITLE VIII--MISCELLANEOUS

``Sec. 801. Reports.
``Sec. 802. Regulations.
``Sec. 803. Plan of implementation.
``Sec. 804. Limitation on use of funds appropriated to Indian Health
Service.
``Sec. 805. Eligibility of California Indians.
``Sec. 806. Health services for ineligible persons.
``Sec. 807. Reallocation of base resources.
``Sec. 808. Results of demonstration projects.
``Sec. 809. Moratorium.
``Sec. 810. Severability provisions.
``Sec. 811. Use of patient safety organizations.
``Sec. 812. Confidentiality of medical quality assurance records;
qualified immunity for participants.
``Sec. 813. Claremore Indian Hospital.
``Sec. 814. Sense of Congress regarding law enforcement and
methamphetamine issues in Indian country.
``Sec. 815. Permitting implementation through contracts with Tribal
Health Programs.
``Sec. 816. Authorization of appropriations; availability.

``SEC. 2. FINDINGS.

``Congress makes the following findings:
``(1) Federal health services to maintain and improve the
health of the Indians are consonant with and required by the
Federal Government's historical and unique legal relationship
with, and resulting responsibility to, the American Indian
people.

[[Page H12797]]

``(2) A major national goal of the United States is to
provide the resources, processes, and structure that will
enable Indian tribes and tribal members to obtain the
quantity and quality of health care services and
opportunities that will eradicate the health disparities
between Indians the general population.
``(3) A major national goal of the United States is to
provide the quantity and quality of health services which
will permit the health status of Indians to be raised to the
highest possible level and to encourage the maximum
participation of Indians in the planning and management of
those services.
``(4) Federal health services to Indians have resulted in a
reduction in the prevalence and incidence of preventable
illnesses among, and unnecessary and premature deaths of,
Indians.
``(5) Despite such services, the unmet health needs of the
American Indian people are severe and the health status of
the Indians is far below that of the general population of
the United States.

``SEC. 3. DECLARATION OF NATIONAL INDIAN HEALTH POLICY.

``Congress declares that it is the policy of this Nation,
in fulfillment of its special trust responsibilities and
legal obligations to Indians--
``(1) to assure the highest possible health status for
Indians and Urban Indians and to provide all resources
necessary to effect that policy;
``(2) to raise the health status of Indians and Urban
Indians to at least the levels set forth in the goals
contained within the Health People 2010 or successor
objectives;
``(3) to the greatest extent possible, to allow Indians to
set their own health care priorities and establish goals that
reflect their unmet needs;
``(4) to increase the proportion of all degrees in the
health professions and allied and associated health
professions awarded to Indians so that the proportion of
Indian health professionals in each Service Area is raised to
at least the level of that of the general population;
``(5) to require meaningful consultation with Indian
Tribes, Tribal Organizations, and urban Indian organizations
to implement this Act and the national policy of Indian self-
determination; and
``(6) to provide funding for programs and facilities
operated by Indian Tribes, Tribal Organizations, and Urban
Indian Organizations in amounts that are not less than the
amounts provided to programs and facilities operated directly
by the Service.

``SEC. 4. DEFINITIONS.

``For purposes of this Act:
``(1) The term `accredited and accessible' means on or near
a reservation and accredited by a national or regional
organization with accrediting authority.
``(2) The term `Area Office' means an administrative
entity, including a program office, within the Service
through which services and funds are provided to the Service
Units within a defined geographic area.
``(3) The term `Assistant Secretary' means the Assistant
Secretary of Indian Health.
``(4)(A) The term `behavioral health' means the blending of
substance (including alcohol, drugs, inhalants, and tobacco)
abuse and mental health prevention and treatment, for the
purpose of providing comprehensive services.
``(B) The term `behavioral health' includes the joint
development of substance abuse and mental health treatment
planning and coordinated case management using a
multidisciplinary approach.
``(5) The term `California Indians' means those Indians who
are eligible for health services of the Service pursuant to
section 805.
``(6) The term `community college' means--
``(A) a tribal college or university, or
``(B) a junior or community college.
``(7) The term `contract health service' means health
services provided at the expense of the Service or a Tribal
Health Program by public or private medical providers or
hospitals, other than the Service Unit or the Tribal Health
Program at whose expense the services are provided.
``(8) The term `Department' means, unless otherwise
designated, the Department of Health and Human Services.
``(9) The term `disease prevention' means the reduction,
limitation, and prevention of disease and its complications
and reduction in the consequences of disease, including--
``(A) controlling--
``(i) the development of diabetes;
``(ii) high blood pressure;
``(iii) infectious agents;
``(iv) injuries;
``(v) occupational hazards and disabilities;
``(vi) sexually transmittable diseases; and
``(vii) toxic agents; and
``(B) providing--
``(i) fluoridation of water; and
``(ii) immunizations.
``(10) The term `health profession' means allopathic
medicine, family medicine, internal medicine, pediatrics,
geriatric medicine, obstetrics and gynecology, podiatric
medicine, nursing, public health nursing, dentistry,
psychiatry, osteopathy, optometry, pharmacy, psychology,
public health, social work, marriage and family therapy,
chiropractic medicine, environmental health and engineering,
allied health professions, naturopathic medicine, and any
other health profession.
``(11) The term `health promotion' means--
``(A) fostering social, economic, environmental, and
personal factors conducive to health, including raising
public awareness about health matters and enabling the people
to cope with health problems by increasing their knowledge
and providing them with valid information;
``(B) encouraging adequate and appropriate diet, exercise,
and sleep;
``(C) promoting education and work in conformity with
physical and mental capacity;
``(D) making available safe water and sanitary facilities;
``(E) improving the physical, economic, cultural,
psychological, and social environment;
``(F) promoting culturally competent care; and
``(G) providing adequate and appropriate programs, which
may include--
``(i) abuse prevention (mental and physical);
``(ii) community health;
``(iii) community safety;
``(iv) consumer health education;
``(v) diet and nutrition;
``(vi) immunization and other prevention of communicable
diseases, including HIV/AIDS;
``(vii) environmental health;
``(viii) exercise and physical fitness;
``(ix) avoidance of fetal alcohol disorders;
``(x) first aid and CPR education;
``(xi) human growth and development;
``(xii) injury prevention and personal safety;
``(xiii) behavioral health;
``(xiv) monitoring of disease indicators between health
care provider visits, through appropriate means, including
Internet-based health care management systems;
``(xv) personal health and wellness practices;
``(xvi) personal capacity building;
``(xvii) prenatal, pregnancy, and infant care;
``(xviii) psychological well-being;
``(xix) reproductive health and family planning;
``(xx) safe and adequate water;
``(xxi) healthy work environments;
``(xxii) elimination, reduction, and prevention of
contaminants that create unhealthy household conditions
(including mold and other allergens);
``(xxiii) stress control;
``(xxiv) substance abuse;
``(xxv) sanitary facilities;
``(xxvi) sudden infant death syndrome prevention;
``(xxvii) tobacco use cessation and reduction;
``(xxviii) violence prevention; and
``(xxix) activities to promote achievement of any of the
objectives described in section 3(2).
``(12) The term `Indian', unless otherwise designated,
means any person who is a member of an Indian Tribe or is
eligible for health services under section 805, except that,
for the purpose of sections 102 and 103, the term also means
any individual who--
``(A)(i) irrespective of whether the individual lives on or
near a reservation, is a member of a tribe, band, or other
organized group of Indians, including those tribes, bands, or
groups terminated since 1940 and those recognized now or in
the future by the State in which they reside; or
``(ii) is a descendant, in the first or second degree, of
any such member;
``(B) is an Eskimo or Aleut or other Alaska Native;
``(C) is considered by the Secretary of the Interior to be
an Indian for any purpose; or
``(D) is determined to be an Indian under regulations
promulgated by the Secretary.
``(13) The term `Indian Health Program' means--
``(A) any health program administered directly by the
Service;
``(B) any Tribal Health Program; or
``(C) any Indian Tribe or Tribal Organization to which the
Secretary provides funding pursuant to section 23 of the Act
of June 25, 1910 (25 U.S.C. 47) (commonly known as the `Buy
Indian Act').
``(14) The term `Indian Tribe' has the meaning given the
term in the Indian Self-Determination and Education
Assistance Act (25 U.S.C. 450 et seq.).
``(15) The term `junior or community college' has the
meaning given the term by section 312(f) of the Higher
Education Act of 1965 (20 U.S.C. 1058(f)).
``(16) The term `reservation' means any federally
recognized Indian Tribe's reservation, Pueblo, or colony,
including former reservations in Oklahoma, Indian allotments,
and Alaska Native Regions established pursuant to the Alaska
Native Claims Settlement Act (43 U.S.C. 1601 et seq.).
``(17) The term `Secretary', unless otherwise designated,
means the Secretary of Health and Human Services.
``(18) The term `Service' means the Indian Health Service.
``(19) The term `Service Area' means the geographical area
served by each Area Office.
``(20) The term `Service Unit' means an administrative
entity of the Service, or a Tribal Health Program through
which services are provided, directly or by contract, to
eligible Indians within a defined geographic area.
``(21) The term `telehealth' has the meaning given the term
in section 330K(a) of the Public Health Service Act (42
U.S.C. 254c-16(a)).
``(22) The term `telemedicine' means a telecommunications
link to an end user through the use of eligible equipment
that electronically links health professionals or patients

[[Page H12798]]

and health professionals at separate sites in order to
exchange health care information in audio, video, graphic, or
other format for the purpose of providing improved health
care services.
``(23) The term `tribal college or university' has the
meaning given the term in section 316(b)(3) of the Higher
Education Act (20 U.S.C. 1059c(b)(3)).
``(24) The term `Tribal Health Program' means an Indian
Tribe or Tribal Organization that operates any health
program, service, function, activity, or facility funded, in
whole or part, by the Service through, or provided for in, a
contract or compact with the Service under the Indian Self-
Determination and Education Assistance Act (25 U.S.C. 450 et
seq.).
``(25) The term `Tribal Organization' has the meaning given
the term in the Indian Self-Determination and Education
Assistance Act (25 U.S.C. 450 et seq.).
``(26) The term `Urban Center' means any community which
has a sufficient Urban Indian population with unmet health
needs to warrant assistance under title V of this Act, as
determined by the Secretary.
``(27) The term `Urban Indian' means any individual who
resides in an Urban Center and who meets 1 or more of the
following criteria:
``(A) Irrespective of whether the individual lives on or
near a reservation, the individual is a member of a tribe,
band, or other organized group of Indians, including those
tribes, bands, or groups terminated since 1940 and those
tribes, bands, or groups that are recognized by the States in
which they reside, or who is a descendant in the first or
second degree of any such member.
``(B) The individual is an Eskimo, Aleut, or other Alaska
Native.
``(C) The individual is considered by the Secretary of the
Interior to be an Indian for any purpose.
``(D) The individual is determined to be an Indian under
regulations promulgated by the Secretary.
``(28) The term `urban Indian organization' means a
nonprofit corporate body that (A) is situated in an Urban
Center; (B) is governed by an Urban Indian-controlled board
of directors; (C) provides for the participation of all
interested Indian groups and individuals; and (D) is capable
of legally cooperating with other public and private entities
for the purpose of performing the activities described in
section 503(a).

``TITLE I--INDIAN HEALTH, HUMAN RESOURCES, AND DEVELOPMENT

``SEC. 101. PURPOSE.

``The purpose of this title is to increase, to the maximum
extent feasible, the number of Indians entering the health
professions and providing health services, and to assure an
optimum supply of health professionals to the Indian Health
Programs and urban Indian organizations involved in the
provision of health services to Indians.

``SEC. 102. HEALTH PROFESSIONS RECRUITMENT PROGRAM FOR
INDIANS.

``(a) In General.--The Secretary, acting through the
Service, shall make grants to public or nonprofit private
health or educational entities, Tribal Health Programs, or
urban Indian organizations to assist such entities in meeting
the costs of--
``(1) identifying Indians with a potential for education or
training in the health professions and encouraging and
assisting them--
``(A) to enroll in courses of study in such health
professions; or
``(B) if they are not qualified to enroll in any such
courses of study, to undertake such postsecondary education
or training as may be required to qualify them for
enrollment;
``(2) publicizing existing sources of financial aid
available to Indians enrolled in any course of study referred
to in paragraph (1) or who are undertaking training necessary
to qualify them to enroll in any such course of study; or
``(3) establishing other programs which the Secretary
determines will enhance and facilitate the enrollment of
Indians in, and the subsequent pursuit and completion by them
of, courses of study referred to in paragraph (1).
``(b) Grants.--
``(1) Application.--No grant may be made under this section
unless an application has been submitted to, and approved by,
the Secretary. Such application shall be in such form,
submitted in such manner, and contain such information, as
the Secretary shall by regulation prescribe pursuant to this
Act. The Secretary shall give a preference to applications
submitted by Tribal Health Programs or urban Indian
organizations.
``(2) Amount of grants; payment.--The amount of a grant
under this section shall be determined by the Secretary.
Payments pursuant to this section may be made in advance or
by way of reimbursement, and at such intervals and on such
conditions as provided for in regulations issued pursuant to
this Act. To the extent not otherwise prohibited by law,
grants shall be for 3 years, as provided in regulations
issued pursuant to this Act.

``SEC. 103. HEALTH PROFESSIONS PREPARATORY SCHOLARSHIP
PROGRAM FOR INDIANS.

``(a) Scholarships Authorized.--The Secretary, acting
through the Service, shall provide scholarship grants to
Indians who--
``(1) have successfully completed their high school
education or high school equivalency; and
``(2) have demonstrated the potential to successfully
complete courses of study in the health professions.
``(b) Purposes.--Scholarship grants provided pursuant to
this section shall be for the following purposes:
``(1) Compensatory preprofessional education of any
recipient, such scholarship not to exceed 2 years on a full-
time basis (or the part-time equivalent thereof, as
determined by the Secretary pursuant to regulations issued
under this Act).
``(2) Pregraduate education of any recipient leading to a
baccalaureate degree in an approved course of study
preparatory to a field of study in a health profession, such
scholarship not to exceed 4 years. An extension of up to 2
years (or the part-time equivalent thereof, as determined by
the Secretary pursuant to regulations issued pursuant to this
Act) may be approved.
``(c) Other Conditions.--Scholarships under this section--
``(1) may cover costs of tuition, books, transportation,
board, and other necessary related expenses of a recipient
while attending school;
``(2) shall not be denied solely on the basis of the
applicant's scholastic achievement if such applicant has been
admitted to, or maintained good standing at, an accredited
institution; and
``(3) shall not be denied solely by reason of such
applicant's eligibility for assistance or benefits under any
other Federal program.

``SEC. 104. INDIAN HEALTH PROFESSIONS SCHOLARSHIPS.

``(a) In General.--
``(1) Authority.--The Secretary, acting through the
Service, shall make scholarship grants to Indians who are
enrolled full or part time in accredited schools pursuing
courses of study in the health professions. Such scholarships
shall be designated Indian Health Scholarships and shall be
made in accordance with section 338A of the Public Health
Services Act (42 U.S.C. 254l), except as provided in
subsection (b) of this section.
``(2) Determinations by secretary.--The Secretary, acting
through the Service, shall determine--
``(A) who shall receive scholarship grants under subsection
(a); and
``(B) the distribution of the scholarships among health
professions on the basis of the relative needs of Indians for
additional service in the health professions.
``(3) Certain delegation not allowed.--The administration
of this section shall be a responsibility of the Assistant
Secretary and shall not be delegated in a contract or compact
under the Indian Self-Determination and Education Assistance
Act (25 U.S.C. 450 et seq.).
``(b) Active Duty Service Obligation.--
``(1) Obligation met.--The active duty service obligation
under a written contract with the Secretary under this
section that an Indian has entered into shall, if that
individual is a recipient of an Indian Health Scholarship, be
met in full-time practice equal to 1 year for each school
year for which the participant receives a scholarship award
under this part, or 2 years, whichever is greater, by service
in 1 or more of the following:
``(A) In an Indian Health Program.
``(B) In a program assisted under title V of this Act.
``(C) In the private practice of the applicable profession
if, as determined by the Secretary, in accordance with
guidelines promulgated by the Secretary, such practice is
situated in a physician or other health professional shortage
area and addresses the health care needs of a substantial
number of Indians.
``(D) In a teaching capacity in a tribal college or
university nursing program (or a related health profession
program) if, as determined by the Secretary, the health
service provided to Indians would not decrease.
``(2) Obligation deferred.--At the request of any
individual who has entered into a contract referred to in
paragraph (1) and who receives a health professions degree
requiring postgraduate training for licensure or to improve
clinical skills, the Secretary shall defer the active duty
service obligation of that individual under that contract, in
order that such individual may complete any internship,
residency, or other advanced clinical training that is
required for the practice of that health profession, for an
appropriate period (in years, as determined by the
Secretary), subject to the following conditions:
``(A) No period of internship, residency, or other advanced
clinical training shall be counted as satisfying any period
of obligated service under this subsection.
``(B) The active duty service obligation of that individual
shall commence not later than 90 days after the completion of
that advanced clinical training (or by a date specified by
the Secretary).
``(C) The active duty service obligation will be served in
the health profession of that individual in a manner
consistent with paragraph (1).
``(D) A recipient of a scholarship under this section may,
at the election of the recipient, meet the active duty
service obligation described in paragraph (1) by service in a
program specified under that paragraph that--
``(i) is located on the reservation of the Indian Tribe in
which the recipient is enrolled; or
``(ii) serves the Indian Tribe in which the recipient is
enrolled.
``(3) Priority when making assignments.--Subject to
paragraph (2), the Secretary, in making assignments of Indian
Health Scholarship recipients required to meet the active

[[Page H12799]]

duty service obligation described in paragraph (1), shall
give priority to assigning individuals to service in those
programs specified in paragraph (1) that have a need for
health professionals to provide health care services as a
result of individuals having breached contracts entered into
under this section.
``(c) Part-time Students.--In the case of an individual
receiving a scholarship under this section who is enrolled
part time in an approved course of study--
``(1) such scholarship shall be for a period of years not
to exceed the part-time equivalent of 4 years, as determined
by the Secretary;
``(2) the period of obligated service described in
subsection (b)(1) shall be equal to the greater of--
``(A) the part-time equivalent of 1 year for each year for
which the individual was provided a scholarship (as
determined by the Secretary); or
``(B) 2 years; and
``(3) the amount of the monthly stipend specified in
section 338A(g)(1)(B) of the Public Health Service Act (42
U.S.C. 254l(g)(1)(B)) shall be reduced pro rata (as
determined by the Secretary) based on the number of hours
such student is enrolled.
``(d) Breach of Contract.--
``(1) Specified breaches.--An individual shall be liable to
the United States for the amount which has been paid to the
individual, or on behalf of the individual, under a contract
entered into with the Secretary under this section on or
after the date of enactment of the Indian Health Care
Improvement Act Amendments of 2009 if that individual--
``(A) fails to maintain an acceptable level of academic
standing in the educational institution in which he or she is
enrolled (such level determined by the educational
institution under regulations of the Secretary);
``(B) is dismissed from such educational institution for
disciplinary reasons;
``(C) voluntarily terminates the training in such an
educational institution for which he or she is provided a
scholarship under such contract before the completion of such
training; or
``(D) fails to accept payment, or instructs the educational
institution in which he or she is enrolled not to accept
payment, in whole or in part, of a scholarship under such
contract, in lieu of any service obligation arising under
such contract.
``(2) Other breaches.--If for any reason not specified in
paragraph (1) an individual breaches a written contract by
failing either to begin such individual's service obligation
required under such contract or to complete such service
obligation, the United States shall be entitled to recover
from the individual an amount determined in accordance with
the formula specified in subsection (l) of section 110 in the
manner provided for in such subsection.
``(3) Cancellation upon death of recipient.--Upon the death
of an individual who receives an Indian Health Scholarship,
any outstanding obligation of that individual for service or
payment that relates to that scholarship shall be canceled.
``(4) Waivers and suspensions.--The Secretary shall provide
for the partial or total waiver or suspension of any
obligation of service or payment of a recipient of an Indian
Health Scholarship if the Secretary determines that--
``(A) it is not possible for the recipient to meet that
obligation or make that payment;
``(B) requiring that recipient to meet that obligation or
make that payment would result in extreme hardship to the
recipient; or
``(C) the enforcement of the requirement to meet the
obligation or make the payment would be unconscionable.
``(5) Extreme hardship.--Notwithstanding any other
provision of law, in any case of extreme hardship or for
other good cause shown, the Secretary may waive, in whole or
in part, the right of the United States to recover funds made
available under this section.
``(6) Bankruptcy.--Notwithstanding any other provision of
law, with respect to a recipient of an Indian Health
Scholarship, no obligation for payment may be released by a
discharge in bankruptcy under title 11, United States Code,
unless that discharge is granted after the expiration of the
5-year period beginning on the initial date on which that
payment is due, and only if the bankruptcy court finds that
the nondischarge of the obligation would be unconscionable.

``SEC. 105. AMERICAN INDIANS INTO PSYCHOLOGY PROGRAM.

``(a) Grants Authorized.--The Secretary, acting through the
Service, shall make grants of not more than $300,000 to each
of 9 colleges and universities for the purpose of developing
and maintaining Indian psychology career recruitment programs
as a means of encouraging Indians to enter the behavioral
health field. These programs shall be located at various
locations throughout the country to maximize their
availability to Indian students and new programs shall be
established in different locations from time to time.
``(b) Quentin N. Burdick Program Grant.--The Secretary
shall provide a grant authorized under subsection (a) to
develop and maintain a program at the University of North
Dakota to be known as the `Quentin N. Burdick American
Indians Into Psychology Program'. Such program shall, to the
maximum extent feasible, coordinate with the Quentin N.
Burdick Indian Health Programs authorized under section
117(b), the Quentin N. Burdick American Indians Into Nursing
Program authorized under section 115(e), and existing
university research and communications networks.
``(c) Regulations.--The Secretary shall issue regulations
pursuant to this Act for the competitive awarding of grants
provided under this section.
``(d) Conditions of Grant.--Applicants under this section
shall agree to provide a program which, at a minimum--
``(1) provides outreach and recruitment for health
professions to Indian communities including elementary,
secondary, and accredited and accessible community colleges
that will be served by the program;
``(2) incorporates a program advisory board comprised of
representatives from the tribes and communities that will be
served by the program;
``(3) provides summer enrichment programs to expose Indian
students to the various fields of psychology through
research, clinical, and experimental activities;
``(4) provides stipends to undergraduate and graduate
students to pursue a career in psychology;
``(5) develops affiliation agreements with tribal colleges
and universities, the Service, university affiliated
programs, and other appropriate accredited and accessible
entities to enhance the education of Indian students;
``(6) to the maximum extent feasible, uses existing
university tutoring, counseling, and student support
services; and
``(7) to the maximum extent feasible, employs qualified
Indians in the program.
``(e) Active Duty Service Requirement.--The active duty
service obligation prescribed under section 338C of the
Public Health Service Act (42 U.S.C. 254m) shall be met by
each graduate who receives a stipend described in subsection
(d)(4) that is funded under this section. Such obligation
shall be met by service--
``(1) in an Indian Health Program;
``(2) in a program assisted under title V of this Act; or
``(3) in the private practice of psychology if, as
determined by the Secretary, in accordance with guidelines
promulgated by the Secretary, such practice is situated in a
physician or other health professional shortage area and
addresses the health care needs of a substantial number of
Indians.
``(f) Authorization of Appropriations.--There is authorized
to be appropriated such sums as may be necessary to carry out
this section.

``SEC. 106. SCHOLARSHIP PROGRAMS FOR INDIAN TRIBES.

``(a) In General.--
``(1) Grants authorized.--The Secretary, acting through the
Service, shall make grants to Tribal Health Programs for the
purpose of providing scholarships for Indians to serve as
health professionals in Indian communities.
``(2) Amount.--Amounts available under paragraph (1) for
any fiscal year shall not exceed 5 percent of the amounts
available for each fiscal year for Indian Health Scholarships
under section 104.
``(3) Application.--An application for a grant under
paragraph (1) shall be in such form and contain such
agreements, assurances, and information as consistent with
this section.
``(b) Requirements.--
``(1) In general.--A Tribal Health Program receiving a
grant under subsection (a) shall provide scholarships to
Indians in accordance with the requirements of this section.
``(2) Costs.--With respect to costs of providing any
scholarship pursuant to subsection (a)--
``(A) 80 percent of the costs of the scholarship shall be
paid from the funds made available pursuant to subsection
(a)(1) provided to the Tribal Health Program; and
``(B) 20 percent of such costs may be paid from any other
source of funds.
``(c) Course of Study.--A Tribal Health Program shall
provide scholarships under this section only to Indians
enrolled or accepted for enrollment in a course of study
(approved by the Secretary) in 1 of the health professions
contemplated by this Act.
``(d) Contract.--
``(1) In general.--In providing scholarships under
subsection (b), the Secretary and the Tribal Health Program
shall enter into a written contract with each recipient of
such scholarship.
``(2) Requirements.--Such contract shall--
``(A) obligate such recipient to provide service in an
Indian Health Program or urban Indian organization, in the
same Service Area where the Tribal Health Program providing
the scholarship is located, for--
``(i) a number of years for which the scholarship is
provided (or the part-time equivalent thereof, as determined
by the Secretary), or for a period of 2 years, whichever
period is greater; or
``(ii) such greater period of time as the recipient and the
Tribal Health Program may agree;
``(B) provide that the amount of the scholarship--
``(i) may only be expended for--

``(I) tuition expenses, other reasonable educational
expenses, and reasonable living expenses incurred in
attendance at the educational institution; and
``(II) payment to the recipient of a monthly stipend of not
more than the amount authorized by section 338(g)(1)(B) of
the Public Health Service Act (42 U.S.C. 254m(g)(1)(B)), with
such amount to be reduced pro rata (as

[[Page H12800]]

determined by the Secretary) based on the number of hours
such student is enrolled, and not to exceed, for any year of
attendance for which the scholarship is provided, the total
amount required for the year for the purposes authorized in
this clause; and

``(ii) may not exceed, for any year of attendance for which
the scholarship is provided, the total amount required for
the year for the purposes authorized in clause (i);
``(C) require the recipient of such scholarship to maintain
an acceptable level of academic standing as determined by the
educational institution in accordance with regulations issued
pursuant to this Act; and
``(D) require the recipient of such scholarship to meet the
educational and licensure requirements appropriate to each
health profession.
``(3) Service in other service areas.--The contract may
allow the recipient to serve in another Service Area,
provided the Tribal Health Program and Secretary approve and
services are not diminished to Indians in the Service Area
where the Tribal Health Program providing the scholarship is
located.
``(e) Breach of Contract.--
``(1) Specific breaches.--An individual who has entered
into a written contract with the Secretary and a Tribal
Health Program under subsection (d) shall be liable to the
United States for the Federal share of the amount which has
been paid to him or her, or on his or her behalf, under the
contract if that individual--
``(A) fails to maintain an acceptable level of academic
standing in the educational institution in which he or she is
enrolled (such level as determined by the educational
institution under regulations of the Secretary);
``(B) is dismissed from such educational institution for
disciplinary reasons;
``(C) voluntarily terminates the training in such an
educational institution for which he or she is provided a
scholarship under such contract before the completion of such
training; or
``(D) fails to accept payment, or instructs the educational
institution in which he or she is enrolled not to accept
payment, in whole or in part, of a scholarship under such
contract, in lieu of any service obligation arising under
such contract.
``(2) Other breaches.--If for any reason not specified in
paragraph (1), an individual breaches a written contract by
failing to either begin such individual's service obligation
required under such contract or to complete such service
obligation, the United States shall be entitled to recover
from the individual an amount determined in accordance with
the formula specified in subsection (l) of section 110 in the
manner provided for in such subsection.
``(3) Cancellation upon death of recipient.--Upon the death
of an individual who receives an Indian Health Scholarship,
any outstanding obligation of that individual for service or
payment that relates to that scholarship shall be canceled.
``(4) Information.--The Secretary may carry out this
subsection on the basis of information received from Tribal
Health Programs involved or on the basis of information
collected through such other means as the Secretary deems
appropriate.
``(f) Relation to Social Security Act.--The recipient of a
scholarship under this section shall agree, in providing
health care pursuant to the requirements herein--
``(1) not to discriminate against an individual seeking
care on the basis of the ability of the individual to pay for
such care or on the basis that payment for such care will be
made pursuant to a program established in title XVIII of the
Social Security Act or pursuant to the programs established
in title XIX or title XXI of such Act; and
``(2) to accept assignment under section 1842(b)(3)(B)(ii)
of the Social Security Act for all services for which payment
may be made under part B of title XVIII of such Act, and to
enter into an appropriate agreement with the State agency
that administers the State plan for medical assistance under
title XIX, or the State child health plan under title XXI, of
such Act to provide service to individuals entitled to
medical assistance or child health assistance, respectively,
under the plan.
``(g) Continuance of Funding.--The Secretary shall make
payments under this section to a Tribal Health Program for
any fiscal year subsequent to the first fiscal year of such
payments unless the Secretary determines that, for the
immediately preceding fiscal year, the Tribal Health Program
has not complied with the requirements of this section.

``SEC. 107. INDIAN HEALTH SERVICE EXTERN PROGRAMS.

``(a) Employment Preference.--Any individual who receives a
scholarship pursuant to section 104 or 106 shall be given
preference for employment in the Service, or may be employed
by a Tribal Health Program or an urban Indian organization,
or other agencies of the Department as available, during any
nonacademic period of the year.
``(b) Not Counted Toward Active Duty Service Obligation.--
Periods of employment pursuant to this subsection shall not
be counted in determining fulfillment of the service
obligation incurred as a condition of the scholarship.
``(c) Timing; Length of Employment.--Any individual
enrolled in a program, including a high school program,
authorized under section 102(a) may be employed by the
Service or by a Tribal Health Program or an urban Indian
organization during any nonacademic period of the year. Any
such employment shall not exceed 120 days during any calendar
year.
``(d) Nonapplicability of Competitive Personnel System.--
Any employment pursuant to this section shall be made without
regard to any competitive personnel system or agency
personnel limitation and to a position which will enable the
individual so employed to receive practical experience in the
health profession in which he or she is engaged in study. Any
individual so employed shall receive payment for his or her
services comparable to the salary he or she would receive if
he or she were employed in the competitive system. Any
individual so employed shall not be counted against any
employment ceiling affecting the Service or the Department.

``SEC. 108. CONTINUING EDUCATION ALLOWANCES.

``In order to encourage scholarship and stipend recipients
under sections 104, 105, 106, and 115 and health
professionals, including community health representatives and
emergency medical technicians, to join or continue in an
Indian Health Program and to provide their services in the
rural and remote areas where a significant portion of Indians
reside, the Secretary, acting through the Service, may--
``(1) provide programs or allowances to transition into an
Indian Health Program, including licensing, board or
certification examination assistance, and technical
assistance in fulfilling service obligations under sections
104, 105, 106, and 115; and
``(2) provide programs or allowances to health
professionals employed in an Indian Health Program to enable
them for a period of time each year prescribed by regulation
of the Secretary to take leave of their duty stations for
professional consultation, management, leadership, and
refresher training courses.

``SEC. 109. COMMUNITY HEALTH REPRESENTATIVE PROGRAM.

``(a) In General.--Under the authority of the Act of
November 2, 1921 (25 U.S.C. 13) (commonly known as the
`Snyder Act'), the Secretary, acting through the Service,
shall maintain a Community Health Representative Program
under which Indian Health Programs--
``(1) provide for the training of Indians as community
health representatives; and
``(2) use such community health representatives in the
provision of health care, health promotion, and disease
prevention services to Indian communities.
``(b) Duties.--The Community Health Representative Program
of the Service, shall--
``(1) provide a high standard of training for community
health representatives to ensure that the community health
representatives provide quality health care, health
promotion, and disease prevention services to the Indian
communities served by the Program;
``(2) in order to provide such training, develop and
maintain a curriculum that--
``(A) combines education in the theory of health care with
supervised practical experience in the provision of health
care; and
``(B) provides instruction and practical experience in
health promotion and disease prevention activities, with
appropriate consideration given to lifestyle factors that
have an impact on Indian health status, such as alcoholism,
family dysfunction, and poverty;
``(3) maintain a system which identifies the needs of
community health representatives for continuing education in
health care, health promotion, and disease prevention and
develop programs that meet the needs for continuing
education;
``(4) maintain a system that provides close supervision of
Community Health Representatives;
``(5) maintain a system under which the work of Community
Health Representatives is reviewed and evaluated; and
``(6) promote traditional health care practices of the
Indian Tribes served consistent with the Service standards
for the provision of health care, health promotion, and
disease prevention.

``SEC. 110. INDIAN HEALTH SERVICE LOAN REPAYMENT PROGRAM.

``(a) Establishment.--The Secretary, acting through the
Service, shall establish and administer a program to be known
as the Service Loan Repayment Program (hereinafter referred
to as the `Loan Repayment Program') in order to ensure an
adequate supply of trained health professionals necessary to
maintain accreditation of, and provide health care services
to Indians through, Indian Health Programs and urban Indian
organizations.
``(b) Eligible Individuals.--To be eligible to participate
in the Loan Repayment Program, an individual must--
``(1)(A) be enrolled--
``(i) in a course of study or program in an accredited
educational institution (as determined by the Secretary under
section 338B(b)(1)(c)(i) of the Public Health Service Act (42
U.S.C. 254l-1(b)(1)(c)(i))) and be scheduled to complete such
course of study in the same year such individual applies to
participate in such program; or
``(ii) in an approved graduate training program in a health
profession; or
``(B) have--
``(i) a degree in a health profession; and
``(ii) a license to practice a health profession;
``(2)(A) be eligible for, or hold, an appointment as a
commissioned officer in the Regular or Reserve Corps of the
Public Health Service;

[[Page H12801]]

``(B) meet the professional standards for civil service
employment in the Service; or
``(C) be employed in an Indian Health Program or urban
Indian organization without a service obligation; and
``(3) submit to the Secretary an application for a contract
described in subsection (e).
``(c) Application.--
``(1) Information to be included with forms.--In
disseminating application forms and contract forms to
individuals desiring to participate in the Loan Repayment
Program, the Secretary shall include with such forms a fair
summary of the rights and liabilities of an individual whose
application is approved (and whose contract is accepted) by
the Secretary, including in the summary a clear explanation
of the damages to which the United States is entitled under
subsection (l) in the case of the individual's breach of
contract. The Secretary shall provide such individuals with
sufficient information regarding the advantages and
disadvantages of service as a commissioned officer in the
Regular or Reserve Corps of the Public Health Service or a
civilian employee of the Service to enable the individual to
make a decision on an informed basis.
``(2) Clear language.--The application form, contract form,
and all other information furnished by the Secretary under
this section shall be written in a manner calculated to be
understood by the average individual applying to participate
in the Loan Repayment Program.
``(3) Timely availability of forms.--The Secretary shall
make such application forms, contract forms, and other
information available to individuals desiring to participate
in the Loan Repayment Program on a date sufficiently early to
ensure that such individuals have adequate time to carefully
review and evaluate such forms and information.
``(d) Priorities.--
``(1) List.--Consistent with subsection (j), the Secretary
shall annually--
``(A) identify the positions in each Indian Health Program
or urban Indian organization for which there is a need or a
vacancy; and
``(B) rank those positions in order of priority.
``(2) Approvals.--Consistent with the priority determined
under paragraph (1), the Secretary, in determining which
applications under the Loan Repayment Program to approve (and
which contracts to accept), shall--
``(A) give first priority to applications made by
individual Indians; and
``(B) after making determinations on all applications
submitted by individual Indians as required under
subparagraph (A), give priority to--
``(i) individuals recruited through the efforts of an
Indian Health Program or urban Indian organization; and
``(ii) other individuals based on the priority rankings
under paragraph (1).
``(e) Recipient Contracts.--
``(1) Contract required.--An individual becomes a
participant in the Loan Repayment Program only upon the
Secretary and the individual entering into a written contract
described in paragraph (2).
``(2) Contents of contract.--The written contract referred
to in this section between the Secretary and an individual
shall contain--
``(A) an agreement under which--
``(i) subject to subparagraph (C), the Secretary agrees--

``(I) to pay loans on behalf of the individual in
accordance with the provisions of this section; and
``(II) to accept (subject to the availability of
appropriated funds for carrying out this section) the
individual into the Service or place the individual with a
Tribal Health Program or urban Indian organization as
provided in clause (ii)(III); and

``(ii) subject to subparagraph (C), the individual agrees--

``(I) to accept loan payments on behalf of the individual;
``(II) in the case of an individual described in subsection
(b)(1)--

``(aa) to maintain enrollment in a course of study or
training described in subsection (b)(1)(A) until the
individual completes the course of study or training; and
``(bb) while enrolled in such course of study or training,
to maintain an acceptable level of academic standing (as
determined under regulations of the Secretary by the
educational institution offering such course of study or
training); and

``(III) to serve for a time period (in this section
referred to as the `period of obligated service') equal to 2
years or such longer period as the individual may agree to
serve in the full-time clinical practice of such individual's
profession in an Indian Health Program or urban Indian
organization to which the individual may be assigned by the
Secretary;

``(B) a provision permitting the Secretary to extend for
such longer additional periods, as the individual may agree
to, the period of obligated service agreed to by the
individual under subparagraph (A)(ii)(III);
``(C) a provision that any financial obligation of the
United States arising out of a contract entered into under
this section and any obligation of the individual which is
conditioned thereon is contingent upon funds being
appropriated for loan repayments under this section;
``(D) a statement of the damages to which the United States
is entitled under subsection (k) for the individual's breach
of the contract; and
``(E) such other statements of the rights and liabilities
of the Secretary and of the individual, not inconsistent with
this section.
``(f) Deadline for Decision on Application.--The Secretary
shall provide written notice to an individual within 21 days
on--
``(1) the Secretary's approving, under subsection (e)(1),
of the individual's participation in the Loan Repayment
Program, including extensions resulting in an aggregate
period of obligated service in excess of 4 years; or
``(2) the Secretary's disapproving an individual's
participation in such Program.
``(g) Payments.--
``(1) In general.--A loan repayment provided for an
individual under a written contract under the Loan Repayment
Program shall consist of payment, in accordance with
paragraph (2), on behalf of the individual of the principal,
interest, and related expenses on government and commercial
loans received by the individual regarding the undergraduate
or graduate education of the individual (or both), which
loans were made for--
``(A) tuition expenses;
``(B) all other reasonable educational expenses, including
fees, books, and laboratory expenses, incurred by the
individual; and
``(C) reasonable living expenses as determined by the
Secretary.
``(2) Amount.--For each year of obligated service that an
individual contracts to serve under subsection (e), the
Secretary may pay up to $35,000 or an amount equal to the
amount specified in section 338B(g)(2)(A) of the Public
Health Service Act, whichever is more, on behalf of the
individual for loans described in paragraph (1). In making a
determination of the amount to pay for a year of such service
by an individual, the Secretary shall consider the extent to
which each such determination--
``(A) affects the ability of the Secretary to maximize the
number of contracts that can be provided under the Loan
Repayment Program from the amounts appropriated for such
contracts;
``(B) provides an incentive to serve in Indian Health
Programs and urban Indian organizations with the greatest
shortages of health professionals; and
``(C) provides an incentive with respect to the health
professional involved remaining in an Indian Health Program
or urban Indian organization with such a health professional
shortage, and continuing to provide primary health services,
after the completion of the period of obligated service under
the Loan Repayment Program.
``(3) Timing.--Any arrangement made by the Secretary for
the making of loan repayments in accordance with this
subsection shall provide that any repayments for a year of
obligated service shall be made no later than the end of the
fiscal year in which the individual completes such year of
service.
``(4) Reimbursements for tax liability.--For the purpose of
providing reimbursements for tax liability resulting from a
payment under paragraph (2) on behalf of an individual, the
Secretary--
``(A) in addition to such payments, may make payments to
the individual in an amount equal to not less than 20 percent
and not more than 39 percent of the total amount of loan
repayments made for the taxable year involved; and
``(B) may make such additional payments as the Secretary
determines to be appropriate with respect to such purpose.
``(5) Payment schedule.--The Secretary may enter into an
agreement with the holder of any loan for which payments are
made under the Loan Repayment Program to establish a schedule
for the making of such payments.
``(h) Employment Ceiling.--Notwithstanding any other
provision of law, individuals who have entered into written
contracts with the Secretary under this section shall not be
counted against any employment ceiling affecting the
Department while those individuals are undergoing academic
training.
``(i) Recruitment.--The Secretary shall conduct recruiting
programs for the Loan Repayment Program and other manpower
programs of the Service at educational institutions training
health professionals or specialists identified in subsection
(a).
``(j) Applicability of Law.--Section 214 of the Public
Health Service Act (42 U.S.C. 215) shall not apply to
individuals during their period of obligated service under
the Loan Repayment Program.
``(k) Assignment of Individuals.--The Secretary, in
assigning individuals to serve in Indian Health Programs or
urban Indian organizations pursuant to contracts entered into
under this section, shall--
``(1) ensure that the staffing needs of Tribal Health
Programs and urban Indian organizations receive consideration
on an equal basis with programs that are administered
directly by the Service; and
``(2) give priority to assigning individuals to Indian
Health Programs and urban Indian organizations that have a
need for health professionals to provide health care services
as a result of individuals having breached contracts entered
into under this section.
``(l) Breach of Contract.--
``(1) Specific breaches.--An individual who has entered
into a written contract with the Secretary under this section
and has not received a waiver under subsection (m) shall be
liable, in lieu of any service obligation arising under such
contract, to the United States for the amount which has been
paid on such individual's behalf under the contract if that
individual--

[[Page H12802]]

``(A) is enrolled in the final year of a course of study
and--
``(i) fails to maintain an acceptable level of academic
standing in the educational institution in which he or she is
enrolled (such level determined by the educational
institution under regulations of the Secretary);
``(ii) voluntarily terminates such enrollment; or
``(iii) is dismissed from such educational institution
before completion of such course of study; or
``(B) is enrolled in a graduate training program and fails
to complete such training program.
``(2) Other breaches; formula for amount owed.--If, for any
reason not specified in paragraph (1), an individual breaches
his or her written contract under this section by failing
either to begin, or complete, such individual's period of
obligated service in accordance with subsection (e)(2), the
United States shall be entitled to recover from such
individual an amount to be determined in accordance with the
following formula: A=3Z(t-s/t) in which--
``(A) `A' is the amount the United States is entitled to
recover;
``(B) `Z' is the sum of the amounts paid under this section
to, or on behalf of, the individual and the interest on such
amounts which would be payable if, at the time the amounts
were paid, they were loans bearing interest at the maximum
legal prevailing rate, as determined by the Secretary of the
Treasury;
``(C) `t' is the total number of months in the individual's
period of obligated service; and
``(D) `s' is the number of months of such period served by
such individual in accordance with this section.
``(3) Time period for repayment.--Any amount of damages
which the United States is entitled to recover under this
subsection shall be paid to the United States within the 1-
year period beginning on the date of the breach or such
longer period beginning on such date as shall be specified by
the Secretary.
``(4) Deductions in medicare payments.--Amounts not paid
within such period shall be subject to collection through
deductions in Medicare payments pursuant to section 1892 of
the Social Security Act.
``(5) Recovery of delinquency.--
``(A) In general.--If damages described in paragraph (4)
are delinquent for 3 months, the Secretary shall, for the
purpose of recovering such damages--
``(i) use collection agencies contracted with by the
Administrator of General Services; or
``(ii) enter into contracts for the recovery of such
damages with collection agencies selected by the Secretary.
``(B) Report.--Each contract for recovering damages
pursuant to this subsection shall provide that the contractor
will, not less than once each 6 months, submit to the
Secretary a status report on the success of the contractor in
collecting such damages. Section 3718 of title 31, United
States Code, shall apply to any such contract to the extent
not inconsistent with this subsection.
``(m) Waiver or Suspension of Obligation.--
``(1) In general.--The Secretary shall by regulation
provide for the partial or total waiver or suspension of any
obligation of service or payment by an individual under the
Loan Repayment Program whenever compliance by the individual
is impossible or would involve extreme hardship to the
individual and if enforcement of such obligation with respect
to any individual would be unconscionable.
``(2) Canceled upon death.--Any obligation of an individual
under the Loan Repayment Program for service or payment of
damages shall be canceled upon the death of the individual.
``(3) Hardship waiver.--The Secretary may waive, in whole
or in part, the rights of the United States to recover
amounts under this section in any case of extreme hardship or
other good cause shown, as determined by the Secretary.
``(4) Bankruptcy.--Any obligation of an individual under
the Loan Repayment Program for payment of damages may be
released by a discharge in bankruptcy under title 11 of the
United States Code only if such discharge is granted after
the expiration of the 5-year period beginning on the first
date that payment of such damages is required, and only if
the bankruptcy court finds that nondischarge of the
obligation would be unconscionable.
``(n) Report.--The Secretary shall submit to the President,
for inclusion in the report required to be submitted to
Congress under section 801, a report concerning the previous
fiscal year which sets forth by Service Area the following:
``(1) A list of the health professional positions
maintained by Indian Health Programs and urban Indian
organizations for which recruitment or retention is
difficult.
``(2) The number of Loan Repayment Program applications
filed with respect to each type of health profession.
``(3) The number of contracts described in subsection (e)
that are entered into with respect to each health profession.
``(4) The amount of loan payments made under this section,
in total and by health profession.
``(5) The number of scholarships that are provided under
sections 104 and 106 with respect to each health profession.
``(6) The amount of scholarship grants provided under
sections 104 and 106, in total and by health profession.
``(7) The number of providers of health care that will be
needed by Indian Health Programs and urban Indian
organizations, by location and profession, during the 3
fiscal years beginning after the date the report is filed.
``(8) The measures the Secretary plans to take to fill the
health professional positions maintained by Indian Health
Programs or urban Indian organizations for which recruitment
or retention is difficult.

``SEC. 111. SCHOLARSHIP AND LOAN REPAYMENT RECOVERY FUND.

``(a) Establishment.--There is established in the Treasury
of the United States a fund to be known as the Indian Health
Scholarship and Loan Repayment Recovery Fund (hereafter in
this section referred to as the `LRRF'). The LRRF shall
consist of such amounts as may be collected from individuals
under section 104(d), section 106(e), and section 110(l) for
breach of contract, such funds as may be appropriated to the
LRRF, and interest earned on amounts in the LRRF. All amounts
collected, appropriated, or earned relative to the LRRF shall
remain available until expended.
``(b) Use of Funds.--
``(1) By secretary.--Amounts in the LRRF may be expended by
the Secretary, acting through the Service, to make payments
to an Indian Health Program--
``(A) to which a scholarship recipient under section 104
and 106 or a loan repayment program participant under section
110 has been assigned to meet the obligated service
requirements pursuant to such sections; and
``(B) that has a need for a health professional to provide
health care services as a result of such recipient or
participant having breached the contract entered into under
section 104, 106, or 110.
``(2) By tribal health programs.--A Tribal Health Program
receiving payments pursuant to paragraph (1) may expend the
payments to provide scholarships or recruit and employ,
directly or by contract, health professionals to provide
health care services.
``(c) Investment of Funds.--The Secretary of the Treasury
shall invest such amounts of the LRRF as the Secretary of
Health and Human Services determines are not required to meet
current withdrawals from the LRRF. Such investments may be
made only in interest bearing obligations of the United
States. For such purpose, such obligations may be acquired on
original issue at the issue price, or by purchase of
outstanding obligations at the market price.
``(d) Sale of Obligations.--Any obligation acquired by the
LRRF may be sold by the Secretary of the Treasury at the
market price.

``SEC. 112. RECRUITMENT ACTIVITIES.

``(a) Reimbursement for Travel.--The Secretary, acting
through the Service, may reimburse health professionals
seeking positions with Indian Health Programs or urban Indian
organizations, including individuals considering entering
into a contract under section 110 and their spouses, for
actual and reasonable expenses incurred in traveling to and
from their places of residence to an area in which they may
be assigned for the purpose of evaluating such area with
respect to such assignment.
``(b) Recruitment Personnel.--The Secretary, acting through
the Service, shall assign 1 individual in each Area Office to
be responsible on a full-time basis for recruitment
activities.

``SEC. 113. INDIAN RECRUITMENT AND RETENTION PROGRAM.

``(a) In General.--The Secretary, acting through the
Service, shall fund, on a competitive basis, innovative
demonstration projects for a period not to exceed 3 years to
enable Indian Health Programs and urban Indian organizations
to recruit, place, and retain health professionals to meet
their staffing needs.
``(b) Eligible Entities; Application.--Any Indian Health
Program or Urban Indian organization may submit an
application for funding of a project pursuant to this
section.

``SEC. 114. ADVANCED TRAINING AND RESEARCH.

``(a) Demonstration Program.--The Secretary, acting through
the Service, shall establish a demonstration project to
enable health professionals who have worked in an Indian
Health Program or urban Indian organization for a substantial
period of time to pursue advanced training or research areas
of study for which the Secretary determines a need exists.
``(b) Service Obligation.--An individual who participates
in a program under subsection (a), where the educational
costs are borne by the Service, shall incur an obligation to
serve in an Indian Health Program or urban Indian
organization for a period of obligated service equal to at
least the period of time during which the individual
participates in such program. In the event that the
individual fails to complete such obligated service, the
individual shall be liable to the United States for the
period of service remaining. In such event, with respect to
individuals entering the program after the date of enactment
of the Indian Health Care Improvement Act Amendments of 2009,
the United States shall be entitled to recover from such
individual an amount to be determined in accordance with the
formula specified in subsection (l) of section 110 in the
manner provided for in such subsection.
``(c) Equal Opportunity for Participation.--Health
professionals from Tribal

[[Page H12803]]

Health Programs and urban Indian organizations shall be given
an equal opportunity to participate in the program under
subsection (a).

``SEC. 115. QUENTIN N. BURDICK AMERICAN INDIANS INTO NURSING
PROGRAM.

``(a) Grants Authorized.--For the purpose of increasing the
number of nurses, nurse midwives, and nurse practitioners who
deliver health care services to Indians, the Secretary,
acting through the Service, shall provide grants to the
following:
``(1) Public or private schools of nursing.
``(2) Tribal colleges or universities.
``(3) Nurse midwife programs and advanced practice nurse
programs that are provided by any tribal college or
university accredited nursing program, or in the absence of
such, any other public or private institutions.
``(b) Use of Grants.--Grants provided under subsection (a)
may be used for 1 or more of the following:
``(1) To recruit individuals for programs which train
individuals to be nurses, nurse midwives, or advanced
practice nurses.
``(2) To provide scholarships to Indians enrolled in such
programs that may pay the tuition charged for such program
and other expenses incurred in connection with such program,
including books, fees, room and board, and stipends for
living expenses.
``(3) To provide a program that encourages nurses, nurse
midwives, and advanced practice nurses to provide, or
continue to provide, health care services to Indians.
``(4) To provide a program that increases the skills of,
and provides continuing education to, nurses, nurse midwives,
and advanced practice nurses.
``(5) To provide any program that is designed to achieve
the purpose described in subsection (a).
``(c) Applications.--Each application for a grant under
subsection (a) shall include such information as the
Secretary may require to establish the connection between the
program of the applicant and a health care facility that
primarily serves Indians.
``(d) Preferences for Grant Recipients.--In providing
grants under subsection (a), the Secretary shall extend a
preference to the following:
``(1) Programs that provide a preference to Indians.
``(2) Programs that train nurse midwives or advanced
practice nurses.
``(3) Programs that are interdisciplinary.
``(4) Programs that are conducted in cooperation with a
program for gifted and talented Indian students.
``(5) Programs conducted by tribal colleges and
universities.
``(e) Quentin N. Burdick Program Grant.--The Secretary
shall provide 1 of the grants authorized under subsection (a)
to establish and maintain a program at the University of
North Dakota to be known as the `Quentin N. Burdick American
Indians Into Nursing Program'. Such program shall, to the
maximum extent feasible, coordinate with the Quentin N.
Burdick Indian Health Programs established under section
117(b) and the Quentin N. Burdick American Indians Into
Psychology Program established under section 105(b).
``(f) Active Duty Service Obligation.--The active duty
service obligation prescribed under section 338C of the
Public Health Service Act (42 U.S.C. 254m) shall be met by
each individual who receives training or assistance described
in paragraph (1) or (2) of subsection (b) that is funded by a
grant provided under subsection (a). Such obligation shall be
met by service--
``(1) in the Service;
``(2) in a program of an Indian Tribe or Tribal
Organization conducted under the Indian Self-Determination
and Education Assistance Act (25 U.S.C. 450 et seq.)
(including programs under agreements with the Bureau of
Indian Affairs);
``(3) in a program assisted under title V of this Act;
``(4) in the private practice of nursing if, as determined
by the Secretary, in accordance with guidelines promulgated
by the Secretary, such practice is situated in a physician or
other health shortage area and addresses the health care
needs of a substantial number of Indians; or
``(5) in a teaching capacity in a tribal college or
university nursing program (or a related health profession
program) if, as determined by the Secretary, health services
provided to Indians would not decrease.

``SEC. 116. TRIBAL CULTURAL ORIENTATION.

``(a) Cultural Education of Employees.--The Secretary,
acting through the Service, shall require that appropriate
employees of the Service who serve Indian Tribes in each
Service Area receive educational instruction in the history
and culture of such Indian Tribes and their relationship to
the Service.
``(b) Program.--In carrying out subsection (a), the
Secretary shall establish a program which shall, to the
extent feasible--
``(1) be developed in consultation with the affected Indian
Tribes, Tribal Organizations, and urban Indian organizations;
``(2) be carried out through tribal colleges or
universities;
``(3) include instruction in American Indian studies; and
``(4) describe the use and place of traditional health care
practices of the Indian Tribes in the Service Area.

``SEC. 117. INMED PROGRAM.

``(a) Grants Authorized.--The Secretary, acting through the
Service, is authorized to provide grants to colleges and
universities for the purpose of maintaining and expanding the
Indian health careers recruitment program known as the
`Indians Into Medicine Program' (hereinafter in this section
referred to as `INMED') as a means of encouraging Indians to
enter the health professions.
``(b) Quentin N. Burdick Grant.--The Secretary shall
provide 1 of the grants authorized under subsection (a) to
maintain the INMED program at the University of North Dakota,
to be known as the `Quentin N. Burdick Indian Health
Programs', unless the Secretary makes a determination, based
upon program reviews, that the program is not meeting the
purposes of this section. Such program shall, to the maximum
extent feasible, coordinate with the Quentin N. Burdick
American Indians Into Psychology Program established under
section 105(b) and the Quentin N. Burdick American Indians
Into Nursing Program established under section 115.
``(c) Regulations.--The Secretary, pursuant to this Act,
shall develop regulations to govern grants pursuant to this
section.
``(d) Requirements.--Applicants for grants provided under
this section shall agree to provide a program which--
``(1) provides outreach and recruitment for health
professions to Indian communities including elementary and
secondary schools and community colleges located on
reservations which will be served by the program;
``(2) incorporates a program advisory board comprised of
representatives from the Indian Tribes and Indian communities
which will be served by the program;
``(3) provides summer preparatory programs for Indian
students who need enrichment in the subjects of math and
science in order to pursue training in the health
professions;
``(4) provides tutoring, counseling, and support to
students who are enrolled in a health career program of study
at the respective college or university; and
``(5) to the maximum extent feasible, employs qualified
Indians in the program.

``SEC. 118. HEALTH TRAINING PROGRAMS OF COMMUNITY COLLEGES.

``(a) Grants To Establish Programs.--
``(1) In general.--The Secretary, acting through the
Service, shall award grants to accredited and accessible
community colleges for the purpose of assisting such
community colleges in the establishment of programs which
provide education in a health profession leading to a degree
or diploma in a health profession for individuals who desire
to practice such profession on or near a reservation or in an
Indian Health Program.
``(2) Amount of grants.--The amount of any grant awarded to
a community college under paragraph (1) for the first year in
which such a grant is provided to the community college shall
not exceed $250,000.
``(b) Grants for Maintenance and Recruiting.--
``(1) In general.--The Secretary, acting through the
Service, shall award grants to accredited and accessible
community colleges that have established a program described
in subsection (a)(1) for the purpose of maintaining the
program and recruiting students for the program.
``(2) Requirements.--Grants may only be made under this
section to a community college which--
``(A) is accredited;
``(B) has a relationship with a hospital facility, Service
facility, or hospital that could provide training of nurses
or health professionals;
``(C) has entered into an agreement with an accredited
college or university medical school, the terms of which--
``(i) provide a program that enhances the transition and
recruitment of students into advanced baccalaureate or
graduate programs that train health professionals; and
``(ii) stipulate certifications necessary to approve
internship and field placement opportunities at Indian Health
Programs;
``(D) has a qualified staff which has the appropriate
certifications;
``(E) is capable of obtaining State or regional
accreditation of the program described in subsection (a)(1);
and
``(F) agrees to provide for Indian preference for
applicants for programs under this section.
``(c) Technical Assistance.--The Secretary shall encourage
community colleges described in subsection (b)(2) to
establish and maintain programs described in subsection
(a)(1) by--
``(1) entering into agreements with such colleges for the
provision of qualified personnel of the Service to teach
courses of study in such programs; and
``(2) providing technical assistance and support to such
colleges.
``(d) Advanced Training.--
``(1) Required.--Any program receiving assistance under
this section that is conducted with respect to a health
profession shall also offer courses of study which provide
advanced training for any health professional who--
``(A) has already received a degree or diploma in such
health profession; and
``(B) provides clinical services on or near a reservation
or for an Indian Health Program.
``(2) May be offered at alternate site.--Such courses of
study may be offered in conjunction with the college or
university with which the community college has entered into
the agreement required under subsection (b)(2)(C).
``(e) Priority.--Where the requirements of subsection (b)
are met, grant award priority

[[Page H12804]]

shall be provided to tribal colleges and universities in
Service Areas where they exist.

``SEC. 119. RETENTION BONUS.

``(a) Bonus Authorized.--The Secretary may pay a retention
bonus to any health professional employed by, or assigned to,
and serving in, an Indian Health Program or urban Indian
organization either as a civilian employee or as a
commissioned officer in the Regular or Reserve Corps of the
Public Health Service who--
``(1) is assigned to, and serving in, a position for which
recruitment or retention of personnel is difficult;
``(2) the Secretary determines is needed by Indian Health
Programs and urban Indian organizations;
``(3) has--
``(A) completed 2 years of employment with an Indian Health
Program or urban Indian organization; or
``(B) completed any service obligations incurred as a
requirement of--
``(i) any Federal scholarship program; or
``(ii) any Federal education loan repayment program; and
``(4) enters into an agreement with an Indian Health
Program or urban Indian organization for continued employment
for a period of not less than 1 year.
``(b) Rates.--The Secretary may establish rates for the
retention bonus which shall provide for a higher annual rate
for multiyear agreements than for single year agreements
referred to in subsection (a)(4), but in no event shall the
annual rate be more than $25,000 per annum.
``(c) Default of Retention Agreement.--Any health
professional failing to complete the agreed upon term of
service, except where such failure is through no fault of the
individual, shall be obligated to refund to the Government
the full amount of the retention bonus for the period covered
by the agreement, plus interest as determined by the
Secretary in accordance with section 110(l)(2)(B).
``(d) Other Retention Bonus.--The Secretary may pay a
retention bonus to any health professional employed by a
Tribal Health Program if such health professional is serving
in a position which the Secretary determines is--
``(1) a position for which recruitment or retention is
difficult; and
``(2) necessary for providing health care services to
Indians.

``SEC. 120. NURSING RESIDENCY PROGRAM.

``(a) Establishment of Program.--The Secretary, acting
through the Service, shall establish a program to enable
Indians who are licensed practical nurses, licensed
vocational nurses, and registered nurses who are working in
an Indian Health Program or urban Indian organization, and
have done so for a period of not less than 1 year, to pursue
advanced training. Such program shall include a combination
of education and work study in an Indian Health Program or
urban Indian organization leading to an associate or
bachelor's degree (in the case of a licensed practical nurse
or licensed vocational nurse), a bachelor's degree (in the
case of a registered nurse), or advanced degrees or
certifications in nursing and public health.
``(b) Service Obligation.--An individual who participates
in a program under subsection (a), where the educational
costs are paid by the Service, shall incur an obligation to
serve in an Indian Health Program or urban Indian
organization for a period of obligated service equal to 1
year for every year that nonprofessional employee (licensed
practical nurses, licensed vocational nurses, nursing
assistants, and various health care technicians), or 2 years
for every year that professional nurse (associate degree and
bachelor-prepared registered nurses), participates in such
program. In the event that the individual fails to complete
such obligated service, the United States shall be entitled
to recover from such individual an amount determined in
accordance with the formula specified subsection (d)(1) of
Section 104 for individuals failing to graduate from their
degree program and subsection (l) of Section 110 for
individuals failing to start or complete the obligated
service.

``SEC. 121. COMMUNITY HEALTH AIDE PROGRAM.

``(a) General Purposes of Program.--Under the authority of
the Act of November 2, 1921 (25 U.S.C. 13) (commonly known as
the `Snyder Act'), the Secretary, acting through the Service,
shall develop and operate a Community Health Aide Program in
Alaska under which the Service--
``(1) provides for the training of Alaska Natives as health
aides or community health practitioners;
``(2) uses such aides or practitioners in the provision of
health care, health promotion, and disease prevention
services to Alaska Natives living in villages in rural
Alaska; and
``(3) provides for the establishment of teleconferencing
capacity in health clinics located in or near such villages
for use by community health aides or community health
practitioners.
``(b) Specific Program Requirements.--The Secretary, acting
through the Community Health Aide Program of the Service,
shall--
``(1) using trainers accredited by the Program, provide a
high standard of training to community health aides and
community health practitioners to ensure that such aides and
practitioners provide quality health care, health promotion,
and disease prevention services to the villages served by the
Program;
``(2) in order to provide such training, develop a
curriculum that--
``(A) combines education in the theory of health care with
supervised practical experience in the provision of health
care;
``(B) provides instruction and practical experience in the
provision of acute care, emergency care, health promotion,
disease prevention, and the efficient and effective
management of clinic pharmacies, supplies, equipment, and
facilities; and
``(C) promotes the achievement of the health status
objectives specified in section 3(2);
``(3) establish and maintain a Community Health Aide
Certification Board to certify as community health aides or
community health practitioners individuals who have
successfully completed the training described in paragraph
(1) or can demonstrate equivalent experience;
``(4) develop and maintain a system which identifies the
needs of community health aides and community health
practitioners for continuing education in the provision of
health care, including the areas described in paragraph
(2)(B), and develop programs that meet the needs for such
continuing education;
``(5) develop and maintain a system that provides close
supervision of community health aides and community health
practitioners;
``(6) develop a system under which the work of community
health aides and community health practitioners is reviewed
and evaluated to assure the provision of quality health care,
health promotion, and disease prevention services; and
``(7) ensure that pulpal therapy (not including pulpotomies
on deciduous teeth) or extraction of adult teeth can be
performed by a dental health aide therapist only after
consultation with a licensed dentist who determines that the
procedure is a medical emergency that cannot be resolved with
palliative treatment, and further that dental health aide
therapists are strictly prohibited from performing all other
oral or jaw surgeries, provided that uncomplicated
extractions shall not be considered oral surgery under this
section.
``(c) Program Review.--
``(1) Neutral panel.--
``(A) Establishment.--The Secretary, acting through the
Service, shall establish a neutral panel to carry out the
study under paragraph (2).
``(B) Membership.--Members of the neutral panel shall be
appointed by the Secretary from among clinicians, economists,
community practitioners, oral epidemiologists, and Alaska
Natives.
``(2) Study.--
``(A) In general.--The neutral panel established under
paragraph (1) shall conduct a study of the dental health aide
therapist services provided by the Community Health Aide
Program under this section to ensure that the quality of care
provided through those services is adequate and appropriate.
``(B) Parameters of study.--The Secretary, in consultation
with interested parties, including professional dental
organizations, shall develop the parameters of the study.
``(C) Inclusions.--The study shall include a determination
by the neutral panel with respect to--
``(i) the ability of the dental health aide therapist
services under this section to address the dental care needs
of Alaska Natives;
``(ii) the quality of care provided through those services,
including any training, improvement, or additional oversight
required to improve the quality of care; and
``(iii) whether safer and less costly alternatives to the
dental health aide therapist services exist.
``(D) Consultation.--In carrying out the study under this
paragraph, the neutral panel shall consult with Alaska Tribal
Organizations with respect to the adequacy and accuracy of
the study.
``(3) Report.--The neutral panel shall submit to the
Secretary, the Committee on Indian Affairs of the Senate, and
the Committee on Natural Resources of the House of
Representatives a report describing the results of the study
under paragraph (2), including a description of--
``(A) any determination of the neutral panel under
paragraph (2)(C); and
``(B) any comments received from an Alaska Tribal
Organization under paragraph (2)(D).
``(d) Nationalization of Program.--
``(1) In general.--Except as provided in paragraph (2), the
Secretary, acting through the Service, may establish a
national Community Health Aide Program in accordance with the
program under this section, as the Secretary determines to be
appropriate.
``(2) Exception.--The national Community Health Aide
Program under paragraph (1) shall not include dental health
aide therapist services.
``(3) Requirement.--In establishing a national program
under paragraph (1), the Secretary shall not reduce the
amount of funds provided for the Community Health Aide
Program described in subsections (a) and (b).

``SEC. 122. TRIBAL HEALTH PROGRAM ADMINISTRATION.

``The Secretary shall, by contract or otherwise, provide
training for individuals in the administration and planning
of Tribal Health Programs, with priority to Indians.

[[Page H12805]]

``SEC. 123. HEALTH PROFESSIONAL CHRONIC SHORTAGE
DEMONSTRATION PROGRAMS.

``(a) Demonstration Programs Authorized.--The Secretary,
acting through the Service, may fund demonstration programs
for Tribal Health Programs to address the chronic shortages
of health professionals.
``(b) Purposes of Programs.--The purposes of demonstration
programs funded under subsection (a) shall be--
``(1) to provide direct clinical and practical experience
at a Service Unit to health profession students and residents
from medical schools;
``(2) to improve the quality of health care for Indians by
assuring access to qualified health care professionals; and
``(3) to provide academic and scholarly opportunities for
health professionals serving Indians by identifying all
academic and scholarly resources of the region.
``(c) Advisory Board.--The demonstration programs
established pursuant to subsection (a) shall incorporate a
program advisory board composed of representatives from the
Indian Tribes and Indian communities in the area which will
be served by the program.

``SEC. 124. NATIONAL HEALTH SERVICE CORPS.

``(a) No Reduction in Services.--The Secretary shall not--
``(1) remove a member of the National Health Service Corps
from an Indian Health Program or urban Indian organization;
or
``(2) withdraw funding used to support such member, unless
the Secretary, acting through the Service, has ensured that
the Indians receiving services from such member will
experience no reduction in services.
``(b) Treatment of Indian Health Programs.--At the request
of an Indian Health Program, the services of a member of the
National Health Service Corps assigned to an Indian Health
Program may be limited to the persons who are eligible for
services from such Program.

``SEC. 125. SUBSTANCE ABUSE COUNSELOR EDUCATIONAL CURRICULA
DEMONSTRATION PROGRAMS.

``(a) Contracts and Grants.--The Secretary, acting through
the Service, may enter into contracts with, or make grants
to, accredited tribal colleges and universities and eligible
accredited and accessible community colleges to establish
demonstration programs to develop educational curricula for
substance abuse counseling.
``(b) Use of Funds.--Funds provided under this section
shall be used only for developing and providing educational
curriculum for substance abuse counseling (including paying
salaries for instructors). Such curricula may be provided
through satellite campus programs.
``(c) Time Period of Assistance; Renewal.--A contract
entered into or a grant provided under this section shall be
for a period of 3 years. Such contract or grant may be
renewed for an additional 2-year period upon the approval of
the Secretary.
``(d) Criteria for Review and Approval of Applications.--
Not later than 180 days after the date of enactment of the
Indian Health Care Improvement Act Amendments of 2009, the
Secretary, after consultation with Indian Tribes and
administrators of tribal colleges and universities and
eligible accredited and accessible community colleges, shall
develop and issue criteria for the review and approval of
applications for funding (including applications for renewals
of funding) under this section. Such criteria shall ensure
that demonstration programs established under this section
promote the development of the capacity of such entities to
educate substance abuse counselors.
``(e) Assistance.--The Secretary shall provide such
technical and other assistance as may be necessary to enable
grant recipients to comply with the provisions of this
section.
``(f) Report.--Each fiscal year, the Secretary shall submit
to the President, for inclusion in the report which is
required to be submitted under section 801 for that fiscal
year, a report on the findings and conclusions derived from
the demonstration programs conducted under this section
during that fiscal year.
``(g) Definition.--For the purposes of this section, the
term `educational curriculum' means 1 or more of the
following:
``(1) Classroom education.
``(2) Clinical work experience.
``(3) Continuing education workshops.

``SEC. 126. BEHAVIORAL HEALTH TRAINING AND COMMUNITY
EDUCATION PROGRAMS.

``(a) Study; List.--The Secretary, acting through the
Service, and the Secretary of the Interior, in consultation
with Indian Tribes and Tribal Organizations, shall conduct a
study and compile a list of the types of staff positions
specified in subsection (b) whose qualifications include, or
should include, training in the identification, prevention,
education, referral, or treatment of mental illness, or
dysfunctional and self-destructive behavior.
``(b) Positions.--The positions referred to in subsection
(a) are--
``(1) staff positions within the Bureau of Indian Affairs,
including existing positions, in the fields of--
``(A) elementary and secondary education;
``(B) social services and family and child welfare;
``(C) law enforcement and judicial services; and
``(D) alcohol and substance abuse;
``(2) staff positions within the Service; and
``(3) staff positions similar to those identified in
paragraphs (1) and (2) established and maintained by Indian
Tribes, Tribal Organizations (without regard to the funding
source), and urban Indian organizations.
``(c) Training Criteria.--
``(1) In general.--The appropriate Secretary shall provide
training criteria appropriate to each type of position
identified in subsection (b)(1) and (b)(2) and ensure that
appropriate training has been, or shall be provided to any
individual in any such position. With respect to any such
individual in a position identified pursuant to subsection
(b)(3), the respective Secretaries shall provide appropriate
training to, or provide funds to, an Indian Tribe, Tribal
Organization, or urban Indian organization for training of
appropriate individuals. In the case of positions funded
under a contract or compact under the Indian Self-
Determination and Education Assistance Act (25 U.S.C. 450 et
seq.), the appropriate Secretary shall ensure that such
training costs are included in the contract or compact, as
the Secretary determines necessary.
``(2) Position specific training criteria.--Position
specific training criteria shall be culturally relevant to
Indians and Indian Tribes and shall ensure that appropriate
information regarding traditional health care practices is
provided.
``(d) Community Education on Mental Illness.--The Service
shall develop and implement, on request of an Indian Tribe,
Tribal Organization, or urban Indian organization, or assist
the Indian Tribe, Tribal Organization, or urban Indian
organization to develop and implement, a program of community
education on mental illness. In carrying out this subsection,
the Service shall, upon request of an Indian Tribe, Tribal
Organization, or urban Indian organization, provide technical
assistance to the Indian Tribe, Tribal Organization, or urban
Indian organization to obtain and develop community
educational materials on the identification, prevention,
referral, and treatment of mental illness and dysfunctional
and self-destructive behavior.
``(e) Plan.--Not later than 90 days after the date of
enactment of the Indian Health Care Improvement Act
Amendments of 2009, the Secretary shall develop a plan under
which the Service will increase the health care staff
providing behavioral health services by at least 500
positions within 5 years after the date of enactment of this
section, with at least 200 of such positions devoted to
child, adolescent, and family services. The plan developed
under this subsection shall be implemented under the Act of
November 2, 1921 (25 U.S.C. 13) (commonly known as the
`Snyder Act').

``SEC. 127. EXEMPTION FROM PAYMENT OF CERTAIN FEES.

``Employees of a Tribal Health Program or an Urban Indian
Organization shall be exempt from payment of licensing,
registration, and other fees imposed by a Federal agency to
the same extent that Commissioned Corps Officers or other
employees of the Indian Health Service are exempt from such
fees.

``SEC. 128. AUTHORIZATION OF APPROPRIATIONS.

``There are authorized to be appropriated such sums as may
be necessary to carry out this title.

``TITLE II--HEALTH SERVICES

``SEC. 201. INDIAN HEALTH CARE IMPROVEMENT FUND.

``(a) Use of Funds.--The Secretary, acting through the
Service, is authorized to expend funds, directly or under the
authority of the Indian Self-Determination and Education
Assistance Act (25 U.S.C. 450 et seq.), which are
appropriated under the authority of this section, for the
purposes of--
``(1) eliminating the deficiencies in health status and
health resources of all Indian Tribes;
``(2) eliminating backlogs in the provision of health care
services to Indians;
``(3) meeting the health needs of Indians in an efficient
and equitable manner, including the use of telehealth and
telemedicine when appropriate;
``(4) eliminating inequities in funding for both direct
care and contract health service programs; and
``(5) augmenting the ability of the Service to meet the
following health service responsibilities with respect to
those Indian Tribes with the highest levels of health status
deficiencies and resource deficiencies:
``(A) Clinical care, including inpatient care, outpatient
care (including audiology, clinical eye, and vision care),
primary care, secondary and tertiary care, and long-term
care.
``(B) Preventive health, including mammography and other
cancer screening in accordance with section 207.
``(C) Dental care.
``(D) Mental health, including community mental health
services, inpatient mental health services, dormitory mental
health services, therapeutic and residential treatment
centers, and training of traditional health care
practitioners.
``(E) Emergency medical services.
``(F) Treatment and control of, and rehabilitative care
related to, alcoholism and drug abuse (including fetal
alcohol syndrome) among Indians.
``(G) Injury prevention programs, including data collection
and evaluation, demonstration projects, training, and
capacity building.
``(H) Home health care.
``(I) Community health representatives.
``(J) Maintenance and improvement.

[[Page H12806]]

``(b) No Offset or Limitation.--Any funds appropriated
under the authority of this section shall not be used to
offset or limit any other appropriations made to the Service
under this Act or the Act of November 2, 1921 (25 U.S.C. 13)
(commonly known as the `Snyder Act'), or any other provision
of law.
``(c) Allocation; Use.--
``(1) In general.--Funds appropriated under the authority
of this section shall be allocated to Service Units, Indian
Tribes, or Tribal Organizations. The funds allocated to each
Indian Tribe, Tribal Organization, or Service Unit under this
paragraph shall be used by the Indian Tribe, Tribal
Organization, or Service Unit under this paragraph to improve
the health status and reduce the resource deficiency of each
Indian Tribe served by such Service Unit, Indian Tribe, or
Tribal Organization.
``(2) Apportionment of allocated funds.--The apportionment
of funds allocated to a Service Unit, Indian Tribe, or Tribal
Organization under paragraph (1) among the health service
responsibilities described in subsection (a)(5) shall be
determined by the Service in consultation with, and with the
active participation of, the affected Indian Tribes and
Tribal Organizations.
``(d) Provisions Relating to Health Status and Resource
Deficiencies.--For the purposes of this section, the
following definitions apply:
``(1) Definition.--The term `health status and resource
deficiency' means the extent to which--
``(A) the health status objectives set forth in section
3(2) are not being achieved; and
``(B) the Indian Tribe or Tribal Organization does not have
available to it the health resources it needs, taking into
account the actual cost of providing health care services
given local geographic, climatic, rural, or other
circumstances.
``(2) Available resources.--The health resources available
to an Indian Tribe or Tribal Organization include health
resources provided by the Service as well as health resources
used by the Indian Tribe or Tribal Organization, including
services and financing systems provided by any Federal
programs, private insurance, and programs of State or local
governments.
``(3) Process for review of determinations.--The Secretary
shall establish procedures which allow any Indian Tribe or
Tribal Organization to petition the Secretary for a review of
any determination of the extent of the health status and
resource deficiency of such Indian Tribe or Tribal
Organization.
``(e) Eligibility for Funds.--Tribal Health Programs shall
be eligible for funds appropriated under the authority of
this section on an equal basis with programs that are
administered directly by the Service.
``(f) Report.--By no later than the date that is 3 years
after the date of enactment of the Indian Health Care
Improvement Act Amendments of 2009, the Secretary shall
submit to Congress the current health status and resource
deficiency report of the Service for each Service Unit,
including newly recognized or acknowledged Indian Tribes.
Such report shall set out--
``(1) the methodology then in use by the Service for
determining Tribal health status and resource deficiencies,
as well as the most recent application of that methodology;
``(2) the extent of the health status and resource
deficiency of each Indian Tribe served by the Service or a
Tribal Health Program;
``(3) the amount of funds necessary to eliminate the health
status and resource deficiencies of all Indian Tribes served
by the Service or a Tribal Health Program; and
``(4) an estimate of--
``(A) the amount of health service funds appropriated under
the authority of this Act, or any other Act, including the
amount of any funds transferred to the Service for the
preceding fiscal year which is allocated to each Service
Unit, Indian Tribe, or Tribal Organization;
``(B) the number of Indians eligible for health services in
each Service Unit or Indian Tribe or Tribal Organization; and
``(C) the number of Indians using the Service resources
made available to each Service Unit, Indian Tribe or Tribal
Organization, and, to the extent available, information on
the waiting lists and number of Indians turned away for
services due to lack of resources.
``(g) Inclusion in Base Budget.--Funds appropriated under
this section for any fiscal year shall be included in the
base budget of the Service for the purpose of determining
appropriations under this section in subsequent fiscal years.
``(h) Clarification.--Nothing in this section is intended
to diminish the primary responsibility of the Service to
eliminate existing backlogs in unmet health care needs, nor
are the provisions of this section intended to discourage the
Service from undertaking additional efforts to achieve equity
among Indian Tribes and Tribal Organizations.
``(i) Funding Designation.--Any funds appropriated under
the authority of this section shall be designated as the
`Indian Health Care Improvement Fund'.

``SEC. 202. HEALTH PROMOTION AND DISEASE PREVENTION SERVICES.

``(a) Findings.--Congress finds that health promotion and
disease prevention activities--
``(1) improve the health and well-being of Indians; and
``(2) reduce the expenses for health care of Indians.
``(b) Provision of Services.--The Secretary, acting through
the Service, shall provide health promotion and disease
prevention services to Indians to achieve the health status
objectives set forth in section 3(2).
``(c) Evaluation.--The Secretary, after obtaining input
from the affected Tribal Health Programs, shall submit to the
President for inclusion in the report which is required to be
submitted to Congress under section 801 an evaluation of--
``(1) the health promotion and disease prevention needs of
Indians;
``(2) the health promotion and disease prevention
activities which would best meet such needs;
``(3) the internal capacity of the Service and Tribal
Health Programs to meet such needs; and
``(4) the resources which would be required to enable the
Service and Tribal Health Programs to undertake the health
promotion and disease prevention activities necessary to meet
such needs.

``SEC. 203. DIABETES PREVENTION, TREATMENT, AND CONTROL.

``(a) Determinations Regarding Diabetes.--The Secretary,
acting through the Service, and in consultation with Indian
Tribes and Tribal Organizations, shall determine--
``(1) by Indian Tribe and by Service Unit, the incidence
of, and the types of complications resulting from, diabetes
among Indians; and
``(2) based on the determinations made pursuant to
paragraph (1), the measures (including patient education and
effective ongoing monitoring of disease indicators) each
Service Unit should take to reduce the incidence of, and
prevent, treat, and control the complications resulting from,
diabetes among Indian Tribes within that Service Unit.
``(b) Diabetes Screening.--To the extent medically
indicated and with informed consent, the Secretary shall
screen each Indian who receives services from the Service for
diabetes and for conditions which indicate a high risk that
the individual will become diabetic and establish a cost-
effective approach to ensure ongoing monitoring of disease
indicators. Such screening and monitoring may be conducted by
a Tribal Health Program and may be conducted through
appropriate Internet-based health care management programs.
``(c) Diabetes Projects.--The Secretary shall continue to
maintain each model diabetes project in existence on the date
of enactment of the Indian Health Care Improvement Act
Amendments of 2009.
``(d) Dialysis Programs.--The Secretary is authorized to
provide, through the Service, Indian Tribes, and Tribal
Organizations, dialysis programs, including the purchase of
dialysis equipment and the provision of necessary staffing.
``(e) Other Duties of the Secretary.--
``(1) In general.--The Secretary shall, to the extent
funding is available--
``(A) in each Area Office, consult with Indian Tribes and
Tribal Organizations regarding programs for the prevention,
treatment, and control of diabetes;
``(B) establish in each Area Office a registry of patients
with diabetes to track the incidence of diabetes and the
complications from diabetes in that area; and
``(C) ensure that data collected in each Area Office
regarding diabetes and related complications among Indians
are disseminated to all other Area Offices, subject to
applicable patient privacy laws.
``(2) Diabetes control officers.--
``(A) In general.--The Secretary may establish and maintain
in each Area Office a position of diabetes control officer to
coordinate and manage any activity of that Area Office
relating to the prevention, treatment, or control of diabetes
to assist the Secretary in carrying out a program under this
section or section 330C of the Public Health Service Act (42
U.S.C. 254c-3).
``(B) Certain activities.--Any activity carried out by a
diabetes control officer under subparagraph (A) that is the
subject of a contract or compact under the Indian Self-
Determination and Education Assistance Act (25 U.S.C. 450 et
seq.), and any funds made available to carry out such an
activity, shall not be divisible for purposes of that Act.

``SEC. 204. SHARED SERVICES FOR LONG-TERM CARE.

``(a) Long-term Care.--Notwithstanding any other provision
of law, the Secretary, acting through the Service, is
authorized to provide directly, or enter into contracts or
compacts under the Indian Self-Determination and Education
Assistance Act (25 U.S.C. 450 et seq.) with Indian Tribes or
Tribal Organizations for, the delivery of long-term care
(including health care services associated with long-term
care) provided in a facility to Indians. Such agreements
shall provide for the sharing of staff or other services
between the Service or a Tribal Health Program and a long-
term care or related facility owned and operated (directly or
through a contract or compact under the Indian Self-
Determination and Education Assistance Act (25 U.S.C. 450 et
seq.)) by such Indian Tribe or Tribal Organization.
``(b) Contents of Agreements.--An agreement entered into
pursuant to subsection (a)--
``(1) may, at the request of the Indian Tribe or Tribal
Organization, delegate to such Indian Tribe or Tribal
Organization such powers of supervision and control over
Service employees as the Secretary deems necessary to carry
out the purposes of this section;

[[Page H12807]]

``(2) shall provide that expenses (including salaries)
relating to services that are shared between the Service and
the Tribal Health Program be allocated proportionately
between the Service and the Indian Tribe or Tribal
Organization; and
``(3) may authorize such Indian Tribe or Tribal
Organization to construct, renovate, or expand a long-term
care or other similar facility (including the construction of
a facility attached to a Service facility).
``(c) Minimum Requirement.--Any nursing facility provided
for under this section shall meet the requirements for
nursing facilities under section 1919 of the Social Security
Act.
``(d) Other Assistance.--The Secretary shall provide such
technical and other assistance as may be necessary to enable
applicants to comply with the provisions of this section.
``(e) Use of Existing or Underused Facilities.--The
Secretary shall encourage the use of existing facilities that
are underused or allow the use of swing beds for long-term or
similar care.

``SEC. 205. HEALTH SERVICES RESEARCH.

``(a) In General.--The Secretary, acting through the
Service, shall make funding available for research to further
the performance of the health service responsibilities of
Indian Health Programs.
``(b) Coordination of Resources and Activities.--The
Secretary shall also, to the maximum extent practicable,
coordinate departmental research resources and activities to
address relevant Indian Health Program research needs.
``(c) Availability.--Tribal Health Programs shall be given
an equal opportunity to compete for, and receive, research
funds under this section.
``(d) Use of Funds.--This funding may be used for both
clinical and nonclinical research.
``(e) Evaluation and Dissemination.--The Secretary shall
periodically--
``(1) evaluate the impact of research conducted under this
section; and
``(2) disseminate to Tribal Health Programs information
regarding that research as the Secretary determines to be
appropriate.

``SEC. 206. MAMMOGRAPHY AND OTHER CANCER SCREENING.

``The Secretary, acting through the Service, shall provide
for screening as follows:
``(1) Screening mammography (as defined in section 1861(jj)
of the Social Security Act) for Indian women at a frequency
appropriate to such women under accepted and appropriate
national standards, and under such terms and conditions as
are consistent with standards established by the Secretary to
ensure the safety and accuracy of screening mammography under
part B of title XVIII of such Act.
``(2) Other cancer screening that receives an A or B rating
as recommended by the United States Preventive Services Task
Force established under section 915(a)(1) of the Public
Health Service Act (42 U.S.C. 299b-4(a)(1)). The Secretary
shall ensure that screening provided for under this paragraph
complies with the recommendations of the Task Force with
respect to--
``(A) frequency;
``(B) the population to be served;
``(C) the procedure or technology to be used;
``(D) evidence of effectiveness; and
``(E) other matters that the Secretary determines
appropriate.

``SEC. 207. PATIENT TRAVEL COSTS.

``(a) Definition of Qualified Escort.--In this section, the
term `qualified escort' means--
``(1) an adult escort (including a parent, guardian, or
other family member) who is required because of the physical
or mental condition, or age, of the applicable patient;
``(2) a health professional for the purpose of providing
necessary medical care during travel by the applicable
patient; or
``(3) other escorts, as the Secretary or applicable Indian
Health Program determines to be appropriate.
``(b) Provision of Funds.--The Secretary, acting through
the Service, is authorized to provide funds for the following
patient travel costs, including qualified escorts, associated
with receiving health care services provided (either through
direct or contract care or through a contract or compact
under the Indian Self-Determination and Education Assistance
Act (25 U.S.C. 450 et seq.)) under this Act--
``(1) emergency air transportation and non-emergency air
transportation where ground transportation is infeasible;
``(2) transportation by private vehicle (where no other
means of transportation is available), specially equipped
vehicle, and ambulance; and
``(3) transportation by such other means as may be
available and required when air or motor vehicle
transportation is not available.

``SEC. 208. EPIDEMIOLOGY CENTERS.

``(a) Establishment of Centers.--The Secretary shall
establish an epidemiology center in each Service Area to
carry out the functions described in subsection (b). Any new
center established after the date of enactment of the Indian
Health Care Improvement Act Amendments of 2008 may be
operated under a grant authorized by subsection (d), but
funding under such a grant shall not be divisible.
``(b) Functions of Centers.--In consultation with and upon
the request of Indian Tribes, Tribal Organizations, and Urban
Indian communities, each Service Area epidemiology center
established under this section shall, with respect to such
Service Area--
``(1) collect data relating to, and monitor progress made
toward meeting, each of the health status objectives of the
Service, the Indian Tribes, Tribal Organizations, and Urban
Indian communities in the Service Area;
``(2) evaluate existing delivery systems, data systems, and
other systems that impact the improvement of Indian health;
``(3) assist Indian Tribes, Tribal Organizations, and Urban
Indian Organizations in identifying their highest priority
health status objectives and the services needed to achieve
such objectives, based on epidemiological data;
``(4) make recommendations for the targeting of services
needed by the populations served;
``(5) make recommendations to improve health care delivery
systems for Indians and Urban Indians;
``(6) provide requested technical assistance to Indian
Tribes, Tribal Organizations, and Urban Indian Organizations
in the development of local health service priorities and
incidence and prevalence rates of disease and other illness
in the community; and
``(7) provide disease surveillance and assist Indian
Tribes, Tribal Organizations, and Urban Indian communities to
promote public health.
``(c) Technical Assistance.--The Director of the Centers
for Disease Control and Prevention shall provide technical
assistance to the centers in carrying out the requirements of
this section.
``(d) Grants for Studies.--
``(1) In general.--The Secretary may make grants to Indian
Tribes, Tribal Organizations, Indian organizations, and
eligible intertribal consortia to conduct epidemiological
studies of Indian communities.
``(2) Eligible intertribal consortia.--An intertribal
consortium or Indian organization is eligible to receive a
grant under this subsection if--
``(A) the intertribal consortium is incorporated for the
primary purpose of improving Indian health; and
``(B) the intertribal consortium is representative of the
Indian Tribes or urban Indian communities in which the
intertribal consortium is located.
``(3) Applications.--An application for a grant under this
subsection shall be submitted in such manner and at such time
as the Secretary shall prescribe.
``(4) Requirements.--An applicant for a grant under this
subsection shall--
``(A) demonstrate the technical, administrative, and
financial expertise necessary to carry out the functions
described in paragraph (5);
``(B) consult and cooperate with providers of related
health and social services in order to avoid duplication of
existing services; and
``(C) demonstrate cooperation from Indian Tribes or Urban
Indian Organizations in the area to be served.
``(5) Use of funds.--A grant awarded under paragraph (1)
may be used--
``(A) to carry out the functions described in subsection
(b);
``(B) to provide information to and consult with tribal
leaders, urban Indian community leaders, and related health
staff on health care and health service management issues;
and
``(C) in collaboration with Indian Tribes, Tribal
Organizations, and urban Indian communities, to provide the
Service with information regarding ways to improve the health
status of Indians.
``(e) Access to Information.--
``(1) An epidemiology center operated by a grantee pursuant
to a grant awarded under subsection (d) shall be treated as a
public health authority for purposes of the Health Insurance
Portability and Accountability Act of 1996, as such entities
are defined in part 164.501 of title 45, Code of Federal
Regulations.
``(2) The Secretary shall grant to such epidemiology center
access to use of the data, data sets, monitoring systems,
delivery systems, and other protected health information in
the possession of the Secretary.
``(3) The activities of such an epidemiology center shall
be for the purposes of research and for preventing and
controlling disease, injury, or disability for purposes of
the Health Insurance Portability and Accountability Act of
1996 (Public Law 104-191; 110 Stat. 2033), as such activities
are described in part 164.512 of title 45, Code of Federal
Regulations (or a successor regulation).
``(f) Funds Not Divisible.--An epidemiology center
established under this section shall be subject to the
provisions of the Indian Self-Determination and Education
Assistance Act (25 U.S.C. 450 et seq.), but the funds for
such center shall not be divisible.

``SEC. 209. COMPREHENSIVE SCHOOL HEALTH EDUCATION PROGRAMS.

``(a) Funding for Development of Programs.--In addition to
carrying out any other program for health promotion or
disease prevention, the Secretary, acting through the
Service, is authorized to award grants to Indian Tribes and
Tribal Organizations to develop comprehensive school health
education programs for children from pre-school through grade
12 in schools for the benefit of Indian children.
``(b) Use of Grant Funds.--A grant awarded under this
section may be used for purposes which may include, but are
not limited to, the following:

[[Page H12808]]

``(1) Developing health education materials both for
regular school programs and afterschool programs.
``(2) Training teachers in comprehensive school health
education materials.
``(3) Integrating school-based, community-based, and other
public and private health promotion efforts.
``(4) Encouraging healthy, tobacco-free school
environments.
``(5) Coordinating school-based health programs with
existing services and programs available in the community.
``(6) Developing school programs on nutrition education,
personal health, oral health, and fitness.
``(7) Developing behavioral health wellness programs.
``(8) Developing chronic disease prevention programs.
``(9) Developing substance abuse prevention programs.
``(10) Developing injury prevention and safety education
programs.
``(11) Developing activities for the prevention and control
of communicable diseases.
``(12) Developing community and environmental health
education programs that include traditional health care
practitioners.
``(13) Violence prevention.
``(14) Such other health issues as are appropriate.
``(c) Technical Assistance.--Upon request, the Secretary,
acting through the Service, shall provide technical
assistance to Indian Tribes and Tribal Organizations in the
development of comprehensive health education plans and the
dissemination of comprehensive health education materials and
information on existing health programs and resources.
``(d) Criteria for Review and Approval of Applications.--
The Secretary, acting through the Service, and in
consultation with Indian Tribes and Tribal Organizations,
shall establish criteria for the review and approval of
applications for grants awarded under this section.
``(e) Development of Program for BIA-funded Schools.--
``(1) In general.--The Secretary of the Interior, acting
through the Bureau of Indian Affairs and in cooperation with
the Secretary, acting through the Service, shall develop a
comprehensive school health education program for children
from preschool through grade 12 in schools for which support
is provided by the Bureau of Indian Affairs.
``(2) Requirements for programs.--Such programs shall
include--
``(A) school programs on nutrition education, personal
health, oral health, and fitness;
``(B) behavioral health wellness programs;
``(C) chronic disease prevention programs;
``(D) substance abuse prevention programs;
``(E) injury prevention and safety education programs; and
``(F) activities for the prevention and control of
communicable diseases.
``(3) Duties of the secretary.--The Secretary of the
Interior shall--
``(A) provide training to teachers in comprehensive school
health education materials;
``(B) ensure the integration and coordination of school-
based programs with existing services and health programs
available in the community; and
``(C) encourage healthy, tobacco-free school environments.

``SEC. 210. INDIAN YOUTH PROGRAM.

``(a) Program Authorized.--The Secretary, acting through
the Service, is authorized to establish and administer a
program to provide grants to Indian Tribes, Tribal
Organizations, and urban Indian organizations for innovative
mental and physical disease prevention and health promotion
and treatment programs for Indian and urban Indian
preadolescent and adolescent youths.
``(b) Use of Funds.--
``(1) Allowable uses.--Funds made available under this
section may be used to--
``(A) develop prevention and treatment programs for Indian
youth which promote mental and physical health and
incorporate cultural values, community and family
involvement, and traditional health care practitioners; and
``(B) develop and provide community training and education.
``(2) Prohibited use.--Funds made available under this
section may not be used to provide services described in
section 707(c).
``(c) Duties of the Secretary.--The Secretary shall--
``(1) disseminate to Indian Tribes, Tribal Organizations,
and urban Indian organizations information regarding models
for the delivery of comprehensive health care services to
Indian and urban Indian adolescents;
``(2) encourage the implementation of such models; and
``(3) at the request of an Indian Tribe, Tribal
Organization, or urban Indian organization, provide technical
assistance in the implementation of such models.
``(d) Criteria for Review and Approval of Applications.--
The Secretary, in consultation with Indian Tribes, Tribal
Organizations, and urban Indian organizations, shall
establish criteria for the review and approval of
applications or proposals under this section.

``SEC. 211. PREVENTION, CONTROL, AND ELIMINATION OF
COMMUNICABLE AND INFECTIOUS DISEASES.

``(a) Grants Authorized.--The Secretary, acting through the
Service, and after consultation with the Centers for Disease
Control and Prevention, may make grants available to Indian
Tribes, Tribal Organizations, and urban Indian organizations
for the following:
``(1) Projects for the prevention, control, and elimination
of communicable and infectious diseases, including
tuberculosis, hepatitis, HIV, respiratory syncytial virus,
hanta virus, sexually transmitted diseases, and H. Pylori.
``(2) Public information and education programs for the
prevention, control, and elimination of communicable and
infectious diseases.
``(3) Education, training, and clinical skills improvement
activities in the prevention, control, and elimination of
communicable and infectious diseases for health
professionals, including allied health professionals.
``(4) Demonstration projects for the screening, treatment,
and prevention of hepatitis C virus (HCV).
``(b) Application Required.--The Secretary may provide
funding under subsection (a) only if an application or
proposal for funding is submitted to the Secretary.
``(c) Coordination With Health Agencies.--Indian Tribes,
Tribal Organizations, and urban Indian organizations
receiving funding under this section are encouraged to
coordinate their activities with the Centers for Disease
Control and Prevention and State and local health agencies.
``(d) Technical Assistance; Report.--In carrying out this
section, the Secretary--
``(1) may, at the request of an Indian Tribe, Tribal
Organization, or urban Indian organization, provide technical
assistance; and
``(2) shall prepare and submit a report to Congress
biennially on the use of funds under this section and on the
progress made toward the prevention, control, and elimination
of communicable and infectious diseases among Indians and
Urban Indians.

``SEC. 212. OTHER AUTHORITY FOR PROVISION OF SERVICES.

``(a) Funding Authorized.--The Secretary may provide
funding under this Act to meet the objectives set forth in
section 3 of this Act through health care-related services
and programs of the Service, Indian Tribes, and Tribal
Organizations not otherwise described in this Act for the
following services:
``(1) Hospice care.
``(2) Assisted living services.
``(3) Long-term care services.
``(4) Home- and community-based services.
``(b) Eligibility.--The following individuals shall be
eligible to receive long-term care under this section:
``(1) Individuals who are unable to perform a certain
number of activities of daily living without assistance.
``(2) Individuals with a mental impairment, such as
dementia, Alzheimer's disease, or another disabling mental
illness, who may be able to perform activities of daily
living under supervision.
``(3) Such other individuals as an applicable Indian Health
Program determines to be appropriate.
``(c) Definitions.--For the purposes of this section, the
following definitions shall apply:
``(1) The term `assisted living services' means any service
provided by an assisted living facility (as defined in
section 232(b) of the National Housing Act (12 U.S.C.
1715w(b))), except that such an assisted living facility--
``(A) shall not be required to obtain a license; but
``(B) shall meet all applicable standards for licensure.
``(2) The term `home- and community-based services' means 1
or more of the services specified in paragraphs (1) through
(9) of section 1929(a) of the Social Security Act (42 U.S.C.
1396t(a)) (whether provided by the Service or by an Indian
Tribe or Tribal Organization pursuant to the Indian Self-
Determination and Education Assistance Act (25 U.S.C. 450 et
seq.)) that are or will be provided in accordance with
applicable standards.
``(3) The term `hospice care' means the items and services
specified in subparagraphs (A) through (H) of section
1861(dd)(1) of the Social Security Act (42 U.S.C.
1395x(dd)(1)), and such other services which an Indian Tribe
or Tribal Organization determines are necessary and
appropriate to provide in furtherance of this care.
``(4) The term `long-term care services' has the meaning
given the term `qualified long-term care services' in section
7702B(c) of the Internal Revenue Code of 1986.
``(d) Authorization of Convenient Care Services.--The
Secretary, acting through the Service, Indian Tribes, and
Tribal Organizations, may also provide funding under this Act
to meet the objectives set forth in section 3 of this Act for
convenient care services programs pursuant to section
306(c)(2)(A).

``SEC. 213. INDIAN WOMEN'S HEALTH CARE.

``The Secretary, acting through the Service and Indian
Tribes, Tribal Organizations, and Urban Indian Organizations,
shall monitor and improve the quality of health care for
Indian women of all ages through the planning and delivery of
programs administered by the Service, in order to improve and
enhance the treatment models of care for Indian women.

``SEC. 214. ENVIRONMENTAL AND NUCLEAR HEALTH HAZARDS.

``(a) Studies and Monitoring.--The Secretary and the
Service shall conduct, in conjunction with other appropriate
Federal agencies and in consultation with concerned

[[Page H12809]]

Indian Tribes and Tribal Organizations, studies and ongoing
monitoring programs to determine trends in the health hazards
to Indian miners and to Indians on or near reservations and
Indian communities as a result of environmental hazards which
may result in chronic or life threatening health problems,
such as nuclear resource development, petroleum
contamination, and contamination of water source and of the
food chain. Such studies shall include--
``(1) an evaluation of the nature and extent of health
problems caused by environmental hazards currently exhibited
among Indians and the causes of such health problems;
``(2) an analysis of the potential effect of ongoing and
future environmental resource development on or near
reservations and Indian communities, including the cumulative
effect over time on health;
``(3) an evaluation of the types and nature of activities,
practices, and conditions causing or affecting such health
problems, including uranium mining and milling, uranium mine
tailing deposits, nuclear power plant operation and
construction, and nuclear waste disposal; oil and gas
production or transportation on or near reservations or
Indian communities; and other development that could affect
the health of Indians and their water supply and food chain;
``(4) a summary of any findings and recommendations
provided in Federal and State studies, reports,
investigations, and inspections during the 5 years prior to
the date of enactment of the Indian Health Care Improvement
Act Amendments of 2009 that directly or indirectly relate to
the activities, practices, and conditions affecting the
health or safety of such Indians; and
``(5) the efforts that have been made by Federal and State
agencies and resource and economic development companies to
effectively carry out an education program for such Indians
regarding the health and safety hazards of such development.
``(b) Health Care Plans.--Upon completion of such studies,
the Secretary and the Service shall take into account the
results of such studies and develop health care plans to
address the health problems studied under subsection (a). The
plans shall include--
``(1) methods for diagnosing and treating Indians currently
exhibiting such health problems;
``(2) preventive care and testing for Indians who may be
exposed to such health hazards, including the monitoring of
the health of individuals who have or may have been exposed
to excessive amounts of radiation or affected by other
activities that have had or could have a serious impact upon
the health of such individuals; and
``(3) a program of education for Indians who, by reason of
their work or geographic proximity to such nuclear or other
development activities, may experience health problems.
``(c) Submission of Report and Plan to Congress.--The
Secretary and the Service shall submit to Congress the study
prepared under subsection (a) no later than 18 months after
the date of enactment of the Indian Health Care Improvement
Act Amendments of 2009. The health care plan prepared under
subsection (b) shall be submitted in a report no later than 1
year after the study prepared under subsection (a) is
submitted to Congress. Such report shall include recommended
activities for the implementation of the plan, as well as an
evaluation of any activities previously undertaken by the
Service to address such health problems.
``(d) Intergovernmental Task Force.--
``(1) Establishment; members.--There is established an
Intergovernmental Task Force to be composed of the following
individuals (or their designees):
``(A) The Secretary of Energy.
``(B) The Secretary of the Environmental Protection Agency.
``(C) The Director of the Bureau of Mines.
``(D) The Assistant Secretary for Occupational Safety and
Health.
``(E) The Secretary of the Interior.
``(F) The Secretary of Health and Human Services.
``(G) The Director of the Indian Health Service.
``(2) Duties.--The Task Force shall--
``(A) identify existing and potential operations related to
nuclear resource development or other environmental hazards
that affect or may affect the health of Indians on or near a
reservation or in an Indian community; and
``(B) enter into activities to correct existing health
hazards and ensure that current and future health problems
resulting from nuclear resource or other development
activities are minimized or reduced.
``(3) Chairman; meetings.--The Secretary of Health and
Human Services shall be the Chairman of the Task Force. The
Task Force shall meet at least twice each year.
``(e) Health Services to Certain Employees.--In the case of
any Indian who--
``(1) as a result of employment in or near a uranium mine
or mill or near any other environmental hazard, suffers from
a work-related illness or condition;
``(2) is eligible to receive diagnosis and treatment
services from an Indian Health Program; and
``(3) by reason of such Indian's employment, is entitled to
medical care at the expense of such mine or mill operator or
entity responsible for the environmental hazard, the Indian
Health Program shall, at the request of such Indian, render
appropriate medical care to such Indian for such illness or
condition and may be reimbursed for any medical care so
rendered to which such Indian is entitled at the expense of
such operator or entity from such operator or entity. Nothing
in this subsection shall affect the rights of such Indian to
recover damages other than such amounts paid to the Indian
Health Program from the employer for providing medical care
for such illness or condition.

``SEC. 215. ARIZONA AS A CONTRACT HEALTH SERVICE DELIVERY
AREA.

``(a) In General.--For fiscal years beginning with the
fiscal year ending September 30, 1983, and ending with the
fiscal year ending September 30, 2025, the State of Arizona
shall be designated as a contract health service delivery
area by the Service for the purpose of providing contract
health care services to members of federally recognized
Indian Tribes of Arizona.
``(b) Maintenance of Services.--The Service shall not
curtail any health care services provided to Indians residing
on reservations in the State of Arizona if such curtailment
is due to the provision of contract services in such State
pursuant to the designation of such State as a contract
health service delivery area pursuant to subsection (a).

``SEC. 216. NORTH DAKOTA AND SOUTH DAKOTA AS CONTRACT HEALTH
SERVICE DELIVERY AREA.

``(a) In General.--Beginning in fiscal year 2003, the
States of North Dakota and South Dakota shall be designated
as a contract health service delivery area by the Service for
the purpose of providing contract health care services to
members of federally recognized Indian Tribes of North Dakota
and South Dakota.
``(b) Limitation.--The Service shall not curtail any health
care services provided to Indians residing on any
reservation, or in any county that has a common boundary with
any reservation, in the State of North Dakota or South Dakota
if such curtailment is due to the provision of contract
services in such States pursuant to the designation of such
States as a contract health service delivery area pursuant to
subsection (a).

``SEC. 217. CALIFORNIA CONTRACT HEALTH SERVICES PROGRAM.

``(a) Funding Authorized.--The Secretary is authorized to
fund a program using an intertribal consortium as a contract
care intermediary to improve the accessibility of health
services to California Indians.
``(b) Reimbursement Contract.--The Secretary shall enter
into an agreement with the intertribal consortium to
reimburse the intertribal consortium for costs (including
reasonable administrative costs) incurred pursuant to this
section, in providing medical treatment under contract to
California Indians described in section 805(a) throughout the
California contract health services delivery area described
in section 219 with respect to high cost contract care cases.
``(c) Administrative Expenses.--Not more than 5 percent of
the amounts provided to the intertribal consortium under this
section for any fiscal year may be for reimbursement for
administrative expenses incurred by the intertribal
consortium during such fiscal year.
``(d) Limitation on Payment.--No payment may be made for
treatment provided hereunder to the extent payment may be
made for such treatment under the Indian Catastrophic Health
Emergency Fund described in section 202 or from amounts
appropriated or otherwise made available to the California
contract health service delivery area for a fiscal year.
``(e) Advisory Board.--There is established an advisory
board which shall advise the intertribal consortium in
carrying out this section. The advisory board shall be
composed of representatives, selected by the intertribal
consortium, from not less than 8 Tribal Health Programs
serving California Indians covered under this section at
least \1/2\ of whom are not affiliated with the intertribal
consortium.

``SEC. 218. CALIFORNIA AS A CONTRACT HEALTH SERVICE DELIVERY
AREA.

``The State of California, excluding the counties of
Alameda, Contra Costa, Los Angeles, Marin, Orange,
Sacramento, San Francisco, San Mateo, Santa Clara, Kern,
Merced, Monterey, Napa, San Benito, San Joaquin, San Luis
Obispo, Santa Cruz, Solano, Stanislaus, and Ventura, shall be
designated as a contract health service delivery area by the
Service for the purpose of providing contract health services
to California Indians. However, any of the counties listed
herein may only be included in the contract health services
delivery area if funding is specifically provided by the
Service for such services in those counties.

``SEC. 219. CONTRACT HEALTH SERVICES FOR THE TRENTON SERVICE
AREA.

``(a) Authorization for Services.--The Secretary, acting
through the Service, is directed to provide contract health
services to members of the Turtle Mountain Band of Chippewa
Indians that reside in the Trenton Service Area of Divide,
McKenzie, and Williams counties in the State of North Dakota
and the adjoining counties of Richland, Roosevelt, and
Sheridan in the State of Montana.
``(b) No Expansion of Eligibility.--Nothing in this section
may be construed as expanding the eligibility of members of
the Turtle Mountain Band of Chippewa Indians for health
services provided by the Service beyond the scope of
eligibility for such health services that applied on May 1,
1986.

[[Page H12810]]

``SEC. 220. PROGRAMS OPERATED BY INDIAN TRIBES AND TRIBAL
ORGANIZATIONS.

``The Service shall provide funds for health care programs,
functions, services, activities, information technology, and
facilities operated by Tribal Health Programs on the same
basis as such funds are provided to programs, functions,
services, activities, information technology, and facilities
operated directly by the Service.

``SEC. 221. LICENSING.

``Licensed health care professionals employed by a Tribal
Health Program shall, if licensed in any State, be exempt
from the licensing requirements of the State in which the
Tribal Health Program performs the services described in its
contract or compact under the Indian Self-Determination and
Education Assistance Act (25 U.S.C. 450 et seq.) while
performing such services.

``SEC. 222. NOTIFICATION OF PROVISION OF EMERGENCY CONTRACT
HEALTH SERVICES.

``With respect to an elderly Indian or an Indian with a
disability receiving emergency medical care or services from
a non-Service provider or in a non-Service facility under the
authority of this Act, the time limitation (as a condition of
payment) for notifying the Service of such treatment or
admission shall be 30 days.

``SEC. 223. PROMPT ACTION ON PAYMENT OF CLAIMS.

``(a) Deadline for Response.--The Service shall respond to
a notification of a claim by a provider of a contract care
service with either an individual purchase order or a denial
of the claim within 5 working days after the receipt of such
notification.
``(b) Effect of Untimely Response.--If the Service fails to
respond to a notification of a claim in accordance with
subsection (a), the Service shall accept as valid the claim
submitted by the provider of a contract care service.
``(c) Deadline for Payment of Valid Claim.--The Service
shall pay a valid contract care service claim within 30 days
after the completion of the claim.

``SEC. 224. LIABILITY FOR PAYMENT.

``(a) No Patient Liability.--A patient who receives
contract health care services that are authorized by the
Service shall not be liable for the payment of any charges or
costs associated with the provision of such services.
``(b) Notification.--The Secretary shall notify a contract
care provider and any patient who receives contract health
care services authorized by the Service that such patient is
not liable for the payment of any charges or costs associated
with the provision of such services not later than 5 business
days after receipt of a notification of a claim by a provider
of contract care services.
``(c) No Recourse.--Following receipt of the notice
provided under subsection (b), or, if a claim has been deemed
accepted under section 224(b), the provider shall have no
further recourse against the patient who received the
services.

``SEC. 225. OFFICE OF INDIAN MEN'S HEALTH.

``(a) Establishment.--The Secretary may establish within
the Service an office to be known as the `Office of Indian
Men's Health' (referred to in this section as the `Office').
``(b) Director.--
``(1) In general.--The Office shall be headed by a
director, to be appointed by the Secretary.
``(2) Duties.--The director shall coordinate and promote
the status of the health of Indian men in the United States.
``(c) Report.--Not later than 2 years after the date of
enactment of the Indian Health Care Improvement Act
Amendments of 2009, the Secretary, acting through the
director of the Office, shall submit to Congress a report
describing--
``(1) any activity carried out by the director as of the
date on which the report is prepared; and
``(2) any finding of the director with respect to the
health of Indian men.

``SEC. 226. CATASTROPHIC HEALTH EMERGENCY FUND.

``(a) Establishment.--There is established an Indian
Catastrophic Health Emergency Fund (hereafter in this section
referred to as the `CHEF') consisting of--
``(1) the amounts deposited under subsection (f); and
``(2) the amounts appropriated to CHEF under this section.
``(b) Administration.--CHEF shall be administered by the
Secretary, acting through the headquarters of the Service,
solely for the purpose of meeting the extraordinary medical
costs associated with the treatment of victims of disasters
or catastrophic illnesses who are within the responsibility
of the Service.
``(c) Conditions on Use of Fund.--No part of CHEF or its
administration shall be subject to contract or grant under
any law, including the Indian Self-Determination and
Education Assistance Act (25 U.S.C. 450 et seq.), nor shall
CHEF funds be allocated, apportioned, or delegated on an Area
Office, Service Unit, or other similar basis.
``(d) Regulations.--The Secretary shall promulgate
regulations consistent with the provisions of this section
to--
``(1) establish a definition of disasters and catastrophic
illnesses for which the cost of the treatment provided under
contract would qualify for payment from CHEF;
``(2) provide that a Service Unit shall not be eligible for
reimbursement for the cost of treatment from CHEF until its
cost of treating any victim of such catastrophic illness or
disaster has reached a certain threshold cost which the
Secretary shall establish at--
``(A) the 2000 level of $19,000; and
``(B) for any subsequent year, not less than the threshold
cost of the previous year increased by the percentage
increase in the medical care expenditure category of the
consumer price index for all urban consumers (United States
city average) for the 12-month period ending with December of
the previous year;
``(3) establish a procedure for the reimbursement of the
portion of the costs that exceeds such threshold cost
incurred by--
``(A) Service Units; or
``(B) whenever otherwise authorized by the Service, non-
Service facilities or providers;
``(4) establish a procedure for payment from CHEF in cases
in which the exigencies of the medical circumstances warrant
treatment prior to the authorization of such treatment by the
Service; and
``(5) establish a procedure that will ensure that no
payment shall be made from CHEF to any provider of treatment
to the extent that such provider is eligible to receive
payment for the treatment from any other Federal, State,
local, or private source of reimbursement for which the
patient is eligible.
``(e) No Offset or Limitation.--Amounts appropriated to
CHEF under this section shall not be used to offset or limit
appropriations made to the Service under the authority of the
Act of November 2, 1921 (25 U.S.C. 13) (commonly known as the
`Snyder Act'), or any other law.
``(f) Deposit of Reimbursement Funds.--There shall be
deposited into CHEF all reimbursements to which the Service
is entitled from any Federal, State, local, or private source
(including third party insurance) by reason of treatment
rendered to any victim of a disaster or catastrophic illness
the cost of which was paid from CHEF.

``SEC. 227. AUTHORIZATION OF APPROPRIATIONS.

``There are authorized to be appropriated such sums as may
be necessary to carry out this title.

``TITLE III--FACILITIES

``SEC. 301. CONSULTATION; CONSTRUCTION AND RENOVATION OF
FACILITIES; REPORTS.

``(a) Prerequisites for Expenditure of Funds.--Prior to the
expenditure of, or the making of any binding commitment to
expend, any funds appropriated for the planning, design,
construction, or renovation of facilities pursuant to the Act
of November 2, 1921 (25 U.S.C. 13) (commonly known as the
`Snyder Act'), the Secretary, acting through the Service,
shall--
``(1) consult with any Indian Tribe that would be
significantly affected by such expenditure for the purpose of
determining and, whenever practicable, honoring tribal
preferences concerning size, location, type, and other
characteristics of any facility on which such expenditure is
to be made; and
``(2) ensure, whenever practicable and applicable, that
such facility meets the construction standards of any
accrediting body recognized by the Secretary for the purposes
of the Medicare, Medicaid, and SCHIP programs under titles
XVIII, XIX, and XXI of the Social Security Act by not later
than 1 year after the date on which the construction or
renovation of such facility is completed.
``(b) Closures.--
``(1) Evaluation required.--Notwithstanding any other
provision of law, no facility operated by the Service may be
closed if the Secretary has not submitted to Congress, not
less than 1 year and not more than 2 years before the date of
the proposed closure, an evaluation, completed not more than
2 years before such submission, of the impact of the proposed
closure that specifies, in addition to other considerations--
``(A) the accessibility of alternative health care
resources for the population served by such facility;
``(B) the cost-effectiveness of such closure;
``(C) the quality of health care to be provided to the
population served by such facility after such closure;
``(D) the availability of contract health care funds to
maintain existing levels of service;
``(E) the views of the Indian Tribes served by such
facility concerning such closure;
``(F) the level of use of such facility by all eligible
Indians; and
``(G) the distance between such facility and the nearest
operating Service hospital.
``(2) Exception for certain temporary closures.--Paragraph
(1) shall not apply to any temporary closure of a facility or
any portion of a facility if such closure is necessary for
medical, environmental, or construction safety reasons.
``(c) Health Care Facility Priority System.--
``(1) In general.--
``(A) Priority system.--The Secretary, acting through the
Service, shall maintain a health care facility priority
system, which--
``(i) shall be developed in consultation with Indian Tribes
and Tribal Organizations;
``(ii) shall give Indian Tribes' needs the highest
priority;
``(iii)(I) may include the lists required in paragraph
(2)(B)(ii); and
``(II) shall include the methodology required in paragraph
(2)(B)(v); and
``(III) may include such other facilities, and such
renovation or expansion needs of any health care facility, as
the Service, Indian Tribes, and Tribal Organizations may
identify; and

[[Page H12811]]

``(iv) shall provide an opportunity for the nomination of
planning, design, and construction projects by the Service,
Indian Tribes, and Tribal Organizations for consideration
under the priority system at least once every 3 years, or
more frequently as the Secretary determines to be
appropriate.
``(B) Needs of facilities under isdeaa agreements.--The
Secretary shall ensure that the planning, design,
construction, renovation, and expansion needs of Service and
non-Service facilities operated under contracts or compacts
in accordance with the Indian Self-Determination and
Education Assistance Act (25 U.S.C. 450 et seq.) are fully
and equitably integrated into the health care facility
priority system.
``(C) Criteria for evaluating needs.--For purposes of this
subsection, the Secretary, in evaluating the needs of
facilities operated under a contract or compact under the
Indian Self-Determination and Education Assistance Act (25
U.S.C. 450 et seq.), shall use the criteria used by the
Secretary in evaluating the needs of facilities operated
directly by the Service.
``(D) Priority of certain projects protected.--The priority
of any project established under the construction priority
system in effect on the date of enactment of the Indian
Health Care Improvement Act Amendments of 2009 shall not be
affected by any change in the construction priority system
taking place after that date if the project--
``(i) was identified in the fiscal year 2008 Service budget
justification as--

``(I) 1 of the 10 top-priority inpatient projects;
``(II) 1 of the 10 top-priority outpatient projects;
``(III) 1 of the 10 top-priority staff quarters
developments; or
``(IV) 1 of the 10 top-priority Youth Regional Treatment
Centers;

``(ii) had completed both Phase I and Phase II of the
construction priority system in effect on the date of
enactment of such Act; or
``(iii) is not included in clause (i) or (ii) and is
selected, as determined by the Secretary--

``(I) on the initiative of the Secretary; or
``(II) pursuant to a request of an Indian Tribe or Tribal
Organization.

``(2) Report; contents.--
``(A) Initial comprehensive report.--
``(i) Definitions.--In this subparagraph:

``(I) Facilities appropriation advisory board.--The term
`Facilities Appropriation Advisory Board' means the advisory
board, comprised of 12 members representing Indian tribes and
2 members representing the Service, established at the
discretion of the Assistant Secretary--

``(aa) to provide advice and recommendations for policies
and procedures of the programs funded pursuant to facilities
appropriations; and
``(bb) to address other facilities issues.

``(II) Facilities needs assessment workgroup.--The term
`Facilities Needs Assessment Workgroup' means the workgroup
established at the discretion of the Assistant Secretary--

``(aa) to review the health care facilities construction
priority system; and
``(bb) to make recommendations to the Facilities
Appropriation Advisory Board for revising the priority
system.
``(ii) Initial report.--

``(I) In general.--Not later than 1 year after the date of
enactment of the Indian Health Care Improvement Act
Amendments of 2009, the Secretary shall submit to the
Committee on Indian Affairs of the Senate and the Committee
on Natural Resources of the House of Representatives a report
that describes the comprehensive, national, ranked list of
all health care facilities needs for the Service, Indian
Tribes, and Tribal Organizations (including inpatient health
care facilities, outpatient health care facilities,
specialized health care facilities (such as for long-term
care and alcohol and drug abuse treatment), wellness centers,
staff quarters and hostels associated with health care
facilities, and the renovation and expansion needs, if any,
of such facilities) developed by the Service, Indian Tribes,
and Tribal Organizations for the Facilities Needs Assessment
Workgroup and the Facilities Appropriation Advisory Board.
``(II) Inclusions.--The initial report shall include--

``(aa) the methodology and criteria used by the Service in
determining the needs and establishing the ranking of the
facilities needs; and
``(bb) such other information as the Secretary determines
to be appropriate.
``(iii) Updates of report.--Beginning in calendar year
2011, the Secretary shall--

``(I) update the report under clause (ii) not less
frequently that once every 5 years; and
``(II) include the updated report in the appropriate annual
report under subparagraph (B) for submission to Congress
under section 801.

``(B) Annual reports.--The Secretary shall submit to the
President, for inclusion in the report required to be
transmitted to Congress under section 801, a report which
sets forth the following:
``(i) A description of the health care facility priority
system of the Service established under paragraph (1).
``(ii) Health care facilities lists, which may include--

``(I) the 10 top-priority inpatient health care facilities;
``(II) the 10 top-priority outpatient health care
facilities;
``(III) the 10 top-priority specialized health care
facilities (such as long-term care and alcohol and drug abuse
treatment);
``(IV) the 10 top-priority staff quarters developments
associated with health care facilities; and
``(V) the 10 top-priority hostels associated with health
care facilities.

``(iii) The justification for such order of priority.
``(iv) The projected cost of such projects.
``(v) The methodology adopted by the Service in
establishing priorities under its health care facility
priority system.
``(3) Requirements for preparation of reports.--In
preparing the report required under paragraph (2), the
Secretary shall--
``(A) consult with and obtain information on all health
care facilities needs from Indian Tribes, Tribal
Organizations, and urban Indian organizations; and
``(B) review the total unmet needs of all Indian Tribes,
Tribal Organizations, and urban Indian organizations for
health care facilities (including hostels and staff
quarters), including needs for renovation and expansion of
existing facilities.
``(d) Review of Methodology Used for Health Facilities
Construction Priority System.--
``(1) In general.--Not later than 1 year after the
establishment of the priority system under subsection
(c)(1)(A), the Comptroller General of the United States shall
prepare and finalize a report reviewing the methodologies
applied, and the processes followed, by the Service in making
each assessment of needs for the list under subsection
(c)(2)(A)(ii) and developing the priority system under
subsection (c)(1), including a review of--
``(A) the recommendations of the Facilities Appropriation
Advisory Board and the Facilities Needs Assessment Workgroup
(as those terms are defined in subsection (c)(2)(A)(i)); and
``(B) the relevant criteria used in ranking or prioritizing
facilities other than hospitals or clinics.
``(2) Submission to congress.--The Comptroller General of
the United States shall submit the report under paragraph (1)
to--
``(A) the Committees on Indian Affairs and Appropriations
of the Senate;
``(B) the Committees on Natural Resources and
Appropriations of the House of Representatives; and
``(C) the Secretary.
``(e) Funding Condition.--All funds appropriated under the
Act of November 2, 1921 (25 U.S.C. 13) (commonly known as the
`Snyder Act'), for the planning, design, construction, or
renovation of health facilities for the benefit of 1 or more
Indian Tribes shall be subject to the provisions of the
Indian Self-Determination and Education Assistance Act (25
U.S.C. 450 et seq.).
``(f) Development of Innovative Approaches.--The Secretary
shall consult and cooperate with Indian Tribes, Tribal
Organizations, and urban Indian organizations in developing
innovative approaches to address all or part of the total
unmet need for construction of health facilities, including
those provided for in other sections of this title and other
approaches.

``SEC. 302. SANITATION FACILITIES.

``(a) Findings.--Congress finds the following:
``(1) The provision of sanitation facilities is primarily a
health consideration and function.
``(2) Indian people suffer an inordinately high incidence
of disease, injury, and illness directly attributable to the
absence or inadequacy of sanitation facilities.
``(3) The long-term cost to the United States of treating
and curing such disease, injury, and illness is substantially
greater than the short-term cost of providing sanitation
facilities and other preventive health measures.
``(4) Many Indian homes and Indian communities still lack
sanitation facilities.
``(5) It is in the interest of the United States, and it is
the policy of the United States, that all Indian communities
and Indian homes, new and existing, be provided with
sanitation facilities.
``(b) Facilities and Services.--In furtherance of the
findings made in subsection (a), Congress reaffirms the
primary responsibility and authority of the Service to
provide the necessary sanitation facilities and services as
provided in section 7 of the Act of August 5, 1954 (42 U.S.C.
2004a). Under such authority, the Secretary, acting through
the Service, is authorized to provide the following:
``(1) Financial and technical assistance to Indian Tribes,
Tribal Organizations, and Indian communities in the
establishment, training, and equipping of utility
organizations to operate and maintain sanitation facilities,
including the provision of existing plans, standard details,
and specifications available in the Department, to be used at
the option of the Indian Tribe, Tribal Organization, or
Indian community.
``(2) Ongoing technical assistance and training to Indian
Tribes, Tribal Organizations, and Indian communities in the
management of utility organizations which operate and
maintain sanitation facilities.
``(3) Priority funding for operation and maintenance
assistance for, and emergency repairs to, sanitation
facilities operated by an Indian Tribe, Tribal Organization
or Indian community when necessary to avoid an imminent
health threat or to protect the investment in sanitation
facilities and the investment in the health benefits gained

[[Page H12812]]

through the provision of sanitation facilities.
``(c) Funding.--Notwithstanding any other provision of
law--
``(1) the Secretary of Housing and Urban Development is
authorized to transfer funds appropriated under the Native
American Housing Assistance and Self-Determination Act of
1996 (25 U.S.C. 4101 et seq.) to the Secretary of Health and
Human Services;
``(2) the Secretary of Health and Human Services is
authorized to accept and use such funds for the purpose of
providing sanitation facilities and services for Indians
under section 7 of the Act of August 5, 1954 (42 U.S.C.
2004a);
``(3) unless specifically authorized when funds are
appropriated, the Secretary shall not use funds appropriated
under section 7 of the Act of August 5, 1954 (42 U.S.C.
2004a), to provide sanitation facilities to new homes
constructed using funds provided by the Department of Housing
and Urban Development;
``(4) the Secretary of Health and Human Services is
authorized to accept from any source, including Federal and
State agencies, funds for the purpose of providing sanitation
facilities and services and place these funds into contracts
or compacts under the Indian Self-Determination and Education
Assistance Act (25 U.S.C. 450 et seq.);
``(5) except as otherwise prohibited by this section, the
Secretary may use funds appropriated under the authority of
section 7 of the Act of August 5, 1954 (42 U.S.C. 2004a), to
fund up to 100 percent of the amount of an Indian Tribe's
loan obtained under any Federal program for new projects to
construct eligible sanitation facilities to serve Indian
homes;
``(6) except as otherwise prohibited by this section, the
Secretary may use funds appropriated under the authority of
section 7 of the Act of August 5, 1954 (42 U.S.C. 2004a), to
meet matching or cost participation requirements under other
Federal and non-Federal programs for new projects to
construct eligible sanitation facilities;
``(7) all Federal agencies are authorized to transfer to
the Secretary funds identified, granted, loaned, or
appropriated whereby the Department's applicable policies,
rules, and regulations shall apply in the implementation of
such projects;
``(8) the Secretary of Health and Human Services shall
enter into interagency agreements with Federal and State
agencies for the purpose of providing financial assistance
for sanitation facilities and services under this Act;
``(9) the Secretary of Health and Human Services shall, by
regulation, establish standards applicable to the planning,
design, and construction of sanitation facilities funded
under this Act; and
``(10) the Secretary of Health and Human Services is
authorized to accept payments for goods and services
furnished by the Service from appropriate public authorities,
nonprofit organizations or agencies, or Indian Tribes, as
contributions by that authority, organization, agency, or
tribe to agreements made under section 7 of the Act of August
5, 1954 (42 U.S.C. 2004a), and such payments shall be
credited to the same or subsequent appropriation account as
funds appropriated under the authority of section 7 of the
Act of August 5, 1954 (42 U.S.C. 2004a).
``(d) Certain Capabilities Not Prerequisite.--The financial
and technical capability of an Indian Tribe, Tribal
Organization, or Indian community to safely operate, manage,
and maintain a sanitation facility shall not be a
prerequisite to the provision or construction of sanitation
facilities by the Secretary.
``(e) Financial Assistance.--The Secretary is authorized to
provide financial assistance to Indian Tribes, Tribal
Organizations, and Indian communities in an amount equal to
the Federal share of the costs of operating, managing, and
maintaining the facilities provided under the plan described
in subsection (h)(1)(F).
``(f) Operation, Management, and Maintenance of
Facilities.--The Indian Tribe has the primary responsibility
to establish, collect, and use reasonable user fees, or
otherwise set aside funding, for the purpose of operating,
managing, and maintaining sanitation facilities. If a
sanitation facility serving a community that is operated by
an Indian Tribe or Tribal Organization is threatened with
imminent failure and such operator lacks capacity to maintain
the integrity or the health benefits of the sanitation
facility, then the Secretary is authorized to assist the
Indian Tribe, Tribal Organization, or Indian community in the
resolution of the problem on a short-term basis through
cooperation with the emergency coordinator or by providing
operation, management, and maintenance service.
``(g) ISDEAA Program Funded on Equal Basis.--Tribal Health
Programs shall be eligible (on an equal basis with programs
that are administered directly by the Service) for--
``(1) any funds appropriated pursuant to this section; and
``(2) any funds appropriated for the purpose of providing
sanitation facilities.
``(h) Report.--
``(1) Required; contents.--The Secretary, in consultation
with the Secretary of Housing and Urban Development, Indian
Tribes, Tribal Organizations, and tribally designated housing
entities (as defined in section 4 of the Native American
Housing Assistance and Self-Determination Act of 1996 (25
U.S.C. 4103)) shall submit to the President, for inclusion in
the report required to be transmitted to Congress under
section 801, a report which sets forth--
``(A) the current Indian sanitation facility priority
system of the Service;
``(B) the methodology for determining sanitation
deficiencies and needs;
``(C) the criteria on which the deficiencies and needs will
be evaluated;
``(D) the level of initial and final sanitation deficiency
for each type of sanitation facility for each project of each
Indian Tribe or Indian community;
``(E) the amount and most effective use of funds, derived
from whatever source, necessary to accommodate the sanitation
facilities needs of new homes assisted with funds under the
Native American Housing Assistance and Self-Determination Act
(25 U.S.C. 4101 et seq.), and to reduce the identified
sanitation deficiency levels of all Indian Tribes and Indian
communities to level I sanitation deficiency as defined in
paragraph (3)(A); and
``(F) a 10-year plan to provide sanitation facilities to
serve existing Indian homes and Indian communities and new
and renovated Indian homes.
``(2) Uniform methodology.--The methodology used by the
Secretary in determining, preparing cost estimates for, and
reporting sanitation deficiencies for purposes of paragraph
(1) shall be applied uniformly to all Indian Tribes and
Indian communities.
``(3) Sanitation deficiency levels.--For purposes of this
subsection, the sanitation deficiency levels for an
individual, Indian Tribe, or Indian community sanitation
facility to serve Indian homes are determined as follows:
``(A) A level I deficiency exists if a sanitation facility
serving an individual, Indian Tribe, or Indian community--
``(i) complies with all applicable water supply, pollution
control, and solid waste disposal laws; and
``(ii) deficiencies relate to routine replacement, repair,
or maintenance needs.
``(B) A level II deficiency exists if a sanitation facility
serving an individual, Indian Tribe, or Indian community
substantially or recently complied with all applicable water
supply, pollution control, and solid waste laws and any
deficiencies relate to--
``(i) small or minor capital improvements needed to bring
the facility back into compliance;
``(ii) capital improvements that are necessary to enlarge
or improve the facilities in order to meet the current needs
for domestic sanitation facilities; or
``(iii) the lack of equipment or training by an Indian
Tribe, Tribal Organization, or an Indian community to
properly operate and maintain the sanitation facilities.
``(C) A level III deficiency exists if a sanitation
facility serving an individual, Indian Tribe or Indian
community meets 1 or more of the following conditions--
``(i) water or sewer service in the home is provided by a
haul system with holding tanks and interior plumbing;
``(ii) major significant interruptions to water supply or
sewage disposal occur frequently, requiring major capital
improvements to correct the deficiencies; or
``(iii) there is no access to or no approved or permitted
solid waste facility available.
``(D) A level IV deficiency exists--
``(i) if a sanitation facility for an individual home, an
Indian Tribe, or an Indian community exists but--

``(I) lacks--

``(aa) a safe water supply system; or
``(bb) a waste disposal system;

``(II) contains no piped water or sewer facilities; or
``(III) has become inoperable due to a major component
failure; or

``(ii) if only a washeteria or central facility exists in
the community.
``(E) A level V deficiency exists in the absence of a
sanitation facility, where individual homes do not have
access to safe drinking water or adequate wastewater
(including sewage) disposal.
``(i) Definitions.--For purposes of this section, the
following terms apply:
``(1) Indian community.--The term `Indian community' means
a geographic area, a significant proportion of whose
inhabitants are Indians and which is served by or capable of
being served by a facility described in this section.
``(2) Sanitation facilities.--The terms `sanitation
facility' and `sanitation facilities' mean safe and adequate
water supply systems, sanitary sewage disposal systems, and
sanitary solid waste systems (and all related equipment and
support infrastructure).

``SEC. 303. PREFERENCE TO INDIANS AND INDIAN FIRMS.

``(a) Buy Indian Act.--The Secretary, acting through the
Service, may use the negotiating authority of section 23 of
the Act of June 25, 1910 (25 U.S.C. 47, commonly known as the
`Buy Indian Act'), to give preference to any Indian or any
enterprise, partnership, corporation, or other type of
business organization owned and controlled by an Indian or
Indians including former or currently federally recognized
Indian Tribes in the State of New York (hereinafter referred
to as an `Indian firm') in the construction and renovation of
Service facilities pursuant to section 301 and in the
construction of sanitation facilities pursuant to section
302. Such preference may be accorded by the Secretary unless
the Secretary finds, pursuant to regulations, that the
project or function to be contracted for will not be
satisfactory or such

[[Page H12813]]

project or function cannot be properly completed or
maintained under the proposed contract. The Secretary, in
arriving at such a finding, shall consider whether the Indian
or Indian firm will be deficient with respect to--
``(1) ownership and control by Indians;
``(2) equipment;
``(3) bookkeeping and accounting procedures;
``(4) substantive knowledge of the project or function to
be contracted for;
``(5) adequately trained personnel; or
``(6) other necessary components of contract performance.
``(b) Pay Rates.--For the purposes of implementing the
provisions of this title, the Secretary shall assure that the
rates of pay for personnel engaged in the construction or
renovation of facilities constructed or renovated in whole or
in part by funds made available pursuant to this title are
not less than the prevailing local wage rates for similar
work as determined in accordance with the Act of March 3,
1931 (40 U.S.C. 276a-276a-5, known as the Davis-Bacon Act).
``(c) Labor Standards.--For the purposes of implementing
the provisions of this title, contracts for the construction
or renovation of health care facilities, staff quarters, and
sanitation facilities, and related support infrastructure,
funded in whole or in part with funds made available pursuant
to this title, shall contain a provision requiring compliance
with subchapter IV of chapter 31 of title 40, United States
Code (commonly known as the `Davis-Bacon Act').

``SEC. 304. EXPENDITURE OF NON-SERVICE FUNDS FOR RENOVATION.

``(a) In General.--Notwithstanding any other provision of
law, if the requirements of subsection (c) are met, the
Secretary, acting through the Service, is authorized to
accept any major expansion, renovation, or modernization by
any Indian Tribe or Tribal Organization of any Service
facility or of any other Indian health facility operated
pursuant to a contract or compact under the Indian Self-
Determination and Education Assistance Act (25 U.S.C. 450 et
seq.), including--
``(1) any plans or designs for such expansion, renovation,
or modernization; and
``(2) any expansion, renovation, or modernization for which
funds appropriated under any Federal law were lawfully
expended.
``(b) Priority List.--
``(1) In general.--The Secretary shall maintain a separate
priority list to address the needs for increased operating
expenses, personnel, or equipment for such facilities. The
methodology for establishing priorities shall be developed
through regulations. The list of priority facilities will be
revised annually in consultation with Indian Tribes and
Tribal Organizations.
``(2) Report.--The Secretary shall submit to the President,
for inclusion in the report required to be transmitted to
Congress under section 801, the priority list maintained
pursuant to paragraph (1).
``(c) Requirements.--The requirements of this subsection
are met with respect to any expansion, renovation, or
modernization if--
``(1) the Indian Tribe or Tribal Organization--
``(A) provides notice to the Secretary of its intent to
expand, renovate, or modernize; and
``(B) applies to the Secretary to be placed on a separate
priority list to address the needs of such new facilities for
increased operating expenses, personnel, or equipment; and
``(2) the expansion, renovation, or modernization--
``(A) is approved by the appropriate area director of the
Service for Federal facilities; and
``(B) is administered by the Indian Tribe or Tribal
Organization in accordance with any applicable regulations
prescribed by the Secretary with respect to construction or
renovation of Service facilities.
``(d) Additional Requirement for Expansion.--In addition to
the requirements under subsection (c), for any expansion, the
Indian Tribe or Tribal Organization shall provide to the
Secretary additional information pursuant to regulations,
including additional staffing, equipment, and other costs
associated with the expansion.
``(e) Closure or Conversion of Facilities.--If any Service
facility which has been expanded, renovated, or modernized by
an Indian Tribe or Tribal Organization under this section
ceases to be used as a Service facility during the 20-year
period beginning on the date such expansion, renovation, or
modernization is completed, such Indian Tribe or Tribal
Organization shall be entitled to recover from the United
States an amount which bears the same ratio to the value of
such facility at the time of such cessation as the value of
such expansion, renovation, or modernization (less the total
amount of any funds provided specifically for such facility
under any Federal program that were expended for such
expansion, renovation, or modernization) bore to the value of
such facility at the time of the completion of such
expansion, renovation, or modernization.

``SEC. 305. FUNDING FOR THE CONSTRUCTION, EXPANSION, AND
MODERNIZATION OF SMALL AMBULATORY CARE
FACILITIES.

``(a) Grants.--
``(1) In general.--The Secretary, acting through the
Service, shall make grants to Indian Tribes and Tribal
Organizations for the construction, expansion, or
modernization of facilities for the provision of ambulatory
care services to eligible Indians (and noneligible persons
pursuant to subsections (b)(2) and (c)(1)(C)). A grant made
under this section may cover up to 100 percent of the costs
of such construction, expansion, or modernization. For the
purposes of this section, the term `construction' includes
the replacement of an existing facility.
``(2) Grant agreement required.--A grant under paragraph
(1) may only be made available to a Tribal Health Program
operating an Indian health facility (other than a facility
owned or constructed by the Service, including a facility
originally owned or constructed by the Service and
transferred to an Indian Tribe or Tribal Organization).
``(b) Use of Grant Funds.--
``(1) Allowable uses.--A grant awarded under this section
may be used for the construction, expansion, or modernization
(including the planning and design of such construction,
expansion, or modernization) of an ambulatory care facility--
``(A) located apart from a hospital;
``(B) not funded under section 301 or section 306; and
``(C) which, upon completion of such construction or
modernization will--
``(i) have a total capacity appropriate to its projected
service population;
``(ii) provide annually no fewer than 150 patient visits by
eligible Indians and other users who are eligible for
services in such facility in accordance with section
806(c)(2); and
``(iii) provide ambulatory care in a Service Area
(specified in the contract or compact under the Indian Self-
Determination and Education Assistance Act (25 U.S.C. 450 et
seq.)) with a population of no fewer than 1,500 eligible
Indians and other users who are eligible for services in such
facility in accordance with section 806(c)(2).
``(2) Additional allowable use.--The Secretary may also
reserve a portion of the funding provided under this section
and use those reserved funds to reduce an outstanding debt
incurred by Indian Tribes or Tribal Organizations for the
construction, expansion, or modernization of an ambulatory
care facility that meets the requirements under paragraph
(1). The provisions of this section shall apply, except that
such applications for funding under this paragraph shall be
considered separately from applications for funding under
paragraph (1).
``(3) Use only for certain portion of costs.--A grant
provided under this section may be used only for the cost of
that portion of a construction, expansion, or modernization
project that benefits the Service population identified above
in subsection (b)(1)(C) (ii) and (iii). The requirements of
clauses (ii) and (iii) of paragraph (1)(C) shall not apply to
an Indian Tribe or Tribal Organization applying for a grant
under this section for a health care facility located or to
be constructed on an island or when such facility is not
located on a road system providing direct access to an
inpatient hospital where care is available to the Service
population.
``(c) Grants.--
``(1) Application.--No grant may be made under this section
unless an application or proposal for the grant has been
approved by the Secretary in accordance with applicable
regulations and has set forth reasonable assurance by the
applicant that, at all times after the construction,
expansion, or modernization of a facility carried out using a
grant received under this section--
``(A) adequate financial support will be available for the
provision of services at such facility;
``(B) such facility will be available to eligible Indians
without regard to ability to pay or source of payment; and
``(C) such facility will, as feasible without diminishing
the quality or quantity of services provided to eligible
Indians, serve noneligible persons on a cost basis.
``(2) Priority.--In awarding grants under this section, the
Secretary shall give priority to Indian Tribes and Tribal
Organizations that demonstrate--
``(A) a need for increased ambulatory care services; and
``(B) insufficient capacity to deliver such services.
``(3) Peer review panels.--The Secretary may provide for
the establishment of peer review panels, as necessary, to
review and evaluate applications and proposals and to advise
the Secretary regarding such applications using the criteria
developed pursuant to subsection (a)(1).
``(d) Reversion of Facilities.--If any facility (or portion
thereof) with respect to which funds have been paid under
this section, ceases, at any time after completion of the
construction, expansion, or modernization carried out with
such funds, to be used for the purposes of providing health
care services to eligible Indians, all of the right, title,
and interest in and to such facility (or portion thereof)
shall transfer to the United States unless otherwise
negotiated by the Service and the Indian Tribe or Tribal
Organization.
``(e) Funding Nonrecurring.--Funding provided under this
section shall be nonrecurring and shall not be available for
inclusion in any individual Indian Tribe's tribal share for
an award under the Indian Self-Determination and Education
Assistance Act (25 U.S.C. 450 et seq.) or for reallocation or
redesign thereunder.

``SEC. 306. INDIAN HEALTH CARE DELIVERY DEMONSTRATION
PROJECT.

``(a) Health Care Demonstration Projects.--The Secretary,
acting through

[[Page H12814]]

the Service, is authorized to make grants to, and enter into
construction contracts or construction project agreements
with, Indian Tribes or Tribal Organizations under the Indian
Self-Determination and Education Assistance Act (25 U.S.C.
450 et seq.) for the purpose of carrying out a health care
delivery demonstration project to test alternative means of
delivering health care and services to Indians through
facilities.
``(b) Use of Funds.--The Secretary, in approving projects
pursuant to this section, may authorize such contracts for
the construction and renovation of hospitals, health centers,
health stations, and other facilities to deliver health care
services and is authorized to--
``(1) waive any leasing prohibition;
``(2) permit carryover of funds appropriated for the
provision of health care services;
``(3) permit the use of other available funds;
``(4) permit the use of funds or property donated from any
source for project purposes;
``(5) provide for the reversion of donated real or personal
property to the donor; and
``(6) permit the use of Service funds to match other funds,
including Federal funds.
``(c) Regulations.--The Secretary shall develop and
promulgate regulations, not later than 1 year after the date
of enactment of the Indian Health Care Improvement Act
Amendments of 2009, for the review and approval of
applications submitted under this section.
``(d) Criteria.--The Secretary may approve projects that
meet the following criteria:
``(1) There is a need for a new facility or program or the
reorientation of an existing facility or program.
``(2) A significant number of Indians, including those with
low health status, will be served by the project.
``(3) The project has the potential to deliver services in
an efficient and effective manner.
``(4) The project is economically viable.
``(5) The Indian Tribe or Tribal Organization has the
administrative and financial capability to administer the
project.
``(6) The project is integrated with providers of related
health and social services and is coordinated with, and
avoids duplication of, existing services.
``(e) Peer Review Panels.--The Secretary may provide for
the establishment of peer review panels, as necessary, to
review and evaluate applications using the criteria developed
pursuant to subsection (d).
``(f) Priority.--The Secretary shall give priority to
applications for demonstration projects in each of the
following Service Units to the extent that such applications
are timely filed and meet the criteria specified in
subsection (d):
``(1) Cass Lake, Minnesota.
``(2) Mescalero, New Mexico.
``(3) Owyhee, Nevada.
``(4) Schurz, Nevada.
``(5) Ft. Yuma, California.
``(g) Technical Assistance.--The Secretary shall provide
such technical and other assistance as may be necessary to
enable applicants to comply with the provisions of this
section.
``(h) Service to Ineligible Persons.--Subject to section
806, the authority to provide services to persons otherwise
ineligible for the health care benefits of the Service and
the authority to extend hospital privileges in Service
facilities to non-Service health practitioners as provided in
section 806 may be included, subject to the terms of such
section, in any demonstration project approved pursuant to
this section.
``(i) Equitable Treatment.--For purposes of subsection
(d)(1), the Secretary shall, in evaluating facilities
operated under any contract or compact under the Indian Self-
Determination and Education Assistance Act (25 U.S.C. 450 et
seq.), use the same criteria that the Secretary uses in
evaluating facilities operated directly by the Service.
``(j) Equitable Integration of Facilities.--The Secretary
shall ensure that the planning, design, construction,
renovation, and expansion needs of Service and non-Service
facilities which are the subject of a contract or compact
under the Indian Self-Determination and Education Assistance
Act (25 U.S.C. 450 et seq.) for health services are fully and
equitably integrated into the implementation of the health
care delivery demonstration projects under this section.

``SEC. 307. LAND TRANSFER.

``Notwithstanding any other provision of law, the Bureau of
Indian Affairs and all other agencies and departments of the
United States are authorized to transfer, at no cost, land
and improvements to the Service for the provision of health
care services. The Secretary is authorized to accept such
land and improvements for such purposes.

``SEC. 308. LEASES, CONTRACTS, AND OTHER AGREEMENTS.

``The Secretary, acting through the Service, may enter into
leases, contracts, and other agreements with Indian Tribes
and Tribal Organizations which hold (1) title to, (2) a
leasehold interest in, or (3) a beneficial interest in (when
title is held by the United States in trust for the benefit
of an Indian Tribe) facilities used or to be used for the
administration and delivery of health services by an Indian
Health Program. Such leases, contracts, or agreements may
include provisions for construction or renovation and provide
for compensation to the Indian Tribe or Tribal Organization
of rental and other costs consistent with section 105(l) of
the Indian Self-Determination and Education Assistance Act
(25 U.S.C. 450j(l)) and regulations thereunder.

``SEC. 309. STUDY ON LOANS, LOAN GUARANTEES, AND LOAN
REPAYMENT.

``(a) In General.--The Secretary, in consultation with the
Secretary of the Treasury, Indian Tribes, and Tribal
Organizations, shall carry out a study to determine the
feasibility of establishing a loan fund to provide to Indian
Tribes and Tribal Organizations direct loans or guarantees
for loans for the construction of health care facilities,
including--
``(1) inpatient facilities;
``(2) outpatient facilities;
``(3) staff quarters;
``(4) hostels; and
``(5) specialized care facilities, such as behavioral
health and elder care facilities.
``(b) Determinations.--In carrying out the study under
subsection (a), the Secretary shall determine--
``(1) the maximum principal amount of a loan or loan
guarantee that should be offered to a recipient from the loan
fund;
``(2) the percentage of eligible costs, not to exceed 100
percent, that may be covered by a loan or loan guarantee from
the loan fund (including costs relating to planning, design,
financing, site land development, construction,
rehabilitation, renovation, conversion, improvements, medical
equipment and furnishings, and other facility-related costs
and capital purchase (but excluding staffing));
``(3) the cumulative total of the principal of direct loans
and loan guarantees, respectively, that may be outstanding at
any 1 time;
``(4) the maximum term of a loan or loan guarantee that may
be made for a facility from the loan fund;
``(5) the maximum percentage of funds from the loan fund
that should be allocated for payment of costs associated with
planning and applying for a loan or loan guarantee;
``(6) whether acceptance by the Secretary of an assignment
of the revenue of an Indian Tribe or Tribal Organization as
security for any direct loan or loan guarantee from the loan
fund would be appropriate;
``(7) whether, in the planning and design of health
facilities under this section, users eligible under section
806(c) may be included in any projection of patient
population;
``(8) whether funds of the Service provided through loans
or loan guarantees from the loan fund should be eligible for
use in matching other Federal funds under other programs;
``(9) the appropriateness of, and best methods for,
coordinating the loan fund with the health care priority
system of the Service under section 301; and
``(10) any legislative or regulatory changes required to
implement recommendations of the Secretary based on results
of the study.
``(c) Report.--Not later than September 30, 2010, the
Secretary shall submit to the Committee on Indian Affairs of
the Senate and the Committee on Natural Resources and the
Committee on Energy and Commerce of the House of
Representatives a report that describes--
``(1) the manner of consultation made as required by
subsection (a); and
``(2) the results of the study, including any
recommendations of the Secretary based on results of the
study.

``SEC. 310. TRIBAL LEASING.

``A Tribal Health Program may lease permanent structures
for the purpose of providing health care services without
obtaining advance approval in appropriation Acts.

``SEC. 311. INDIAN HEALTH SERVICE/TRIBAL FACILITIES JOINT
VENTURE PROGRAM.

``(a) In General.--The Secretary, acting through the
Service, shall make arrangements with Indian Tribes and
Tribal Organizations to establish joint venture demonstration
projects under which an Indian Tribe or Tribal Organization
shall expend tribal, private, or other available funds, for
the acquisition or construction of a health facility for a
minimum of 10 years, under a no-cost lease, in exchange for
agreement by the Service to provide the equipment, supplies,
and staffing for the operation and maintenance of such a
health facility. An Indian Tribe or Tribal Organization may
use tribal funds, private sector, or other available
resources, including loan guarantees, to fulfill its
commitment under a joint venture entered into under this
subsection. An Indian Tribe or Tribal Organization shall be
eligible to establish a joint venture project if, when it
submits a letter of intent, it--
``(1) has begun but not completed the process of
acquisition or construction of a health facility to be used
in the joint venture project;
``(2) has not begun the process of acquisition or
construction of a health facility for use in the joint
venture project; or
``(3) in its application for a joint venture agreement,
agrees--
``(A) to construct a facility for the joint venture which
complies with the size and space criteria established by the
Service; or
``(B) if the facility it proposes for the joint venture is
already in existence or under construction, that only the
portion of such facility which complies with the size and
space criteria of the Service will be eligible for the joint
venture agreement.
``(b) Requirements.--The Secretary shall make such an
arrangement with an Indian Tribe or Tribal Organization only
if--
``(1) the Secretary first determines that the Indian Tribe
or Tribal Organization has

[[Page H12815]]

the administrative and financial capabilities necessary to
complete the timely acquisition or construction of the
relevant health facility; and
``(2) the Indian Tribe or Tribal Organization meets the
need criteria determined using the criteria developed under
the health care facility priority system under section 301,
unless the Secretary determines, pursuant to regulations,
that other criteria will result in a more cost-effective and
efficient method of facilitating and completing construction
of health care facilities.
``(c) Continued Operation.--The Secretary shall negotiate
an agreement with the Indian Tribe or Tribal Organization
regarding the continued operation of the facility at the end
of the initial 10 year no-cost lease period.
``(d) Breach of Agreement.--An Indian Tribe or Tribal
Organization that has entered into a written agreement with
the Secretary under this section, and that breaches or
terminates without cause such agreement, shall be liable to
the United States for the amount that has been paid to the
Indian Tribe or Tribal Organization, or paid to a third party
on the Indian Tribe's or Tribal Organization's behalf, under
the agreement. The Secretary has the right to recover
tangible property (including supplies) and equipment, less
depreciation, and any funds expended for operations and
maintenance under this section. The preceding sentence does
not apply to any funds expended for the delivery of health
care services, personnel, or staffing.
``(e) Recovery for Nonuse.--An Indian Tribe or Tribal
Organization that has entered into a written agreement with
the Secretary under this subsection shall be entitled to
recover from the United States an amount that is proportional
to the value of such facility if, at any time within the 10-
year term of the agreement, the Service ceases to use the
facility or otherwise breaches the agreement.
``(f) Definition.--For the purposes of this section, the
term `health facility' or `health facilities' includes
quarters needed to provide housing for staff of the relevant
Tribal Health Program.

``SEC. 312. LOCATION OF FACILITIES.

``(a) In General.--In all matters involving the
reorganization or development of Service facilities or in the
establishment of related employment projects to address
unemployment conditions in economically depressed areas, the
Bureau of Indian Affairs and the Service shall give priority
to locating such facilities and projects on Indian lands, or
lands in Alaska owned by any Alaska Native village, or
village or regional corporation under the Alaska Native
Claims Settlement Act (43 U.S.C. 1601 et seq.), or any land
allotted to any Alaska Native, if requested by the Indian
owner and the Indian Tribe with jurisdiction over such lands
or other lands owned or leased by the Indian Tribe or Tribal
Organization. Top priority shall be given to Indian land
owned by 1 or more Indian Tribes.
``(b) Definition.--For purposes of this section, the term
`Indian lands' means--
``(1) all lands within the exterior boundaries of any
reservation; and
``(2) any lands title to which is held in trust by the
United States for the benefit of any Indian Tribe or
individual Indian or held by any Indian Tribe or individual
Indian subject to restriction by the United States against
alienation.

``SEC. 313. MAINTENANCE AND IMPROVEMENT OF HEALTH CARE
FACILITIES.

``(a) Report.--The Secretary shall submit to the President,
for inclusion in the report required to be transmitted to
Congress under section 801, a report which identifies the
backlog of maintenance and repair work required at both
Service and tribal health care facilities, including new
health care facilities expected to be in operation in the
next fiscal year. The report shall also identify the need for
renovation and expansion of existing facilities to support
the growth of health care programs.
``(b) Maintenance of Newly Constructed Space.--The
Secretary, acting through the Service, is authorized to
expend maintenance and improvement funds to support
maintenance of newly constructed space only if such space
falls within the approved supportable space allocation for
the Indian Tribe or Tribal Organization. Supportable space
allocation shall be defined through the health care facility
priority system under section 301(c).
``(c) Replacement Facilities.--In addition to using
maintenance and improvement funds for renovation,
modernization, and expansion of facilities, an Indian Tribe
or Tribal Organization may use maintenance and improvement
funds for construction of a replacement facility if the costs
of renovation of such facility would exceed a maximum
renovation cost threshold. The Secretary shall consult with
Indian Tribes and Tribal Organizations in determining the
maximum renovation cost threshold.

``SEC. 314. TRIBAL MANAGEMENT OF FEDERALLY OWNED QUARTERS.

``(a) Rental Rates.--
``(1) Establishment.--Notwithstanding any other provision
of law, a Tribal Health Program which operates a hospital or
other health facility and the federally owned quarters
associated therewith pursuant to a contract or compact under
the Indian Self-Determination and Education Assistance Act
(25 U.S.C. 450 et seq.) shall have the authority to establish
the rental rates charged to the occupants of such quarters by
providing notice to the Secretary of its election to exercise
such authority.
``(2) Objectives.--In establishing rental rates pursuant to
authority of this subsection, a Tribal Health Program shall
endeavor to achieve the following objectives:
``(A) To base such rental rates on the reasonable value of
the quarters to the occupants thereof.
``(B) To generate sufficient funds to prudently provide for
the operation and maintenance of the quarters, and subject to
the discretion of the Tribal Health Program, to supply
reserve funds for capital repairs and replacement of the
quarters.
``(3) Equitable funding.--Any quarters whose rental rates
are established by a Tribal Health Program pursuant to this
subsection shall remain eligible for quarters improvement and
repair funds to the same extent as all federally owned
quarters used to house personnel in Services-supported
programs.
``(4) Notice of rate change.--A Tribal Health Program which
exercises the authority provided under this subsection shall
provide occupants with no less than 60 days notice of any
change in rental rates.
``(b) Direct Collection of Rent.--
``(1) In general.--Notwithstanding any other provision of
law, and subject to paragraph (2), a Tribal Health Program
shall have the authority to collect rents directly from
Federal employees who occupy such quarters in accordance with
the following:
``(A) The Tribal Health Program shall notify the Secretary
and the subject Federal employees of its election to exercise
its authority to collect rents directly from such Federal
employees.
``(B) Upon receipt of a notice described in subparagraph
(A), the Federal employees shall pay rents for occupancy of
such quarters directly to the Tribal Health Program and the
Secretary shall have no further authority to collect rents
from such employees through payroll deduction or otherwise.
``(C) Such rent payments shall be retained by the Tribal
Health Program and shall not be made payable to or otherwise
be deposited with the United States.
``(D) Such rent payments shall be deposited into a separate
account which shall be used by the Tribal Health Program for
the maintenance (including capital repairs and replacement)
and operation of the quarters and facilities as the Tribal
Health Program shall determine.
``(2) Retrocession of authority.--If a Tribal Health
Program which has made an election under paragraph (1)
requests retrocession of its authority to directly collect
rents from Federal employees occupying federally owned
quarters, such retrocession shall become effective on the
earlier of--
``(A) the first day of the month that begins no less than
180 days after the Tribal Health Program notifies the
Secretary of its desire to retrocede; or
``(B) such other date as may be mutually agreed by the
Secretary and the Tribal Health Program.
``(c) Rates in Alaska.--To the extent that a Tribal Health
Program, pursuant to authority granted in subsection (a),
establishes rental rates for federally owned quarters
provided to a Federal employee in Alaska, such rents may be
based on the cost of comparable private rental housing in the
nearest established community with a year-round population of
1,500 or more individuals.

``SEC. 315. APPLICABILITY OF BUY AMERICAN ACT REQUIREMENT.

``(a) Applicability.--The Secretary shall ensure that the
requirements of the Buy American Act apply to all
procurements made with funds provided pursuant to section
317. Indian Tribes and Tribal Organizations shall be exempt
from these requirements.
``(b) Effect of Violation.--If it has been finally
determined by a court or Federal agency that any person
intentionally affixed a label bearing a `Made in America'
inscription or any inscription with the same meaning, to any
product sold in or shipped to the United States that is not
made in the United States, such person shall be ineligible to
receive any contract or subcontract made with funds provided
pursuant to section 317, pursuant to the debarment,
suspension, and ineligibility procedures described in
sections 9.400 through 9.409 of title 48, Code of Federal
Regulations.
``(c) Definitions.--For purposes of this section, the term
`Buy American Act' means title III of the Act entitled `An
Act making appropriations for the Treasury and Post Office
Departments for the fiscal year ending June 30, 1934, and for
other purposes', approved March 3, 1933 (41 U.S.C. 10a et
seq.).

``SEC. 316. OTHER FUNDING FOR FACILITIES.

``(a) Authority To Accept Funds.--The Secretary is
authorized to accept from any source, including Federal and
State agencies, funds that are available for the construction
of health care facilities and use such funds to plan, design,
and construct health care facilities for Indians and to place
such funds into a contract or compact under the Indian Self-
Determination and Education Assistance Act (25 U.S.C. 450 et
seq.). Receipt of such funds shall have no effect on the
priorities established pursuant to section 301.
``(b) Interagency Agreements.--The Secretary is authorized
to enter into interagency agreements with other Federal
agencies or State agencies and other entities and to accept
funds from such Federal or State agencies or other sources to
provide for the

[[Page H12816]]

planning, design, and construction of health care facilities
to be administered by Indian Health Programs in order to
carry out the purposes of this Act and the purposes for which
the funds were appropriated or for which the funds were
otherwise provided.
``(c) Transferred Funds.--Any Federal agency to which funds
for the construction of health care facilities are
appropriated is authorized to transfer such funds to the
Secretary for the construction of health care facilities to
carry out the purposes of this Act as well as the purposes
for which such funds are appropriated to such other Federal
agency.
``(d) Establishment of Standards.--The Secretary, through
the Service, shall establish standards by regulation for the
planning, design, and construction of health care facilities
serving Indians under this Act.

``SEC. 317. AUTHORIZATION OF APPROPRIATIONS.

``There are authorized to be appropriated such sums as may
be necessary to carry out this title.

``TITLE IV--ACCESS TO HEALTH SERVICES

``SEC. 401. TREATMENT OF PAYMENTS UNDER SOCIAL SECURITY ACT
HEALTH BENEFITS PROGRAMS.

``(a) Disregard of Medicare, Medicaid, and SCHIP Payments
in Determining Appropriations.--Any payments received by an
Indian Health Program or by an urban Indian organization
under title XVIII, XIX, or XXI of the Social Security Act for
services provided to Indians eligible for benefits under such
respective titles shall not be considered in determining
appropriations for the provision of health care and services
to Indians.
``(b) Nonpreferential Treatment.--Nothing in this Act
authorizes the Secretary to provide services to an Indian
with coverage under title XVIII, XIX, or XXI of the Social
Security Act in preference to an Indian without such
coverage.
``(c) Use of Funds.--
``(1) Special fund.--
``(A) 100 percent pass-through of payments due to
facilities.--Notwithstanding any other provision of law, but
subject to paragraph (2), payments to which a facility of the
Service is entitled by reason of a provision of title XVIII
or XIX of the Social Security Act shall be placed in a
special fund to be held by the Secretary. In making payments
from such fund, the Secretary shall ensure that each Service
Unit of the Service receives 100 percent of the amount to
which the facilities of the Service, for which such Service
Unit makes collections, are entitled by reason of a provision
of either such title.
``(B) Use of funds.--Amounts received by a facility of the
Service under subparagraph (A) by reason of a provision of
title XVIII or XIX of the Social Security Act shall first be
used (to such extent or in such amounts as are provided in
appropriation Acts) for the purpose of making any
improvements in the programs of the Service operated by or
through such facility which may be necessary to achieve or
maintain compliance with the applicable conditions and
requirements of such respective title. Any amounts so
received that are in excess of the amount necessary to
achieve or maintain such conditions and requirements shall,
subject to consultation with the Indian Tribes being served
by the Service Unit, be used for increasing the facility's
capacity to provide, or improving the quality or
accessibility of, services.
``(2) Direct payment option.--Paragraph (1) shall not apply
to a Tribal Health Program upon the election of such Program
under subsection (d) to receive payments directly. No payment
may be made out of the special fund described in such
paragraph with respect to reimbursement made for services
provided by such Program during the period of such election.
``(d) Direct Billing.--
``(1) In general.--Subject to complying with the
requirements of paragraph (2), a Tribal Health Program may
elect to directly bill for, and receive payment for, health
care items and services provided by such Program for which
payment is made under title XVIII, XIX, or XXI of the Social
Security Act.
``(2) Direct reimbursement.--
``(A) Use of funds.--Each Tribal Health Program making the
election described in paragraph (1) with respect to a program
under title XVIII, XIX, or XXI of the Social Security Act
shall be reimbursed directly by that program for items and
services furnished without regard to subsection (c)(1), but
all amounts so reimbursed shall be used by the Tribal Health
Program for the same purposes with respect to such Program
for which payment under subparagraph (A) of subsection (c)(1)
to a facility of the Service may be used pursuant to
subparagraph (B) of such subsection with respect to the
Service.
``(B) Audits.--The amounts paid to a Tribal Health Program
making the election described in paragraph (1) with respect
to a program under title XVIII, XIX, or XXI of the Social
Security Act shall be subject to all auditing requirements
applicable to the program under such title, as well as all
auditing requirements applicable to programs administered by
an Indian Health Program. Nothing in the preceding sentence
shall be construed as limiting the application of auditing
requirements applicable to amounts paid under title XVIII,
XIX, or XXI of the Social Security Act.
``(C) Identification of source of payments.--Any Tribal
Health Program that receives reimbursements or payments under
title XVIII, XIX, or XXI of the Social Security Act shall
provide to the Service a list of each provider enrollment
number (or other identifier) under which such Program
receives such reimbursements or payments.
``(3) Examination and implementation of changes.--
``(A) In general.--The Secretary, acting through the
Service and with the assistance of the Administrator of the
Centers for Medicare & Medicaid Services, shall examine on an
ongoing basis and implement any administrative changes that
may be necessary to facilitate direct billing and
reimbursement under the program established under this
subsection, including any agreements with States that may be
necessary to provide for direct billing under a program under
title XIX or XXI of the Social Security Act.
``(B) Coordination of information.--The Service shall
provide the Administrator of the Centers for Medicare &
Medicaid Services with copies of the lists submitted to the
Service under paragraph (2)(C), enrollment data regarding
patients served by the Service (and by Tribal Health
Programs, to the extent such data is available to the
Service), and such other information as the Administrator may
require for purposes of administering title XVIII, XIX, or
XXI of the Social Security Act.
``(4) Withdrawal from program.--A Tribal Health Program
that bills directly under the program established under this
subsection may withdraw from participation in the same manner
and under the same conditions that an Indian Tribe or Tribal
Organization may retrocede a contracted program to the
Secretary under the authority of the Indian Self-
Determination and Education Assistance Act (25 U.S.C. 450 et
seq.). All cost accounting and billing authority under the
program established under this subsection shall be returned
to the Secretary upon the Secretary's acceptance of the
withdrawal of participation in this program.
``(5) Termination for failure to comply with
requirements.--The Secretary may terminate the participation
of a Tribal Health Program or in the direct billing program
established under this subsection if the Secretary determines
that the Program has failed to comply with the requirements
of paragraph (2). The Secretary shall provide a Tribal Health
Program with notice of a determination that the Program has
failed to comply with any such requirement and a reasonable
opportunity to correct such noncompliance prior to
terminating the Program's participation in the direct billing
program established under this subsection.
``(e) Related Provisions Under the Social Security Act.--
For provisions related to subsections (c) and (d), see
sections 1880, 1911, and 2107(e)(1)(D) of the Social Security
Act.

``SEC. 402. GRANTS TO AND CONTRACTS WITH THE SERVICE, INDIAN
TRIBES, TRIBAL ORGANIZATIONS, AND URBAN INDIAN
ORGANIZATIONS TO FACILITATE OUTREACH,
ENROLLMENT, AND COVERAGE OF INDIANS UNDER
SOCIAL SECURITY ACT HEALTH BENEFIT PROGRAMS.

``(a) Indian Tribes and Tribal Organizations.--The
Secretary, acting through the Service, shall make grants to
or enter into contracts with Indian Tribes and Tribal
Organizations to assist such Tribes and Tribal Organizations
in establishing and administering programs on or near
reservations, trust lands, and Alaska Native Villages,
including programs to provide outreach and enrollment through
video, electronic delivery methods, or telecommunication
devices that allow real-time or time-delayed communication
between individual Indians and the benefit program, to assist
individual Indians--
``(1) to enroll for benefits under a program established
under title XVIII, XIX, or XXI of the Social Security Act;
and
``(2) with respect to such programs for which the charging
of premiums and cost sharing is not prohibited under such
programs, to pay premiums or cost sharing for coverage for
such benefits, which may be based on financial need (as
determined by the Indian Tribe or Tribes or Tribal
Organizations being served based on a schedule of income
levels developed or implemented by such Tribe, Tribes, or
Tribal Organizations).
``(b) Conditions.--The Secretary, acting through the
Service, shall place conditions as deemed necessary to effect
the purpose of this section in any grant or contract which
the Secretary makes with any Indian Tribe or Tribal
Organization pursuant to this section. Such conditions shall
include requirements that the Indian Tribe or Tribal
Organization successfully undertake--
``(1) to determine the population of Indians eligible for
the benefits described in subsection (a);
``(2) to educate Indians with respect to the benefits
available under the respective programs;
``(3) to provide transportation for such individual Indians
to the appropriate offices for enrollment or applications for
such benefits; and
``(4) to develop and implement methods of improving the
participation of Indians in receiving benefits under such
programs.
``(c) Application to Urban Indian Organizations.--
``(1) In general.--The provisions of subsection (a) shall
apply with respect to grants and other funding to urban
Indian organizations with respect to populations served by
such organizations in the same manner they apply to grants
and contracts with Indian Tribes and Tribal Organizations
with respect to programs on or near reservations.

[[Page H12817]]

``(2) Requirements.--The Secretary shall include in the
grants or contracts made or provided under paragraph (1)
requirements that are--
``(A) consistent with the requirements imposed by the
Secretary under subsection (b);
``(B) appropriate to urban Indian organizations and urban
Indians; and
``(C) necessary to effect the purposes of this section.
``(d) Facilitating Cooperation in Enrollment and
Retention.--The Secretary, acting through the Centers for
Medicare & Medicaid Services, shall consult with States, the
Service, Indian Tribes, Tribal Organizations, and urban
Indian organizations to develop and disseminate best
practices with respect to facilitating agreements between the
States and Indian Tribes, Tribal Organizations, and urban
Indian organizations relating to enrollment and retention of
Indians in programs established under titles XVIII, XIX, and
XXI of the Social Security Act.
``(e) Agreements To Improve Enrollment of Indians Under
Social Security Act Health Benefits Programs.--For provisions
relating to agreements between the Secretary and the Service,
Indian Tribes, Tribal Organizations, and urban Indian
organizations for the collection, preparation, and submission
of applications by Indians for assistance under the Medicaid
and children's health insurance programs established under
titles XIX and XXI of the Social Security Act, and benefits
under the Medicare program established under title XVIII of
such Act, see subsections (a) and (b) of section 1139 of the
Social Security Act.
``(f) Definitions.--In this section:
``(1) Premium.--The term `premium' includes any enrollment
fee or similar charge.
``(2) Cost sharing.--The term `cost sharing' includes any
deduction, deductible, copayment, coinsurance, or similar
charge.
``(3) Benefits.--The term `benefits' means, with respect
to--
``(A) title XVIII of the Social Security Act, benefits
under such title;
``(B) title XIX of such Act, medical assistance under such
title; and
``(C) title XXI of such Act, assistance under such title.

``SEC. 403. REIMBURSEMENT FROM CERTAIN THIRD PARTIES OF COSTS
OF HEALTH SERVICES.

``(a) Right of Recovery.--Except as provided in subsection
(f), the United States, an Indian Tribe, or Tribal
Organization shall have the right to recover from an
insurance company, health maintenance organization, employee
benefit plan, third-party tortfeasor, or any other
responsible or liable third party (including a political
subdivision or local governmental entity of a State) the
reasonable charges incurred by the Secretary, an Indian
Tribe, or Tribal Organization, or, if higher, the highest
amount the third party would pay for care and services
furnished by providers other than governmental entities, in
providing health services through the Service, an Indian
Tribe, or Tribal Organization to any individual to the same
extent that such individual, or any nongovernmental provider
of such services, would be eligible to receive damages,
reimbursement, or indemnification for such charges if--
``(1) such services had been provided by a nongovernmental
provider; and
``(2) such individual had been required to pay such charges
or expenses and did pay such charges or expenses.
``(b) Limitations on Recoveries From States.--Subsection
(a) shall provide a right of recovery against any State, only
if the injury, illness, or disability for which health
services were provided is covered under--
``(1) workers' compensation laws; or
``(2) a no-fault automobile accident insurance plan or
program.
``(c) Nonapplication of Other Laws.--No law of any State,
or of any political subdivision of a State and no provision
of any contract, insurance or health maintenance organization
policy, employee benefit plan, self-insurance plan, managed
care plan, or other health care plan or program entered into
or renewed after the date of the enactment of the Indian
Health Care Amendments of 1988, shall prevent or hinder the
right of recovery of the United States, an Indian Tribe, or
Tribal Organization under subsection (a).
``(d) No Effect on Private Rights of Action.--No action
taken by the United States, an Indian Tribe, or Tribal
Organization to enforce the right of recovery provided under
this section shall operate to deny to the injured person the
recovery for that portion of the person's damage not covered
hereunder.
``(e) Enforcement.--
``(1) In general.--The United States, an Indian Tribe, or
Tribal Organization may enforce the right of recovery
provided under subsection (a) by--
``(A) intervening or joining in any civil action or
proceeding brought--
``(i) by the individual for whom health services were
provided by the Secretary, an Indian Tribe, or Tribal
Organization; or
``(ii) by any representative or heirs of such individual,
or
``(B) instituting a civil action, including a civil action
for injunctive relief and other relief and including, with
respect to a political subdivision or local governmental
entity of a State, such an action against an official
thereof.
``(2) Notice.--All reasonable efforts shall be made to
provide notice of action instituted under paragraph (1)(B) to
the individual to whom health services were provided, either
before or during the pendency of such action.
``(3) Recovery from tortfeasors.--
``(A) In general.--In any case in which an Indian Tribe or
Tribal Organization that is authorized or required under a
compact or contract issued pursuant to the Indian Self-
Determination and Education Assistance Act (25 U.S.C. 450 et
seq.) to furnish or pay for health services to a person who
is injured or suffers a disease on or after the date of
enactment of the Indian Health Care Improvement Act
Amendments of 2009 under circumstances that establish grounds
for a claim of liability against the tortfeasor with respect
to the injury or disease, the Indian Tribe or Tribal
Organization shall have a right to recover from the
tortfeasor (or an insurer of the tortfeasor) the reasonable
value of the health services so furnished, paid for, or to be
paid for, in accordance with the Federal Medical Care
Recovery Act (42 U.S.C. 2651 et seq.), to the same extent and
under the same circumstances as the United States may recover
under that Act.
``(B) Treatment.--The right of an Indian Tribe or Tribal
Organization to recover under subparagraph (A) shall be
independent of the rights of the injured or diseased person
served by the Indian Tribe or Tribal Organization.
``(f) Limitation.--Absent specific written authorization by
the governing body of an Indian Tribe for the period of such
authorization (which may not be for a period of more than 1
year and which may be revoked at any time upon written notice
by the governing body to the Service), the United States
shall not have a right of recovery under this section if the
injury, illness, or disability for which health services were
provided is covered under a self-insurance plan funded by an
Indian Tribe, Tribal Organization, or urban Indian
organization. Where such authorization is provided, the
Service may receive and expend such amounts for the provision
of additional health services consistent with such
authorization.
``(g) Costs and Attorneys' Fees.--In any action brought to
enforce the provisions of this section, a prevailing
plaintiff shall be awarded its reasonable attorneys' fees and
costs of litigation.
``(h) Nonapplication of Claims Filing Requirements.--An
insurance company, health maintenance organization, self-
insurance plan, managed care plan, or other health care plan
or program (under the Social Security Act or otherwise) may
not deny a claim for benefits submitted by the Service or by
an Indian Tribe or Tribal Organization based on the format in
which the claim is submitted if such format complies with the
format required for submission of claims under title XVIII of
the Social Security Act or recognized under section 1175 of
such Act.
``(i) Application to Urban Indian Organizations.--The
previous provisions of this section shall apply to urban
Indian organizations with respect to populations served by
such Organizations in the same manner they apply to Indian
Tribes and Tribal Organizations with respect to populations
served by such Indian Tribes and Tribal Organizations.
``(j) Statute of Limitations.--The provisions of section
2415 of title 28, United States Code, shall apply to all
actions commenced under this section, and the references
therein to the United States are deemed to include Indian
Tribes, Tribal Organizations, and urban Indian organizations.
``(k) Savings.--Nothing in this section shall be construed
to limit any right of recovery available to the United
States, an Indian Tribe, or Tribal Organization under the
provisions of any applicable, Federal, State, or Tribal law,
including medical lien laws.

``SEC. 404. CREDITING OF REIMBURSEMENTS.

``(a) Retention of Amounts for Use by Program.--Except as
provided in section 202(f) (relating to the Catastrophic
Health Emergency Fund) and section 806 (relating to health
services for ineligible persons), all reimbursements received
or recovered, including under section 806, by reason of the
provision of health services by the Service, by an Indian
Tribe or Tribal Organization, or by an urban Indian
organization, shall be credited to the Service, such Indian
Tribe or Tribal Organization, or such urban Indian
organization, respectively, and may be used as provided in
section 401. In the case of such a service provided by or
through a Service Unit, such amounts shall be credited to
such unit and used for such purposes.
``(b) No Offset of Amounts.--The Service may not offset or
limit any amount obligated to any Service Unit or entity
receiving funding from the Service because of the receipt of
reimbursements under subsection (a).

``SEC. 405. PURCHASING HEALTH CARE COVERAGE.

``(a) Purchasing Coverage.--
``(1) In general.--Insofar as amounts are made available
under law (including a provision of the Social Security Act,
the Indian Self-Determination and Education Assistance Act
(25 U.S.C. 450 et seq.), or other law, other than under
section 402) to Indian Tribes, Tribal Organizations, and
urban Indian organizations for health benefits for Service
beneficiaries, Indian Tribes, Tribal Organizations, and urban
Indian organizations may use such amounts to purchase health
benefits coverage that qualifies as creditable coverage under
section 2701(c)(1) of the Public Health Service Act for such
beneficiaries, including, subject to paragraph (2), through--
``(A) a tribally owned and operated health care plan;

[[Page H12818]]

``(B) a State or locally authorized or licensed health care
plan;
``(C) a health insurance provider or managed care
organization; or
``(D) a self-insured plan.
``(2) Exception.--The coverage provided under paragraph (1)
may not include coverage consisting of--
``(A) benefits provided under a health flexible spending
arrangement (as defined in section 106(c)(2) of the Internal
Revenue Code of 1986); or
``(B) a high deductible health plan (as defined in section
223(c)(2) of such Code), without regard to whether the plan
is purchased in conjunction with a health savings account (as
defined under section 223(d) of such Code).
``(3) Permitting purchase of coverage based on financial
need.--The purchase of coverage by an Indian Tribe, Tribal
Organization, or urban Indian organization under this
subsection may be based on the financial needs of
beneficiaries (as determined by the Indian Tribe or Tribes
being served based on a schedule of income levels developed
or implemented by such Indian Tribe or Tribes).
``(b) Expenses for Self-insured Plan.--In the case of a
self-insured plan under subsection (a)(4), the amounts may be
used for expenses of operating the plan, including
administration and insurance to limit the financial risks to
the entity offering the plan.
``(c) Construction.--Nothing in this section shall be
construed as affecting the use of any amounts not referred to
in subsection (a).

``SEC. 406. SHARING ARRANGEMENTS WITH FEDERAL AGENCIES.

``(a) Authority.--
``(1) In general.--The Secretary may enter into (or expand)
arrangements for the sharing of medical facilities and
services between the Service, Indian Tribes, and Tribal
Organizations and the Department of Veterans Affairs and the
Department of Defense.
``(2) Consultation by secretary required.--The Secretary
may not finalize any arrangement between the Service and a
Department described in paragraph (1) without first
consulting with the Indian Tribes which will be significantly
affected by the arrangement.
``(b) Limitations.--The Secretary shall not take any action
under this section or under subchapter IV of chapter 81 of
title 38, United States Code, which would impair--
``(1) the priority access of any Indian to health care
services provided through the Service and the eligibility of
any Indian to receive health services through the Service;
``(2) the quality of health care services provided to any
Indian through the Service;
``(3) the priority access of any veteran to health care
services provided by the Department of Veterans Affairs;
``(4) the quality of health care services provided by the
Department of Veterans Affairs or the Department of Defense;
or
``(5) the eligibility of any Indian who is a veteran to
receive health services through the Department of Veterans
Affairs.
``(c) Reimbursement.--The Service, Indian Tribe, or Tribal
Organization shall be reimbursed by the Department of
Veterans Affairs or the Department of Defense (as the case
may be) where services are provided through the Service, an
Indian Tribe, or a Tribal Organization to beneficiaries
eligible for services from either such Department,
notwithstanding any other provision of law.
``(d) Construction.--Nothing in this section may be
construed as creating any right of a non-Indian veteran to
obtain health services from the Service.

``SEC. 407. ELIGIBLE INDIAN VETERAN SERVICES.

``(a) Findings; Purpose.--
``(1) Findings.--Congress finds that--
``(A) collaborations between the Secretary and the
Secretary of Veterans Affairs regarding the treatment of
Indian veterans at facilities of the Service should be
encouraged to the maximum extent practicable; and
``(B) increased enrollment for services of the Department
of Veterans Affairs by veterans who are members of Indian
tribes should be encouraged to the maximum extent
practicable.
``(2) Purpose.--The purpose of this section is to reaffirm
the goals stated in the document entitled `Memorandum of
Understanding Between the VA/Veterans Health Administration
And HHS/Indian Health Service' and dated February 25, 2003
(relating to cooperation and resource sharing between the
Veterans Health Administration and Service).
``(b) Definitions.--In this section:
``(1) Eligible indian veteran.--The term `eligible Indian
veteran' means an Indian or Alaska Native veteran who
receives any medical service that is--
``(A) authorized under the laws administered by the
Secretary of Veterans Affairs; and
``(B) administered at a facility of the Service (including
a facility operated by an Indian tribe or tribal organization
through a contract or compact with the Service under the
Indian Self-Determination and Education Assistance Act (25
U.S.C. 450 et seq.)) pursuant to a local memorandum of
understanding.
``(2) Local memorandum of understanding.--The term `local
memorandum of understanding' means a memorandum of
understanding between the Secretary (or a designee, including
the director of any Area Office of the Service) and the
Secretary of Veterans Affairs (or a designee) to implement
the document entitled `Memorandum of Understanding Between
the VA/Veterans Health Administration And HHS/Indian Health
Service' and dated February 25, 2003 (relating to cooperation
and resource sharing between the Veterans Health
Administration and Indian Health Service).
``(c) Eligible Indian Veterans' Expenses.--
``(1) In general.--Notwithstanding any other provision of
law, the Secretary shall provide for veteran-related expenses
incurred by eligible Indian veterans as described in
subsection (b)(1)(B).
``(2) Method of payment.--The Secretary shall establish
such guidelines as the Secretary determines to be appropriate
regarding the method of payments to the Secretary of Veterans
Affairs under paragraph (1).
``(d) Tribal Approval of Memoranda.--In negotiating a local
memorandum of understanding with the Secretary of Veterans
Affairs regarding the provision of services to eligible
Indian veterans, the Secretary shall consult with each Indian
tribe that would be affected by the local memorandum of
understanding.
``(e) Funding.--
``(1) Treatment.--Expenses incurred by the Secretary in
carrying out subsection (c)(1) shall not be considered to be
Contract Health Service expenses.
``(2) Use of funds.--Of funds made available to the
Secretary in appropriations Acts for the Service (excluding
funds made available for facilities, Contract Health
Services, or contract support costs), the Secretary shall use
such sums as are necessary to carry out this section.

``SEC. 408. PAYOR OF LAST RESORT.

``Indian Health Programs and health care programs operated
by Urban Indian Organizations shall be the payor of last
resort for services provided to persons eligible for services
from Indian Health Programs and Urban Indian Organizations,
notwithstanding any Federal, State, or local law to the
contrary.

``SEC. 409. CONSULTATION.

``For provisions related to consultation with
representatives of Indian Health Programs and urban Indian
organizations with respect to the health care programs
established under titles XVIII, XIX, and XXI of the Social
Security Act, see section 1139(d) of the Social Security Act
(42 U.S.C. 1320b-9(d)).

``SEC. 410. STATE CHILDREN'S HEALTH INSURANCE PROGRAM
(SCHIP).

``For provisions relating to--
``(1) outreach to families of Indian children likely to be
eligible for child health assistance under the State
children's health insurance program established under title
XXI of the Social Security Act, see sections 2105(c)(2)(C)
and 1139(a) of such Act (42 U.S.C. 1397ee(c)(2), 1320b-9);
and
``(2) ensuring that child health assistance is provided
under such program to targeted low-income children who are
Indians and that payments are made under such program to
Indian Health Programs and urban Indian organizations
operating in the State that provide such assistance, see
sections 2102(b)(3)(D) and 2105(c)(6)(B) of such Act (42
U.S.C. 1397bb(b)(3)(D), 1397ee(c)(6)(B)).

``SEC. 411. PREMIUM AND COST SHARING PROTECTIONS AND
ELIGIBILITY DETERMINATIONS UNDER MEDICAID AND
SCHIP AND PROTECTION OF CERTAIN INDIAN PROPERTY
FROM MEDICAID ESTATE RECOVERY.

``For provisions relating to--
``(1) premiums or cost sharing protections for Indians
furnished items or services directly by Indian Health
Programs or through referral under the contract health
service under the Medicaid program established under title
XIX of the Social Security Act, see sections 1916(j) and
1916A(a)(1) of the Social Security Act (42 U.S.C. 1396o(j),
1396o-1(a)(1));
``(2) rules regarding the treatment of certain property for
purposes of determining eligibility under such programs, see
sections 1902(e)(13) and 2107(e)(1)(B) of such Act (42 U.S.C.
1396a(e)(13), 1397gg(e)(1)(B)); and
``(3) the protection of certain property from estate
recovery provisions under the Medicaid program, see section
1917(b)(3)(B) of such Act (42 U.S.C. 1396p(b)(3)(B)).

``SEC. 412. TREATMENT UNDER MEDICAID AND SCHIP MANAGED CARE.

``For provisions relating to the treatment of Indians
enrolled in a managed care entity under the Medicaid program
under title XIX of the Social Security Act and Indian Health
Programs and urban Indian organizations that are providers of
items or services to such Indian enrollees, see sections
1932(h) and 2107(e)(1)(H) of the Social Security Act (42
U.S.C. 1396u-2(h), 1397gg(e)(1)(H)).

``SEC. 413. NAVAJO NATION MEDICAID AGENCY FEASIBILITY STUDY.

``(a) Study.--The Secretary shall conduct a study to
determine the feasibility of treating the Navajo Nation as a
State for the purposes of title XIX of the Social Security
Act, to provide services to Indians living within the
boundaries of the Navajo Nation through an entity established
having the same authority and performing the same functions
as single-State Medicaid agencies responsible for the
administration of the State plan under title XIX of the
Social Security Act.
``(b) Considerations.--In conducting the study, the
Secretary shall consider the feasibility of--
``(1) assigning and paying all expenditures for the
provision of services and related administration funds, under
title XIX of the Social Security Act, to Indians living
within the boundaries of the Navajo Nation that are currently
paid to or would otherwise be paid

[[Page H12819]]

to the State of Arizona, New Mexico, or Utah;
``(2) providing assistance to the Navajo Nation in the
development and implementation of such entity for the
administration, eligibility, payment, and delivery of medical
assistance under title XIX of the Social Security Act;
``(3) providing an appropriate level of matching funds for
Federal medical assistance with respect to amounts such
entity expends for medical assistance for services and
related administrative costs; and
``(4) authorizing the Secretary, at the option of the
Navajo Nation, to treat the Navajo Nation as a State for the
purposes of title XIX of the Social Security Act (relating to
the State children's health insurance program) under terms
equivalent to those described in paragraphs (2) through (4).
``(c) Report.--Not later than 3 years after the date of
enactment of the Indian Health Care Improvement Act
Amendments of 2009, the Secretary shall submit to the
Committee on Indian Affairs and Committee on Finance of the
Senate and the Committee on Natural Resources and Committee
on Energy and Commerce of the House of Representatives a
report that includes--
``(1) the results of the study under this section;
``(2) a summary of any consultation that occurred between
the Secretary and the Navajo Nation, other Indian Tribes, the
States of Arizona, New Mexico, and Utah, counties which
include Navajo Lands, and other interested parties, in
conducting this study;
``(3) projected costs or savings associated with
establishment of such entity, and any estimated impact on
services provided as described in this section in relation to
probable costs or savings; and
``(4) legislative actions that would be required to
authorize the establishment of such entity if such entity is
determined by the Secretary to be feasible.

``SEC. 414. EXCEPTION FOR EXCEPTED BENEFITS.

``The previous provisions of this title shall not apply to
the provision of excepted benefits described in paragraph
(1)(A) or (3) of section 2791(c) of the Public Health Service
Act (42 U.S.C. 300gg-91(c)).

``SEC. 415. AUTHORIZATION OF APPROPRIATIONS.

``There are authorized to be appropriated such sums as may
be necessary to carry out this title.

``TITLE V--HEALTH SERVICES FOR URBAN INDIANS

``SEC. 501. PURPOSE.

``The purpose of this title is to establish and maintain
programs in Urban Centers to make health services more
accessible and available to Urban Indians.

``SEC. 502. CONTRACTS WITH, AND GRANTS TO, URBAN INDIAN
ORGANIZATIONS.

``Under authority of the Act of November 2, 1921 (25 U.S.C.
13) (commonly known as the `Snyder Act'), the Secretary,
acting through the Service, shall enter into contracts with,
or make grants to, urban Indian organizations to assist such
organizations in the establishment and administration, within
Urban Centers, of programs which meet the requirements set
forth in this title. Subject to section 506, the Secretary,
acting through the Service, shall include such conditions as
the Secretary considers necessary to effect the purpose of
this title in any contract into which the Secretary enters
with, or in any grant the Secretary makes to, any urban
Indian organization pursuant to this title.

``SEC. 503. CONTRACTS AND GRANTS FOR THE PROVISION OF HEALTH
CARE AND REFERRAL SERVICES.

``(a) Requirements for Grants and Contracts.--Under
authority of the Act of November 2, 1921 (25 U.S.C. 13)
(commonly known as the `Snyder Act'), the Secretary, acting
through the Service, shall enter into contracts with, and
make grants to, urban Indian organizations for the provision
of health care and referral services for Urban Indians. Any
such contract or grant shall include requirements that the
urban Indian organization successfully undertake to--
``(1) estimate the population of Urban Indians residing in
the Urban Center or centers that the organization proposes to
serve who are or could be recipients of health care or
referral services;
``(2) estimate the current health status of Urban Indians
residing in such Urban Center or centers;
``(3) estimate the current health care needs of Urban
Indians residing in such Urban Center or centers;
``(4) provide basic health education, including health
promotion and disease prevention education, to Urban Indians;
``(5) make recommendations to the Secretary and Federal,
State, local, and other resource agencies on methods of
improving health service programs to meet the needs of Urban
Indians; and
``(6) where necessary, provide, or enter into contracts for
the provision of, health care services for Urban Indians.
``(b) Criteria.--The Secretary, acting through the Service,
shall, by regulation, prescribe the criteria for selecting
urban Indian organizations to enter into contracts or receive
grants under this section. Such criteria shall, among other
factors, include--
``(1) the extent of unmet health care needs of Urban
Indians in the Urban Center or centers involved;
``(2) the size of the urban Indian population in the Urban
Center or centers involved;
``(3) the extent, if any, to which the activities set forth
in subsection (a) would duplicate any project funded under
this title, or under any current public health service
project funded in a manner other than pursuant to this title;
``(4) the capability of an urban Indian organization to
perform the activities set forth in subsection (a) and to
enter into a contract with the Secretary or to meet the
requirements for receiving a grant under this section;
``(5) the satisfactory performance and successful
completion by an urban Indian organization of other contracts
with the Secretary under this title;
``(6) the appropriateness and likely effectiveness of
conducting the activities set forth in subsection (a) in an
Urban Center or centers; and
``(7) the extent of existing or likely future participation
in the activities set forth in subsection (a) by appropriate
health and health-related Federal, State, local, and other
agencies.
``(c) Access to Health Promotion and Disease Prevention
Programs.--The Secretary, acting through the Service, shall
facilitate access to or provide health promotion and disease
prevention services for Urban Indians through grants made to
urban Indian organizations administering contracts entered
into or receiving grants under subsection (a).
``(d) Immunization Services.--
``(1) Access or services provided.--The Secretary, acting
through the Service, shall facilitate access to, or provide,
immunization services for Urban Indians through grants made
to urban Indian organizations administering contracts entered
into or receiving grants under this section.
``(2) Definition.--For purposes of this subsection, the
term `immunization services' means services to provide
without charge immunizations against vaccine-preventable
diseases.
``(e) Behavioral Health Services.--
``(1) Access or services provided.--The Secretary, acting
through the Service, shall facilitate access to, or provide,
behavioral health services for Urban Indians through grants
made to urban Indian organizations administering contracts
entered into or receiving grants under subsection (a).
``(2) Assessment required.--Except as provided by paragraph
(3)(A), a grant may not be made under this subsection to an
urban Indian organization until that organization has
prepared, and the Service has approved, an assessment of the
following:
``(A) The behavioral health needs of the urban Indian
population concerned.
``(B) The behavioral health services and other related
resources available to that population.
``(C) The barriers to obtaining those services and
resources.
``(D) The needs that are unmet by such services and
resources.
``(3) Purposes of grants.--Grants may be made under this
subsection for the following:
``(A) To prepare assessments required under paragraph (2).
``(B) To provide outreach, educational, and referral
services to Urban Indians regarding the availability of
direct behavioral health services, to educate Urban Indians
about behavioral health issues and services, and effect
coordination with existing behavioral health providers in
order to improve services to Urban Indians.
``(C) To provide outpatient behavioral health services to
Urban Indians, including the identification and assessment of
illness, therapeutic treatments, case management, support
groups, family treatment, and other treatment.
``(D) To develop innovative behavioral health service
delivery models which incorporate Indian cultural support
systems and resources.
``(f) Prevention of Child Abuse.--
``(1) Access or services provided.--The Secretary, acting
through the Service, shall facilitate access to or provide
services for Urban Indians through grants to urban Indian
organizations administering contracts entered into or
receiving grants under subsection (a) to prevent and treat
child abuse (including sexual abuse) among Urban Indians.
``(2) Evaluation required.--Except as provided by paragraph
(3)(A), a grant may not be made under this subsection to an
urban Indian organization until that organization has
prepared, and the Service has approved, an assessment that
documents the prevalence of child abuse in the urban Indian
population concerned and specifies the services and programs
(which may not duplicate existing services and programs) for
which the grant is requested.
``(3) Purposes of grants.--Grants may be made under this
subsection for the following:
``(A) To prepare assessments required under paragraph (2).
``(B) For the development of prevention, training, and
education programs for Urban Indians, including child
education, parent education, provider training on
identification and intervention, education on reporting
requirements, prevention campaigns, and establishing service
networks of all those involved in Indian child protection.
``(C) To provide direct outpatient treatment services
(including individual treatment, family treatment, group
therapy, and support groups) to Urban Indians who are child
victims of abuse (including sexual abuse) or adult survivors
of child sexual abuse, to the families of such child victims,

[[Page H12820]]

and to urban Indian perpetrators of child abuse (including
sexual abuse).
``(4) Considerations when making grants.--In making grants
to carry out this subsection, the Secretary shall take into
consideration--
``(A) the support for the urban Indian organization
demonstrated by the child protection authorities in the area,
including committees or other services funded under the
Indian Child Welfare Act of 1978 (25 U.S.C. 1901 et seq.), if
any;
``(B) the capability and expertise demonstrated by the
urban Indian organization to address the complex problem of
child sexual abuse in the community; and
``(C) the assessment required under paragraph (2).
``(g) Other Grants.--The Secretary, acting through the
Service, may enter into a contract with or make grants to an
urban Indian organization that provides or arranges for the
provision of health care services (through satellite
facilities, provider networks, or otherwise) to Urban Indians
in more than 1 Urban Center.

``SEC. 504. USE OF FEDERAL GOVERNMENT FACILITIES AND SOURCES
OF SUPPLY.

``(a) In General.--The Secretary may permit an urban Indian
organization that has entered into a contract or received a
grant pursuant to this title, in carrying out such contract
or grant, to use existing facilities and all equipment
therein or pertaining thereto and other personal property
owned by the Federal Government within the Secretary's
jurisdiction under such terms and conditions as may be agreed
upon for their use and maintenance.
``(b) Donations.--Subject to subsection (d), the Secretary
may donate to an urban Indian organization that has entered
into a contract or received a grant pursuant to this title
any personal or real property determined to be excess to the
needs of the Indian Health Service or the General Services
Administration for the purposes of carrying out the contract
or grant.
``(c) Acquisition of Property.--The Secretary may acquire
excess or surplus government personal or real property for
donation, subject to subsection (d) to an urban Indian
organization that has entered into a contract or received a
grant pursuant to this title if the Secretary determines that
the property is appropriate for use by the urban Indian
organization for a purpose for which a contract or grant is
authorized under this title.
``(d) Priority.--In the event that the Secretary receives a
request for a specific item of personal or real property
described in subsections (b) or (c) from an urban Indian
organization and from an Indian Tribe or Tribal Organization,
the Secretary shall give priority to the request for donation
to the Indian Tribe or Tribal Organization if the Secretary
receives the request from the Indian Tribe or Tribal
Organization before the date the Secretary transfers title to
the property or, if earlier, the date the Secretary transfers
the property physically, to the urban Indian organization.
``(e) Executive Agency Status.--For purposes of section
201(a) of the Federal Property and Administrative Services
Act of 1949 (40 U.S.C. 481(a)) (relating to Federal sources
of supply), an urban Indian organization that has entered
into a contract or received a grant pursuant to this title
may be deemed to be an executive agency when carrying out
such contract or grant.

``SEC. 505. CONTRACTS AND GRANTS FOR THE DETERMINATION OF
UNMET HEALTH CARE NEEDS.

``(a) Grants and Contracts Authorized.--Under authority of
the Act of November 2, 1921 (25 U.S.C. 13) (commonly known as
the `Snyder Act'), the Secretary, acting through the Service,
may enter into contracts with or make grants to urban Indian
organizations situated in Urban Centers for which contracts
have not been entered into or grants have not been made under
section 503.
``(b) Purpose.--The purpose of a contract or grant made
under this section shall be the determination of the matters
described in subsection (c)(1) in order to assist the
Secretary in assessing the health status and health care
needs of Urban Indians in the Urban Center involved and
determining whether the Secretary should enter into a
contract or make a grant under section 503 with respect to
the urban Indian organization which the Secretary has entered
into a contract with, or made a grant to, under this section.
``(c) Grant and Contract Requirements.--Any contract
entered into, or grant made, by the Secretary under this
section shall include requirements that--
``(1) the urban Indian organization successfully undertakes
to--
``(A) document the health care status and unmet health care
needs of urban Indians in the Urban Center involved; and
``(B) with respect to urban Indians in the Urban Center
involved, determine the matters described in paragraphs (2),
(3), (4), and (7) of section 503(b); and
``(2) the urban Indian organization complete performance of
the contract, or carry out the requirements of the grant,
within 1 year after the date on which the Secretary and such
organization enter into such contract, or within 1 year after
such organization receives such grant, whichever is
applicable.
``(d) No Renewals.--The Secretary may not renew any
contract entered into or grant made under this section.

``SEC. 506. EVALUATIONS; RENEWALS.

``(a) Procedures for Evaluations.--The Secretary, acting
through the Service, shall develop procedures to evaluate
compliance with grant requirements and compliance with and
performance of contracts entered into by urban Indian
organizations under this title. Such procedures shall include
provisions for carrying out the requirements of this section.
``(b) Evaluations.--The Secretary, acting through the
Service, shall evaluate the compliance of each Urban Indian
Organization which has entered into a contract or received a
grant under section 503 with the terms of such contract or
grant. For purposes of this evaluation, the Secretary shall--
``(1) acting through the Service, conduct an annual onsite
evaluation of the organization; or
``(2) accept in lieu of such onsite evaluation evidence of
the organization's provisional or full accreditation by a
private independent entity recognized by the Secretary for
purposes of conducting quality reviews of providers
participating in the Medicare program under title XVIII of
the Social Security Act.
``(c) Noncompliance; Unsatisfactory Performance.--If, as a
result of the evaluations conducted under this section, the
Secretary determines that an urban Indian organization has
not complied with the requirements of a grant or complied
with or satisfactorily performed a contract under section
503, the Secretary shall, prior to renewing such contract or
grant, attempt to resolve with the organization the areas of
noncompliance or unsatisfactory performance and modify the
contract or grant to prevent future occurrences of
noncompliance or unsatisfactory performance. If the Secretary
determines that the noncompliance or unsatisfactory
performance cannot be resolved and prevented in the future,
the Secretary shall not renew the contract or grant with the
organization and is authorized to enter into a contract or
make a grant under section 503 with another urban Indian
organization which is situated in the same Urban Center as
the urban Indian organization whose contract or grant is not
renewed under this section.
``(d) Considerations for Renewals.--In determining whether
to renew a contract or grant with an urban Indian
organization under section 503 which has completed
performance of a contract or grant under section 504, the
Secretary shall review the records of the urban Indian
organization, the reports submitted under section 507, and
shall consider the results of the onsite evaluations or
accreditations under subsection (b).

``SEC. 507. OTHER CONTRACT AND GRANT REQUIREMENTS.

``(a) Procurement.--Contracts with urban Indian
organizations entered into pursuant to this title shall be in
accordance with all Federal contracting laws and regulations
relating to procurement except that in the discretion of the
Secretary, such contracts may be negotiated without
advertising and need not conform to the provisions of
sections 1304 and 3131 through 3133 of title 40, United
States Code.
``(b) Payments Under Contracts or Grants.--
``(1) In general.--Payments under any contracts or grants
pursuant to this title, notwithstanding any term or condition
of such contract or grant--
``(A) may be made in a single advance payment by the
Secretary to the urban Indian organization by no later than
the end of the first 30 days of the funding period with
respect to which the payments apply, unless the Secretary
determines through an evaluation under section 505 that the
organization is not capable of administering such a single
advance payment; and
``(B) if any portion thereof is unexpended by the urban
Indian organization during the funding period with respect to
which the payments initially apply, shall be carried forward
for expenditure with respect to allowable or reimbursable
costs incurred by the organization during 1 or more
subsequent funding periods without additional justification
or documentation by the organization as a condition of
carrying forward the availability for expenditure of such
funds.
``(2) Semiannual and quarterly payments and
reimbursements.--If the Secretary determines under paragraph
(1)(A) that an urban Indian organization is not capable of
administering an entire single advance payment, on request of
the urban Indian organization, the payments may be made--
``(A) in semiannual or quarterly payments by not later than
30 days after the date on which the funding period with
respect to which the payments apply begins; or
``(B) by way of reimbursement.
``(c) Revision or Amendment of Contracts.--Notwithstanding
any provision of law to the contrary, the Secretary may, at
the request and consent of an urban Indian organization,
revise or amend any contract entered into by the Secretary
with such organization under this title as necessary to carry
out the purposes of this title.
``(d) Fair and Uniform Services and Assistance.--Contracts
with or grants to urban Indian organizations and regulations
adopted pursuant to this title shall include provisions to
assure the fair and uniform provision to urban Indians of
services and assistance under such contracts or grants by
such organizations.

``SEC. 508. REPORTS AND RECORDS.

``(a) Reports.--

[[Page H12821]]

``(1) In general.--For each fiscal year during which an
urban Indian organization receives or expends funds pursuant
to a contract entered into or a grant received pursuant to
this title, such urban Indian organization shall submit to
the Secretary not more frequently than every 6 months, a
report that includes the following:
``(A) In the case of a contract or grant under section 503,
recommendations pursuant to section 503(a)(5).
``(B) Information on activities conducted by the
organization pursuant to the contract or grant.
``(C) An accounting of the amounts and purpose for which
Federal funds were expended.
``(D) A minimum set of data, using uniformly defined
elements, as specified by the Secretary after consultation
with urban Indian organizations.
``(2) Health status and services.--
``(A) In general.--Not later than 18 months after the date
of enactment of the Indian Health Care Improvement Act
Amendments of 2009, the Secretary, acting through the
Service, shall submit to Congress a report evaluating--
``(i) the health status of urban Indians;
``(ii) the services provided to Indians pursuant to this
title; and
``(iii) areas of unmet needs in the delivery of health
services to urban Indians.
``(B) Consultation and contracts.--In preparing the report
under paragraph (1), the Secretary--
``(i) shall consult with urban Indian organizations; and
``(ii) may enter into a contract with a national
organization representing urban Indian organizations to
conduct any aspect of the report.
``(b) Audit.--The reports and records of the urban Indian
organization with respect to a contract or grant under this
title shall be subject to audit by the Secretary and the
Comptroller General of the United States.
``(c) Costs of Audits.--The Secretary shall allow as a cost
of any contract or grant entered into or awarded under
section 502 or 503 the cost of an annual independent
financial audit conducted by--
``(1) a certified public accountant; or
``(2) a certified public accounting firm qualified to
conduct Federal compliance audits.

``SEC. 509. LIMITATION ON CONTRACT AUTHORITY.

``The authority of the Secretary to enter into contracts or
to award grants under this title shall be to the extent, and
in an amount, provided for in appropriation Acts.

``SEC. 510. FACILITIES.

``(a) Grants.--The Secretary, acting through the Service,
may make grants to contractors or grant recipients under this
title for the lease, purchase, renovation, construction, or
expansion of facilities, including leased facilities, in
order to assist such contractors or grant recipients in
complying with applicable licensure or certification
requirements.
``(b) Loan Fund Study.--The Secretary, acting through the
Service, may carry out a study to determine the feasibility
of establishing a loan fund to provide to urban Indian
organizations direct loans or guarantees for loans for the
construction of health care facilities in a manner consistent
with section 309, including by submitting a report in
accordance with subsection (c) of that section.

``SEC. 511. DIVISION OF URBAN INDIAN HEALTH.

``There is established within the Service a Division of
Urban Indian Health, which shall be responsible for--
``(1) carrying out the provisions of this title;
``(2) providing central oversight of the programs and
services authorized under this title; and
``(3) providing technical assistance to urban Indian
organizations.

``SEC. 512. GRANTS FOR ALCOHOL AND SUBSTANCE ABUSE-RELATED
SERVICES.

``(a) Grants Authorized.--The Secretary, acting through the
Service, may make grants for the provision of health-related
services in prevention of, treatment of, rehabilitation of,
or school- and community-based education regarding, alcohol
and substance abuse in Urban Centers to those urban Indian
organizations with which the Secretary has entered into a
contract under this title or under section 201.
``(b) Goals.--Each grant made pursuant to subsection (a)
shall set forth the goals to be accomplished pursuant to the
grant. The goals shall be specific to each grant as agreed to
between the Secretary and the grantee.
``(c) Criteria.--The Secretary shall establish criteria for
the grants made under subsection (a), including criteria
relating to the following:
``(1) The size of the urban Indian population.
``(2) Capability of the organization to adequately perform
the activities required under the grant.
``(3) Satisfactory performance standards for the
organization in meeting the goals set forth in such grant.
The standards shall be negotiated and agreed to between the
Secretary and the grantee on a grant-by-grant basis.
``(4) Identification of the need for services.
``(d) Allocation of Grants.--The Secretary shall develop a
methodology for allocating grants made pursuant to this
section based on the criteria established pursuant to
subsection (c).
``(e) Grants Subject to Criteria.--Any grant received by an
urban Indian organization under this Act for substance abuse
prevention, treatment, and rehabilitation shall be subject to
the criteria set forth in subsection (c).

``SEC. 513. TREATMENT OF CERTAIN DEMONSTRATION PROJECTS.

``Notwithstanding any other provision of law, the Tulsa
Clinic and Oklahoma City Clinic demonstration projects
shall--
``(1) be permanent programs within the Service's direct
care program;
``(2) continue to be treated as Service Units and Operating
Units in the allocation of resources and coordination of
care; and
``(3) continue to meet the requirements and definitions of
an urban Indian organization in this Act, and shall not be
subject to the provisions of the Indian Self-Determination
and Education Assistance Act (25 U.S.C. 450 et seq.).

``SEC. 514. URBAN NIAAA TRANSFERRED PROGRAMS.

``(a) Grants and Contracts.--The Secretary, through the
Division of Urban Indian Health, shall make grants or enter
into contracts with urban Indian organizations, to take
effect not later than September 30, 2010, for the
administration of urban Indian alcohol programs that were
originally established under the National Institute on
Alcoholism and Alcohol Abuse (hereafter in this section
referred to as `NIAAA') and transferred to the Service.
``(b) Use of Funds.--Grants provided or contracts entered
into under this section shall be used to provide support for
the continuation of alcohol prevention and treatment services
for urban Indian populations and such other objectives as are
agreed upon between the Service and a recipient of a grant or
contract under this section.
``(c) Eligibility.--Urban Indian organizations that operate
Indian alcohol programs originally funded under the NIAAA and
subsequently transferred to the Service are eligible for
grants or contracts under this section.
``(d) Report.--The Secretary shall evaluate and report to
Congress on the activities of programs funded under this
section not less than every 5 years.

``SEC. 515. CONFERRING WITH URBAN INDIAN ORGANIZATIONS.

``(a) In General.--The Secretary shall ensure that the
Service confers or conferences, to the greatest extent
practicable, with Urban Indian Organizations.
``(b) Definition of Confer; Conference.--In this section,
the terms `confer' and `conference' mean an open and free
exchange of information and opinions that--
``(1) leads to mutual understanding and comprehension; and
``(2) emphasizes trust, respect, and shared responsibility.

``SEC. 516. URBAN YOUTH TREATMENT CENTER DEMONSTRATION.

``(a) Construction and Operation.--
``(1) In general.--The Secretary, acting through the
Service, through grant or contract, shall fund the
construction and operation of at least 1 residential
treatment center in each Service Area that meets the
eligibility requirements set forth in subsection (b) to
demonstrate the provision of alcohol and substance abuse
treatment services to Urban Indian youth in a culturally
competent residential setting.
``(2) Treatment.--Each residential treatment center
described in paragraph (1) shall be in addition to any
facilities constructed under section 707(b).
``(b) Eligibility Requirements.--To be eligible to obtain a
facility under subsection (a)(1), a Service Area shall meet
the following requirements:
``(1) There is an Urban Indian Organization in the Service
Area.
``(2) There reside in the Service Area Urban Indian youth
with need for alcohol and substance abuse treatment services
in a residential setting.
``(3) There is a significant shortage of culturally
competent residential treatment services for Urban Indian
youth in the Service Area.

``SEC. 517. GRANTS FOR DIABETES PREVENTION, TREATMENT, AND
CONTROL.

``(a) Grants Authorized.--The Secretary may make grants to
those urban Indian organizations that have entered into a
contract or have received a grant under this title for the
provision of services for the prevention and treatment of,
and control of the complications resulting from, diabetes
among urban Indians.
``(b) Goals.--Each grant made pursuant to subsection (a)
shall set forth the goals to be accomplished under the grant.
The goals shall be specific to each grant as agreed to
between the Secretary and the grantee.
``(c) Establishment of Criteria.--The Secretary shall
establish criteria for the grants made under subsection (a)
relating to--
``(1) the size and location of the urban Indian population
to be served;
``(2) the need for prevention of and treatment of, and
control of the complications resulting from, diabetes among
the urban Indian population to be served;
``(3) performance standards for the organization in meeting
the goals set forth in such grant that are negotiated and
agreed to by the Secretary and the grantee;
``(4) the capability of the organization to adequately
perform the activities required under the grant; and

[[Page H12822]]

``(5) the willingness of the organization to collaborate
with the registry, if any, established by the Secretary under
section 203(e)(1)(B) in the Area Office of the Service in
which the organization is located.
``(d) Funds Subject to Criteria.--Any funds received by an
urban Indian organization under this Act for the prevention,
treatment, and control of diabetes among urban Indians shall
be subject to the criteria developed by the Secretary under
subsection (c).

``SEC. 518. COMMUNITY HEALTH REPRESENTATIVES.

``The Secretary, acting through the Service, may enter into
contracts with, and make grants to, urban Indian
organizations for the employment of Indians trained as health
service providers through the Community Health
Representatives Program under section 109 in the provision of
health care, health promotion, and disease prevention
services to urban Indians.

``SEC. 519. EFFECTIVE DATE.

``The amendments made by the Indian Health Care Improvement
Act Amendments of 2009 to this title shall take effect
beginning on the date of enactment of that Act, regardless of
whether the Secretary has promulgated regulations
implementing such amendments.

``SEC. 520. ELIGIBILITY FOR SERVICES.

``Urban Indians shall be eligible for, and the ultimate
beneficiaries of, health care or referral services provided
pursuant to this title.

``SEC. 521. AUTHORIZATION OF APPROPRIATIONS.

``(a) In General.--There are authorized to be appropriated
such sums as may be necessary to carry out this title.
``(b) Urban Indian Organizations.--The Secretary, acting
through the Service, is authorized to establish programs,
including programs for the awarding of grants, for urban
Indian organizations that are identical to any programs
established pursuant to section 126 (behavioral health
training), section 209 (school health education), section 211
(prevention of communicable diseases), section 701
(behavioral health prevention and treatment services), and
section 707(g) (multidrug abuse program).

``SEC. 522. HEALTH INFORMATION TECHNOLOGY.

``The Secretary, acting through the Service, may make
grants to urban Indian organizations under this title for the
development, adoption, and implementation of health
information technology (as defined in section 3000(5) of the
American Recovery and Reinvestment Act), telemedicine
services development, and related infrastructure.

``TITLE VI--ORGANIZATIONAL IMPROVEMENTS

``SEC. 601. ESTABLISHMENT OF THE INDIAN HEALTH SERVICE AS AN
AGENCY OF THE PUBLIC HEALTH SERVICE.

``(a) Establishment.--
``(1) In general.--In order to more effectively and
efficiently carry out the responsibilities, authorities, and
functions of the United States to provide health care
services to Indians and Indian Tribes, as are or may be
hereafter provided by Federal statute or treaties, there is
established within the Public Health Service of the
Department the Indian Health Service.
``(2) Assistant secretary of indian health.--The Service
shall be administered by an Assistant Secretary of Indian
Health, who shall be appointed by the President, by and with
the advice and consent of the Senate. The Assistant Secretary
shall report to the Secretary. Effective with respect to an
individual appointed by the President, by and with the advice
and consent of the Senate, after January 1, 2010, the term of
service of the Assistant Secretary shall be 4 years. An
Assistant Secretary may serve more than 1 term.
``(3) Incumbent.--The individual serving in the position of
Director of the Service on the day before the date of
enactment of the Indian Health Care Improvement Act
Amendments of 2009 shall serve as Assistant Secretary.
``(4) Advocacy and consultation.--The position of Assistant
Secretary is established to, in a manner consistent with the
government-to-government relationship between the United
States and Indian Tribes--
``(A) facilitate advocacy for the development of
appropriate Indian health policy; and
``(B) promote consultation on matters relating to Indian
health.
``(b) Agency.--The Service shall be an agency within the
Public Health Service of the Department, and shall not be an
office, component, or unit of any other agency of the
Department.
``(c) Duties.--The Assistant Secretary shall--
``(1) perform all functions that were, on the day before
the date of enactment of the Indian Health Care Improvement
Act Amendments of 2009, carried out by or under the direction
of the individual serving as Director of the Service on that
day;
``(2) perform all functions of the Secretary relating to
the maintenance and operation of hospital and health
facilities for Indians and the planning for, and provision
and utilization of, health services for Indians;
``(3) administer all health programs under which health
care is provided to Indians based upon their status as
Indians which are administered by the Secretary, including
programs under--
``(A) this Act;
``(B) the Act of November 2, 1921 (25 U.S.C. 13);
``(C) the Act of August 5, 1954 (42 U.S.C. 2001 et seq.);
``(D) the Act of August 16, 1957 (42 U.S.C. 2005 et seq.);
and
``(E) the Indian Self-Determination and Education
Assistance Act (25 U.S.C. 450 et seq.);
``(4) administer all scholarship and loan functions carried
out under title I;
``(5) report directly to the Secretary concerning all
policy- and budget-related matters affecting Indian health;
``(6) collaborate with the Assistant Secretary for Health
concerning appropriate matters of Indian health that affect
the agencies of the Public Health Service;
``(7) advise each Assistant Secretary of the Department
concerning matters of Indian health with respect to which
that Assistant Secretary has authority and responsibility;
``(8) advise the heads of other agencies and programs of
the Department concerning matters of Indian health with
respect to which those heads have authority and
responsibility;
``(9) coordinate the activities of the Department
concerning matters of Indian health; and
``(10) perform such other functions as the Secretary may
designate.
``(d) Authority.--
``(1) In general.--The Secretary, acting through the
Assistant Secretary, shall have the authority--
``(A) except to the extent provided for in paragraph (2),
to appoint and compensate employees for the Service in
accordance with title 5, United States Code;
``(B) to enter into contracts for the procurement of goods
and services to carry out the functions of the Service; and
``(C) to manage, expend, and obligate all funds
appropriated for the Service.
``(2) Personnel actions.--Notwithstanding any other
provision of law, the provisions of section 12 of the Act of
June 18, 1934 (48 Stat. 986; 25 U.S.C. 472), shall apply to
all personnel actions taken with respect to new positions
created within the Service as a result of its establishment
under subsection (a).
``(e) References.--Any reference to the Director of the
Indian Health Service in any other Federal law, Executive
order, rule, regulation, or delegation of authority, or in
any document of or relating to the Director of the Indian
Health Service, shall be deemed to refer to the Assistant
Secretary.

``SEC. 602. AUTOMATED MANAGEMENT INFORMATION SYSTEM.

``(a) Establishment.--
``(1) In general.--The Secretary shall establish an
automated management information system for the Service.
``(2) Requirements of system.--The information system
established under paragraph (1) shall include--
``(A) a financial management system;
``(B) a patient care information system for each area
served by the Service;
``(C) privacy protections consistent with the regulations
promulgated under section 264(c) of the Health Insurance
Portability and Accountability Act of 1996 or, to the extent
consistent with such regulations, other Federal rules
applicable to privacy of automated management information
systems of a Federal agency;
``(D) a services-based cost accounting component that
provides estimates of the costs associated with the provision
of specific medical treatments or services in each Area
office of the Service;
``(E) an interface mechanism for patient billing and
accounts receivable system; and
``(F) a training component.
``(b) Provision of Systems to Tribes and Organizations.--
The Secretary shall provide each Tribal Health Program
automated management information systems which--
``(1) meet the management information needs of such Tribal
Health Program with respect to the treatment by the Tribal
Health Program of patients of the Service; and
``(2) meet the management information needs of the Service.
``(c) Access to Records.--The Service shall provide access
of patients to their medical or health records which are held
by, or on behalf of, the Service in accordance with the
regulations promulgated under section 264(c) of the Health
Insurance Portability and Accountability Act of 1996 or, to
the extent consistent with such regulations, other Federal
rules applicable to access to health care records.
``(d) Authority To Enhance Information Technology.--The
Secretary, acting through the Assistant Secretary, shall have
the authority to enter into contracts, agreements, or joint
ventures with other Federal agencies, States, private and
nonprofit organizations, for the purpose of enhancing
information technology in Indian Health Programs and
facilities.

``SEC. 603. AUTHORIZATION OF APPROPRIATIONS.

``There is authorized to be appropriated such sums as may
be necessary to carry out this title.

``TITLE VII--BEHAVIORAL HEALTH PROGRAMS

``SEC. 701. BEHAVIORAL HEALTH PREVENTION AND TREATMENT
SERVICES.

``(a) Purposes.--The purposes of this section are as
follows:
``(1) To authorize and direct the Secretary, acting through
the Service, to develop a comprehensive behavioral health
prevention and treatment program which emphasizes
collaboration among alcohol and substance abuse, social
services, and mental health programs.

[[Page H12823]]

``(2) To provide information, direction, and guidance
relating to mental illness and dysfunction and self-
destructive behavior, including child abuse and family
violence, to those Federal, tribal, State, and local agencies
responsible for programs in Indian communities in areas of
health care, education, social services, child and family
welfare, alcohol and substance abuse, law enforcement, and
judicial services.
``(3) To assist Indian Tribes to identify services and
resources available to address mental illness and
dysfunctional and self-destructive behavior.
``(4) To provide authority and opportunities for Indian
Tribes and Tribal Organizations to develop, implement, and
coordinate with community-based programs which include
identification, prevention, education, referral, and
treatment services, including through multidisciplinary
resource teams.
``(5) To ensure that Indians, as citizens of the United
States and of the States in which they reside, have the same
access to behavioral health services to which all citizens
have access.
``(6) To modify or supplement existing programs and
authorities in the areas identified in paragraph (2).
``(b) Plans.--
``(1) Development.--The Secretary, acting through the
Service, shall encourage Indian Tribes and Tribal
Organizations to develop tribal plans, and urban Indian
organizations to develop local plans, and for all such groups
to participate in developing areawide plans for Indian
Behavioral Health Services. The plans shall include, to the
extent feasible, the following components:
``(A) An assessment of the scope of alcohol or other
substance abuse, mental illness, and dysfunctional and self-
destructive behavior, including suicide, child abuse, and
family violence, among Indians, including--
``(i) the number of Indians served who are directly or
indirectly affected by such illness or behavior; or
``(ii) an estimate of the financial and human cost
attributable to such illness or behavior.
``(B) An assessment of the existing and additional
resources necessary for the prevention and treatment of such
illness and behavior, including an assessment of the progress
toward achieving the availability of the full continuum of
care described in subsection (c).
``(C) An estimate of the additional funding needed by the
Service, Indian Tribes, Tribal Organizations, and urban
Indian organizations to meet their responsibilities under the
plans.
``(2) National clearinghouse.--The Secretary, acting
through the Service, shall coordinate with existing national
clearinghouses and information centers to include at the
clearinghouses and centers plans and reports on the outcomes
of such plans developed by Indian Tribes, Tribal
Organizations, urban Indian organizations, and Service Areas
relating to behavioral health. The Secretary shall ensure
access to these plans and outcomes by any Indian Tribe,
Tribal Organization, urban Indian organization, or the
Service.
``(3) Technical assistance.--The Secretary shall provide
technical assistance to Indian Tribes, Tribal Organizations,
and urban Indian organizations in preparation of plans under
this section and in developing standards of care that may be
used and adopted locally.
``(c) Programs.--The Secretary, acting through the Service,
shall provide, to the extent feasible and if funding is
available, programs including the following:
``(1) Comprehensive care.--A comprehensive continuum of
behavioral health care which provides--
``(A) community-based prevention, intervention, outpatient,
and behavioral health aftercare;
``(B) detoxification (social and medical);
``(C) acute hospitalization;
``(D) intensive outpatient/day treatment;
``(E) residential treatment;
``(F) transitional living for those needing a temporary,
stable living environment that is supportive of treatment and
recovery goals;
``(G) emergency shelter;
``(H) intensive case management; and
``(I) diagnostic services.
``(2) Child care.--Behavioral health services for Indians
from birth through age 17, including--
``(A) preschool and school age fetal alcohol disorder
services, including assessment and behavioral intervention;
``(B) mental health and substance abuse services
(emotional, organic, alcohol, drug, inhalant, and tobacco);
``(C) identification and treatment of co-occurring
disorders and comorbidity;
``(D) prevention of alcohol, drug, inhalant, and tobacco
use;
``(E) early intervention, treatment, and aftercare;
``(F) promotion of healthy approaches to risk and safety
issues; and
``(G) identification and treatment of neglect and physical,
mental, and sexual abuse.
``(3) Adult care.--Behavioral health services for Indians
from age 18 through 55, including--
``(A) early intervention, treatment, and aftercare;
``(B) mental health and substance abuse services
(emotional, alcohol, drug, inhalant, and tobacco), including
sex specific services;
``(C) identification and treatment of co-occurring
disorders (dual diagnosis) and comorbidity;
``(D) promotion of healthy approaches for risk-related
behavior;
``(E) treatment services for women at risk of giving birth
to a child with a fetal alcohol disorder; and
``(F) sex specific treatment for sexual assault and
domestic violence.
``(4) Family care.--Behavioral health services for
families, including--
``(A) early intervention, treatment, and aftercare for
affected families;
``(B) treatment for sexual assault and domestic violence;
and
``(C) promotion of healthy approaches relating to
parenting, domestic violence, and other abuse issues.
``(5) Elder care.--Behavioral health services for Indians
56 years of age and older, including--
``(A) early intervention, treatment, and aftercare;
``(B) mental health and substance abuse services
(emotional, alcohol, drug, inhalant, and tobacco), including
sex specific services;
``(C) identification and treatment of co-occurring
disorders (dual diagnosis) and comorbidity;
``(D) promotion of healthy approaches to managing
conditions related to aging;
``(E) sex specific treatment for sexual assault, domestic
violence, neglect, physical and mental abuse and
exploitation; and
``(F) identification and treatment of dementias regardless
of cause.
``(d) Community Behavioral Health Plan.--
``(1) Establishment.--The governing body of any Indian
Tribe, Tribal Organization, or urban Indian organization may
adopt a resolution for the establishment of a community
behavioral health plan providing for the identification and
coordination of available resources and programs to identify,
prevent, or treat substance abuse, mental illness, or
dysfunctional and self-destructive behavior, including child
abuse and family violence, among its members or its service
population. This plan should include behavioral health
services, social services, intensive outpatient services, and
continuing aftercare.
``(2) Technical assistance.--At the request of an Indian
Tribe, Tribal Organization, or urban Indian organization, the
Bureau of Indian Affairs and the Service shall cooperate with
and provide technical assistance to the Indian Tribe, Tribal
Organization, or urban Indian organization in the development
and implementation of such plan.
``(3) Funding.--The Secretary, acting through the Service,
may make funding available to Indian Tribes and Tribal
Organizations which adopt a resolution pursuant to paragraph
(1) to obtain technical assistance for the development of a
community behavioral health plan and to provide
administrative support in the implementation of such plan.
``(e) Coordination for Availability of Services.--The
Secretary, acting through the Service, shall coordinate
behavioral health planning, to the extent feasible, with
other Federal agencies and with State agencies, to encourage
comprehensive behavioral health services for Indians
regardless of their place of residence.
``(f) Mental Health Care Need Assessment.--Not later than 1
year after the date of enactment of the Indian Health Care
Improvement Act Amendments of 2009, the Secretary, acting
through the Service, shall make an assessment of the need for
inpatient mental health care among Indians and the
availability and cost of inpatient mental health facilities
which can meet such need. In making such assessment, the
Secretary shall consider the possible conversion of existing,
underused Service hospital beds into psychiatric units to
meet such need.

``SEC. 702. MEMORANDA OF AGREEMENT WITH THE DEPARTMENT OF THE
INTERIOR.

``(a) Contents.--Not later than 12 months after the date of
enactment of the Indian Health Care Improvement Act
Amendments of 2009, the Secretary, acting through the
Service, and the Secretary of the Interior shall develop and
enter into a memoranda of agreement, or review and update any
existing memoranda of agreement, as required by section 4205
of the Indian Alcohol and Substance Abuse Prevention and
Treatment Act of 1986 (25 U.S.C. 2411) under which the
Secretaries address the following:
``(1) The scope and nature of mental illness and
dysfunctional and self-destructive behavior, including child
abuse and family violence, among Indians.
``(2) The existing Federal, tribal, State, local, and
private services, resources, and programs available to
provide behavioral health services for Indians.
``(3) The unmet need for additional services, resources,
and programs necessary to meet the needs identified pursuant
to paragraph (1).
``(4)(A) The right of Indians, as citizens of the United
States and of the States in which they reside, to have access
to behavioral health services to which all citizens have
access.
``(B) The right of Indians to participate in, and receive
the benefit of, such services.
``(C) The actions necessary to protect the exercise of such
right.
``(5) The responsibilities of the Bureau of Indian Affairs
and the Service, including mental illness identification,
prevention, education, referral, and treatment services
(including services through multidisciplinary resource
teams), at the central, area,

[[Page H12824]]

and agency and Service Unit, Service Area, and headquarters
levels to address the problems identified in paragraph (1).
``(6) A strategy for the comprehensive coordination of the
behavioral health services provided by the Bureau of Indian
Affairs and the Service to meet the problems identified
pursuant to paragraph (1), including--
``(A) the coordination of alcohol and substance abuse
programs of the Service, the Bureau of Indian Affairs, and
Indian Tribes and Tribal Organizations (developed under the
Indian Alcohol and Substance Abuse Prevention and Treatment
Act of 1986 (25 U.S.C. 2401 et seq.)) with behavioral health
initiatives pursuant to this Act, particularly with respect
to the referral and treatment of dually diagnosed individuals
requiring behavioral health and substance abuse treatment;
and
``(B) ensuring that the Bureau of Indian Affairs and
Service programs and services (including multidisciplinary
resource teams) addressing child abuse and family violence
are coordinated with such non-Federal programs and services.
``(7) Directing appropriate officials of the Bureau of
Indian Affairs and the Service, particularly at the agency
and Service Unit levels, to cooperate fully with tribal
requests made pursuant to community behavioral health plans
adopted under section 701(c) and section 4206 of the Indian
Alcohol and Substance Abuse Prevention and Treatment Act of
1986 (25 U.S.C. 2412).
``(8) Providing for an annual review of such agreement by
the Secretaries which shall be provided to Congress and
Indian Tribes and Tribal Organizations.
``(b) Specific Provisions Required.--The memoranda of
agreement updated or entered into pursuant to subsection (a)
shall include specific provisions pursuant to which the
Service shall assume responsibility for--
``(1) the determination of the scope of the problem of
alcohol and substance abuse among Indians, including the
number of Indians within the jurisdiction of the Service who
are directly or indirectly affected by alcohol and substance
abuse and the financial and human cost;
``(2) an assessment of the existing and needed resources
necessary for the prevention of alcohol and substance abuse
and the treatment of Indians affected by alcohol and
substance abuse; and
``(3) an estimate of the funding necessary to adequately
support a program of prevention of alcohol and substance
abuse and treatment of Indians affected by alcohol and
substance abuse.
``(c) Publication.--Each memorandum of agreement entered
into or renewed (and amendments or modifications thereto)
under subsection (a) shall be published in the Federal
Register. At the same time as publication in the Federal
Register, the Secretary shall provide a copy of such
memoranda, amendment, or modification to each Indian Tribe,
Tribal Organization, and urban Indian organization.

``SEC. 703. COMPREHENSIVE BEHAVIORAL HEALTH PREVENTION AND
TREATMENT PROGRAM.

``(a) Establishment.--
``(1) In general.--The Secretary, acting through the
Service, shall provide a program of comprehensive behavioral
health, prevention, treatment, and aftercare, including
Systems of Care, which shall include--
``(A) prevention, through educational intervention, in
Indian communities;
``(B) acute detoxification, psychiatric hospitalization,
residential, and intensive outpatient treatment;
``(C) community-based rehabilitation and aftercare;
``(D) community education and involvement, including
extensive training of health care, educational, and
community-based personnel;
``(E) specialized residential treatment programs for high-
risk populations, including pregnant and postpartum women and
their children; and
``(F) diagnostic services.
``(2) Target populations.--The target population of such
programs shall be members of Indian Tribes. Efforts to train
and educate key members of the Indian community shall also
target employees of health, education, judicial, law
enforcement, legal, and social service programs.
``(b) Contract Health Services.--
``(1) In general.--The Secretary, acting through the
Service, may enter into contracts with public or private
providers of behavioral health treatment services for the
purpose of carrying out the program required under subsection
(a).
``(2) Provision of assistance.--In carrying out this
subsection, the Secretary shall provide assistance to Indian
Tribes and Tribal Organizations to develop criteria for the
certification of behavioral health service providers and
accreditation of service facilities which meet minimum
standards for such services and facilities.

``SEC. 704. MENTAL HEALTH TECHNICIAN PROGRAM.

``(a) In General.--Under the authority of the Act of
November 2, 1921 (25 U.S.C. 13) (commonly known as the
`Snyder Act'), the Secretary shall establish and maintain a
mental health technician program within the Service which--
``(1) provides for the training of Indians as mental health
technicians; and
``(2) employs such technicians in the provision of
community-based mental health care that includes
identification, prevention, education, referral, and
treatment services.
``(b) Paraprofessional Training.--In carrying out
subsection (a), the Secretary, acting through the Service,
shall provide high-standard paraprofessional training in
mental health care necessary to provide quality care to the
Indian communities to be served. Such training shall be based
upon a curriculum developed or approved by the Secretary
which combines education in the theory of mental health care
with supervised practical experience in the provision of such
care.
``(c) Supervision and Evaluation of Technicians.--The
Secretary, acting through the Service, shall supervise and
evaluate the mental health technicians in the training
program.
``(d) Traditional Health Care Practices.--The Secretary,
acting through the Service, shall ensure that the program
established pursuant to this subsection involves the use and
promotion of the traditional health care practices of the
Indian Tribes to be served.

``SEC. 705. LICENSING REQUIREMENT FOR MENTAL HEALTH CARE
WORKERS.

``(a) In General.--Subject to the provisions of section
221, and except as provided in subsection (b), any individual
employed as a psychologist, social worker, or marriage and
family therapist for the purpose of providing mental health
care services to Indians in a clinical setting under this Act
is required to be licensed as a psychologist, social worker,
or marriage and family therapist, respectively.
``(b) Trainees.--An individual may be employed as a trainee
in psychology, social work, or marriage and family therapy to
provide mental health care services described in subsection
(a) if such individual--
``(1) works under the direct supervision of a licensed
psychologist, social worker, or marriage and family
therapist, respectively;
``(2) is enrolled in or has completed at least 2 years of
course work at a post-secondary, accredited education program
for psychology, social work, marriage and family therapy, or
counseling; and
``(3) meets such other training, supervision, and quality
review requirements as the Secretary may establish.

``SEC. 706. INDIAN WOMEN TREATMENT PROGRAMS.

``(a) Grants.--The Secretary, consistent with section 701,
may make grants to Indian Tribes, Tribal Organizations, and
urban Indian organizations to develop and implement a
comprehensive behavioral health program of prevention,
intervention, treatment, and relapse prevention services that
specifically addresses the cultural, historical, social, and
child care needs of Indian women, regardless of age.
``(b) Use of Grant Funds.--A grant made pursuant to this
section may be used to--
``(1) develop and provide community training, education,
and prevention programs for Indian women relating to
behavioral health issues, including fetal alcohol disorders;
``(2) identify and provide psychological services,
counseling, advocacy, support, and relapse prevention to
Indian women and their families; and
``(3) develop prevention and intervention models for Indian
women which incorporate traditional health care practices,
cultural values, and community and family involvement.
``(c) Criteria.--The Secretary, in consultation with Indian
Tribes and Tribal Organizations, shall establish criteria for
the review and approval of applications and proposals for
funding under this section.
``(d) Allocation of Funds for Urban Indian Organizations.--
Twenty percent of the funds appropriated pursuant to this
section shall be used to make grants to urban Indian
organizations.

``SEC. 707. INDIAN YOUTH PROGRAM.

``(a) Detoxification and Rehabilitation.--The Secretary,
acting through the Service, consistent with section 701,
shall develop and implement a program for acute
detoxification and treatment for Indian youths, including
behavioral health services. The program shall include
regional treatment centers designed to include detoxification
and rehabilitation for both sexes on a referral basis and
programs developed and implemented by Indian Tribes or Tribal
Organizations at the local level under the Indian Self-
Determination and Education Assistance Act (25 U.S.C. 450 et
seq.). Regional centers shall be integrated with the intake
and rehabilitation programs based in the referring Indian
community.
``(b) Alcohol and Substance Abuse Treatment Centers or
Facilities.--
``(1) Establishment.--
``(A) In general.--The Secretary, acting through the
Service, shall construct, renovate, or, as necessary,
purchase, and appropriately staff and operate, at least 1
youth regional treatment center or treatment network in each
area under the jurisdiction of an Area Office.
``(B) Area office in california.--For the purposes of this
subsection, the Area Office in California shall be considered
to be 2 Area Offices, 1 office whose jurisdiction shall be
considered to encompass the northern area of the State of
California, and 1 office whose jurisdiction shall be
considered to encompass the remainder of the State of
California for the purpose of implementing California
treatment networks.
``(2) Funding.--For the purpose of staffing and operating
such centers or facilities, funding shall be pursuant to the
Act of November 2, 1921 (25 U.S.C. 13).

[[Page H12825]]

``(3) Location.--A youth treatment center constructed or
purchased under this subsection shall be constructed or
purchased at a location within the area described in
paragraph (1) agreed upon (by appropriate tribal resolution)
by a majority of the Indian Tribes to be served by such
center.
``(4) Specific provision of funds.--
``(A) In general.--Notwithstanding any other provision of
this title, the Secretary may, from amounts authorized to be
appropriated for the purposes of carrying out this section,
make funds available to--
``(i) the Tanana Chiefs Conference, Incorporated, for the
purpose of leasing, constructing, renovating, operating, and
maintaining a residential youth treatment facility in
Fairbanks, Alaska; and
``(ii) the Southeast Alaska Regional Health Corporation to
staff and operate a residential youth treatment facility
without regard to the proviso set forth in section 4(l) of
the Indian Self-Determination and Education Assistance Act
(25 U.S.C. 450b(l)).
``(B) Provision of services to eligible youths.--Until
additional residential youth treatment facilities are
established in Alaska pursuant to this section, the
facilities specified in subparagraph (A) shall make every
effort to provide services to all eligible Indian youths
residing in Alaska.
``(c) Intermediate Adolescent Behavioral Health Services.--
``(1) In general.--The Secretary, acting through the
Service, may provide intermediate behavioral health services,
which may incorporate Systems of Care, to Indian children and
adolescents, including--
``(A) pretreatment assistance;
``(B) inpatient, outpatient, and aftercare services;
``(C) emergency care;
``(D) suicide prevention and crisis intervention; and
``(E) prevention and treatment of mental illness and
dysfunctional and self-destructive behavior, including child
abuse and family violence.
``(2) Use of funds.--Funds provided under this subsection
may be used--
``(A) to construct or renovate an existing health facility
to provide intermediate behavioral health services;
``(B) to hire behavioral health professionals;
``(C) to staff, operate, and maintain an intermediate
mental health facility, group home, sober housing,
transitional housing or similar facilities, or youth shelter
where intermediate behavioral health services are being
provided;
``(D) to make renovations and hire appropriate staff to
convert existing hospital beds into adolescent psychiatric
units; and
``(E) for intensive home- and community-based services.
``(3) Criteria.--The Secretary, acting through the Service,
shall, in consultation with Indian Tribes and Tribal
Organizations, establish criteria for the review and approval
of applications or proposals for funding made available
pursuant to this subsection.
``(d) Federally Owned Structures.--
``(1) In general.--The Secretary, in consultation with
Indian Tribes and Tribal Organizations, shall--
``(A) identify and use, where appropriate, federally owned
structures suitable for local residential or regional
behavioral health treatment for Indian youths; and
``(B) establish guidelines for determining the suitability
of any such federally owned structure to be used for local
residential or regional behavioral health treatment for
Indian youths.
``(2) Terms and conditions for use of structure.--Any
structure described in paragraph (1) may be used under such
terms and conditions as may be agreed upon by the Secretary
and the agency having responsibility for the structure and
any Indian Tribe or Tribal Organization operating the
program.
``(e) Rehabilitation and Aftercare Services.--
``(1) In general.--The Secretary, Indian Tribes, or Tribal
Organizations, in cooperation with the Secretary of the
Interior, shall develop and implement within each Service
Unit, community-based rehabilitation and follow-up services
for Indian youths who are having significant behavioral
health problems, and require long-term treatment, community
reintegration, and monitoring to support the Indian youths
after their return to their home community.
``(2) Administration.--Services under paragraph (1) shall
be provided by trained staff within the community who can
assist the Indian youths in their continuing development of
self-image, positive problem-solving skills, and nonalcohol
or substance abusing behaviors. Such staff may include
alcohol and substance abuse counselors, mental health
professionals, and other health professionals and
paraprofessionals, including community health
representatives.
``(f) Inclusion of Family in Youth Treatment Program.--In
providing the treatment and other services to Indian youths
authorized by this section, the Secretary, acting through the
Service, shall provide for the inclusion of family members of
such youths in the treatment programs or other services as
may be appropriate. Not less than 10 percent of the funds
appropriated for the purposes of carrying out subsection (e)
shall be used for outpatient care of adult family members
related to the treatment of an Indian youth under that
subsection.
``(g) Multidrug Abuse Program.--The Secretary, acting
through the Service, shall provide, consistent with section
701, programs and services to prevent and treat the abuse of
multiple forms of substances, including alcohol, drugs,
inhalants, and tobacco, among Indian youths residing in
Indian communities, on or near reservations, and in urban
areas and provide appropriate mental health services to
address the incidence of mental illness among such youths.
``(h) Indian Youth Mental Health.--The Secretary, acting
through the Service, shall collect data for the report under
section 801 with respect to--
``(1) the number of Indian youth who are being provided
mental health services through the Service and Tribal Health
Programs;
``(2) a description of, and costs associated with, the
mental health services provided for Indian youth through the
Service and Tribal Health Programs;
``(3) the number of youth referred to the Service or Tribal
Health Programs for mental health services;
``(4) the number of Indian youth provided residential
treatment for mental health and behavioral problems through
the Service and Tribal Health Programs, reported separately
for on- and off-reservation facilities; and
``(5) the costs of the services described in paragraph (4).

``SEC. 708. INDIAN YOUTH TELEMENTAL HEALTH DEMONSTRATION
PROJECT.

``(a) Purpose.--The purpose of this section is to authorize
the Secretary to carry out a demonstration project to test
the use of telemental health services in suicide prevention,
intervention and treatment of Indian youth, including
through--
``(1) the use of psychotherapy, psychiatric assessments,
diagnostic interviews, therapies for mental health conditions
predisposing to suicide, and alcohol and substance abuse
treatment;
``(2) the provision of clinical expertise to, consultation
services with, and medical advice and training for frontline
health care providers working with Indian youth;
``(3) training and related support for community leaders,
family members and health and education workers who work with
Indian youth;
``(4) the development of culturally relevant educational
materials on suicide; and
``(5) data collection and reporting.
``(b) Definitions.--For the purpose of this section, the
following definitions shall apply:
``(1) Demonstration project.--The term `demonstration
project' means the Indian youth telemental health
demonstration project authorized under subsection (c).
``(2) Telemental health.--The term `telemental health'
means the use of electronic information and
telecommunications technologies to support long distance
mental health care, patient and professional-related
education, public health, and health administration.
``(c) Authorization.--
``(1) In general.--The Secretary is authorized to award
grants under the demonstration project for the provision of
telemental health services to Indian youth who--
``(A) have expressed suicidal ideas;
``(B) have attempted suicide; or
``(C) have mental health conditions that increase or could
increase the risk of suicide.
``(2) Eligibility for grants.--Such grants shall be awarded
to Indian Tribes and Tribal Organizations that operate 1 or
more facilities--
``(A) located in Alaska and part of the Alaska Federal
Health Care Access Network;
``(B) reporting active clinical telehealth capabilities; or
``(C) offering school-based telemental health services
relating to psychiatry to Indian youth.
``(3) Grant period.--The Secretary shall award grants under
this section for a period of up to 4 years.
``(4) Awarding of grants.--Not more than 5 grants shall be
provided under paragraph (1), with priority consideration
given to Indian Tribes and Tribal Organizations that--
``(A) serve a particular community or geographic area where
there is a demonstrated need to address Indian youth suicide;
``(B) enter in to collaborative partnerships with Indian
Health Service or Tribal Health Programs or facilities to
provide services under this demonstration project;
``(C) serve an isolated community or geographic area which
has limited or no access to behavioral health services; or
``(D) operate a detention facility at which Indian youth
are detained.
``(d) Use of Funds.--
``(1) In general.--An Indian Tribe or Tribal Organization
shall use a grant received under subsection (c) for the
following purposes:
``(A) To provide telemental health services to Indian
youth, including the provision of--
``(i) psychotherapy;
``(ii) psychiatric assessments and diagnostic interviews,
therapies for mental health conditions predisposing to
suicide, and treatment; and
``(iii) alcohol and substance abuse treatment.
``(B) To provide clinician-interactive medical advice,
guidance and training, assistance in diagnosis and
interpretation, crisis counseling and intervention, and
related assistance to Service, tribal, or urban clinicians
and health services providers working with youth being served
under this demonstration project.
``(C) To assist, educate and train community leaders,
health education professionals

[[Page H12826]]

and paraprofessionals, tribal outreach workers, and family
members who work with the youth receiving telemental health
services under this demonstration project, including with
identification of suicidal tendencies, crisis intervention
and suicide prevention, emergency skill development, and
building and expanding networks among these individuals and
with State and local health services providers.
``(D) To develop and distribute culturally appropriate
community educational materials on--
``(i) suicide prevention;
``(ii) suicide education;
``(iii) suicide screening;
``(iv) suicide intervention; and
``(v) ways to mobilize communities with respect to the
identification of risk factors for suicide.
``(E) For data collection and reporting related to Indian
youth suicide prevention efforts.
``(2) Traditional health care practices.--In carrying out
the purposes described in paragraph (1), an Indian Tribe or
Tribal Organization may use and promote the traditional
health care practices of the Indian Tribes of the youth to be
served.
``(e) Applications.--To be eligible to receive a grant
under subsection (c), an Indian Tribe or Tribal Organization
shall prepare and submit to the Secretary an application, at
such time, in such manner, and containing such information as
the Secretary may require, including--
``(1) a description of the project that the Indian Tribe or
Tribal Organization will carry out using the funds provided
under the grant;
``(2) a description of the manner in which the project
funded under the grant would--
``(A) meet the telemental health care needs of the Indian
youth population to be served by the project; or
``(B) improve the access of the Indian youth population to
be served to suicide prevention and treatment services;
``(3) evidence of support for the project from the local
community to be served by the project;
``(4) a description of how the families and leadership of
the communities or populations to be served by the project
would be involved in the development and ongoing operations
of the project;
``(5) a plan to involve the tribal community of the youth
who are provided services by the project in planning and
evaluating the mental health care and suicide prevention
efforts provided, in order to ensure the integration of
community, clinical, environmental, and cultural components
of the treatment; and
``(6) a plan for sustaining the project after Federal
assistance for the demonstration project has terminated.
``(f) Collaboration; Reporting to National Clearinghouse.--
``(1) Collaboration.--The Secretary, acting through the
Service, shall encourage Indian Tribes and Tribal
Organizations receiving grants under this section to
collaborate to enable comparisons about best practices across
projects.
``(2) Reporting to national clearinghouse.--The Secretary,
acting through the Service, shall also encourage Indian
Tribes and Tribal Organizations receiving grants under this
section to submit relevant, declassified project information
to the national clearinghouse authorized under section
701(b)(2) in order to better facilitate program performance
and improve suicide prevention, intervention, and treatment
services.
``(g) Annual Report.--Each grant recipient shall submit to
the Secretary an annual report that--
``(1) describes the number of telemental health services
provided; and
``(2) includes any other information that the Secretary may
require.
``(h) Report to Congress.--Not later than 270 days after
the termination of the demonstration project, the Secretary
shall submit to the Committee on Indian Affairs of the Senate
and the Committee on Natural Resources and Committee on
Energy and Commerce of the House of Representatives a final
report, based on the annual reports provided by grant
recipients under subsection (h), that--
``(1) describes the results of the projects funded by
grants awarded under this section, including any data
available which indicates the number of attempted suicides;
``(2) evaluates the impact of the telemental health
services funded by the grants in reducing the number of
completed suicides among Indian youth;
``(3) evaluates whether the demonstration project should
be--
``(A) expanded to provide more than 5 grants; and
``(B) designated a permanent program; and
``(4) evaluates the benefits of expanding the demonstration
project to include urban Indian organizations.
``(i) Authorization of Appropriations.--There is authorized
to be appropriated such sums as may be necessary to carry out
this section.

``SEC. 709. INPATIENT AND COMMUNITY-BASED MENTAL HEALTH
FACILITIES DESIGN, CONSTRUCTION, AND STAFFING.

``Not later than 1 year after the date of enactment of the
Indian Health Care Improvement Act Amendments of 2009, the
Secretary, acting through the Service, may provide, in each
area of the Service, not less than 1 inpatient mental health
care facility, or the equivalent, for Indians with behavioral
health problems. For the purposes of this subsection,
California shall be considered to be 2 Area Offices, 1 office
whose location shall be considered to encompass the northern
area of the State of California and 1 office whose
jurisdiction shall be considered to encompass the remainder
of the State of California. The Secretary shall consider the
possible conversion of existing, underused Service hospital
beds into psychiatric units to meet such need.

``SEC. 710. TRAINING AND COMMUNITY EDUCATION.

``(a) Program.--The Secretary, in cooperation with the
Secretary of the Interior, shall develop and implement or
assist Indian Tribes and Tribal Organizations to develop and
implement, within each Service Unit or tribal program, a
program of community education and involvement which shall be
designed to provide concise and timely information to the
community leadership of each tribal community. Such program
shall include education about behavioral health issues to
political leaders, Tribal judges, law enforcement personnel,
members of tribal health and education boards, health care
providers including traditional practitioners, and other
critical members of each tribal community. Such program may
also include community-based training to develop local
capacity and tribal community provider training for
prevention, intervention, treatment, and aftercare.
``(b) Instruction.--The Secretary, acting through the
Service, shall provide instruction in the area of behavioral
health issues, including instruction in crisis intervention
and family relations in the context of alcohol and substance
abuse, child sexual abuse, youth alcohol and substance abuse,
and the causes and effects of fetal alcohol disorders to
appropriate employees of the Bureau of Indian Affairs and the
Service, and to personnel in schools or programs operated
under any contract with the Bureau of Indian Affairs or the
Service, including supervisors of emergency shelters and
halfway houses described in section 4213 of the Indian
Alcohol and Substance Abuse Prevention and Treatment Act of
1986 (25 U.S.C. 2433).
``(c) Training Models.--In carrying out the education and
training programs required by this section, the Secretary, in
consultation with Indian Tribes, Tribal Organizations, Indian
behavioral health experts, and Indian alcohol and substance
abuse prevention experts, shall develop and provide
community-based training models. Such models shall address--
``(1) the elevated risk of alcohol and behavioral health
problems faced by children of alcoholics;
``(2) the cultural, spiritual, and multigenerational
aspects of behavioral health problem prevention and recovery;
and
``(3) community-based and multidisciplinary strategies,
including Systems of Care, for preventing and treating
behavioral health problems.

``SEC. 711. BEHAVIORAL HEALTH PROGRAM.

``(a) Innovative Programs.--The Secretary, acting through
the Service, consistent with section 701, may plan, develop,
implement, and carry out programs to deliver innovative
community-based behavioral health services to Indians.
``(b) Awards; Criteria.--The Secretary may award a grant
for a project under subsection (a) to an Indian Tribe or
Tribal Organization and may consider the following criteria:
``(1) The project will address significant unmet behavioral
health needs among Indians.
``(2) The project will serve a significant number of
Indians.
``(3) The project has the potential to deliver services in
an efficient and effective manner.
``(4) The Indian Tribe or Tribal Organization has the
administrative and financial capability to administer the
project.
``(5) The project may deliver services in a manner
consistent with traditional health care practices.
``(6) The project is coordinated with, and avoids
duplication of, existing services.
``(c) Equitable Treatment.--For purposes of this
subsection, the Secretary shall, in evaluating project
applications or proposals, use the same criteria that the
Secretary uses in evaluating any other application or
proposal for such funding.

``SEC. 712. FETAL ALCOHOL DISORDER PROGRAMS.

``(a) Programs.--
``(1) Establishment.--The Secretary, consistent with
section 701 and acting through the Service, is authorized to
establish and operate fetal alcohol disorder programs as
provided in this section for the purposes of meeting the
health status objectives specified in section 3.
``(2) Use of funds.--
``(A) In general.--Funding provided pursuant to this
section shall be used for the following:
``(i) To develop and provide for Indians community and in-
school training, education, and prevention programs relating
to fetal alcohol disorders.
``(ii) To identify and provide behavioral health treatment
to high-risk Indian women and high-risk women pregnant with
an Indian's child.

[[Page H12827]]

``(iii) To identify and provide appropriate psychological
services, educational and vocational support, counseling,
advocacy, and information to fetal alcohol disorder affected
Indians and their families or caretakers.
``(iv) To develop and implement counseling and support
programs in schools for fetal alcohol disorder affected
Indian children.
``(v) To develop prevention and intervention models which
incorporate practitioners of traditional health care
practices, cultural values, and community involvement.
``(vi) To develop, print, and disseminate education and
prevention materials on fetal alcohol disorder.
``(vii) To develop and implement, in consultation with
Indian Tribes, Tribal Organizations, and urban Indian
organizations, culturally sensitive assessment and diagnostic
tools including dysmorphology clinics and multidisciplinary
fetal alcohol disorder clinics for use in Indian communities
and Urban Centers.
``(B) Additional uses.--In addition to any purpose under
subparagraph (A), funding provided pursuant to this section
may be used for 1 or more of the following:
``(i) Early childhood intervention projects from birth on
to mitigate the effects of fetal alcohol disorder among
Indians.
``(ii) Community-based support services for Indians and
women pregnant with Indian children.
``(iii) Community-based housing for adult Indians with
fetal alcohol disorder.
``(3) Criteria for applications.--The Secretary shall
establish criteria for the review and approval of
applications for funding under this section.
``(b) Services.--The Secretary, acting through the Service,
shall--
``(1) develop and provide services for the prevention,
intervention, treatment, and aftercare for those affected by
fetal alcohol disorder in Indian communities; and
``(2) provide supportive services, including services to
meet the special educational, vocational, school-to-work
transition, and independent living needs of adolescent and
adult Indians with fetal alcohol disorder.
``(c) Task Force.--The Secretary shall establish a task
force to be known as the Fetal Alcohol Disorder Task Force to
advise the Secretary in carrying out subsection (b). Such
task force shall be composed of representatives from the
following:
``(1) The National Institute on Drug Abuse.
``(2) The National Institute on Alcohol and Alcoholism.
``(3) The Office of Substance Abuse Prevention.
``(4) The National Institute of Mental Health.
``(5) The Service.
``(6) The Office of Minority Health of the Department of
Health and Human Services.
``(7) The Administration for Native Americans.
``(8) The National Institute of Child Health and Human
Development (NICHD).
``(9) The Centers for Disease Control and Prevention.
``(10) The Bureau of Indian Affairs.
``(11) Indian Tribes.
``(12) Tribal Organizations.
``(13) urban Indian organizations.
``(14) Indian fetal alcohol spectrum disorders experts.
``(d) Applied Research Projects.--The Secretary, acting
through the Substance Abuse and Mental Health Services
Administration, shall make grants to Indian Tribes, Tribal
Organizations, and urban Indian organizations for applied
research projects which propose to elevate the understanding
of methods to prevent, intervene, treat, or provide
rehabilitation and behavioral health aftercare for Indians
and urban Indians affected by fetal alcohol spectrum
disorders.
``(e) Funding for Urban Indian Organizations.--Ten percent
of the funds appropriated pursuant to this section shall be
used to make grants to urban Indian organizations funded
under title V.

``SEC. 713. CHILD SEXUAL ABUSE AND PREVENTION TREATMENT
PROGRAMS.

``(a) Establishment.--The Secretary, acting through the
Service, shall establish, consistent with section 701, in
every Service Area, programs involving treatment for--
``(1) victims of sexual abuse who are Indian children or
children in an Indian household; and
``(2) perpetrators of child sexual abuse who are Indian or
members of an Indian household.
``(b) Use of Funds.--Funding provided pursuant to this
section shall be used for the following:
``(1) To develop and provide community education and
prevention programs related to sexual abuse of Indian
children or children in an Indian household.
``(2) To identify and provide behavioral health treatment
to victims of sexual abuse who are Indian children or
children in an Indian household, and to their family members
who are affected by sexual abuse.
``(3) To develop prevention and intervention models which
incorporate traditional health care practices, cultural
values, and community involvement.
``(4) To develop and implement culturally sensitive
assessment and diagnostic tools for use in Indian communities
and Urban Centers.
``(5) To identify and provide behavioral health treatment
to Indian perpetrators and perpetrators who are members of an
Indian household--
``(A) making efforts to begin offender and behavioral
health treatment while the perpetrator is incarcerated or at
the earliest possible date if the perpetrator is not
incarcerated; and
``(B) providing treatment after the perpetrator is
released, until it is determined that the perpetrator is not
a threat to children.
``(c) Coordination.--The programs established under
subsection (a) shall be carried out in coordination with
programs and services authorized under the Indian Child
Protection and Family Violence Prevention Act (25 U.S.C. 3201
et seq.).

``SEC. 714. DOMESTIC AND SEXUAL VIOLENCE PREVENTION AND
TREATMENT.

``(a) In General.--The Secretary, in accordance with
section 701, is authorized to establish in each Service Area
programs involving the prevention and treatment of--
``(1) Indian victims of domestic violence or sexual abuse;
and
``(2) perpetrators of domestic violence or sexual abuse who
are Indian or members of an Indian household.
``(b) Use of Funds.--Funds made available to carry out this
section shall be used--
``(1) to develop and implement prevention programs and
community education programs relating to domestic violence
and sexual abuse;
``(2) to provide behavioral health services, including
victim support services, and medical treatment (including
examinations performed by sexual assault nurse examiners) to
Indian victims of domestic violence or sexual abuse;
``(3) to purchase rape kits;
``(4) to develop prevention and intervention models, which
may incorporate traditional health care practices; and
``(5) to identify and provide behavioral health treatment
to perpetrators who are Indian or members of an Indian
household.
``(c) Training and Certification.--
``(1) In general.--Not later than 1 year after the date of
enactment of the Indian Health Care Improvement Act
Amendments of 2009, the Secretary shall establish appropriate
protocols, policies, procedures, standards of practice, and,
if not available elsewhere, training curricula and training
and certification requirements for services for victims of
domestic violence and sexual abuse.
``(2) Report.--Not later than 18 months after the date of
enactment of the Indian Health Care Improvement Act
Amendments of 2008, the Secretary shall submit to the
Committee on Indian Affairs of the Senate and the Committee
on Natural Resources of the House of Representatives a report
that describes the means and extent to which the Secretary
has carried out paragraph (1).
``(d) Coordination.--
``(1) In general.--The Secretary, in coordination with the
Attorney General, Federal and tribal law enforcement
agencies, Indian Health Programs, and domestic violence or
sexual assault victim organizations, shall develop
appropriate victim services and victim advocate training
programs--
``(A) to improve domestic violence or sexual abuse
responses;
``(B) to improve forensic examinations and collection;
``(C) to identify problems or obstacles in the prosecution
of domestic violence or sexual abuse; and
``(D) to meet other needs or carry out other activities
required to prevent, treat, and improve prosecutions of
domestic violence and sexual abuse.
``(2) Report.--Not later than 2 years after the date of
enactment of the Indian Health Care Improvement Act
Amendments of 2008, the Secretary shall submit to the
Committee on Indian Affairs of the Senate and the Committee
on Natural Resources of the House of Representatives a report
that describes, with respect to the matters described in
paragraph (1), the improvements made and needed, problems or
obstacles identified, and costs necessary to address the
problems or obstacles, and any other recommendations that the
Secretary determines to be appropriate.

``SEC. 715. BEHAVIORAL HEALTH RESEARCH.

``The Secretary, in consultation with appropriate Federal
agencies, shall make grants to, or enter into contracts with,
Indian Tribes, Tribal Organizations, and urban Indian
organizations or enter into contracts with, or make grants to
appropriate institutions for, the conduct of research on the
incidence and prevalence of behavioral health problems among
Indians served by the Service, Indian Tribes, or Tribal
Organizations and among Indians in urban areas. Research
priorities under this section shall include--
``(1) the multifactorial causes of Indian youth suicide,
including--
``(A) protective and risk factors and scientific data that
identifies those factors; and
``(B) the effects of loss of cultural identity and the
development of scientific data on those effects;
``(2) the interrelationship and interdependence of
behavioral health problems with alcoholism and other
substance abuse, suicide, homicides, other injuries, and the
incidence of family violence; and
``(3) the development of models of prevention techniques.
The effect of the interrelationships and interdependencies
referred to in paragraph (2) on children, and the development
of prevention techniques under paragraph (3) applicable to
children, shall be emphasized.

``SEC. 716. DEFINITIONS.

``For the purpose of this title, the following definitions
shall apply:

[[Page H12828]]

``(1) Assessment.--The term `assessment' means the
systematic collection, analysis, and dissemination of
information on health status, health needs, and health
problems.
``(2) Alcohol-related neurodevelopmental disorders or
arnd.--The term `alcohol-related neurodevelopmental
disorders' or `ARND' means, with a history of maternal
alcohol consumption during pregnancy, central nervous system
involvement such as developmental delay, intellectual
deficit, or neurologic abnormalities. Behaviorally, there can
be problems with irritability, and failure to thrive as
infants. As children become older there will likely be
hyperactivity, attention deficit, language dysfunction, and
perceptual and judgment problems.
``(3) Behavioral health aftercare.--The term `behavioral
health aftercare' includes those activities and resources
used to support recovery following inpatient, residential,
intensive substance abuse, or mental health outpatient or
outpatient treatment. The purpose is to help prevent or deal
with relapse by ensuring that by the time a client or patient
is discharged from a level of care, such as outpatient
treatment, an aftercare plan has been developed with the
client. An aftercare plan may use such resources as a
community-based therapeutic group, transitional living
facilities, a 12-step sponsor, a local 12-step or other
related support group, and other community-based providers.
``(4) Dual diagnosis.--The term `dual diagnosis' means
coexisting substance abuse and mental illness conditions or
diagnosis. Such clients are sometimes referred to as mentally
ill chemical abusers (MICAs).
``(5) Fetal alcohol spectrum disorders.--
``(A) In general.--The term `fetal alcohol spectrum
disorders' includes a range of effects that can occur in an
individual whose mother drank alcohol during pregnancy,
including physical, mental, behavioral, and/or learning
disabilities with possible lifelong implications.
``(B) Inclusions.--The term `fetal alcohol spectrum
disorders' may include--
``(i) fetal alcohol syndrome (FAS);
``(ii) fetal alcohol effect (FAE);
``(iii) alcohol-related birth defects; and
``(iv) alcohol-related neurodevelopmental disorders (ARND).
``(6) Fetal alcohol syndrome or fas.--The term `fetal
alcohol syndrome' or `FAS' means any 1 of a spectrum of
effects that may occur when a woman drinks alcohol during
pregnancy, the diagnosis of which involves the confirmed
presence of the following 3 criteria:
``(A) Craniofacial abnormalities.
``(B) Growth deficits.
``(C) Central nervous system abnormalities.
``(7) Rehabilitation.--The term `rehabilitation' means
medical and health care services that--
``(A) are recommended by a physician or licensed
practitioner of the healing arts within the scope of their
practice under applicable law;
``(B) are furnished in a facility, home, or other setting
in accordance with applicable standards; and
``(C) have as their purpose any of the following:
``(i) The maximum attainment of physical, mental, and
developmental functioning.
``(ii) Averting deterioration in physical or mental
functional status.
``(iii) The maintenance of physical or mental health
functional status.
``(8) Substance abuse.--The term `substance abuse' includes
inhalant abuse.
``(9) Systems of care.--The term `Systems of Care' means a
system for delivering services to children and their families
that is child-centered, family-focused and family-driven,
community-based, and culturally competent and responsive to
the needs of the children and families being served. The
systems of care approach values prevention and early
identification, smooth transitions for children and families,
child and family participation and advocacy, comprehensive
array of services, individualized service planning, services
in the least restrictive environment, and integrated services
with coordinated planning across the child-serving systems.

``SEC. 717. AUTHORIZATION OF APPROPRIATIONS.

``There is authorized to be appropriated such sums as may
be necessary to carry out the provisions of this title.

``TITLE VIII--MISCELLANEOUS

``SEC. 801. REPORTS.

``For each fiscal year following the date of enactment of
the Indian Health Care Improvement Act Amendments of 2009,
the Secretary shall transmit to Congress a report containing
the following:
``(1) A report on the progress made in meeting the
objectives of this Act, including a review of programs
established or assisted pursuant to this Act and assessments
and recommendations of additional programs or additional
assistance necessary to, at a minimum, provide health
services to Indians and ensure a health status for Indians,
which are at a parity with the health services available to
and the health status of the general population.
``(2) A report on whether, and to what extent, new national
health care programs, benefits, initiatives, or financing
systems have had an impact on the purposes of this Act and
any steps that the Secretary may have taken to consult with
Indian Tribes, Tribal Organizations, and urban Indian
organizations to address such impact, including a report on
proposed changes in allocation of funding pursuant to section
807.
``(3) A report on the use of health services by Indians--
``(A) on a national and area or other relevant geographical
basis;
``(B) by gender and age;
``(C) by source of payment and type of service;
``(D) comparing such rates of use with rates of use among
comparable non-Indian populations; and
``(E) provided under contracts.
``(4) A report of contractors to the Secretary on Health
Care Educational Loan Repayments every 6 months required by
section 110.
``(5) A general audit report of the Secretary on the Health
Care Educational Loan Repayment Program as required by
section 110(m).
``(6) A report of the findings and conclusions of
demonstration programs on development of educational
curricula for substance abuse counseling as required in
section 125(f).
``(7) A separate statement which specifies the amount of
funds requested to carry out the provisions of section 201.
``(8) A report of the evaluations of health promotion and
disease prevention as required in section 203(c).
``(9) A biennial report to Congress on infectious diseases
as required by section 212.
``(10) A report on environmental and nuclear health hazards
as required by section 215.
``(11) An annual report on the status of all health care
facilities needs as required by section 301(c)(2)(B) and
301(d).
``(12) Reports on safe water and sanitary waste disposal
facilities as required by section 302(h).
``(13) An annual report on the expenditure of non-Service
funds for renovation as required by sections 304(b)(2).
``(14) A report identifying the backlog of maintenance and
repair required at Service and tribal facilities required by
section 313(a).
``(15) A report providing an accounting of reimbursement
funds made available to the Secretary under titles XVIII,
XIX, and XXI of the Social Security Act.
``(16) A report on any arrangements for the sharing of
medical facilities or services, as authorized by section 406.
``(17) A report on evaluation and renewal of urban Indian
programs under section 505.
``(18) A report on the evaluation of programs as required
by section 513(d).
``(19) A report on alcohol and substance abuse as required
by section 701(f).
``(20) A report on Indian youth mental health services as
required by section 707(h).
``(21) A report on the reallocation of base resources if
required by section 807.
``(22) A report on the movement of patients between Service
Units, including--
``(A) a list of those Service Units that have a net
increase and those that have a net decrease of patients due
to patients assigned to one Service Unit voluntarily choosing
to receive service at another Service Unit;
``(B) an analysis of the effect of patient movement on the
quality of services for those Service Units experiencing an
increase in the number of patients served; and
``(C) what funding changes are necessary to maintain a
consistent quality of service at Service Units that have an
increase in the number of patients served.
``(23) A report on the extent to which health care
facilities of the Service, Indian Tribes, Tribal
Organizations, and urban Indian organizations comply with
credentialing requirements of the Service or licensure
requirements of States.

``SEC. 802. REGULATIONS.

``(a) Deadlines.--
``(1) Procedures.--Not later than 90 days after the date of
enactment of the Indian Health Care Improvement Act
Amendments of 2009, the Secretary shall initiate procedures
under subchapter III of chapter 5 of title 5, United States
Code, to negotiate and promulgate such regulations or
amendments thereto that are necessary to carry out this Act,
except sections 105, 115, 117, 202, and 409 through 414. The
Secretary may promulgate regulations to carry out such
sections using the procedures required by chapter 5 of title
5, United States Code (commonly known as the `Administrative
Procedure Act').
``(2) Proposed regulations.--Proposed regulations to
implement this Act shall be published in the Federal Register
by the Secretary no later than 2 years after the date of
enactment of the Indian Health Care Improvement Act
Amendments of 2009 and shall have no less than a 120-day
comment period.
``(3) Final regulations.--The Secretary shall publish in
the Federal Register final regulations to implement this Act
by not later than 3 years after the date of enactment of the
Indian Health Care Improvement Act Amendments of 2009.
``(b) Committee.--A negotiated rulemaking committee
established pursuant to section 565 of title 5, United States
Code, to carry out this section shall have as its members
only representatives of the Federal Government and
representatives of Indian Tribes, and Tribal Organizations, a
majority of whom shall be nominated by and be representatives
of Indian Tribes and Tribal Organizations from each Service
Area.
``(c) Adaptation of Procedures.--The Secretary shall adapt
the negotiated rulemaking procedures to the unique context of

[[Page H12829]]

self-governance and the government-to-government relationship
between the United States and Indian Tribes.
``(d) Lack of Regulations.--The lack of promulgated
regulations shall not limit the effect of this Act.

``SEC. 803. PLAN OF IMPLEMENTATION.

``(a) In General.--Not later than 1 year after the date of
enactment of the Indian Health Care Improvement Act
Amendments of 2009, the Secretary, in consultation with
Indian Tribes, Tribal Organizations, and urban Indian
organizations, shall submit to Congress a plan explaining the
manner and schedule, by title and section, by which the
Secretary will implement the provisions of this Act. This
consultation may be conducted jointly with the annual budget
consultation pursuant to the Indian Self-Determination and
Education Assistance Act (25 U.S.C. 450 et seq.).
``(b) Lack of Plan.--The lack of (or failure to submit)
such a plan shall not limit the effect, or prevent the
implementation, of this Act.

``SEC. 804. LIMITATION ON USE OF FUNDS APPROPRIATED TO INDIAN
HEALTH SERVICE.

``Any limitation on the use of funds contained in an Act
providing appropriations for the Department for a period with
respect to the performance of abortions shall apply for that
period with respect to the performance of abortions using
funds contained in an Act providing appropriations for the
Service.

``SEC. 805. ELIGIBILITY OF CALIFORNIA INDIANS.

``(a) In General.--The following California Indians shall
be eligible for health services provided by the Service:
``(1) Any member of a federally recognized Indian Tribe.
``(2) Any descendant of an Indian who was residing in
California on June 1, 1852, if such descendant--
``(A) is a member of the Indian community served by a local
program of the Service; and
``(B) is regarded as an Indian by the community in which
such descendant lives.
``(3) Any Indian who holds trust interests in public
domain, national forest, or reservation allotments in
California.
``(4) Any Indian in California who is listed on the plans
for distribution of the assets of rancherias and reservations
located within the State of California under the Act of
August 18, 1958 (72 Stat. 619), and any descendant of such an
Indian.
``(b) Clarification.--Nothing in this section may be
construed as expanding the eligibility of California Indians
for health services provided by the Service beyond the scope
of eligibility for such health services that applied on May
1, 1986.

``SEC. 806. HEALTH SERVICES FOR INELIGIBLE PERSONS.

``(a) Children.--Any individual who--
``(1) has not attained 19 years of age;
``(2) is the natural or adopted child, stepchild, foster
child, legal ward, or orphan of an eligible Indian; and
``(3) is not otherwise eligible for health services
provided by the Service,
shall be eligible for all health services provided by the
Service on the same basis and subject to the same rules that
apply to eligible Indians until such individual attains 19
years of age. The existing and potential health needs of all
such individuals shall be taken into consideration by the
Service in determining the need for, or the allocation of,
the health resources of the Service. If such an individual
has been determined to be legally incompetent prior to
attaining 19 years of age, such individual shall remain
eligible for such services until 1 year after the date of a
determination of competency.
``(b) Spouses.--Any spouse of an eligible Indian who is not
an Indian, or who is of Indian descent but is not otherwise
eligible for the health services provided by the Service,
shall be eligible for such health services if all such
spouses or spouses who are married to members of each Indian
Tribe being served are made eligible, as a class, by an
appropriate resolution of the governing body of the Indian
Tribe or Tribal Organization providing such services. The
health needs of persons made eligible under this paragraph
shall not be taken into consideration by the Service in
determining the need for, or allocation of, its health
resources.
``(c) Provision of Services to Other Individuals.--
``(1) In general.--The Secretary is authorized to provide
health services under this subsection through health programs
operated directly by the Service to individuals who reside
within the Service area of the Service Unit and who are not
otherwise eligible for such health services if--
``(A) the Indian Tribes served by such Service Unit request
such provision of health services to such individuals; and
``(B) the Secretary and the served Indian Tribes have
jointly determined that--
``(i) the provision of such health services will not result
in a denial or diminution of health services to eligible
Indians; and
``(ii) there is no reasonable alternative health facilities
or services, within or without the Service Unit, available to
meet the health needs of such individuals.
``(2) ISDEAA programs.--In the case of health programs and
facilities operated under a contract or compact entered into
under the Indian Self-Determination and Education Assistance
Act (25 U.S.C. 450 et seq.), the governing body of the Indian
Tribe or Tribal Organization providing health services under
such contract or compact is authorized to determine whether
health services should be provided under such contract to
individuals who are not eligible for such health services
under any other subsection of this section or under any other
provision of law. In making such determinations, the
governing body of the Indian Tribe or Tribal Organization
shall take into account the considerations described in
paragraph (1)(B).
``(3) Payment for services.--
``(A) In general.--Persons receiving health services
provided by the Service under this subsection shall be liable
for payment of such health services under a schedule of
charges prescribed by the Secretary which, in the judgment of
the Secretary, results in reimbursement in an amount not less
than the actual cost of providing the health services.
Notwithstanding section 404 of this Act or any other
provision of law, amounts collected under this subsection,
including Medicare, Medicaid, or SCHIP reimbursements under
titles XVIII, XIX, and XXI of the Social Security Act, shall
be credited to the account of the program providing the
service and shall be used for the purposes listed in section
401(d)(2) and amounts collected under this subsection shall
be available for expenditure within such program.
``(B) Indigent people.--Health services may be provided by
the Secretary through the Service under this subsection to an
indigent individual who would not be otherwise eligible for
such health services but for the provisions of paragraph (1)
only if an agreement has been entered into with a State or
local government under which the State or local government
agrees to reimburse the Service for the expenses incurred by
the Service in providing such health services to such
indigent individual.
``(4) Revocation of consent for services.--
``(A) Single tribe service area.--In the case of a Service
Area which serves only 1 Indian Tribe, the authority of the
Secretary to provide health services under paragraph (1)
shall terminate at the end of the fiscal year succeeding the
fiscal year in which the governing body of the Indian Tribe
revokes its concurrence to the provision of such health
services.
``(B) Multitribal service area.--In the case of a
multitribal Service Area, the authority of the Secretary to
provide health services under paragraph (1) shall terminate
at the end of the fiscal year succeeding the fiscal year in
which at least 51 percent of the number of Indian Tribes in
the Service Area revoke their concurrence to the provisions
of such health services.
``(d) Other Services.--The Service may provide health
services under this subsection to individuals who are not
eligible for health services provided by the Service under
any other provision of law in order to--
``(1) achieve stability in a medical emergency;
``(2) prevent the spread of a communicable disease or
otherwise deal with a public health hazard;
``(3) provide care to non-Indian women pregnant with an
eligible Indian's child for the duration of the pregnancy
through postpartum; or
``(4) provide care to immediate family members of an
eligible individual if such care is directly related to the
treatment of the eligible individual.
``(e) Hospital Privileges for Practitioners.--
``(1) In general.--Hospital privileges in health facilities
operated and maintained by the Service or operated under a
contract or compact pursuant to the Indian Self-Determination
and Education Assistance Act (25 U.S.C. 450 et seq.) may be
extended to non-Service health care practitioners who provide
services to individuals described in subsection (a), (b),
(c), or (d). Such non-Service health care practitioners may,
as part of the privileging process, be designated as
employees of the Federal Government for purposes of section
1346(b) and chapter 171 of title 28, United States Code
(relating to Federal tort claims) only with respect to acts
or omissions which occur in the course of providing services
to eligible individuals as a part of the conditions under
which such hospital privileges are extended.
``(2) Definition.--For purposes of this subsection, the
term `non-Service health care practitioner' means a
practitioner who is not--
``(A) an employee of the Service; or
``(B) an employee of an Indian tribe or tribal organization
operating a contract or compact under the Indian Self-
Determination and Education Assistance Act or an individual
who provides health care services pursuant to a personal
services contract with such Indian tribe or tribal
organization.
``(f) Eligible Indian.--For purposes of this section, the
term `eligible Indian' means any Indian who is eligible for
health services provided by the Service without regard to the
provisions of this section.

``SEC. 807. REALLOCATION OF BASE RESOURCES.

``(a) Report Required.--Notwithstanding any other provision
of law, any allocation of Service funds for a fiscal year
that reduces by 5 percent or more from the previous fiscal
year the funding for any recurring program, project, or
activity of a Service Unit may be implemented only after the
Secretary has submitted to Congress, under section 801, a
report on the proposed change in allocation of funding,
including the reasons for the change and its likely effects.
``(b) Exception.--Subsection (a) shall not apply if the
total amount appropriated to the Service for a fiscal year is
at least 5 percent less than the amount appropriated to the
Service for the previous fiscal year.

[[Page H12830]]

``SEC. 808. RESULTS OF DEMONSTRATION PROJECTS.

``The Secretary shall provide for the dissemination to
Indian Tribes, Tribal Organizations, and urban Indian
organizations of the findings and results of demonstration
projects conducted under this Act.

``SEC. 809. MORATORIUM.

``During the period of the moratorium imposed on
implementation of the final rule published in the Federal
Register on September 16, 1987, by the Department of Health
and Human Services, relating to eligibility for the health
care services of the Indian Health Service, the Indian Health
Service shall provide services pursuant to the criteria for
eligibility for such services that were in effect on
September 15, 1987, subject to the provisions of sections 805
and 806, until the Service has submitted to the Committees on
Appropriations of the Senate and the House of Representatives
a budget request reflecting the increased costs associated
with the proposed final rule, and the request has been
included in an appropriations Act and enacted into law.

``SEC. 810. SEVERABILITY PROVISIONS.

``If any provision of this Act, any amendment made by the
Act, or the application of such provision or amendment to any
person or circumstances is held to be invalid, the remainder
of this Act, the remaining amendments made by this Act, and
the application of such provisions to persons or
circumstances other than those to which it is held invalid,
shall not be affected thereby.

``SEC. 811. USE OF PATIENT SAFETY ORGANIZATIONS.

``The Service, an Indian Tribe, Tribal Organization, or
urban Indian organization may provide for quality assurance
activities through the use of a patient safety organization
in accordance with title IX of the Public Health Service Act.

``SEC. 812. CONFIDENTIALITY OF MEDICAL QUALITY ASSURANCE
RECORDS; QUALIFIED IMMUNITY FOR PARTICIPANTS.

``(a) Confidentiality of Records.--Medical quality
assurance records created by or for any Indian Health Program
or a health program of an Urban Indian Organization as part
of a medical quality assurance program are confidential and
privileged. Such records may not be disclosed to any person
or entity, except as provided in subsection (c).
``(b) Prohibition on Disclosure and Testimony.--
``(1) In general.--No part of any medical quality assurance
record described in subsection (a) may be subject to
discovery or admitted into evidence in any judicial or
administrative proceeding, except as provided in subsection
(c).
``(2) Testimony.--A person who reviews or creates medical
quality assurance records for any Indian Health Program or
Urban Indian Organization who participates in any proceeding
that reviews or creates such records may not be permitted or
required to testify in any judicial or administrative
proceeding with respect to such records or with respect to
any finding, recommendation, evaluation, opinion, or action
taken by such person or body in connection with such records
except as provided in this section.
``(c) Authorized Disclosure and Testimony.--
``(1) In general.--Subject to paragraph (2), a medical
quality assurance record described in subsection (a) may be
disclosed, and a person referred to in subsection (b) may
give testimony in connection with such a record, only as
follows:
``(A) To a Federal executive agency or private
organization, if such medical quality assurance record or
testimony is needed by such agency or organization to perform
licensing or accreditation functions related to any Indian
Health Program or to a health program of an Urban Indian
Organization to perform monitoring, required by law, of such
program or organization.
``(B) To an administrative or judicial proceeding commenced
by a present or former Indian Health Program or Urban Indian
Organization provider concerning the termination, suspension,
or limitation of clinical privileges of such health care
provider.
``(C) To a governmental board or agency or to a
professional health care society or organization, if such
medical quality assurance record or testimony is needed by
such board, agency, society, or organization to perform
licensing, credentialing, or the monitoring of professional
standards with respect to any health care provider who is or
was an employee of any Indian Health Program or Urban Indian
Organization.
``(D) To a hospital, medical center, or other institution
that provides health care services, if such medical quality
assurance record or testimony is needed by such institution
to assess the professional qualifications of any health care
provider who is or was an employee of any Indian Health
Program or Urban Indian Organization and who has applied for
or been granted authority or employment to provide health
care services in or on behalf of such program or
organization.
``(E) To an officer, employee, or contractor of the Indian
Health Program or Urban Indian Organization that created the
records or for which the records were created. If that
officer, employee, or contractor has a need for such record
or testimony to perform official duties.
``(F) To a criminal or civil law enforcement agency or
instrumentality charged under applicable law with the
protection of the public health or safety, if a qualified
representative of such agency or instrumentality makes a
written request that such record or testimony be provided for
a purpose authorized by law.
``(G) In an administrative or judicial proceeding commenced
by a criminal or civil law enforcement agency or
instrumentality referred to in subparagraph (F), but only
with respect to the subject of such proceeding.
``(2) Identity of participants.--With the exception of the
subject of a quality assurance action, the identity of any
person receiving health care services from any Indian Health
Program or Urban Indian Organization or the identity of any
other person associated with such program or organization for
purposes of a medical quality assurance program that is
disclosed in a medical quality assurance record described in
subsection (a) shall be deleted from that record or document
before any disclosure of such record is made outside such
program or organization.
``(d) Disclosure for Certain Purposes.--
``(1) In general.--Nothing in this section shall be
construed as authorizing or requiring the withholding from
any person or entity aggregate statistical information
regarding the results of any Indian Health Program or Urban
Indian Organizations's medical quality assurance programs.
``(2) Withholding from congress.--Nothing in this section
shall be construed as authority to withhold any medical
quality assurance record from a committee of either House of
Congress, any joint committee of Congress, or the Government
Accountability Office if such record pertains to any matter
within their respective jurisdictions.
``(e) Prohibition on Disclosure of Record or Testimony.--A
person or entity having possession of or access to a record
or testimony described by this section may not disclose the
contents of such record or testimony in any manner or for any
purpose except as provided in this section.
``(f) Exemption From Freedom of Information Act.--Medical
quality assurance records described in subsection (a) may not
be made available to any person under section 552 of title 5,
United States Code.
``(g) Limitation on Civil Liability.--A person who
participates in or provides information to a person or body
that reviews or creates medical quality assurance records
described in subsection (a) shall not be civilly liable for
such participation or for providing such information if the
participation or provision of information was in good faith
based on prevailing professional standards at the time the
medical quality assurance program activity took place.
``(h) Application to Information in Certain Other
Records.--Nothing in this section shall be construed as
limiting access to the information in a record created and
maintained outside a medical quality assurance program,
including a patient's medical records, on the grounds that
the information was presented during meetings of a review
body that are part of a medical quality assurance program.
``(i) Regulations.--The Secretary, acting through the
Service, shall promulgate regulations pursuant to section
802.
``(j) Definitions.--In this section:
``(1) The term `health care provider' means any health care
professional, including community health aides and
practitioners certified under section 121, who are granted
clinical practice privileges or employed to provide health
care services in an Indian Health Program or health program
of an Urban Indian Organization, who is licensed or certified
to perform health care services by a governmental board or
agency or professional health care society or organization.
``(2) The term `medical quality assurance program' means
any activity carried out before, on, or after the date of
enactment of this Act by or for any Indian Health Program or
Urban Indian Organization to assess the quality of medical
care, including activities conducted by or on behalf of
individuals, Indian Health Program or Urban Indian
Organization medical or dental treatment review committees,
or other review bodies responsible for quality assurance,
credentials, infection control, patient safety, patient care
assessment (including treatment procedures, blood, drugs, and
therapeutics), medical records, health resources management
review and identification and prevention of medical or dental
incidents and risks.
``(3) The term `medical quality assurance record' means the
proceedings, records, minutes, and reports that emanate from
quality assurance program activities described in paragraph
(2) and are produced or compiled by or for an Indian Health
Program or Urban Indian Organization as part of a medical
quality assurance program.
``(k) Continued Protection.--Disclosure under subsection
(c) does not permit redisclosure except to the extent such
further disclosure is authorized under subsection (c) or is
otherwise authorized to be disclosed under this section.
``(l) Inconsistencies.--To the extent that the protections
under the Patient Safety and Quality Improvement Act of 2005
and this section are inconsistent, the provisions of
whichever is more protective shall control.
``(m) Relationship to Other Law.--This section shall
continue in force and effect, except as otherwise
specifically provided in any Federal law enacted after the
date of enactment of the Indian Health Care Improvement Act
Amendments of 2009.

``SEC. 813. CLAREMORE INDIAN HOSPITAL.

``The Claremore Indian Hospital shall be deemed to be a
dependant Indian community

[[Page H12831]]

for the purposes of section 1151 of title 18, United States
Code.

``SEC. 814. SENSE OF CONGRESS REGARDING LAW ENFORCEMENT AND
METHAMPHETAMINE ISSUES IN INDIAN COUNTRY.

``It is the sense of Congress that Congress encourages
State, local, and Indian tribal law enforcement agencies to
enter into memoranda of agreement between and among those
agencies for purposes of streamlining law enforcement
activities and maximizing the use of limited resources--
``(1) to improve law enforcement services provided to
Indian tribal communities; and
``(2) to increase the effectiveness of measures to address
problems relating to methamphetamine use in Indian country
(as defined in section 1151 of title 18, United States Code).

``SEC. 815. PERMITTING IMPLEMENTATION THROUGH CONTRACTS WITH
TRIBAL HEALTH PROGRAMS.

``Nothing in this Act shall be construed as preventing the
Secretary from--
``(1) carrying out any section of this Act through
contracts with Tribal Health Programs; and
``(2) carrying out sections through 214, 701(a)(1),
701(b)(1), 701(c), 707(g), and 712(b), through contracts with
urban Indian organizations.
The previous sentence shall not affect the authority the
Secretary may otherwise have to carry out other provisions of
this Act through such contracts.

``SEC. 816. AUTHORIZATION OF APPROPRIATIONS; AVAILABILITY.

``(a) Authorization of Appropriations.--There are
authorized to be appropriated such sums as may be necessary
to carry out this title.
``(b) Limitation on New Spending Authority.--Any new
spending authority (described in subparagraph (A) or (B) of
section 401(c)(2) of the Congressional Budget Act of 1974
(Public Law 93-344; 88 Stat. 317)) which is provided under
this Act shall be effective for any fiscal year only to such
extent or in such amounts as are provided in appropriation
Acts.
``(c) Availability.--The funds appropriated pursuant to
this Act shall remain available until expended.''.
(b) Rate of Pay.--
(1) Positions at level iv.--Section 5315 of title 5, United
States Code, is amended by striking ``Assistant Secretaries
of Health and Human Services (6).'' and inserting ``Assistant
Secretaries of Health and Human Services (7)''.
(2) Positions at level v.--Section 5316 of title 5, United
States Code, is amended by striking ``Director, Indian Health
Service, Department of Health and Human Services''.
(c) Amendments to Other Provisions of Law.--
(1) Section 3307(b)(1)(C) of the Children's Health Act of
2000 (25 U.S.C. 1671 note; Public Law 106-310) is amended by
striking ``Director of the Indian Health Service'' and
inserting ``Assistant Secretary for Indian Health''.
(2) The Indian Lands Open Dump Cleanup Act of 1994 is
amended--
(A) in section 3 (25 U.S.C. 3902)--
(i) by striking paragraph (2);
(ii) by redesignating paragraphs (1), (3), (4), (5), and
(6) as paragraphs (4), (5), (2), (6), and (1), respectively,
and moving those paragraphs so as to appear in numerical
order; and
(iii) by inserting before paragraph (4) (as redesignated by
subclause (II)) the following:
``(3) Assistant secretary.--The term `Assistant Secretary'
means the Assistant Secretary for Indian Health.'';
(B) in section 5 (25 U.S.C. 3904), by striking the section
designation and heading and inserting the following:

``SEC. 5. AUTHORITY OF ASSISTANT SECRETARY FOR INDIAN
HEALTH.'';

(C) in section 6(a) (25 U.S.C. 3905(a)), in the subsection
heading, by striking ``Director'' and inserting ``Assistant
Secretary'';
(D) in section 9(a) (25 U.S.C. 3908(a)), in the subsection
heading, by striking ``Director'' and inserting ``Assistant
Secretary''; and
(E) by striking ``Director'' each place it appears and
inserting ``Assistant Secretary''.
(3) Section 5504(d)(2) of the Augustus F. Hawkins-Robert T.
Stafford Elementary and Secondary School Improvement
Amendments of 1988 (25 U.S.C. 2001 note; Public Law 100-297)
is amended by striking ``Director of the Indian Health
Service'' and inserting ``Assistant Secretary for Indian
Health''.
(4) Section 203(a)(1) of the Rehabilitation Act of 1973 (29
U.S.C. 763(a)(1)) is amended by striking ``Director of the
Indian Health Service'' and inserting ``Assistant Secretary
for Indian Health''.
(5) Subsections (b) and (e) of section 518 of the Federal
Water Pollution Control Act (33 U.S.C. 1377) are amended by
striking ``Director of the Indian Health Service'' each place
it appears and inserting ``Assistant Secretary for Indian
Health''.
(6) Section 317M(b) of the Public Health Service Act (42
U.S.C. 247b-14(b)) is amended--
(A) by striking ``Director of the Indian Health Service''
each place it appears and inserting ``Assistant Secretary for
Indian Health''; and
(B) in paragraph (2)(A), by striking ``the Directors
referred to in such paragraph'' and inserting ``the Director
of the Centers for Disease Control and Prevention and the
Assistant Secretary for Indian Health''.
(7) Section 417C(b) of the Public Health Service Act (42
U.S.C. 285-9(b)) is amended by striking ``Director of the
Indian Health Service'' and inserting ``Assistant Secretary
for Indian Health''.
(8) Section 1452(i) of the Safe Drinking Water Act (42
U.S.C. 300j-12(i)) is amended by striking ``Director of the
Indian Health Service'' each place it appears and inserting
``Assistant Secretary for Indian Health''.
(9) Section 803B(d)(1) of the Native American Programs Act
of 1974 (42 U.S.C. 2991b-2(d)(1)) is amended in the last
sentence by striking ``Director of the Indian Health
Service'' and inserting ``Assistant Secretary for Indian
Health''.
(10) Section 203(b) of the Michigan Indian Land Claims
Settlement Act (Public Law 105-143; 111 Stat. 2666) is
amended by striking ``Director of the Indian Health Service''
and inserting ``Assistant Secretary for Indian Health''.

SEC. 3102. NATIVE AMERICAN HEALTH AND WELLNESS FOUNDATION.

(a) In General.--The Indian Self-Determination and
Education Assistance Act (25 U.S.C. 450 et seq.) is amended
by adding at the end the following:

``TITLE VIII--NATIVE AMERICAN HEALTH AND WELLNESS FOUNDATION

``SEC. 801. DEFINITIONS.

``In this title:
``(1) Board.--The term `Board' means the Board of Directors
of the Foundation.
``(2) Committee.--The term `Committee' means the Committee
for the Establishment of Native American Health and Wellness
Foundation established under section 802(f).
``(3) Foundation.--The term `Foundation' means the Native
American Health and Wellness Foundation established under
section 802.
``(4) Secretary.--The term `Secretary' means the Secretary
of Health and Human Services.
``(5) Service.--The term `Service' means the Indian Health
Service of the Department of Health and Human Services.

``SEC. 802. NATIVE AMERICAN HEALTH AND WELLNESS FOUNDATION.

``(a) Establishment.--
``(1) In general.--As soon as practicable after the date of
enactment of this title, the Secretary shall establish, under
the laws of the District of Columbia and in accordance with
this title, the Native American Health and Wellness
Foundation.
``(2) Funding determinations.--No funds, gift, property, or
other item of value (including any interest accrued on such
an item) acquired by the Foundation shall--
``(A) be taken into consideration for purposes of
determining Federal appropriations relating to the provision
of health care and services to Indians; or
``(B) otherwise limit, diminish, or affect the Federal
responsibility for the provision of health care and services
to Indians.
``(b) Perpetual Existence.--The Foundation shall have
perpetual existence.
``(c) Nature of Corporation.--The Foundation--
``(1) shall be a charitable and nonprofit federally
chartered corporation; and
``(2) shall not be an agency or instrumentality of the
United States.
``(d) Place of Incorporation and Domicile.--The Foundation
shall be incorporated and domiciled in the District of
Columbia.
``(e) Duties.--The Foundation shall--
``(1) encourage, accept, and administer private gifts of
real and personal property, and any income from or interest
in such gifts, for the benefit of, or in support of, the
mission of the Service;
``(2) undertake and conduct such other activities as will
further the health and wellness activities and opportunities
of Native Americans; and
``(3) participate with and assist Federal, State, and
tribal governments, agencies, entities, and individuals in
undertaking and conducting activities that will further the
health and wellness activities and opportunities of Native
Americans.
``(f) Committee for the Establishment of Native American
Health and Wellness Foundation.--
``(1) In general.--The Secretary shall establish the
Committee for the Establishment of Native American Health and
Wellness Foundation to assist the Secretary in establishing
the Foundation.
``(2) Duties.--Not later than 180 days after the date of
enactment of this section, the Committee shall--
``(A) carry out such activities as are necessary to
incorporate the Foundation under the laws of the District of
Columbia, including acting as incorporators of the
Foundation;
``(B) ensure that the Foundation qualifies for and
maintains the status required to carry out this section,
until the Board is established;
``(C) establish the constitution and initial bylaws of the
Foundation;
``(D) provide for the initial operation of the Foundation,
including providing for temporary or interim quarters,
equipment, and staff; and
``(E) appoint the initial members of the Board in
accordance with the constitution and initial bylaws of the
Foundation.
``(g) Board of Directors.--
``(1) In general.--The Board of Directors shall be the
governing body of the Foundation.
``(2) Powers.--The Board may exercise, or provide for the
exercise of, the powers of the Foundation.
``(3) Selection.--
``(A) In general.--Subject to subparagraph (B), the number
of members of the Board, the manner of selection of the
members (including the filling of vacancies), and the terms
of

[[Page H12832]]

office of the members shall be as provided in the
constitution and bylaws of the Foundation.
``(B) Requirements.--
``(i) Number of members.--The Board shall have at least 11
members, who shall have staggered terms.
``(ii) Initial voting members.--The initial voting members
of the Board--

``(I) shall be appointed by the Committee not later than
180 days after the date on which the Foundation is
established; and
``(II) shall have staggered terms.

``(iii) Qualification.--The members of the Board shall be
United States citizens who are knowledgeable or experienced
in Native American health care and related matters.
``(C) Compensation.--A member of the Board shall not
receive compensation for service as a member, but shall be
reimbursed for actual and necessary travel and subsistence
expenses incurred in the performance of the duties of the
Foundation.
``(h) Officers.--
``(1) In general.--The officers of the Foundation shall
be--
``(A) a secretary, elected from among the members of the
Board; and
``(B) any other officers provided for in the constitution
and bylaws of the Foundation.
``(2) Chief operating officer.--The secretary of the
Foundation may serve, at the direction of the Board, as the
chief operating officer of the Foundation, or the Board may
appoint a chief operating officer, who shall serve at the
direction of the Board.
``(3) Election.--The manner of election, term of office,
and duties of the officers of the Foundation shall be as
provided in the constitution and bylaws of the Foundation.
``(i) Powers.--The Foundation--
``(1) shall adopt a constitution and bylaws for the
management of the property of the Foundation and the
regulation of the affairs of the Foundation;
``(2) may adopt and alter a corporate seal;
``(3) may enter into contracts;
``(4) may acquire (through a gift or otherwise), own,
lease, encumber, and transfer real or personal property as
necessary or convenient to carry out the purposes of the
Foundation;
``(5) may sue and be sued; and
``(6) may perform any other act necessary and proper to
carry out the purposes of the Foundation.
``(j) Principal Office.--
``(1) In general.--The principal office of the Foundation
shall be in the District of Columbia.
``(2) Activities; offices.--The activities of the
Foundation may be conducted, and offices may be maintained,
throughout the United States in accordance with the
constitution and bylaws of the Foundation.
``(k) Service of Process.--The Foundation shall comply with
the law on service of process of each State in which the
Foundation is incorporated and of each State in which the
Foundation carries on activities.
``(l) Liability of Officers, Employees, and Agents.--
``(1) In general.--The Foundation shall be liable for the
acts of the officers, employees, and agents of the Foundation
acting within the scope of their authority.
``(2) Personal liability.--A member of the Board shall be
personally liable only for gross negligence in the
performance of the duties of the member.
``(m) Restrictions.--
``(1) Limitation on spending.--Beginning with the fiscal
year following the first full fiscal year during which the
Foundation is in operation, the administrative costs of the
Foundation shall not exceed the percentage described in
paragraph (2) of the sum of--
``(A) the amounts transferred to the Foundation under
subsection (o) during the preceding fiscal year; and
``(B) donations received from private sources during the
preceding fiscal year.
``(2) Percentages.--The percentages referred to in
paragraph (1) are--
``(A) for the first fiscal year described in that
paragraph, 20 percent;
``(B) for the following fiscal year, 15 percent; and
``(C) for each fiscal year thereafter, 10 percent.
``(3) Appointment and hiring.--The appointment of officers
and employees of the Foundation shall be subject to the
availability of funds.
``(4) Status.--A member of the Board or officer, employee,
or agent of the Foundation shall not by reason of association
with the Foundation be considered to be an officer, employee,
or agent of the United States.
``(n) Audits.--The Foundation shall comply with section
10101 of title 36, United States Code, as if the Foundation
were a corporation under part B of subtitle II of that title.
``(o) Funding.--
``(1) Authorization of appropriations.--There is authorized
to be appropriated to carry out subsection (e)(1) $500,000
for each fiscal year, as adjusted to reflect changes in the
Consumer Price Index for all-urban consumers published by the
Department of Labor.
``(2) Transfer of donated funds.--The Secretary shall
transfer to the Foundation funds held by the Department of
Health and Human Services under the Act of August 5, 1954 (42
U.S.C. 2001 et seq.), if the transfer or use of the funds is
not prohibited by any term under which the funds were
donated.

``SEC. 803. ADMINISTRATIVE SERVICES AND SUPPORT.

``(a) Provision of Support by Secretary.--Subject to
subsection (b), during the 5-year period beginning on the
date on which the Foundation is established, the Secretary--
``(1) may provide personnel, facilities, and other
administrative support services to the Foundation;
``(2) may provide funds for initial operating costs and to
reimburse the travel expenses of the members of the Board;
and
``(3) shall require and accept reimbursements from the
Foundation for--
``(A) services provided under paragraph (1); and
``(B) funds provided under paragraph (2).
``(b) Reimbursement.--Reimbursements accepted under
subsection (a)(3)--
``(1) shall be deposited in the Treasury of the United
States to the credit of the applicable appropriations
account; and
``(2) shall be chargeable for the cost of providing
services described in subsection (a)(1) and travel expenses
described in subsection (a)(2).
``(c) Continuation of Certain Services.--The Secretary may
continue to provide facilities and necessary support services
to the Foundation after the termination of the 5-year period
specified in subsection (a) if the facilities and services--
``(1) are available; and
``(2) are provided on reimbursable cost basis.''.
(b) Technical Amendments.--The Indian Self-Determination
and Education Assistance Act is amended--
(1) by redesignating title V (25 U.S.C. 458bbb et seq.) as
title VII;
(2) by redesignating sections 501, 502, and 503 (25 U.S.C.
458bbb, 458bbb-1, 458bbb-2) as sections 701, 702, and 703,
respectively; and
(3) in subsection (a)(2) of section 702 and paragraph (2)
of section 703 (as redesignated by paragraph (2)), by
striking ``section 501'' and inserting ``section 701''.

SEC. 3103. GAO STUDY AND REPORT ON PAYMENTS FOR CONTRACT
HEALTH SERVICES.

(a) Study.--
(1) In general.--The Comptroller General of the United
States (in this section referred to as the ``Comptroller
General'') shall conduct a study on the utilization of health
care furnished by health care providers under the contract
health services program funded by the Indian Health Service
and operated by the Indian Health Service, an Indian Tribe,
or a Tribal Organization (as those terms are defined in
section 4 of the Indian Health Care Improvement Act).
(2) Analysis.--The study conducted under paragraph (1)
shall include an analysis of--
(A) the amounts reimbursed under the contract health
services program described in paragraph (1) for health care
furnished by entities, individual providers, and suppliers,
including a comparison of reimbursement for such health care
through other public programs and in the private sector;
(B) barriers to accessing care under such contract health
services program, including, but not limited to, barriers
relating to travel distances, cultural differences, and
public and private sector reluctance to furnish care to
patients under such program;
(C) the adequacy of existing Federal funding for health
care under such contract health services program; and
(D) any other items determined appropriate by the
Comptroller General.
(b) Report.--Not later than 18 months after the date of
enactment of this Act, the Comptroller General shall submit
to Congress a report on the study conducted under subsection
(a), together with recommendations regarding--
(1) the appropriate level of Federal funding that should be
established for health care under the contract health
services program described in subsection (a)(1); and
(2) how to most efficiently utilize such funding.
(c) Consultation.--In conducting the study under subsection
(a) and preparing the report under subsection (b), the
Comptroller General shall consult with the Indian Health
Service, Indian Tribes, and Tribal Organizations.

TITLE II--IMPROVEMENT OF INDIAN HEALTH CARE PROVIDED UNDER THE SOCIAL
SECURITY ACT

SEC. 3201. EXPANSION OF PAYMENTS UNDER MEDICARE, MEDICAID,
AND SCHIP FOR ALL COVERED SERVICES FURNISHED BY
INDIAN HEALTH PROGRAMS.

(a) Medicaid.--
(1) Expansion to all covered services.--Section 1911 of the
Social Security Act (42 U.S.C. 1396j) is amended--
(A) by amending the heading to read as follows:

``SEC. 1911. INDIAN HEALTH PROGRAMS.'';

and
(B) by amending subsection (a) to read as follows:
``(a) Eligibility for Payment for Medical Assistance.--An
Indian Health Program shall be eligible for payment for
medical assistance provided under a State plan or under
waiver authority with respect to items and services furnished
by the Program if the furnishing of such services meets all
the conditions and requirements which are applicable
generally to the furnishing of items and services under this
title and under such plan or waiver authority.''.
(2) Repeal of obsolete provision.--Subsection (b) of such
section is repealed.
(3) Revision of authority to enter into agreements.--
Subsection (c) of such section is amended to read as follows:

[[Page H12833]]

``(c) Authority To Enter Into Agreements.--The Secretary
may enter into an agreement with a State for the purpose of
reimbursing the State for medical assistance provided by the
Indian Health Service, an Indian Tribe, Tribal Organization,
or an Urban Indian Organization (as so defined), directly,
through referral, or under contracts or other arrangements
between the Indian Health Service, an Indian Tribe, Tribal
Organization, or an Urban Indian Organization and another
health care provider to Indians who are eligible for medical
assistance under the State plan or under waiver authority.
This subsection shall not be construed to impair the
entitlement of a State to reimbursement for such medical
assistance under this title.''.
(4) Cross-references to special fund for improvement of ihs
facilities; direct billing option; definitions.--Such section
is further amended by striking subsection (d) and adding at
the end the following new subsections:
``(c) Special Fund for Improvement of IHS Facilities.--For
provisions relating to the authority of the Secretary to
place payments to which a facility of the Indian Health
Service is eligible for payment under this title into a
special fund established under section 401(c)(1) of the
Indian Health Care Improvement Act, see subparagraphs (A) and
(B) of section 401(c)(1) of such Act.
``(d) Direct Billing.--For provisions relating to the
authority of an Tribal Health Program to elect to directly
bill for, and receive payment for, health care items and
services provided by such Program for which payment is made
under this title, see section 401(d) of the Indian Health
Care Improvement Act.''.
(5) Definitions.--Section 1101(a) of such Act (42 U.S.C.
1301(a)) is amended by adding at the end the following new
paragraph:
``(11) For purposes of this title and titles XVIII, XIX,
and XXI, the terms `Indian Health Program', `Indian Tribe'
(and `Indian tribe'), `Tribal Health Program', `Tribal
Organization' (and `tribal organization'), and `urban Indian
organization' (and `urban Indian organization') have the
meanings given those terms in section 4 of the Indian Health
Care Improvement Act.''.
(b) Medicare.--
(1) Expansion to all covered services.--Section 1880 of
such Act (42 U.S.C. 1395qq) is amended--
(A) by amending the heading to read as follows:

``SEC. 1880. INDIAN HEALTH PROGRAMS.'';

and
(B) by amending subsection (a) to read as follows:
``(a) Eligibility for Payments.--Subject to subsection (e),
an Indian Health Program shall be eligible for payments under
this title with respect to items and services furnished by
the Program if the furnishing of such services meets all the
conditions and requirements which are applicable generally to
the furnishing of items and services under this title.''.
(2) Repeal of obsolete provision.--Subsection (b) of such
section is repealed.
(3) Cross-references to special fund for improvement of ihs
facilities; direct billing option; definitions.--
(A) In general.--Such section is further amended by
striking subsections (c) and (d) and inserting the following
new subsections:
``(b) Special Fund for Improvement of IHS Facilities.--For
provisions relating to the authority of the Secretary to
place payments to which a facility of the Indian Health
Service is eligible for payment under this title into a
special fund established under section 401(c)(1) of the
Indian Health Care Improvement Act, and the requirement to
use amounts paid from such fund for making improvements in
accordance with subsection (b), see subparagraphs (A) and (B)
of section 401(c)(1) of such Act.
``(c) Direct Billing.--For provisions relating to the
authority of a Tribal Health Program to elect to directly
bill for, and receive payment for, health care items and
services provided by such Program for which payment is made
under this title, see section 401(d) of the Indian Health
Care Improvement Act.''.
(B) Conforming amendments.--Such section is further
amended--
(i) in subsection (e)(3), by striking ``Subsection (c)''
and inserting ``Subsection (b) and section 401(b)(1) of the
Indian Health Care Improvement Act'';
(ii) by redesignating subsection (e) as subsection (d); and
(iii) by striking subsection (f).
(4) Definitions.--Such section is further amended by
amending adding at the end the following new subsection:
``(e) Definitions.--In this section, the terms `Indian
Health Program', `Indian Tribe', `Service Unit', `Tribal
Health Program', `Tribal Organization', and `Urban Indian
Organization' have the meanings given those terms in section
4 of the Indian Health Care Improvement Act.''.
(c) Application to SCHIP.--Section 2107(e)(1) of the Social
Security Act (42 U.S.C. 1397gg(e)(1)) is amended--
(1) by redesignating subparagraphs (K) through (M) as
subparagraphs (L) through (N), respectively; and
(2) by inserting after subparagraph (J), the following new
subparagraph:
``(K) Section 1911 (relating to Indian Health Programs,
other than subsection (c) of such section).''.

SEC. 3202. ADDITIONAL PROVISIONS TO INCREASE OUTREACH TO, AND
ENROLLMENT OF, INDIANS IN SCHIP AND MEDICAID.

(a) Assurance of Payments to Indian Health Care Providers
for Child Health Assistance.--Section 2102(b)(3)(D) of the
Social Security Act (42 U.S.C. 1397bb(b)(3)(D)) is amended by
striking ``(as defined in section 4(c) of the Indian Health
Care Improvement Act, 25 U.S.C. 1603(c))'' and inserting ``,
including how the State will ensure that payments are made to
Indian Health Programs and urban Indian organizations
operating in the State for the provision of such
assistance''.
(b) Inclusion of Other Indian Financed Health Care Programs
in Exemption From Prohibition on Certain Payments.--Section
2105(c)(6)(B) of such Act (42 U.S.C. 1397ee(c)(6)(B)) is
amended by striking ``insurance program, other than an
insurance program operated or financed by the Indian Health
Service'' and inserting ``program, other than a health care
program operated or financed by the Indian Health Service or
by an Indian Tribe, Tribal Organization, or urban Indian
organization''.
(c) Definitions.--Section 2110(c) of such Act (42 U.S.C.
1397jj(c)) is amended by adding at the end the following new
paragraph:
``(9) Indian; indian health program; indian tribe; etc.--
The terms `Indian', `Indian Health Program', `Indian Tribe',
`Tribal Organization', and `Urban Indian Organization' have
the meanings given those terms in section 4 of the Indian
Health Care Improvement Act.''.

SEC. 3203. SOLICITATION OF PROPOSALS FOR SAFE HARBORS UNDER
THE SOCIAL SECURITY ACT FOR FACILITIES OF
INDIAN HEALTH PROGRAMS AND URBAN INDIAN
ORGANIZATIONS.

The Secretary of Health and Human Services, acting through
the Office of the Inspector General of the Department of
Health and Human Services, shall publish a notice, described
in section 1128D(a)(1)(A) of the Social Security Act (42
U.S.C. 1320a-7d(a)(1)(A)), soliciting a proposal, not later
than July 1, 2010, on the development of safe harbors
described in such section relating to health care items and
services provided by facilities of Indian Health Programs or
an urban Indian organization (as such terms are defined in
section 4 of the Indian Health Care Improvement Act). Such a
safe harbor may relate to areas such as transportation,
housing, or cost-sharing, assistance provided through such
facilities or contract health services for Indians.

SEC. 3204. ANNUAL REPORT ON INDIANS SERVED BY SOCIAL SECURITY
ACT HEALTH BENEFIT PROGRAMS.

Section 1139 of the Social Security Act (42 U.S.C. 1320b-
9), as amended by the sections 3203 and 3204, is amended by
redesignating subsection (e) as subsection (f), and inserting
after subsection (d) the following new subsection:
``(e) Annual Report on Indians Served by Health Benefit
Programs Funded Under This Act.--Beginning January 1, 2011,
and annually thereafter, the Secretary, acting through the
Administrator of the Centers for Medicare & Medicaid Services
and the Director of the Indian Health Service, shall submit a
report to Congress regarding the enrollment and health status
of Indians receiving items or services under health benefit
programs funded under this Act during the preceding year.
Each such report shall include the following:
``(1) The total number of Indians enrolled in, or receiving
items or services under, such programs, disaggregated with
respect to each such program.
``(2) The number of Indians described in paragraph (1) that
also received health benefits under programs funded by the
Indian Health Service.
``(3) General information regarding the health status of
the Indians described in paragraph (1), disaggregated with
respect to specific diseases or conditions and presented in a
manner that is consistent with protections for privacy of
individually identifiable health information under section
264(c) of the Health Insurance Portability and Accountability
Act of 1996.
``(4) A detailed statement of the status of facilities of
the Indian Health Service or an Indian Tribe, Tribal
Organization, or an Urban Indian Organization with respect to
such facilities' compliance with the applicable conditions
and requirements of titles XVIII, XIX, and XXI, and, in the
case of title XIX or XXI, under a State plan under such title
or under waiver authority, and of the progress being made by
such facilities (under plans submitted under 1911(b) or
otherwise) toward the achievement and maintenance of such
compliance.
``(5) Such other information as the Secretary determines is
appropriate.''.

SEC. 3205. DEVELOPMENT OF RECOMMENDATIONS TO IMPROVE
INTERSTATE COORDINATION OF MEDICAID AND SCHIP
COVERAGE OF INDIAN CHILDREN AND OTHER CHILDREN
WHO ARE OUTSIDE OF THEIR STATE OF RESIDENCY
BECAUSE OF EDUCATIONAL OR OTHER NEEDS.

(a) Study.--The Secretary shall conduct a study to identify
barriers to interstate coordination of enrollment and
coverage under the Medicaid program under title XIX of the
Social Security Act and the State Children's Health Insurance
Program under title XXI of such Act of children who are
eligible for medical assistance or child health assistance
under such programs and who, because of educational needs,
migration of families,

[[Page H12834]]

emergency evacuations, or otherwise, frequently change their
State of residency or otherwise are temporarily present
outside of the State of their residency. Such study shall
include an examination of the enrollment and coverage
coordination issues faced by Indian children who are eligible
for medical assistance or child health assistance under such
programs in their State of residence and who temporarily
reside in an out-of-State boarding school or peripheral
dormitory funded by the Bureau of Indian Affairs.
(b) Report.--Not later than 18 months after the date of
enactment of this Act, the Secretary, in consultation with
directors of State Medicaid programs under title XIX of the
Social Security Act and directors of State Children's Health
Insurance Programs under title XXI of such Act, shall submit
a report to Congress that contains recommendations for such
legislative and administrative actions as the Secretary
determines appropriate to address the enrollment and coverage
coordination barriers identified through the study required
under subsection (a).
The SPEAKER pro tempore. After 4 hours of debate on the bill, as
amended, equally divided among and controlled by the Chair and ranking
minority member of the Committee on Energy and Commerce, the Chair and
ranking minority member of the Committee on Ways and Means, and the
Chair and ranking minority member of the Committee on Education and
Labor, the further amendment printed in part C of the report, if
offered by the gentleman from Michigan (Mr. Stupak) or his designee,
shall be considered read, and shall be debatable for 20 minutes,
equally divided and controlled by the proponent and an opponent. The
further amendment in the nature of a substitute printed in part D of
the report, if offered by the gentleman from Ohio (Mr. Boehner) or his
designee, shall be considered as read, and shall be debatable for 1
hour equally divided and controlled by the proponent and an opponent.
The gentleman from California (Mr. Waxman), the gentleman from Texas
(Mr. Barton), the gentleman from New York (Mr. Rangel), the gentleman
from Michigan (Mr. Camp), the gentleman from California (Mr. George
Miller), and the gentleman from Minnesota (Mr. Kline) each will control
40 minutes.
The Chair now recognizes the gentleman from California (Mr. Waxman).

{time}  1400

Mr. WAXMAN. Mr. Speaker, I am pleased to start off the debate by
recognizing our very distinguished majority leader, Steny Hoyer from
the State of Maryland, for 1 minute.
Mr. HOYER. I thank Mr. Waxman for yielding.
Our rule was chaired by John Dingell, himself a historic figure on a
historic day.
I want to congratulate all of those who have participated in the
accomplishment of the product that we consider this day: Mr. Waxman,
one of our senior Members in the House; Mr. Rangel, one of our senior
Members in the House; and Mr. Miller.
I want to thank too the Republicans who engaged in this discussion,
in this debate, because it is historic, and all of us who sit in this
Chamber know that it will have a great effect on our people. Some
perceive that effect as not positive. More, I believe, think it is
positive. In any event, none of us believe that it is not
extraordinarily important.
Soon each one of us is going to look into his or her conscience and
vote on this bill. And when the time comes, I don't know if any words
of mine will sway any of you. But I know that the most powerful
arguments for the bill won't be spoken on this floor. They are being
lived right now in our country in every one of our districts, in every
one of our towns and counties and municipalities.
In the anxiety of the family that finds itself paying more and more
each year for health insurance that grows weaker and weaker.
In the frustration of the small business owner weighing the choices
of dropping her employees' coverage against the threat of being driven
out of business by her competitors.
And in the fury of the patient who learns that an insurance company
bureaucrat has deemed him too sick for the coverage he paid for.
They are our families, our neighbors, our fellow citizens. They are
waiting for health insurance reform that is more affordable, more
secure, more just. Their stories will be with me and I know with each
of us when we cast our vote.
Because I want to say to every American facing down illness: never
again, never again will you be denied coverage because you have
diabetes or asthma or some other disease or because you're pregnant or
because you have anything else your insurer decides is a preexisting
condition. Never again will your coverage run out. Nor will you find
the coverage you thought you had paid for was actually not there at
all. And never again can insurance companies drive out competition and
set premiums as high as they like, because there will be a public
insurance option and a transparent marketplace to keep them honest, to
keep them competitive, to bring prices down.
I want to say to our middle class families, the backbone of our
country: you will have coverage that you can depend upon. Even if you
change your job or lose your job or decide to start a business, you
will be able to find affordable coverage in a competitive marketplace,
an insurance exchange that offers you a choice of good policies at fair
rates. In fact, according to an MIT analysis, buying coverage on the
exchange will bring your premiums down by a great deal, even without
the affordability credits.
If your family makes $90,000 or more, you'll save more than 1,200
bucks. If your family makes $60,000, you'll save more than $5,000. And
if your family is making $38,000, you'll save more than $9,000. That's
the kind of tax cut that America needs to secure its medical future.
I want to say to our seniors: you can count on Medicare, on a Federal
program, for dignity and peace of mind in your golden years. And that
will not change. Today we will vote to protect your access to your
doctor, to encourage Medicare physicians to cooperate on higher quality
care, to keep your Medicare solvent for longer, and to bring an end to
the doughnut hole that leaves prescription drugs unaffordable for so
many.
I want to say to our small businessmen and women: I know your
premiums keep going up and that each year they make it harder to stay
in business, to compete with Big Business and with foreign firms. You
deserve a fair playing field; and in the insurance exchange
marketplace, you'll be able to buy coverage at the low group rates
you're now being denied.
I want to say to the 35 million Americans without insurance, who are
forced to skip checkups and preventative care, who are forced to turn
to the ER as the first and only line of defense, who live sicker and
shorter lives: you will have what every man, woman, and child has in
every other industrialized country in the world: health coverage you
can afford and that you can count on.
And every American who is rightly worried about our mounting deficits
and debt, I can tell you this: this bill does not add to the deficit
over the next 10 years or the 10 years thereafter. This bill means
health care that is more fiscally sustainable for years to come.
That is what this bill, the Affordable Health Care for America Act,
can achieve for our country and for our people. It isn't a simple bill.
It isn't a perfect bill, but it is the product of months and months of
careful debate, sometimes animated debate, yes, even angry debate,
careful scrutiny, hard work, and citizen input. And it's the right
response to this time of economic insecurity in which we have been
called to lead.
If we miss this chance, or if we vote for a Republican plan that does
very little to expand coverage, weakens insurance, frankly, for
millions who have it, and continues to allow millions of Americans to
be denied affordable coverage, we'll find ourselves back here again.
But by then, premiums will eat up even more of our families' budgets;
health care will consume even more of our economy; and even more
Americans will have died for the lack of health care.
If we miss this chance, if we miss this challenge of nearly a
century's duration, when Teddy Roosevelt, one of the great Presidents
of this country, a Republican President of this country, said a hundred
years ago we need to have health care coverage for all Americans--this
is not a new idea, but it is

[[Page H12835]]

an idea whose time has surely come--the years between this chance and
our next one will be filled with stories that are unworthy of America
at its best.
Stories like Linda's, who wrote to The New York Times of the anguish
she felt suffering from abdominal cancer and standing in the hospital
just feet away from the drugs that could help save her life, drugs her
insurance company was denying her.
Stories like Deamonte Driver's from Prince George's County, just a
few miles down the road, who died at the age of 12 from a toothache, a
toothache that was not treated by a dentist; and, as a result, it
became infected. That infection went into his brain. He was in the
hospital for 30 days at a cost of $250,000. Why? Because he didn't have
$80 to get that tooth filled.
This bill will change that. We can be better than that. America is
better than that. We must be.
Americans rightly want to know what's in this bill for them and for
their families, but there's also something important in this bill for
us as a people: a system worthy of the values we profess and the
principles we hold dear. We will vote for a healthier America. We will
vote to give our fellow citizens a greater sense of security. We will
vote to make Medicare stronger for our seniors. We will vote for a
healthier economy, for affordable coverage for individuals and small
business. We will vote to begin containing costs, which will otherwise
be unsustainable for our children and for our grandchildren.
We will, in sum, my colleagues, on this historic day, vote for a more
perfect Union of which our Founders dreamed.
Mr. WAXMAN. Mr. Speaker, I reserve the balance of my time.
Mr. BARTON of Texas. Mr. Speaker, I yield myself 2 minutes.
(Mr. BARTON of Texas asked and was given permission to revise and
extend his remarks.)
Mr. BARTON of Texas. Mr. Speaker, I first want to apologize to my
wife, Terry. Back in September for my 60th birthday, she gave me a
birthday present of a weekend in Las Vegas today. I obviously can't be
there because I have to be here doing my duty for the 6th District of
Texas. But like many of us, we wear two hats. So to my wife and all the
families that had things planned this weekend, I do want to apologize.
I would also point out that my wife works for a public hospital in
Fort Worth, Texas; and this is something that's very, very dear to her
heart.
Mr. Speaker, there are many reasons to oppose the bill before us,
H.R. 3962. There are numerous policy reasons. It's going to cost over
$1.2 trillion over 10 years if you include the physician reimbursement
fix in the separate bill. When fully implemented, it's my opinion that
two-thirds to three-fourths of every dollar spent on health care in
America is going to be spent by the Federal Government in some shape,
form, or fashion. It's going to create, in my opinion, Mr. Speaker, a
two-tiered health care system: the public system for most of us and
then a private system for the elites of the country that can afford to
go outside the public system.
It's a bad deal for average Americans. The average person today who
works and has a health care plan through their employer, the average
plan costs about $10,000 a year. The employee pays $3,500; the employer
pays $6,500. Since there's an 8 percent payroll tax, on the average of
$40,000, that would be about $3,200. Most employers, when this plan is
implemented, can pay the 8 percent tax, which is $3,200, or the $6,500
premium that they pay for their employees.
They're going to stop providing health care through the employment
and they're just going to put them in the public option. The employee
is going to take that $3,500 that he or she was paying for their
premium for a $10,000 plan and they're going to find out that when they
go into the health care exchange, their $3,500 doesn't buy a $10,000
policy. It buys a $3,500 policy. It's a bad deal.
The SPEAKER pro tempore. The time of the gentleman has expired.
Mr. BARTON of Texas. Mr. Speaker, I yield myself 1 more minute.
So there are lots of policy reasons.
But the real reason, Mr. Speaker, is that I just don't think it's
right, in the guise of helping Americans, to mandate what they have to
do. I don't think it's right to mandate that you have to have health
insurance or you might go to jail. I don't think it's right that you
mandate an employer to provide health care insurance or they're going
to pay all these penalties. I don't think it's right that we set up a
health choice administration that sets what the health care plans have
to be. I don't think it's right that you say that 70 to 90 percent of
those premiums of the benefit package that is mandated has to be paid
by the employer.
I just don't think mandating to Americans is a good idea, except in a
few cases. To protect the country in times of war, we have on occasion
had to mandate our young men, and now our young women, to have to
serve. We mandate we have to pay our taxes. But we don't have to
mandate that you need health insurance.
Vote ``no'' on the bill and ``yes'' on the Republican substitute.
Mr. WAXMAN. Mr. Speaker, I am pleased at this time to yield 3 minutes
to the majority whip of the House of Representatives, Mr. Clyburn.
Mr. CLYBURN. I thank Chairman Waxman for yielding me the time.
Mr. Speaker, today I'm thinking about a woman from South Carolina. A
few months ago during the August break, I participated in a talk radio
program on health reform, and a gentleman called in to tell me that his
health care was great, and he didn't want me or the government to mess
with it.

{time}  1415

I explained to him that our plan was about choice, bringing down
costs, and providing quality care.
But the next caller got right to the heart of the matter. She said,
Of course he likes his health insurance; it is probably because he has
never tried to use it. She explained that she had recently been
diagnosed with cancer and thought she liked her coverage until she
tried to use it. She said that when she began to get treatment she was
dropped from her insurance coverage.
Mr. Speaker, that is why we are here today, to respond to that caller
and others who have asked, What's in this plan for me?
When this bill is signed into law, 15 reforms will immediately occur.
Among them are: beginning to close the doughnut hole by increasing
Medicare part D coverage by $500; increased funding for community
health centers, doubling the number of patients seen over 5 years;
extending coverage for young people to stay on their parents' insurance
plans up to their 27th birthday; access for the uninsured with
preexisting conditions to a temporary insurance plan that we are
calling a high-risk pool; from the date of enactment, and until the
exchange is available, insurers will be prohibited from dropping your
coverage if you get sick; from the date of enactment, COBRA health
insurance coverage will be extended until the exchange is available and
displaced workers can have affordable coverage; and from the date of
enactment, we will hinder price-gouging with sunshine requirements on
insurance companies to disclose insurance rate increases.
Now, after 2013, when the mandate for coverage and exchange are in
place, you will see three additional protections: no more copays for
routine checkups and preventive care; no lifetime or yearly caps on
what insurance companies will cover; there will be yearly caps on your
out-of-pocket expenses; and, as has been said so often, there will be
an end to discrimination because of preexisting conditions like
diabetes, heart disease or cancer.
Mr. Speaker, these are just 11 reasons to support this bill. My
colleagues will share with you many others.
Mr. BARTON of Texas. Mr. Speaker, I yield 1 minute to a member of the
committee, the gentleman from Illinois (Mr. Shimkus).
(Mr. SHIMKUS asked and was given permission to revise and extend his
remarks.)
Mr. SHIMKUS. Mr. Speaker, I think it spoke volumes that my friend,
John Dingell, chaired the rule. John Dingell has always been a single-
payer advocate. That speaks volumes to what the real intent of this
bill is.
The goal of this legislation has been clear: to pass a public option
that will serve as a gateway to a single-payer,

[[Page H12836]]

government-controlled system. Don't trust me; ask my friend, Jan
Schakowsky, or ask Chairman Barney Frank. Or believe President Obama
who said, ``I happen to be a proponent of a single-payer health care
program. But I don't think we're going to be able to eliminate employer
coverage immediately.''
Make no mistake, this bill will achieve the single-payer goal. And
along with it, it will raise premiums, increase taxes, cuts billions of
dollars from Medicare, and cost millions of working Americans their
job. And at the end, a single-payer system will force every American
into a one-size-fits-all system that rations care. A government that
rations care is anti-life.
Mr. WAXMAN. Mr. Speaker, at this time I am very pleased to recognize
and to yield 1 minute to the gentlewoman from Connecticut (Ms.
DeLauro).
Ms. DeLAURO. Mr. Speaker, I rise at this historic moment in support
of the Affordable Health Care for America Act. None of us will again
have such an opportunity in our time serving in the United States
Congress to do something so enduring and fulfilling, to make sure that
every American shall have access to quality, affordable health
insurance.
For more than a century, the special interests have won this moment.
Presidents Theodore and Franklin Roosevelt, Truman, Kennedy, Nixon, and
Clinton have spoken of our country's aspiration, but only now have we
come so far.
When the Democrats and the Congress passed Medicare, we lifted
seniors out of poverty forever, and now we get to say to working
Americans, You can no longer be broken by a health insurance system
that drops you when you are sick or lose a job.
It says to women, You will no longer be denied coverage on account of
a C-section or domestic violence. No longer will maternity or
preventive care be ignored.
I urge my colleagues to vote for history and for America today. This
is why we are here.

Announcement by the Speaker Pro Tempore

The SPEAKER pro tempore. The Chair will remind all persons in the
gallery that they are here as guests of the House and that any
manifestation of approval or disapproval of proceedings or other
audible conversation is in violation of the rules of the House.
Mr. BARTON of Texas. Mr. Speaker, I would like to yield 1 minute to
the gentlewoman from California (Mrs. Bono Mack), a member of the
committee.
Mrs. BONO MACK. Mr. Speaker, I rise today to express my strong
opposition to this bill. It is a bill that flies in the face of the
Hippocratic oath which both my father and grandfather took as young
doctors, which says, ``Do no harm.''
In fact, this bill does a tremendous amount of harm and would inflict
an enormous burden on current and future generations of Americans. It
would raise insurance premiums, raise taxes, and create huge new
government bureaucracies to stand squarely between patients and
doctors.
This bill does not offer real health care reform. Rather than reduce
costs and make health care more affordable and accessible, this bill
will increase costs to consumers and put the government in charge of
deciding what treatment and care Americans are entitled to.
Millions of Americans have resoundingly rejected this shell game
masquerading as reform. The very least we can do is listen to the
American people and reject this flawed bill.
Mr. WAXMAN. Mr. Speaker, I am pleased now to yield 2 minutes to the
gentleman from Connecticut (Mr. Larson), the chairman of the Democratic
Caucus.
Mr. LARSON of Connecticut. Mr. Speaker, I thank Mr. Waxman and Mr.
Rangel and Mr. Miller for their help.
The growth of this great Nation cannot be achieved without caring for
the health of all of its citizens. Thirty-six million Americans await
our action on the House floor today. Thirty-six million Americans
watched as the fearmongers stood on the steps of the Capitol this week
telling them to be afraid.
The same fear was spread during the debate on Social Security and
Medicare. Today, we will put a stop to the fear and address the real
threat, the real danger the American people face. The woman next to you
on the train spreading the flu because she couldn't afford to see a
doctor. The little boy in the sandbox with your child whose parents
couldn't afford the vaccinations. And if we have learned anything from
the H1N1 epidemic, the billions of dollars these public health
emergencies cost all of us, and that disease has no boundaries or
borders; it affects all of us.
On this historic day, this Congress will pass what will improve both
the fiscal and physical health of the entire Nation by improving health
care for all of our citizens. It is a statement of our values. It is
testimony to how we care for our fellow citizens. It is at the very
core of all that America stands for and why we came here to serve.
Thirty-six million Americans deserve nothing less.
Mr. BARTON of Texas. Mr. Speaker, I yield 2 minutes to the gentleman
from Georgia (Mr. Deal), a subcommittee ranking member.
Mr. DEAL of Georgia. Mr. Speaker, I rise in opposition to this bill,
and I express three major concerns.
First of all, I raise a question. The question is: what authority in
the United States Constitution gives this Congress the right to mandate
that every citizen must purchase a health insurance policy, and upon
failing to do so, shall be fined and possibly imprisoned? I think the
answer to that question is, there is no such congressional authority.
Secondly, make no mistake about it, illegal aliens will receive
government-funded health care under this because all they are required
to show is a Social Security number and a name. There is no way to
prevent the same Social Security number from being used by numerous
individuals, and there is no requirement that a picture ID be produced
in order to prove that the person is in fact the name that appears on
the Social Security card. If you think identity theft is a problem now,
just wait until this bill passes.
Thirdly, this bill requires States to increase their Medicaid rolls
to 150 percent of the Federal poverty level. In an ever-increasing
fashion, States will have to absorb the cost of this burden. I offered
an amendment which would have allowed States to opt out from under this
mandate, but it has been rejected. In States like mine, where we have
to balance our budget, right now schoolteachers and law enforcement
officers are having to take unfunded furlough days. If this bill
passes, it will get even worse. We should not be passing a bill that
takes days and money out of the paychecks of teachers and law
enforcement officers to pay for this piece of legislation.

Announcement by the Speaker Pro Tempore

The SPEAKER pro tempore. The Chair will remind all persons in the
gallery that they are here as guests of the House and that any
manifestation of approval or disapproval of proceedings or other
audible conversation is in violation of the rules of the House.
Mr. WAXMAN. Mr. Speaker, I am pleased at this time to yield 2 minutes
to the gentleman from the State of Maryland, Mr. Chris Van Hollen.
Mr. VAN HOLLEN. Mr. Speaker, today our Nation stands at an historic
crossroads. We can choose the road that dead-ends in the status quo
where the health industry will continue to call the shots and ration
our health care or we can pass this bill and take the path that will
provide every American citizen access to quality, affordable health
care.
What we do in this bill is preserve what is best and fix what is
broken. We currently face unsustainable skyrocketing health care costs
that are breaking our family's budget, forcing businesses to drop
health insurance, and will eventually bankrupt our Nation. We saw
health insurance premiums more than double between 2000 and 2008; and
during that period of time, health insurance profits soared by 500
percent. How did they do it? Essentially by saying ``no'' to people who
had preexisting conditions and using the fine print in insurance
policies to deny people promised benefits when they needed help the
most.
This bill will end those abuses. It ends the antitrust exemption that

[[Page H12837]]

shielded the health insurance industry from price-fixing. It
establishes a health insurance exchange like a shopping supermarket for
health policies that provides more choice, including a public option.
Mr. Speaker, that's why the Consumers Union and Consumer Reports
support this legislation. That's why the AARP, the largest organization
protecting the rights of seniors, has endorsed this. And that's why the
doctors of America have endorsed this.

{time}  1430

I understand why the insurance industry opposes this bill, but our
job is not to protect the special interests of the insurance industry;
our job is to do what's right by the American people.
Let's move this country forward. Let's vote ``yes'' for America.
Mr. BARTON of Texas. Mr. Speaker, I would like to yield 1 minute to
another member of the committee, Congresswoman Marsha Blackburn of
Nashville, Tennessee.
Mrs. BLACKBURN. Mr. Speaker, I find it so interesting that some are
so excited about voting for this bill. Quite frankly, I find it to be a
very sad day that this body would take a step moving toward a single-
payer system in health care.
We have all heard the horror stories of what happens in Europe and in
Canada as women seek to get care for breast cancer and die before that
care can be found, because care delayed is care denied. We've heard
about heart surgeries that never came to pass because they were waiting
in the queue. We have talked to mothers who sought desperately to have
children treated for chronic illnesses and could not get that help. We
have heard about our seniors, and we know what this bill will do to
Medicare, making one-half trillion dollars worth of cuts. We have
talked to mothers who have said, My goodness, you cannot even get H1N1
vaccine out there and you think you're going to handle the health care
for my children?
And today, recorded in the Wall Street Journal, Betsy McCaughey,
former Lieutenant Governor of New York, cites some of the provisions
and what it will do to the seniors in this Nation as it cuts into their
access.
This is not the action we should take.

Announcement by the Speaker Pro Tempore

The SPEAKER pro tempore. The time of the gentlewoman has expired.
The Chair would ask all Members to adhere to the time limits and to
heed the gavel.
Mr. WAXMAN. Mr. Speaker, I yield myself 3 minutes.
Today, we have a historic opportunity. Sixty-five years after
Franklin Roosevelt and Social Security and 35 years after Medicare, we
have an opportunity, under the leadership of President Obama and
Speaker Pelosi, to reform our health care system and at last provide
coverage to all Americans.
We know that health insurance today is failing our families and our
economy. If we do nothing, the system will go bankrupt, premiums will
keep skyrocketing, benefits will be slashed, what you get will cost
more, and the deficit will increase by billions of dollars.
Today, Americans with health insurance know that they are one serious
illness away from debt and bankruptcy, and millions of Americans have
no insurance at all. With this legislation, we can fix these problems.
First and foremost, this bill provides health insurance security for
all Americans. If you have health insurance today, you can keep it; you
keep your doctor and your other health providers. But if you lose your
job, you will not lose your health insurance. If you have a preexisting
medical condition, you cannot be denied health insurance. If you have a
serious illness, we remove the cap insurance companies have imposed on
paying for treatments over your lifetime. Effective immediately, it
will be illegal for insurance companies to put lifetime caps on your
coverage. And children all the way up to age 27 can continue on their
parents' policies.
Our bill has historic reforms. It expands coverage and reduces costs.
It trains doctors and supports community health centers. It provides a
public health insurance option that will give Americans more choice and
competition.
Our legislation strengthens Medicare. We will eliminate copayments
for preventive services. We close and then eliminate the doughnut hole
that makes prescription drugs unaffordable for so many of our seniors.
And this legislation is affordable. The only thing not affordable is
to do nothing. The legislation is fully paid for. It will not add to
the deficit over the next two decades.
Today, we have the chance of a lifetime to do something great and
momentous for the American people. By passing this bill, we can reform
health insurance in America and provide all Americans with the security
of knowing that when they get sick, care will be available and
affordable.
I urge all my colleagues to support this bill.
Mr. Speaker, I reserve the balance of my time.
Mr. BARTON of Texas. Mr. Speaker, I yield for a unanimous consent
request to the former chairman of the Appropriations Committee, Mr.
Bill Young of Florida.
(Mr. YOUNG of Florida asked and was given permission to revise and
extend his remarks.)
Mr. YOUNG of Florida. Mr. Speaker, I rise in opposition to the bill.
Mr. Speaker, this bill, H.R. 3962, does not represent good public
policy. I rise to express my concerns about H.R. 3962, the Affordable
Health Care for America Act.
This legislation is misnamed, as even the nonpartisan Congressional
Budget Office says it will not be affordable for the American people
and our nation as a whole.
The Congressional Budget Office says this legislation will cost
$1.055 trillion over the next 10 years, raising taxes on American
taxpayers and businesses by $729.5 billion. Of great concern to me, and
the 138,647 Medicare beneficiaries I represent, is that it will also
cut Medicare payments by $500 billion. There is no possible way you can
cut such a significant amount of funding out of a program that is so
vital to senior citizens without compromising the availability or
quality of their care and without disrupting the relationship they have
with their current doctors and medical providers.
Within the Medicare program, H.R. 3962 also cuts the reimbursement
rate for seniors enrolled in Medicare Advantage programs. In the 10th
Congressional District of Florida which I represent, more than one-
third of the Medicare beneficiaries, or 47,729 seniors, are currently
enrolled in Medicare Advantage plans. The Chief Actuary of the Centers
for Medicare and Medicaid Services estimates that if enacted, the
legislation we consider today would cut enrollment in Medicare
Advantage by 64 percent over 4 years. This means that more than 30,500
of the seniors I represent will lose or have to give up the health care
coverage they currently have and like. This violates the number one
promise made by the sponsors of this legislation, who say that if you
like your current health care coverage, you can keep it.
The Congressional Budget Office also notes that changes in this
legislation to the Medicare Part D program will, in the end, drive up
Part D premiums by as much as 20 percent. These are additional premiums
that seniors living on fixed incomes will have to pay to keep their
prescription drug coverage.
Finally, with regard to Medicare, this legislation does nothing to
correct a 21 percent cut in physician reimbursement rates that is
scheduled to take effect January 1st for doctors who provide care to
our seniors. Having met with doctors I represent throughout the past
year, I know that one of their major concerns about health care reform
is that they will be asked to take larger and larger cuts in Medicare
reimbursement rates. These cuts, they say, will make it more and more
difficult for them to care for Medicare patients. In the end, many
seniors could be forced to find new doctors.
In addition to the impact this legislation would have on senior
citizens, I am concerned about the economic impact this legislation
will have on those seniors, their children, their grandchildren, and
their great grandchildren. H.R. 3962 creates a brand new federal
entitlement program at a time when our nation is struggling to sustain
those entitlement programs already on the books. While the
Congressional Budget Office says that under a best case scenario the
$500 billion in Medicare cuts and $729.5 billion in tax increases will
pay for this legislation over its first 10 years if there are no
unexpected costs, it is doubtful that this will keep the program from
running up federal deficits after that and leaves no margin for error.
In fact, despite one of the goals of this legislation to make health
insurance more available and affordable for uninsured Americans, we
simply move an estimated 18 million people into the government Medicaid
program. This is more than half of the 34 million uninsured

[[Page H12838]]

Americans who the Chief Actuary of the Centers for Medicare and
Medicaid Services says will receive coverage under this legislation.
Of the 13 million uninsured Americans who will receive coverage under
the Health Insurance Exchange program created in this legislation, the
Chief Actuary estimates that 40 percent, or 5.2 million, will take
advantage of the government subsidized public option created by H.R.
3962.
The creation of a government subsidized public option is another
major concern of the large majority of my constituents who have called
and written me in opposition to this legislation. We are concerned
about the insertion of the federal government into the precious
patient-doctor relationship. At last count, this 1,990 page bill
creates more than 100 new boards, bureaucracies, commissions and
programs. Among those created by the bill is the ``Health Benefits
Advisory Committee,'' that would be chaired by the U.S. Surgeon
General, to make recommendations on cost and coverage issues.
This 27-member government committee of unelected administrators will
be in charge of advising other bureaucrats, who will then decide what
procedures American citizens are allowed to have and what doctors you
are allowed to see under your healthcare plan. This places another
layer of bureaucracy between you and your doctor.
This committee is in addition to another newly created federal
organization called the ``Health Choices Administration,'' which will
be governed by a new Commissioner who will distribute billions of
dollars of taxpayer-funded subsidies. Additionally, the Commissioner
will have complete control over all insurance plans offered through the
newly created Health Insurance Exchange.
Perhaps the toughest of the mandates handed down by the federal
government under this legislation is that businesses must provide
health care for their employees or pay an 8 percent payroll tax and
that individuals must purchase health insurance or pay a 2.5 percent
tax on their adjusted gross income. This is not the federal government
providing incentives to individuals or employers. This is the federal
government imposing its will on individuals and businesses, and
penalizing those who do not comply.

This legislation further penalizes small businesses by imposing a 5.4
percent surtax on individuals earning more than $500,000. Half of these
so-called ``high earners'' are small business owners. Just imagine how
small business owners all across our nation will react to this $544
billion in new federal taxes they will pay over the next 10 years. With
the unemployment rate nationally at 10.2 percent and 11.4 percent in
Florida, Congress should not be making it harder for business owners to
create new jobs.
Finally, at a time when we are trying to lower health care costs,
this legislation imposes a new 2.5 percent excise tax on the cost of
wheelchairs, portable oxygen systems, diabetes testing equipment, and a
whole range of other medical devices. This tax will be paid by our
constituents who have no choice but to purchase this medical equipment
and who may already be stretched thin by other medical costs.
Mr. Speaker, I have discussed here some of my concerns about
provisions in this bill; however there are glaring omissions to this
legislation as well. The most significant provision that has been left
out is medical liability reform. This is a top issue for doctors,
hospitals and all medical providers, as it is one of the major drivers
increasing the cost of health care. Tort reform would help reduce the
filing of unwarranted lawsuits, decrease the number of duplicative
tests that are a part of defensive medicine, and lower the cost of
medical malpractice insurance rates, which would translate in lower
medical costs.
Tort reform is one of the many areas that we can and should be able
to agree upon to increase the availability and decrease the cost of
health care. There are others I support, some in this bill, including
requiring coverage for individuals with pre-existing conditions,
preventing insurance companies from cancelling the policies of
individuals when they become sick, providing for the availability of
health insurance across state lines, ensuring that employees can retain
access to health insurance when they change or lose their jobs,
creating health insurance pools that small business owners and self-
employed individuals can join to provide lower cost health insurance
for their employees and themselves, and closing the so-called doughnut
hole in the Medicare Part D prescription drug program.
Mr. Speaker, there is no doubt that our nation can and should do
better to provide quality and affordable health care for the American
people. Throughout my service in Congress, I have done all I could to
expand health care opportunities nationally and throughout the 10th
Congressional District, which I represent.
By establishing the National Marrow Donor Program in 1986, I sought
to provide life-saving medical options to terminally ill patients
suffering from leukemia and more than 60 otherwise fatal blood
disorders. Today the national registry has more than 7 million
volunteers available to donate the life-saving bone marrow.
During the time that I worked to establish the national registry and
as we began to find matched marrow donors for patients, I met with
family after family who needed help convincing health insurance
companies to cover the marrow transplant procedure. From this
experience, I witnessed first-hand the tragedy of families losing their
health insurance coverage at their time of greatest need and of being
denied coverage for a life-saving procedure.

In a similar manner, I have identified other national and local
health care needs and have done something to solve the problems that
include increasing the vaccination rates for our nation's children;
ensuring the availability of specialized services, facilities and
equipment at our nation's hospital emergency rooms to meet the needs of
children; expanding the funding for graduate medical education programs
to increase the number of doctors who receive the next step of their
training; increasing the Inspector General force at federal agencies to
uncover waste, fraud and abuse which threaten the safety of seniors and
veterans, and divert limited federal health care resources; improving
the quality of health care through our investment in biomedical
research by doubling the budget for the National Institutes of Health
during my 6 years as Chairman of the Appropriations Committee;
expanding other research opportunities through the Department of
Defense in the areas of breast cancer, prostate cancer, Parkinson's
Disease, ALS, multiple sclerosis and diabetes; and expanding the number
of community health centers throughout Florida and Pinellas County.
Mr. Speaker, I take a back seat to no one when it comes to my work to
improve and expand the quality and availability of health care for the
American people and the people I represent. I supported the creation
and expansion of the State Children's Insurance Program, which
increases access to health care for our nation's youth, and likewise
the Family and Medical Leave Act, allowing employees to take time off
from work to care for a sick and recovering family member.
However, I cannot support legislation that would threaten the
sanctity of the patient-doctor relationship, that would establish new
federal bureaucracies that would insert themselves into the health care
programs of individuals and employers, that creates a new and
financially unsustainable federal entitlement program, that threatens
the availability of health care for our nation's seniors, that raises
taxes substantially and threatens the viability of many small
businesses at a time when we are trying to get our nation's economy
back on track, and that ultimately will not make health care insurance
more affordable for the American people.
We have all heard from the American people we represent over the past
few months that this legislation has been under consideration. We have
heard that they are closely following its progress. We have heard that
they have many concerns about this legislation before us. And we have
heard that they want us to work together in a bipartisan manner to
bring down the cost and expand the availability of health care
coverage.
Today, we have a historic opportunity to tell the American people we
hear their voices. We can commit to them that, on this issue which will
affect every single household and business in our nation, we will go
back to our respective committees and work together--as Republicans and
Democrats; conservatives, moderates and liberals; Blue Dogs and
Progressives--to come up with a solution that the American people can
support and, most importantly, have confidence knowing it will do the
job without bankrupting our nation, jeopardizing our economic recovery
and violating the free market principles upon which our nation was
founded.
Mr. BARTON of Texas. Mr. Speaker, I yield a clock 3 minutes to the
minority leader, Mr. Boehner. This is not his leadership imperial
minute. It is the clock 3 minutes.
Mr. BOEHNER. Let me thank my colleague for yielding.
It will be no surprise to any of you that I rise in opposition to
this bill.
One of the issues in this bill that is of concern to Members on both
sides of the aisle has to do with the sanctity of life. The Rules
Committee made in order an amendment by our colleague from Michigan
(Mr. Stupak) that would continue existing law that no Federal funds
will be used for abortion.
While I am grateful that we're going to have this vote in the House,
I want to ask the chairman of the Energy and Commerce Committee, Mr.
Waxman, if the House does vote, in fact, for Mr. Stupak's amendment, if
the gentleman will guarantee me that when this bill

[[Page H12839]]

comes back from conference, that that language will remain in the bill.
Mr. WAXMAN. If the gentleman would yield.
Mr. BOEHNER. I would be happy to yield.
Mr. WAXMAN. As the gentleman well knows, the decision is not up to
one person; it will be up to the conferees. The conferees will have to
be meeting with the Senate conferees and going over a number of
positions.
If this amendment is adopted by the House, it will be the House
position as we go into conference. We will have to discuss it further,
and then we will see what will be the result. But no guarantee can be
made by me or any other Member at this time.
There will be an opportunity, as you know, to instruct the conferees,
which reinforces, of course, a particular part of the House bill.
Mr. BOEHNER. Reclaiming my time, the reason that I rise at this point
in the debate is that, while we are grateful to have this amendment and
this chance to vote to make sure that taxpayer funding is not used for
abortion--which has been the policy of the land for the last 30 years--
as the gentleman pointed out, there is no guarantee that at the end of
the day this language will be in the bill.
Now, I've been a chairman of a committee. I understand that there are
no guarantees, but that's the whole point here. The only reason this
amendment is allowed to be offered is in order to secure enough votes
to try to move this bill through the floor today. I have my doubts
about whether this language, if it passes, has any chance of ever being
in the final version of this bill.
Mr. WAXMAN. Mr. Speaker, at this time, I am honored to yield 2
minutes to the gentleman from New Jersey (Mr. Pallone), the chairman of
the Health Subcommittee of the Energy and Commerce Committee.
Mr. PALLONE. Mr. Speaker, I want to thank my chairman, Mr. Waxman,
for all his hard work on this bill.
For far too long, our Nation has endured a health care system that is
chaotic, costly, and crippling American families. In casting our votes
today, each of us must make a simple choice: Do we want to maintain the
broken system we currently have or do we want to make it better?
And you should ask yourself, first, are you in favor of allowing
health care premiums for American families to continue to spiral out of
control, forcing them to delay care or drop coverage altogether, or are
you in favor of providing every American with access to affordable and
quality health insurance?
Second, are you in favor of more American families falling into
bankruptcy under the weight of medical bills, or are you in favor of
providing every American with the security of knowing that they won't
go broke if they get sick?
Third, are you in favor of more American businesses delaying
investments, closing their doors or laying off workers because of
increasing health care costs, or are you in favor of making it more
affordable for those businesses to provide health care coverage for
their workers?
And finally, are you in favor of allowing health insurance companies
to be able to discriminate against people because they are sick, women,
or older, or are you in favor of putting an end to this explicit and
immoral form of discrimination that insurance companies get away with
today?
Mr. Speaker, there are many reasons to vote for this bill, but there
is really only one reason to vote against it, and that is to maintain
the broken health care system we currently have.
If you want to change the system, vote ``yes''; vote for affordable
and quality health care for every American.
Mr. BARTON of Texas. I yield 2 minutes to a member of the Republican
leadership, Mr. McCarthy of California.
Mr. McCARTHY of California. I thank my friend for yielding.
Mr. Speaker, this is my second term. Since being elected by the
people of California's 22nd District, I am reminded about how much
things have changed.
Three years ago on this date, unemployment was 4.5 percent. Today,
the unemployment rate has more than doubled to a 26-year high of 10.2.
Three years ago on this date, the stock market was over 12,000. Today,
the stock market has dropped by 2,000 points. Three years ago on this
date the current House majority promised to drain the swamp. Today, the
swamp in Washington isn't drained; it's overflowing. And 3 years ago on
this date, November 7, 2006, the Democratic Party was victorious in
winning control of this House.
Today, we are here on the floor to vote on a $1 trillion government
takeover that can replace the health insurance that millions of
Americans have. This is a defining vote for this Congress. We can
reject tax increases on small business at a time when 2.8 million jobs
have been lost since the stimulus was signed into law and say yes to
helping small businesses access more affordable health insurance for
their employees. We can reject the government takeover of our health
care that will increase health insurance costs and say yes to saving
American families up to $5,000 off their current health care premiums.
I know that over the last 3 years there have been many
disappointments, when the voices of Americans have been overruled by
government bailouts and now a government takeover of health care, but I
urge my colleagues to reject the politics of the past and fight for a
better direction for our country, for our children, and for our
grandchildren.
I urge a ``no'' vote on H.R. 3962 and a ``yes'' vote for the
Republican bill.
Mr. WAXMAN. Mr. Speaker, this bill reflects the input and the
inspiration of two Kennedys in the Congress of the United States,
certainly Senator Ted Kennedy, but also Patrick Kennedy, who has been
such a leader in the areas of mental health and addiction.
I yield to the gentleman from Rhode Island for a unanimous consent
request.
(Mr. KENNEDY asked and was given permission to revise and extend his
remarks.)
Mr. KENNEDY. I rise in support of mental health benefits in this bill
to support suicide, addiction, and depression coverage in this
legislation for whole health coverage.

General Leave

Mr. WAXMAN. Mr. Speaker, I ask unanimous consent that Members have 5
legislative days in which to revise and extend their remarks on H.R.
3962 and include extraneous material in the Record.
The SPEAKER pro tempore. Is there objection to the request of the
gentleman from California?
There was no objection.
Mr. WAXMAN. Mr. Speaker, at this point, I am greatly honored to yield
3 minutes to the chairman of the Ways and Means Committee, one of the
crafters of this bill and one of the great leaders in health care as
well as other policy areas, the gentleman from New York (Mr. Rangel).
(Mr. RANGEL asked and was given permission to revise and extend his
remarks.)
Mr. RANGEL. We have an expression in my community, ``God is good,''
and basically it means that it gives us all an opportunity in our lives
to do some of the things that we had hoped and dreamed would be
possible. Since God has been good to our country and to this Congress,
it means that we have a responsibility to extend our power to make
certain that people have access to health care.
It's really surprising that the other side would believe that, as a
party, their answer to this crisis that we face as a Nation in
providing health care to so many millions of people that don't have it,
that their answer is ``no'' and their vote will reflect ``no.'' But a
short visit to history would see that every time we're talking about
compassion--Social Security, Medicaid, and Medicare--their answer is
going to be ``no.''
I want to thank our President for recognizing that even though we
have to carry this load alone, it is an honor to be working under the
leadership of Speaker Nancy Pelosi, our chairmen, Chairman Waxman and
Chairman Miller, and all of the wonderful people that have worked
together under the caucus chair of Mr. Larson so that we all would
understand that we only have this one chance to get it right; Mr.
Clyburn, who brought our votes together so that we are able to be here
on

[[Page H12840]]

this Saturday to pass this. But to me, most of all, it would be the
hardworking members of my committee, men and women who worked day and
night to make certain that we got out our initial bill and we also
found a way to pay for it. And not only to make certain that this great
Nation of ours would not have a deficit but, indeed, would decrease the
deficit of this country by $100 billion over 10 years. And the staff,
of course, of the Ways and Means Committee that serviced not just our
committee, but all of the committees in the House and every Member who
needed to know just how can we get this thing right and to do the right
thing.
How proud we are that nobody is going to be denied health care
because they had a preexisting condition before that. How proud we are
that we don't have to select our jobs based on the health insurance
that we have. And how proud we are that people who lose their jobs will
not be losing their health coverage.
It is a small thing for some people like Members of Congress that
already have their insurance, but for those of us that have the
compassion to understand what it's like not to be able to take care of
your family or your dear friends, not to be able to have health
insurance, and for a Nation to be able to say that we are competing
with industrial countries all over the world and they provide education
and health care for their children, and this great country of ours,
with all of the wealth, have to shamefully say that we can't afford to
take care of our own people.

{time}  1445

So, to those who don't understand what we're doing, this is going to
be a historic day for you as well. Unfortunately, it won't be like it
would be for us, because we can now have our names under Roosevelt's
and under Obama's and under the right thing.
God is certainly good.
Mr. BARTON of Texas. Mr. Speaker, I yield 1 minute to the
distinguished ranking member of the Science Committee and a member of
the Energy and Commerce Committee, the gentleman from Rockwall, Texas,
Congressman Ralph Hall.
(Mr. HALL of Texas asked and was given permission to revise and
extend his remarks.)
Mr. HALL of Texas. Mr. Speaker, I rise today to urge, of course, a
``no'' vote on the Democratic health care proposal.
I have five grandchildren, and already they will spend their entire
lives paying the debts that we are accumulating. They will be in their
late sixties before they are even paid. This bill is a generation
killer, and the targets are your grandchildren and mine. My Fourth
District of Texas is 100-1 against this bill, and I believe it's a good
composite of other districts around the country.
I urge you all to please listen and to vote with your constituents,
and I say to Members on both sides of this aisle: remember who sent you
here, and vote their wishes. The American people have memories that
will survive the actions of today's vote. They will not forget. I ask
you to vote ``no.''
Mr. WAXMAN. Mr. Speaker, I yield 1 minute to the gentlewoman from
California, Anna Eshoo.
Ms. ESHOO. Mr. Speaker, I come to the floor today to cast one of the
most important votes of my congressional career, a vote for the
Affordable Health Care for America Act. This effort is historic, almost
a century in the making.
For many of us, this long battle has had a singular, courageous
champion who fought like a lion for the sick, the elderly, the left
behind, and the left out, Senator Edward Kennedy, and this bill is a
fitting memorial to him.
Most uninsured Americans want to purchase health insurance, but they
simply can't afford it. They are priced out. The middle class is priced
out. Millions more live under the crushing weight of medical bills that
bankrupt households or that shutter small businesses. This bill
provides access to affordable health care for every American.
The abhorrent insurance practices of dropping sick patients to avoid
paying expensive medical bills and discriminating against those with
preexisting conditions will end with this legislation.
Very importantly, seniors, your Medicare will be strengthened; and it
will provide you with better care.
I am proud to be part of making history. I think it is a privilege to
do so. I urge all of my colleagues to vote for this legislation.
The SPEAKER pro tempore. The Chair will note that the gentleman from
Texas has 28 minutes remaining, and the gentleman from California has
22\1/2\ minutes remaining.
Mr. BARTON of Texas. Mr. Speaker, I yield 1 minute to a distinguished
member of the Energy and Commerce Committee, one of our ranking members
of the subcommittee, the gentleman from Michigan (Mr. Upton).
Mr. UPTON. Mr. Speaker, I rise against this bill. I don't know if you
saw the headline today in The Wall Street Journal: ``Grim Milestone as
Jobless Rate Tops 10 percent.'' The New York Times: ``Jobless rate hits
10.2 percent with more unemployed. Official figure is highest since
1980. Broader measure stands at 17.5 percent.''
Mr. Speaker, I am from Michigan where our unemployment rate exceeds
15 percent. People want to work and pay taxes. They don't want to be
laid off and receive benefits.
This 1,990-page bill is almost 20 pounds. Does anyone actually
believe that spending another $1 trillion is going to reduce our
unemployment? We add employer mandates. The Joint Committee on Taxation
says that one-third of the $460 billion in taxes is going to be paid
for by small businesses. How does that decrease our unemployment? It
doesn't.
In closing, Mr. Speaker, let me say this: one of our colleagues today
is quoted as saying: Health care costs are rising faster than wages and
inflation, and this bill does not change that trend.
That was a Democrat and not a Republican who said it.
Mr. WAXMAN. Mr. Speaker, I yield 1 minute to a member of our
committee, the gentleman from New York, Eliot Engel.
Mr. ENGEL. Mr. Speaker, I rise in strong support of the Affordable
Health Care for Americans Act.
As a senior New Yorker on the Energy and Commerce Committee and on
the Health Subcommittee, I am proud of the role I played in helping to
make this bill a reality.
On this historic day, our Congress honors our country; it honors our
citizens; and it honors a moral imperative to provide all Americans
with comprehensive, affordable access to quality health care.
This is the reason why so many of us sought public office, and it is
the reason why our constituents sent us to Congress, to right the
wrongs of our broken health care system and to steer our country back
in the right direction.
Never again will families worry late into the night over whether
their preexisting medical conditions will prevent their loved ones from
getting access to the health care coverage they so desperately need.
Never again will insurance companies be allowed to drop coverage for
those who have paid their premiums diligently only to have their
policies canceled when they get sick and need it the most. Never again
will families have to worry that, if they lose their jobs, they will
also lose their health care coverage.
Don't believe the scare tactics you are hearing from the other side.
This bill is good for seniors, good for young adults, and good for all
Americans. I urge my colleagues to support the bill.
Mr. BARTON of Texas. Mr. Speaker, I yield 1 minute to the
distinguished former mayor of Fort Worth, Texas, the Honorable Kay
Granger.
Ms. GRANGER. Mr. Speaker, unemployment is over 10 percent in this
Nation. Our debt is nearly $12 trillion. Our deficit is $1.4 trillion.
Families are sitting at their kitchen tables trying to figure out how
to pay their bills. Businesses have cut everything they can cut just to
keep their doors open. Grandparents are taking in their kids and their
grandkids.
We are going to vote another $1 trillion so government can take over
our health care, cost those families more money, throw more mandates on
our States, add 118 new departments and agencies to this already
bloated Federal Government, take Medicare Advantage away from our
seniors, let the health choices commissioner take the

[[Page H12841]]

place of our family doctors, mandate health insurance with jail for not
complying with or for paying a tax, and ignore the voices of thousands
of people who came here and who said, Listen to us. Don't pass this
bill.
Mr. Speaker, what are people in this Chamber thinking of?
Mr. WAXMAN. Mr. Speaker, I yield 1 minute to a member of our
committee, the gentleman from Texas, Gene Green.
Mr. GENE GREEN of Texas. Mr. Speaker, I rise in strong support of
H.R. 3962, the Affordable Health Care for America Act. This is a
momentous day like that day in 1935 when Social Security was created
and also like that day in 1965 when Medicare was passed.
We are in desperate need of health care reform. Health insurance
premiums are growing three times as fast as wages; and, last year, more
than half of Americans postponed medical care or skipped their
medications because they couldn't afford them.
The 29th District in Texas, which I represent, has the highest number
of uninsured individuals in the country as 40 percent of the residents
are uninsured. If enacted, H.R. 3962 will provide coverage to 96
percent of all Americans and to 230,000 currently uninsured residents
in our district. It will also improve the employer-based coverage for
217,000 residents in our district.
H.R. 3962 will give individuals the ability to access quality,
affordable health insurance. They will no longer be denied coverage for
preexisting conditions, and their coverage will not be capped or
dropped when they are sick. The bill ensures no more co-pays for
preventative care, no more yearly caps for what insurance companies
will cover, and it provides premium subsidies for those who need it.
This is not government controlled medicine--individuals will be able
to choose their own insurance plan and their physician.
This bill ensures individuals will be able to have access to primary
and preventive care services so they will be able to see a doctor
before they are sick, and be able to access quality medical services.
H.R. 3962 will rein in rising health costs for American families and
small businesses--introducing competition that will drive premiums
down, capping out-of-pocket spending.
The time for health reform has come and I urge my colleagues to vote
in favor of H.R. 3962 not only for my constituents, but for all
Americans.
Mr. BARTON of Texas. Mr. Speaker, I yield 1 minute to one of the
distinguished ranking members of the Energy and Commerce Committee, the
gentleman from Florida (Mr. Cliff Stearns).
(Mr. STEARNS asked and was given permission to revise and extend his
remarks.)
Mr. STEARNS. I thank my colleague.
Mr. Speaker, I rise against this bill. The Congressional Budget
Office has said that tort reform will save the Federal Government $54
billion. Instead, we get a bill today that makes a mockery of tort
reform.
The Democrats add a provision that will clearly increase costs for
health care and that will make it harder to recruit doctors. The new
language explicitly prevents States who accept these grant funds from
capping noneconomic damages or attorneys' fees even if it is current
law.
Said another way, the Secretary of Health and Human Services can give
such sums as he deems necessary to any States that do not cap
attorneys' fees, or said another way, the bill undoes all States' tort
reform.
This bill violates States' rights. It undermines their efforts at
real tort reform. It allows trial lawyers to begin open season on our
doctors and medical providers.
Mr. WAXMAN. Mr. Speaker, I yield 1 minute to a very active and
important member of the Health Subcommittee and of the full Energy and
Commerce Committee, my colleague from California, Lois Capps.
Mrs. CAPPS. Mr. Speaker, I am honored to rise in emphatic support of
H.R. 3962. As we pass this historic legislation today which improves
health care for all Americans, I want to focus on the benefits for
women's health.
When this bill becomes law, a woman will no longer be discriminated
against by an insurance company simply for being a woman. Women will no
longer be discriminated against by insurance companies for being
victims of domestic violence. Women will automatically be covered for
maternity care. Women will not have to pay co-pays for important
preventative screenings, like mammograms and cervical cancer. Most
importantly, women who make the bulk of the health care decisions for
their families will have access to quality, affordable health care for
their families.
This is an excellent bill, and I am humbled by the fact that, as a
Representative of the 23rd Congressional District in California--a
nurse, a mother and a grandmother--I am privileged to vote today in
favor of this bill. I urge all of my colleagues to do the same.
Mr. BARTON of Texas. I yield 1 minute to another of my distinguished
ranking members on the Energy and Commerce Committee, the gentleman
from the Bluegrass State of Kentucky (Mr. Whitfield).
Mr. WHITFIELD. Mr. Speaker, there are many provisions of this 2,000-
page Affordable Health Care for America Act that we can support on this
side.
Yet we do not support the establishment of a Federal health care
board to control health care in America. We do not support establishing
civil penalties of up to $10,000 a day for violating health
regulations. We do not support reducing Medicare funding by $500
billion. We do not support cutting funding for hospitals by $155
billion and rural hospitals by $6 billion between 2017-2019. We do not
support increasing taxes on small business owners, particularly at a
time when we have an unemployment rate of 10.2 percent.
If we had a surplus, we could support spending billions of dollars
for the sovereign states of Micronesia, the Marshall Islands and Pulau.
Since we have a $11 trillion debt, why should we be spending money for
health care in those countries? We are also increasing by $10 billion
health care for Puerto Rico, the Virgin Islands, Guam, the Northern
Mariana Islands, and American Samoa in this bill.
Mr. WAXMAN. Mr. Speaker, I yield 1 minute to the gentleman from
Pennsylvania (Mr. Doyle).

{time}  1500

Mr. DOYLE. Mr. Speaker, my colleagues on the other side of the aisle
are trying to scare our seniors. They are telling tall tales, saying
that passing health care reform will destroy Medicare.
For Americans watching this debate, I want to make this clear: This
bill will strengthen Medicare. My good friend from Michigan, John
Dingell, helped write the law that created Medicare, and he authored
this health care reform bill we will vote on today.
This bill protects seniors and gives all Americans access to quality,
affordable health insurance. This bill will start to close the Medicare
prescription drug doughnut hole and ban insurance companies from
dropping people for having the audacity to get sick. This bill makes
sure that preventive services are free to seniors in Medicare and all
Americans with insurance.
This bill extends the Medicare's solvency by at least 5 years, it
pays for itself and it will reduce the national debt. Finally, this
bill is endorsed by doctors, nurses, patients, the Autism Society of
America and the AARP.
Mr. BARTON of Texas. I would like to yield 1 minute to the gentlelady
who has the privilege of representing Key West, Florida, the Honorable
Ileana Ros-Lehtinen.
Ms. ROS-LEHTINEN. Mr. Speaker, I am blessed that even though my
elderly mother has Alzheimer's, we are able to provide her with high
quality health care, but I am worried.
I am worried about the families who, like mine, have an elderly
parent who needs care and assistance. It's not easy for any family to
support a loved one through hard times, and there is no doubt that
these are hard times.
Unemployment in my area of south Florida is over 11 percent. In the
midst of this, the Pelosi bill takes away from seniors. Yes, it does.
The Pelosi bill makes $170 billion in cuts to Medicare Advantage,
causing 3 million seniors to lose their current coverage. The Pelosi
bill will increase Medicare prescription drug premiums by over 20
percent, a rate unaffordable to most seniors.
When I see my mother, I know that health care reform should not occur
at the expense of America's seniors. Reject the Pelosi sock-it-to-the-
seniors plan.
Mr. WAXMAN. Mr. Speaker, I yield 1 minute to the gentleman from the

[[Page H12842]]

State of Washington, a very important member of the Energy and Commerce
Committee, Mr. Inslee.
Mr. INSLEE. Mr. Speaker, I just want to relate one call from a small
businessman who told me we needed health care reform so that his wife
can finally start a small business of her own and be freed from the
insurance industry that stopped her from getting insurance.
I would like to enter into a colloquy with Mr. Waxman.
Mr. Chairman, I would like to clarify section 1188, the generic fill
provision in the bill. This section allows Medicare part D plans to
waive patient's copays for generic, bioequivalent and biosimilar drugs.
I believe that absent explicit approval from the patient's doctor, this
inducement should only apply to those biosimilars that have been rated
``interchangeable'' by the FDA, meaning that they can be expected to
produce the same clinical result in any given patient and switching
medicines poses no greater risk than not switching. With respect to
biosimilars that have not been rated as interchangeable, is it your
intent that under this provision patients could not be switched to a
non-interchangeable biosimilar drug without an explicit request by a
patient and approval by their doctor?
Mr. WAXMAN. Congressman Inslee, you are correct. It's our intent that
the patient would not be switched from a referenced product to a non-
interchangeable biosimilar without approval from the doctor.
The SPEAKER pro tempore. The time of the gentleman has expired.
Mr. WAXMAN. I yield the gentleman an additional 30 seconds.
Our intent is also that a patient could not be financially induced by
their plan to switch to a non-interchangeable biosimilar without the
consent of their doctor, and I am happy to work with the gentleman to
clarify the language in conference.
Mr. INSLEE. Today we should pass this bill.
Mr. BARTON of Texas. Mr. Speaker, I would like to yield 2 minutes now
to the leader of the Republican Health Care Task Force and a member of
our committee, the deputy ranking member, Mr. Roy Blunt.
Mr. BLUNT. Thank you, Mr. Barton.
Mr. Speaker, there are so many things that I am for in health care.
In our Health Care Solutions Group, I am sponsoring a dozen bills. The
core of those bills we will talk about later when we get to the
Republican substitute.
But if those bills cost $1.1 trillion, the bills I am for, I would be
against those bills. We can't afford this bill. It cuts Medicare $505
billion. It raises taxes.
There is no estimate I see of people who have estimated the job
impact who don't say that it cuts jobs. Instead, it's a 2,000-page
roadmap to a government takeover of health care.
We could be here today talking about real reforms, medical liability
reform, access for everybody regardless of preexisting conditions. We
think you can do that by expanding a risk pool concept. It costs a
little money, but it doesn't cost billions and billions and billions of
dollars.
If we could find Medicare savings, Mr. Speaker, we should use those
Medicare savings to save Medicare. Only the government would have made
a commitment to a program like Medicare, know that program is in huge
trouble beginning in about 2017, and be here today saying we should
make savings from that program to fund a new program. If there are
savings in Medicare, we should be using them to save Medicare, Mr.
Speaker.
I hope we reject this bill. Even if this bill passes today and
doesn't go further than this, I hope we can work together to do the
things we really need to do to reform the system.
Mr. WAXMAN. Mr. Speaker, at this time I yield 1 minute to the
gentleman from the State of North Carolina, an important member of our
committee, Mr. Butterfield.
Mr. BUTTERFIELD. I thank the gentleman for yielding the time.
Mr. Speaker, later today we will have an opportunity to fix a broken
health care system. I have listened to both sides of this debate, I
have read everything available, and I have prayed for guidance.
We have an obligation, constitutional and moral, to provide for the
general welfare of every American citizen. Allowing a broken health
care system to continue to bankrupt families, businesses and hospitals
and deny coverage to millions is a failure of duty.
We must act now. Reject the false rhetoric surrounding this debate.
Reject the false claims about Medicare coverage reductions. The bill
strengthens Medicare. Reject the false rhetoric about government-run
health care. The bill provides healthy and needed competition.
Reject the claim that this legislation will increase the debt. Doing
nothing will increase the debt by billions. We should not delay any
longer.
I urge my colleagues to vote ``yes'' on this legislation.
Mr. BARTON of Texas. Mr. Speaker, I see that we have changed from the
Jets and the Giants to the Green Bay Packers in the chair.
I would like to yield 1 minute to a Ramblin' Wreck from Georgia Tech,
a member of the Committee on Energy and Commerce, Dr. Gingrey.
Mr. GINGREY of Georgia. Mr. Speaker, having spent most of my life in
medicine and healing the sick, I rise in strong opposition to this
bill. With double-digit unemployment at 10.2 percent, this so-called
reform, which will destroy an additional 5.5 million jobs, is not what
the American people want. Yet their opposition and protests have fallen
on deaf ears as this majority simply does not seem to care.
One can perhaps see why. Democrats have the White House, 60 votes in
the Senate and an 81-seat majority in this House. They have all the
power. They can pass government-run health care without one single
Republican vote. Mr. Speaker, just because they can does not mean they
should. Might does not make it right. With $750 billion in tax
increases, $500 billion cuts in Medicare, Mr. Speaker, if the House
proceeds down this precarious path, I have no doubt that though the
American people may forget what was said here, they will never forget
what was done here and who did it to them.
Mr. WAXMAN. Mr. Speaker, I yield for the purpose of a colloquy to the
chairman of the subcommittee, Mr. Pallone, 1 minute.
Mr. PALLONE. Thank you, Chairman Waxman.
The bill we are debating today includes the CLASS Act, a bill I
sponsored, along with Representative Dingell, which would encourage
individuals to plan ahead for future long-term care needs. But there
are other things we can do to help increase the availability of home
and community-based services. The Empowered at Home Act, H.R. 2688,
which I sponsored with Representative DeGette, helps encourage States
to improve and increase access to home and community-based services
under their Medicaid programs.
While we were not able to include these other provisions from the
Empowered at Home Act in H.R. 3962, I hope that we can consider their
inclusion in the final health reform bill that emerges from the
conference with our Senate colleagues.
Mr. WAXMAN. I want to thank the gentleman from New Jersey for his
leadership on the bill before us today and for his tireless efforts on
behalf of low-income Americans who need long-term care. I support the
elimination of barriers to the provision of home and community-based
services under Medicaid, a result that the gentleman's Empowered at
Home Act would achieve.
The SPEAKER pro tempore (Mr. Obey). The time of the gentleman has
expired.
Mr. WAXMAN. I yield the gentleman an additional 30 seconds.
I will continue to work with you and other Members to enact
legislation that gives State Medicaid programs a robust option for
offering low-income Americans the choice of receiving long-term care
services in the community rather than in a nursing home.
Mr. BARTON of Texas. Mr. Speaker, I yield 1 minute to the gentlewoman
from Missouri, who represents the hometown of Rush Limbaugh, Cape
Girardeau, Missouri, Congresswoman Jo Ann Emerson.
Mrs. EMERSON. Mr. Speaker, this could have been a great day in the
House of Representatives, but we have missed an opportunity for
consensus, to improve access and save money for

[[Page H12843]]

taxpayers and patients alike. Americans pay the highest prices for
prescription drugs in the world and this bill binds us to that fate.
For every Member of Congress, there are two and a half pharmaceutical
lobbyists. In the first half of 2009, drug companies spent $609,000
every day on lobbying. We have missed an opportunity to tell the drug
companies that they no longer set the agenda in Congress.
We have missed an opportunity to put the interests of Americans ahead
of special interests. We have missed an opportunity to end the pill-
splitting, skipped doses and unfilled prescriptions that plague
Americans who can't afford the medicine their doctor prescribes.
This bill shifts those costs from patients to taxpayers, from this
generation to the next. It trades affordable generics for pricey name-
brand name drugs. It intentionally makes quality care more expensive
for our Nation, and it is wrong to leave hundreds of billions in
savings on the table.
Mr. WAXMAN. Mr. Speaker, I am pleased to yield 1 minute to a very
important member of our committee, the gentlewoman from the Virgin
Islands (Mrs. Christensen).
Mrs. CHRISTENSEN. Thank you, Mr. Chairman.
Mr. Speaker, as a family physician who practiced for more than 20
years, a mother, a grandmother and an American, I am proud to stand
here in support of the Affordable Health Care for America Act. This
bill is for the many patients I know who put off health care until it
was too late because they couldn't afford it and the tens of millions
like them who will now have access to full health care.
This year and every year past, over 80,000 African Americans died,
whose deaths were preventable, because they were unable to get health
care. This bill is for all people of color, those in our rural areas,
the territories and the poor, because beyond insurance, this bill will
provide the services some of them never had.
H.R. 3962 will give young people for whom a health care professional
is out of the reach the opportunity to help heal their communities. It
will cover 36 million uninsured people, making insurance secure and
affordable, strengthen prevention and public health, improve Medicare
and Medicaid, help poor communities, create an environment that
supports good health, and finally begin to eliminate health
disparities.
Today we have the opportunity to vote for health and a better life
for everyone in this country and for a better country where life,
liberty and the pursuit of happiness is truly a right for all.
Let's make history together. Vote ``yes'' for affordable health care
for America.
Mr. BARTON of Texas. Mr. Speaker, I recognize one of my ranking
subcommittee members, Mr. Radanovich, who represents Fresno,
California, for 1 minute.
Mr. RADANOVICH. Mr. Speaker, we are standing on the precipice of a
major shift in this country's history. In less than a year, the Obama
administration, working with the Pelosi Congress, has recklessly spent
taxpayer funds to expand government to a level never before seen in
history.
The government is now more involved in our lives than I think any of
us could have imagined. The result has been double-digit unemployment
for the first time since the early 1980s. And now we are going to vote
on whether the government should take over the Nation's health care
system at a cost of $1.3 trillion and up to 5.5 million jobs.
Despite all this, the leadership of this Congress has chosen to
ignore the will of the people and say, America, you are wrong. We know
what's best for you.
Well, this bill is not what the American people want, and it
certainly is not what the doctor ordered for health care improvement.

{time}  1515

Mr. WAXMAN. Mr. Speaker, I yield 1 minute to the gentlewoman from
Illinois (Ms. Schakowsky), a senior member of the Energy and Commerce
Committee.
Ms. SCHAKOWSKY. This is a great moment in history because today we
act to guarantee affordable health care for this and future
generations. It is a great day for women. Our bill stops gender rating,
preventing insurance companies from charging women 48 percent more than
men for the same coverage.
We eliminate preexisting conditions. Being a breast cancer survivor
or domestic violence victim will no longer prevent access to care. We
require coverage of maternity and well-baby care. We ensure that older
women not yet eligible for Medicare can buy affordable coverage.
We improve Medicare. Senior women will be able to afford preventive
services like cancer screenings because we eliminate cost-sharing. We
close the doughnut hole, so they can afford their medications.
Women need health care reform. They need H.R. 3962.
Mr. BARTON of Texas. Mr. Speaker, I am proud to yield 1 minute to the
honorable gentlewoman from North Carolina (Mrs. Myrick), a cancer
survivor.
Mrs. MYRICK. Mr. Speaker, Americans are struggling with health care
costs. We all know that. Too many families can't afford coverage, and
small businesses are struggling to find coverage for their employees.
However, this bill does not fix the underlying problem, the cost of
health insurance. It is an unprecedented expansion of Federal
Government spending that will only dig a deeper hole of debt for
generations to come.
Margaret Thatcher once said, ``We want a society in which we are free
to make choices, to make mistakes, to be generous and compassionate.
Not a society in which the State is responsible for everything, and no
one is responsible for the State.''
The majority's bill creates a society that resembles the latter, and
it is a mistake. I urge my colleagues to vote ``no.''
Mr. WAXMAN. Mr. Speaker, can I inquire how much time is available on
each side?
The SPEAKER pro tempore. The gentleman from California has 13\1/2\
minutes remaining. The gentleman from Texas has 17\1/2\ minutes
remaining.
Mr. WAXMAN. Mr. Speaker, I yield 1 minute to the gentlewoman from
Wisconsin (Ms. Baldwin).
Ms. BALDWIN. Mr. Speaker, I rise in support of this bill, which will
provide affordable health coverage to 36 million people who lack it
today. This has been an aspiration for our Nation and our people for
decades.
I first ran for office motivated by my belief that every American
should have access to quality health care, and I will not stop fighting
until every American is covered. There are far too many daily reminders
of the failures and injustices of our current system, the countless
stories of bankruptcy, care delayed and premature death. And yet we
have let years go by while people suffer.
Today, we convene to debate and advance legislation that delivers
meaningful insurance reform, outlawing outrageous insurance abuses,
lowering costs, and extending coverage to all. I will cast my vote
today on behalf of the people in Wisconsin and millions throughout
America who have said enough is enough.
Today, we declare with conviction: every American deserves health
care, and every American shall have it.
Mr. BARTON of Texas. Mr. Speaker, I am proud to yield 1 minute to the
sixth Frelinghuysen to represent a district from the Garden State of
New Jersey, the Honorable Rodney Frelinghuysen.
(Mr. FRELINGHUYSEN asked and was given permission to revise and
extend his remarks.)
Mr. FRELINGHUYSEN. Mr. Speaker, I thank the gentleman for yielding.
Mr. Speaker, I rise in opposition to this legislation because I have
been listening to my constituents. Over the past several months, I have
received over 13,000 letters, emails, faxes and calls from New Jersey
families and employers. Unprecedented. I have listened to hundreds of
residents in town hall meetings, retirement communities, nursing homes
and senior clubs.
I have visited areas hospitals and businesses, large and small. I
have met with medical societies, health providers, doctors, nurses,
anesthesiologists, home health aides, chiropractors, surgeons, all of
them.

[[Page H12844]]

In each of these meetings, these men and women have expressed deep
concern about the so-called health care reforms that have been
sponsored by the House majority, the Pelosi bill, and most are opposed.
They are worried about how this massive bill, over 1,900 pages long,
will affect their doctor-patient relationship, their personal care, and
their ability to afford their health insurance. And they are worried
with good reason.
H.R. 3962 is a toxic-mixture of job-killing higher taxes, rampant new
mandates on businesses and individuals of all ages and damaging
Medicare cuts, combined with a government takeover of health care.
It demands opposition on so many grounds:
First, according to the Congressional Budget Office, H.R. 3962 will
cost at least $1.2 trillion over the next ten years! This is mind-
boggling, on top of earlier borrowing and deficits!
To pay for this massive new spending, Speaker Pelosi wants to raise
taxes and cut Medicare that older Americans depend on each and every
day.
My colleagues, we heard the grim news yesterday that unemployment
currently is at a 26-year high--10.2 percent. (And we know it's
actually higher.) And yet, this bill contains $735 billion in new
taxes!
Using the formula developed by the chief White House economic
advisor, 5.5 million Americans could lose their jobs as a result of
enactment of the Pelosi Health Care bill.
$735 billion in new taxes.
Among the new taxes is a new ``surtax'' on high-income filers--many
of whom are small business men and women.
While this tax is intended to target ``high-income'' individuals and
couples, it is not indexed for inflation, meaning it will reach
millions more New Jersey residents over time just like the Alternative
Minimum Tax.
H.R. 3962 also includes taxes on individuals who do not purchase
government-mandated health insurance.
Think about this! You do not make enough money to afford health
insurance and this bill actually fines you! The end result: you still
don't have coverage and you've been fined as well!
Young people will be particularly surprised that they will be subject
to such a fine!
Mr. WAXMAN. Mr. Speaker, at this time I yield 1 minute to the
gentleman from Massachusetts (Mr. Frank) for the purpose of a colloquy.
Mr. FRANK of Massachusetts. I thank the chairman, and I congratulate
him for the excellent work he and others have done on this bill.
I want to discuss the importance of the bill in addressing hard-to-
reach communities, including commercial fishermen, who are a very
important part of my constituency, but also farmers and ranchers.
Ranchers tend to be a less important part of my constituency.
We are creating a new health insurance marketplace and requiring
everyone to have coverage, which I support. This makes it particularly
important to educate those that haven't had reliable, continuous access
to quality, affordable health care.
Under the bill, will the commissioner be able to contract with
entities such as commercial fishing organizations or others to
facilitate the dissemination of information?
Mr. WAXMAN. The answer is yes.
Mr. FRANK of Massachusetts. I thank the gentleman. I assume this
means also the commissioner can work with the Small Business
Administration on this sort of outreach and education?
Mr. WAXMAN. Yes. The bill ensures the commissioner will work with the
Small Business Administration.
Mr. FRANK of Massachusetts. I thank the chairman for clarifying these
points.
Section 2229 of the Senate bill recognizes the unique health care
educational outreach needs of commercial fishermen, farmers and
ranchers, and I hope that that will be accepted in the final bill.
Mr. BARTON of Texas. Mr. Speaker, I am proud to yield 1 minute to the
honorable gentleman from Pennsylvania (Mr. Pitts), one of the strong
pro-life leaders in the U.S. Congress, a combat veteran of Vietnam, and
a member of the Energy and Commerce Committee.
Mr. PITTS. Mr. Speaker, there has been some recent confusion
surrounding the inclusion of abortion coverage in H.R. 3962, but the
issue is actually quite clear. The Capps amendment in the bill, which
some have argued is neutral on abortion, explicitly authorizes the
Federal Government to directly fund elective abortions using Federal
funds drawn from a Federal Treasury account. The provision has been
billed as a so-called compromise amendment. But this bill will
radically expand current and longstanding Federal policy with respect
to abortion.
Currently, there is not a single government health care program that
provides coverage for elective abortion; not SCHIP, not Medicaid, not
DOD, Indian Health or the Federal Employee Health Benefit Program, all
because of congressional action to explicitly prohibit coverage of
abortion under each of these programs. But such an explicit exclusion
is missing from this bill.
Therefore, I urge my colleagues to support, when it comes up later,
the Stupak-Pitts-Chris Smith-Ellsworth-Dahlkemper-Kaptur amendment that
would prevent Federal funding of abortion in this bill.
Mr. WAXMAN. Mr. Speaker, I yield 1 minute to the gentlewoman from
Florida (Ms. Castor), a member of our committee.
Ms. CASTOR of Florida. Mr. Speaker, Democrats will now deliver on
what American families and businesses have been asking for when it
comes to their health: one, meaningful, secure and stable insurance;
two, improved Medicare for seniors; and, three, vital consumer
protections.
For families with health insurance, health reform will provide you
with coverage you can count on. Families will no longer have to worry
about insurance companies canceling their coverage because someone in
their family gets sick. Health insurance companies will no longer be
able to bar you from insurance just because you have diabetes or cancer
or some other chronic condition.
American families have been doing everything right. They have been
paying their copays and paying their premiums, even as those costs have
risen dramatically. Our health bill says that in return, that coverage
must be meaningful, stable and secure. And for our family members who
rely on Medicare, you will see immediate improvements, in your
prescriptions, your checkups, and a provision I worked on, to penalize
unscrupulous practices of private Medicare insurance sales agents.
The meaningful health reform that will pass the House today builds on
the great legacies of Social Security and Medicare, and I am proud to
represent Florida families in this historic vote.
Mr. BARTON of Texas. Mr. Speaker, I yield 1 minute to the gentlewoman
from Wyoming (Mrs. Lummis), who represents the entire State.
Mrs. LUMMIS. Mr. Speaker, I stand before you today on behalf of the
people of Wyoming, where individual freedom and personal responsibility
are hallmark values.
This $1 trillion tax-everybody-right-down-to-the-wheelchair debacle
will impact every person in Wyoming. This bill will force my
constituents to buy insurance, whether it makes sense for them or not.
This bill will dump some of my constituents into a government-run
health care program to which Members of Congress will not even subject
themselves.
I sought an amendment that would allow States to shield their
citizens from government-forced insurance, from taxes and possible
fines or imprisonment, from government policies that come between
themselves and their doctors, from unfunded mandates on States. But my
amendment and dozens of others were swept away by the majority, and
American freedoms right along with it.
Our Constitution was designed to empower the American people and
shackle the Federal Government. This bill will shackle the American
people while empowering the Federal Government. It is a sad day for
Wyoming, Mr. Speaker.

Announcement by the Speaker Pro Tempore

The SPEAKER pro tempore. The Chair will remind all persons in the
gallery that they are here as guests of the House and that any
manifestation of approval or disapproval of proceedings or other
audible conversation is in violation of the rules of the House.
Mr. WAXMAN. Mr. Speaker, I am pleased to yield 1 minute to the
gentleman from Pennsylvania (Mr. Patrick J. Murphy), who has been a
leader in our efforts to lower growth in premiums through measures such
as immediate review and justification of insurance rate increases.
Mr. PATRICK J. MURPHY of Pennsylvania. Colleagues, voting ``yes''

[[Page H12845]]

today means tax incentives for Joe Frederick, a small business owner in
Bucks County, Pennsylvania, who struggles with skyrocketing health care
costs for his employees. It is a vote for Mrs. St. Clair, whose niece
died because she couldn't get insurance. It is a vote for Jay Doroshow,
who was kicked off his plan after being diagnosed with Lou Gehrig's
disease.
I urge a ``yes'' vote for our fellow Americans who want to secure
affordable health insurance which can't be taken away from them when
they need it most.
Sixteen years have passed since we last tried to reform health care.
Premiums have more than doubled. Every day in the State of
Pennsylvania, 510 families are kicked off their coverage. That is every
single day.
Mr. Speaker, as I said, I am a proud Blue Dog Democrat, and there is
universal agreement that to get our country's fiscal house back in
order, we must first get our health care spending under control. And
this bill does just that. It actually reduces our deficit by $129
billion, taking important steps to rein in health care costs.
But there is more work to be done, and I look forward to working with
you and our leadership to accomplish this goal.
The SPEAKER pro tempore. The time of the gentleman has expired.
Mr. WAXMAN. Mr. Speaker, I yield the gentleman an additional 10
seconds.
If the gentleman would permit, I want to thank you for your
leadership, and assure you we are going to continue to work in
conference to do everything we can to make coverage affordable for the
American people.
Mr. PATRICK J. MURPHY of Pennsylvania. Thank you, and I urge my
colleagues to vote ``yes'' today.
Mr. BARTON of Texas. Mr. Speaker, I yield 1 minute to the gentleman
from Nebraska (Mr. Terry), who represents Omaha, Nebraska, the home of
the College World Series.
Mr. TERRY. Mr. Speaker, it is clear that skyrocketing health care
costs do exist, causing a number of Americans to become uninsured. But
instead of addressing these issues, the Speaker has offered us a bill
that dramatically overhauls the present health care system.
It injects government into every corner of health care decision-
making, from arming the Health Choices Commissioner with unprecedented
power to dictate coverage and influence costs, to imposing crushing
taxes on small businesses. It transfers $600 billion from Medicare and
Medicaid and imposes mandates on States by expanding Medicaid, which
will then trickle down and force the States and the localities to
increase taxes, really masking the true cost of this massive $1.2
trillion bill.
There is a better way that we can accomplish providing Americans with
affordable health care.

{time}  1530

Mr. WAXMAN. Mr. Speaker, I yield 1 minute to the gentleman from
Connecticut (Mr. Murphy).
Mr. MURPHY of Connecticut. Mr. Speaker, every night in my State,
thousands of kids go to sleep sick in their beds just because their
mothers can't afford to get them to doctors. This is the most affluent,
most compassionate Nation in the world, and it makes absolutely no
sense that our health care system is the most inefficient, most unfair
in the world. But to change this, we don't need to throw out what we've
got.
Despite all this nonsense political speak from the Republicans about
government takeovers, this bill simply seeks to reset the rules of the
private health care marketplace so that it starts working again like it
should, so that small businesses can band together to negotiate for
lower prices, so that individuals will have access to tax credits to
help them pay for private insurance, insurance that's fair and doesn't
discriminate against them because they're sick. We'll fix this crisis
in our health care system all on the shoulders of a reformed private
system so that never again does a child fall asleep sick in his bed
because his country, the most powerful in the world, didn't have the
coverage to make him well.
Mr. BARTON of Texas. I would like to recognize the gentleman from
Virginia, Congressman Frank Wolf, for a unanimous consent request.
(Mr. WOLF asked and was given permission to revise and extend his
remarks.)
Mr. WOLF. I rise in strong opposition to the bill because our Nation
is going broke.
I rise in opposition to this bill.
We must carefully weigh the implications of a costly new government
spending program at a time when the country already owes more than $56
trillion in entitlement obligations.
I am also deeply concerned about the national debt, which has doubled
since 2000 and is nearing $12 trillion for the first time in our
history.
Any plan put forward must control costs, not add billions of dollars
to an already ballooning deficit.
America is going broke. Is this the legacy this Congress wants to
leave our children and grandchildren?

News Release

``Health care is a very personal issue and there are very
real consequences to what Congress does on this issue.
Congress must be committed to offering affordable,
accessible, and portable health care choices with the goal of
fixing what's broken and keeping what works. I know there are
good and reasonable people with deeply held views on every
side of the health care reform issue. That's why I believe
all sides need an opportunity to be heard and offer ideas so
that a bipartisan consensus can be reached.
``I believe every fair-minded person would agree that
Congress needs to find a way for the millions of Americans
without health insurance to be assured of quality, affordable
health care when they need it and to address the concerns of
those who are paying for a plan they believe falls short of
the coverage they need. Part and parcel of that discussion, I
believe, also must be the recognition that there are many
folks are paying for a health insurance plan that they like
and want to keep and they don't want the government involved
in their health care decisions.
``I am very concerned, however, about the health care
reform process under way in Congress. House Democrats on
October 29 unveiled a 1,990-page health reform bill--H.R.
3962--which is estimated to cost just under $900 billion over
10 years. Especially troubling is the majority leadership's
intention to fast track the legislation for House
consideration within days of its introduction.
``Congress needs to listen to the American people, take its
time and get health care reform legislation right. This is
too important an issue to rush through under some artificial
timeline. It is for this reason that I am cosponsoring a
resolution calling for any health care reform legislation
considered by Congress to be made available online in its
final form 30 days prior to being voted on in the House. I
believe that every American must have the opportunity to read
and understand what Congress is considering. Now with the
latest bill covering nearly 2,000 pages, that is more
important than ever. A copy of H.R. 3962 is available on my
Web page,
www.wolf.house.gov
.
``I opposed the first version of the Democrats' health
reform legislation (H.R. 3200) that was introduced this
summer, and nothing that I have read so far in the newest
version introduced on October 29 changes my view. This
legislation would set up a government insurance option with
rates to be negotiated between providers and federal health
officials. It has mandates for every American to have
insurance and for employers to provide insurance. It would
expand Medicaid to historic levels adding new mandates on
states. The revenue sources identified include a surcharge
on wealthy taxpayers and changes to Medicaid and Medicare
which would translate to about $500 billion in cost
savings over 10 years, according to the Congressional
Budget Office.
``When President Obama earlier this year directed Congress
to come up with a health reform plan, I had hoped that both
Republicans and Democrats could work together on this issue
of such complexity in a bipartisan way and reach consensus on
a plan to address the needs of uninsured Americans, protect
those with insurance plans they like, and keep a lid on
deficit spending at a time when our economy is reeling from
recession and spiking unemployment. What we have seen,
however, is the opposite. The speaker and House majority
worked alone on H.R. 3200 that initially was to be voted on
by the House in early August. They have continued to work
behind closed doors to refine that plan, and the latest bill,
H.R. 3962, was drafted solely by the majority.
``I don't believe that is the right way to develop public
policy on an issue of such importance and far-reaching
consequence to every American. This is a complex issue to
legislate, and there are legitimate questions that Congress
must answer. Among the many questions to be resolved are how
to make sure health care decisions are patient-centered and
remain between physicians and patients and not prescribed by
some government formula; how to provide for Americans who
don't have health insurance and ensure those with pre-
existing conditions can get insurance; how to protect those
who have health insurance and don't want to be forced to give
up their plans or pay more for them; how to control health
care costs and pay for health care reform without increasing
the

[[Page H12846]]

deficit; how to ensure that U.S. taxpayers are not
subsidizing health insurance for those illegally in our
country; how to ensure that the self-employed and small
business owners can afford insurance, and how to ensure that
young adults can continue to be carried under their parents'
health plan until they reach age 25.
``I have concerns about a government-run insurance option
and what that will mean in the way of costly mandates for
small businesses and other employers during a time when
unemployment is teetering near 10 percent. I am also
concerned about how Americans will pay for a $900 billion
plan as our country tries to work its way out of an economic
recession and faces trillions of dollars in debt and a
growing annual deficit that could be near $2 trillion. I also
have questions about finding a half trillion dollars in
savings in Medicare and Medicaid costs. What will that mean
for senior citizens today?
``We must carefully weigh the implications of a costly new
government spending program at a time when the country
already owes more than $56 trillion in promised entitlement
obligations through Medicare and Social Security. I'm also
concerned about the national debt, which has doubled since
2000 and is nearing $12 trillion for the first time in our
history, and unprecedented federal deficits, which could
result in increased interest rates for consumers if we
continue to finance government by borrowing from foreign
lenders. I have the leading bill in the House to establish a
bipartisan commission to review entitlement spending with tax
policy on the table to ensure that Congress addresses these
spending issues, which if left unchecked, will be disastrous
for future generations. (For more information about the SAFE
commission, go to <a href='http://www.wolf
.house.gov/SAFE'>www.wolf
.house.gov/SAFE</a>.)
``I again want to emphasize: it is important for Congress
to fix what's broken with our nation's health insurance
system. But we have to do it the right way without changing
what is working. We need a plan that controls costs without
adding billions of dollars to an already ballooning deficit;
ensures competition and choice; provides that patients and
their doctors make the decisions on medical care rather than
a government-run agency, and addresses skyrocketing medical
liability costs and tort reform.
``I believe that the legislation in the House falls short
of those goals and that Congress has a lot more work to do to
provide the kind of health reforms Americans want and need.''

Mr. BARTON of Texas. Mr. Speaker, I yield 1 minute to the former FBI
man from the great State of Michigan (Mr. Rogers), a member of the
committee.
Mr. ROGERS of Michigan. Mr. Speaker, there are huge consequences to
the 85 percent of Americans who have earned their health care in this
bill. Not only will they get longer wait times and more expensive
premiums, but at the end of that, with new debts, some $1.5 trillion in
new spending, 18 million Americans won't have coverage. But more
importantly, there will be another victim.
There is nothing more sacred than the bond between a mother and a
child, that trust, that love, that nurturing when that child is sick.
And when a mother goes to the doctor under that 2,000-page bill, that
relationship that they enjoy between their patient and their doctor and
what that mother wants for that child is no longer sacred, because now,
through the 118 different boards and commissions, their comparative
effectiveness research allows the Federal Government, through forced
government insurance, to ration and deny care. You have violated the
most important trust, the most important thing that we have in the
building block and the foundation of the values of this country. That
mother, that doctor knows what's best for that child. You will find no
compassion in a Federal bureaucracy.
Mr. Speaker, I would urge the strong rejection and the protection of
that bond between doctor and patient and mother and child.
Mr. WAXMAN. Mr. Speaker, I yield 1 minute to the gentleman from
Colorado (Mr. Salazar).
Mr. SALAZAR. Mr. Speaker, I am especially pleased that this bill will
help rural America. Currently, physicians in rural areas are reimbursed
less from Medicare than their urban counterparts. H.R. 3962 will
reimburse primary care physicians in rural areas 10 percent more than
the urban physicians not only to equalize the disparity, but to make
rural communities more attractive to physicians.
Most of my district is considered a health professional shortage
area. In my district in Colorado, we have three counties with only one
practicing physician. We have one county with none at all. This bill
will increase the number of physicians in all of my counties and
improve access for 106,000 Medicare beneficiaries.
This bill will expand insurance coverage to 111,000 currently
uninsured residents in my district. In my district, it will protect 900
families from going bankrupt due to excessive health care costs. It
will help 184,000 low-income families pay for their insurance.
Our current system is broken, and it is time to fix it now.
Mr. BARTON of Texas. Mr. Speaker, I yield 1 minute to the gentleman
from the Pelican State, Congressman Scalise from New Orleans, a member
of the committee.
Mr. SCALISE. I want to thank the ranking member from Texas for
yielding.
I rise in opposition to Speaker Pelosi's 1,990-page government
takeover of health care. Weighing in at nearly 20 pounds, this bill
comes out to over $530 million of spending per page. And where does
this bill spend that money? Well, first of all, it fails the American
people. It fails those small businesses and families that are going to
have to pay the $730 billion in new taxes in this bill. It fails our
seniors who have to deal with over $500 billion in cuts to Medicare.
And it fails many of President Obama's own pledges and promises he made
right here on this floor, like when he said, If you make less than
$250,000 a year, you won't pay any new taxes, ``not a dime.''
In this bill, there is over $20 billion of new taxes just on people
who have no insurance. The President has said multiple times, If you
like what you have, you can keep it. Unfortunately, this bill fails the
President's promise because it allows the health care czar to take away
your insurance even if you like it. It's so bad, that even when we
brought our amendment to say all Members of Congress have to abide by
this bill, they actually refused to allow a vote on that amendment.
We need to defeat this legislation and do real reform.
The SPEAKER pro tempore. The Chair would announce that the gentleman
from Texas has 11\1/2\ minutes remaining, and the gentleman from
California has 6\1/4\ minutes.
Mr. WAXMAN. Mr. Speaker, I yield 1 minute to the gentlewoman from
Ohio, Betty Sutton, a member of our committee.
Ms. SUTTON. Mr. Speaker, the American people have been waiting for
this day, a day that we will finally pass a health care bill that will
work for and with them, that will provide them with access to more
affordable quality care, care that they can count on.
Mr. Speaker, they have been waiting for us to put an end to the
egregious discriminatory practices of insurance companies who deny
coverage based on preexisting conditions and place caps on coverage to
prevent people from accessing the care they need just when they need it
the most.
Today we act to improve the employer-based coverage for 420,000
residents in my district, to improve Medicare for 107,000
beneficiaries, and to move to close the prescription drug doughnut hole
for seniors across this country.
Yes, Mr. Speaker, the American people have been waiting, and today we
act for a health care system that will work for and with them.
Mr. BARTON of Texas. Mr. Speaker, could I ask how much time. You said
it a minute ago, but I was not listening.
The SPEAKER pro tempore. The gentleman from Texas has 11\1/2\ minutes
remaining. The gentleman from California has 5\1/4\ minutes remaining.
Mr. BARTON of Texas. Thank you, Mr. Speaker. I was listening to my
distinguished friends on the majority raptly.
I now yield 1 minute to one of our doctors, physicians, the gentleman
from Lewisville, Texas, the Honorable Michael Burgess, also a member of
the committee.
Mr. BURGESS. I thank the gentleman for yielding.
Last spring and summer, as we got into this debate, America's doctors
were pretty clear of what they wanted to see if Congress was going to
undertake health care reform. They wanted to see some relief in the
medical justice system. They wanted to see some medical liability
reform. They desperately needed a fix to the payment formula in
Medicare that shows reductions in Medicare reimbursement rates every
year for as far as the eye could see, and they wanted a little help
with

[[Page H12847]]

antitrust relief. After all, if we're going to ask our doctors to be
our partners in this brave new world of health care reform, the least
we could do is let them talk amongst themselves about the best way to
deliver high-quality care at low cost.
Well, what happened? Antitrust; not in this bill. SGR; we'll take
that up at some point in the future. Medical liability; a smidgeon of
medical liability reform in this bill, but nothing compared to what
doctors actually need.
In the last 6 years, Texas has done what this country needs to
realize would be the way forward in medical liability reform. Caps on
noneconomic damages have worked in the State of Texas. You don't have
to take my word for it. There are almost 15,000 new physicians that
have come to the State of Texas since 2003 when this was enacted. There
are 82 counties that now have doctors which did not have them before.
Emergency room services and OB services particularly have seen
significant increases since Texas passed their sensible liability
reform.
Mr. WAXMAN. Mr. Speaker, for a unanimous consent request, I yield to
the gentleman from Iowa (Mr. Boswell).
(Mr. BOSWELL asked and was given permission to revise and extend his
remarks.)
Mr. BOSWELL. I rise in support of this bill. The people in my area
are waiting and so is my State and our country.
Mr. Speaker, I rise today in support of H.R. 3962, the Affordable
Health Care for America Act.
Today, I am pleased to vote for the most transformative piece of
legislation that I have considered during my 13 years in Congress.
I am voting to grant access to health care coverage for 18,000
uninsured constituents in my district and to make it more affordable
for another 440,000 insured.
I am voting to guarantee that 6,400 of my constituents with
preexisting conditions could never be denied coverage and to reduce
insurance costs for 14,800 small businesses.
I am voting to finally address how Iowa's hospitals and providers are
reimbursed for the care they provide.
Under this legislation, the Government will not force individuals and
families with employer-based coverage to give up their insurance plans.
However, as a result of the insurance reforms in this bill, they will
no longer be required to pay co-pays or deductibles for preventive
care; no more rate increases or coverage denials for preexisting
conditions, gender, or occupation; and guaranteed oral, vision, and
hearing benefits for children. The public option offered in the health
insurance exchange would drive down costs across the board by fostering
competition and expanding insurance choices.
Iowa's hospitals and providers have shouldered the burden of unfair
Medicare reimbursements for the high-quality care they provide for too
long. This bill will require studies on the reimbursement formula and
move toward a payment system based on quality, not quantity. Providers
who participate in the public option would be reimbursed through
negotiated rates that balance what private insurance companies pay for
services with the current Medicare rates.
Mr. WAXMAN. Mr. Speaker, I yield 1 minute to the gentleman from
Virginia (Mr. Perriello) for the purpose of a colloquy.
Mr. PERRIELLO. Mr. Chairman, I recognize the good things this bill
does to make health care more affordable for families and expand access
to preventive and wellness care. I just want to clarify for the record
that maternity care is a required benefit in the essential benefits
package for all individual insurance and employer insurance across the
country.
Mr. WAXMAN. If the gentleman will yield, yes, it is. That is a
correct statement.
Mr. PERRIELLO. And it is my understanding that prenatal and postnatal
care is generally considered to be part of maternity care, as
recognized by organizations such as the American College of
Obstetricians and Gynecologists.
Mr. WAXMAN. The gentleman is correct in that statement.
Mr. PERRIELLO. Thank you, Mr. Chairman, for this clarification.
Mr. BARTON of Texas. Mr. Speaker, I yield 1 minute to the gentleman
from Phoenix, Arizona, Congressman John Shadegg, a member of the
committee.
Mr. SHADEGG. I thank the gentleman for yielding.
This is Maddie. Maddie believes in freedom. Maddie likes America
because we have freedom here, and Maddie believes in patient-choice
health care. She asked to come here today to say that she doesn't want
the government to take over health care. She wants to be able to keep
her plan.
You see, Maddie knows that if this bill passes, it says that her
mom's health care goes away and won't be around in 5 years. As a matter
of fact, the bill says, if the bill passes, then no more health care
for her mom because it has to change.
Maddie wants patient choice. Maddie doesn't want her mom's premiums
to go up. She doesn't want her mom's taxes to go up by $730 billion, do
you, Maddie? That's too much money. She doesn't want a health care bill
that will cost $1.5 trillion. She wants America's health insurance
companies to have to compete with each other.
She believes in choice, but most of all, Maddie says, Don't tax me to
pay for health care that you guys want. If you want health care, pay
for it yourselves, because it's not fair to pass your health care bills
on to me and my grandchildren.
Thank you, Maddie.

Announcement by the Speaker Pro Tempore

The SPEAKER pro tempore. The gentleman is reminded not to refer to
guests of the House as props.
Mr. WAXMAN. Mr. Speaker, that was a remarkable child and a great
ventriloquist.
I would like to yield for a unanimous consent request to the
gentleman from Virginia (Mr. Boucher).
(Mr. BOUCHER asked and was given permission to revise and extend his
remarks.)
Mr. BOUCHER. Mr. Speaker, I rise in opposition to the bill.
Health care reform is needed. More than 36 million American citizens
do not have health insurance, and millions more are underinsured and
cannot afford to pay for the medical care they need. As those without
insurance are treated in emergency rooms, the high cost of that care is
borne by those who have insurance, driving up health insurance costs
for everyone. The typical family pays an extra $1,100 each year in
health insurance premiums as a cost of treating the uninsured. Health
insurance premiums are increasing 3.5 times as fast as the rate of
increase in family incomes.
This status quo is unsustainable, and finding a way for everyone to
afford health insurance is necessary to benefit both the uninsured and
those who have insurance. I hope that following a House-Senate
conference on the legislation, we will be able to send to the White
House the needed reform measure.
But reform legislation must ensure that Southwest Virginia residents
continue to have access to the high quality health care services now
delivered locally.
I oppose the health care reform legislation now before the House for
several reasons including the continued existence of disparities in
Medicare reimbursements between urban and rural areas under the House
bill. Rural areas have traditionally received less under Medicare than
urban areas, and while the bill makes some improvements in this regard,
I would like to see more done to increase the payments to rural health
care providers. Higher Medicare reimbursements would enable the
attraction of more doctors to serve our medically underserved region.
I also oppose the bill because of my concern that a government
operated health insurance plan could place at risk the survival of our
region's hospitals. Most of our hospitals are operated on a non-profit
basis for the benefit of the community. While most of their receipts
are from Medicare and Medicaid payments, they lose money on each
Medicare or Medicaid patient they treat. These programs reimburse
hospitals at rates below the actual cost of providing patient care.
The financial viability of our hospitals comes from the payments they
receive from privately insured patients. A government operated health
insurance plan competing with private insurance will attract patients
who are privately insured today, with the result that the hospitals
would treat less privately insured patients and lose the critical
revenues that are essential to their survival.
A government operated plan would reimburse health care providers at
rates approximating Medicare rates, and hospitals would lose money on
each of their patients insured under the government plan.
I am concerned that for these reasons the creation of a government
operated insurance plan as envisioned in the House bill could result in
the closure of hospitals in our region. Families depend on our
community hospitals for health care services, and financially healthy
hospitals are essential to the health of Southwest Virginians.
Many of our hospitals are financially stressed in normal times, and
two hospitals in

[[Page H12848]]

the district I represent closed for periods of time in recent years for
financial reasons. The government owned insurance plan as outlined in
the House bill could push many more over the edge. I cannot support
legislation that could lead to that result.
I also believe that bipartisan participation is needed on a measure
of this scope which affects every American. The best ideas of Democrats
and Republicans alike should be drawn upon to fashion the final
legislation. That did not happen as the House bill was constructed.
In July, I opposed the health care reform measure when it was
considered by the House Energy and Commerce Committee and expressed my
concerns at that time. The bill passed by the House did not address
those concerns.
Passage of the House bill is but a first step in a long legislative
process to final enactment of a reform. I look forward to future steps
in that process offering an opportunity for my concerns to be resolved.
Reform is needed, and I hope to support the final passage of
legislation that emerges from a House-Senate conference that creates
affordable access to health care for all Americans and does so in a way
that enables the continued delivery of the excellent care now offered
in our region.
Mr. WAXMAN. At this time, I yield 1 minute to the gentleman from the
State of Maryland (Mr. Sarbanes), a member of our committee.
Mr. SARBANES. Mr. Speaker, every day millions of people wake up with
a knot in their stomach because they have anxiety and fear that they
may lose their health care coverage or they don't have it to begin
with. They need this health care bill. We in this Chamber are conscious
of the sweep of history, but the people in my district and millions
more across the country have a much less ambitious perspective. They
just want to know is this a good bill, does it make sense, and will it
help them and their families.
Well, if you are a senior, the answer is yes. We're going to begin
closing the doughnut hole. If you are a young person, the answer is
yes. You can now stay on your parents' policy through age 26. If you
are a working adult, the answer is yes, because we're going to curb the
abusive practices of the health insurance industry.
So what I want to say to people in my district and to others is this
is a good bill, it makes sense, and it will help millions of Americans
across this country.
I urge its passage.
Mr. BARTON of Texas. Mr. Speaker, I am proud to yield 1 minute to the
gentleman from the Hoosier State of Indiana, Mr. Steve Buyer, another
member of the Energy and Commerce Committee, and the ranking member on
the Veterans' Affairs Committee.
Mr. BUYER. Mr. Speaker, in a few days, all of us are going to be
going back to our districts. We are going to be celebrating Veterans
Day. Many of you are going to be giving speeches. You are going to be
throwing your arms around the soldier, the marine, the sailor, the
airman, the coastguardsman. Do you throw your arm around them in this
bill? You don't.
And when you go home and you give that speech, you can tap into the
American character and you can say, Americans go to a land where
they've never been to fight for a people that they've never met. They
do so at no bounty of their own, and they leave freedom in their
footsteps. Yet when they get to come home, how does our Congress right
now treat them? In this 2,000-page bill, we deny them their rights of
choice with regard to the health system which they can go to. Can you
imagine that?
Now, I received a pledge not only from the Speaker, but also from the
leadership, that veterans would be taken care of in this bill. My
amendments were denied last night in the Rules Committee. How do you
deny veterans their choice in this bill?
Shame on this institution.

Announcement by the Speaker Pro Tempore

The SPEAKER pro tempore. The Chair would again remind all persons in
the gallery that they are here as guests of the House and that any
manifestation of approval or disapproval of proceedings or other
audible conversation is in violation of the Rules of the House, and are
asked to respect those rules.

{time}  1545

Mr. WAXMAN. Mr. Speaker, I yield myself 1 minute.
Before I yield to another very important member of our committee, I
just want to set the record straight. We keep faith with the veterans
in this bill. We allow them to keep their veterans benefits. We allow
them to keep their benefits. They may, if they choose to, go into the
exchange; but if they don't, they keep their benefits.
Mr. BUYER. Will the gentleman yield?
Mr. WAXMAN. I yield 1 minute to the gentleman from Iowa (Mr. Braley),
a member of the Energy and Commerce Committee.
Mr. BUYER. We do not. Mr. Speaker, we don't protect veterans' rights.
The SPEAKER pro tempore. The gentleman from California controls the
time and has yielded to the gentleman from Iowa.
Mr. BUYER. * * *
The SPEAKER pro tempore. The gentleman does not have the time. The
gentleman from Iowa has the floor.
Mr. BUYER. I ask that----
The SPEAKER pro tempore. The gentleman is asked to respect the rules
of the House.
Mr. BUYER. I will.
Mr. BARTON of Texas. Mr. Speaker, I will yield 1 minute to the
gentleman, if that's allowed.
The SPEAKER pro tempore. The gentleman from California has already
yielded time to another Member.
Mr. BUYER. Just protect veterans and I'll go sit down.
The SPEAKER pro tempore. The Chair would ask that the gentleman abide
by the rules of the House.
The gentleman from Iowa is recognized.
Mr. BRALEY of Iowa. I thank the chairman for his extraordinary
leadership on this bill.
Mr. Speaker, I rise today on the third anniversary of my election to
Congress to urge my colleagues to speak truth to fear and vote for the
Affordable Choices for America Health Care Act.
We were elected, my class, to come and change the direction of this
country. That's exactly what this bill does.
We just saw a beautiful young child. I want to tell you about another
beautiful young child, Tucker Wright, my nephew's son, who at age 18
months was diagnosed with liver cancer, had two-thirds of his liver
removed, and faces a lifetime of expensive medical care. Tucker was
lucky because both of his parents work full time. Both of them have
health care. And yet he still has tens of thousands of uninsured
medical costs that his parents have to pay for.
That is what's wrong with health care delivery in this country.
That's why we need to reform health care. And that's why this bill will
do for America what we should have done 100 years ago: provide health
care for all Americans as a matter of right, not as a matter of
privilege. And that's why I support this bill.
Mr. BARTON of Texas. Mr. Speaker, I yield 1 minute to the
distinguished ranking member of the Financial Services Committee from
the great State of Alabama, Mr. Spencer Bachus.
Mr. BACHUS. Mr. Speaker, when I joined the Army, they sent me to Fort
Lewis, Washington; and one of the first things we did there was get in
line to get our hair cut.
We noticed on the wall there were pictures of four different
haircuts, and they told us to choose one of those haircuts, get a
number, and give it to the barber.
We thought this was going to be pretty good. So we all gave him that
number for the longest haircut. We all gave our numbers to the barber,
and he cut all our hair off, every one of us. The numbers meant
absolutely nothing.
When we got back to the barracks, we knew who was in charge. We knew
who was making the decisions, and it wasn't us. The Army was making all
the decisions.
Just like thinking you're going to get the haircut you choose, we're
promised the right to choose under this bill. But the reality is, just
like the Army, when the government's in

[[Page H12849]]

charge, you're not. This bill is about a new government bureaucracy
making all the choices for us.
We're Americans. America is about freedom. Freedom is about making
choices. And given the choice, I'll always put my faith in the
individual, not the government.
Mr. WAXMAN. Mr. Speaker, I yield 1 minute to the gentlewoman from the
State of California (Mrs. Davis) for the purposes of a colloquy.
Mrs. DAVIS of California. Mr. Speaker, I appreciate the opportunity
to raise this issue also on behalf of my colleague from California,
Congresswoman Speier.
Unfortunately, the provisions in section 309 allowing States to enter
health insurance compacts may bring unintended consequences that could
threaten long-established patient protections, and I know that that is
not the intention.
I certainly plan on supporting this legislation today; but I would
ask you for the commitment, Mr. Chairman, to continue working on the
language in section 309 to ensure it does not impact strong State
consumer safeguards such as we have in California.
Mr. WAXMAN. If the gentlewoman would yield, I thank you and I'm
encouraged you and your staff have committed to further working on
these provisions and not allowing health insurers to find loopholes in
State laws.
Mrs. DAVIS of California. Thank you, Mr. Chairman. I look forward to
that.
Mr. BARTON of Texas. Mr. Speaker, it is my privilege to yield 1
minute to Congressman Fortenberry of Lincoln, Nebraska, which today,
since Oklahoma is playing Nebraska at Lincoln, is the largest city in
Nebraska.
Mr. FORTENBERRY. I thank the gentleman for the insight.
Mr. Speaker, our health care system must be strengthened. No one
disputes the diagnosis. We need to improve health care outcomes for all
Americans and reduce costs, especially for small businesses and
families, while we protect vulnerable persons.
But this bill is a massive, risky restructuring of our health care
system. Why could there not be agreement on reasonable reforms such as
portability of insurance, buying insurance across State lines, and
creating new insurance association models for farmers and families,
providing affordable options just like corporations have?
I agree we should promote a health care culture that focuses on
wellness and prevention, removes lifetime caps, and expands high-risk
pools to help those with preexisting conditions. However, I fear that
this 2,000-page bill at $1.3 trillion will fail to reduce costs, would
simply shift the costs to more government-run health care and reduce
health care liberties.
Mr. Speaker, what is at issue now is winning and power, not
effective, reasonable reforms. We've missed an opportunity. I cannot
support this bill.
Mr. WAXMAN. Mr. Speaker, I reserve the balance of my time.
Mr. BARTON of Texas. Mr. Speaker, I yield 1 minute to the gentleman
from Lubbock, Texas, a recent beneficiary of the best health care
system in the world, Congressman Randy Neugebauer.
Mr. NEUGEBAUER. Mr. Speaker, I rise today as a proud cancer survivor.
August 1 of this year, I was diagnosed with the early stages of
prostrate cancer. And thank goodness I live in America and I was able
to sit down with my doctor and work out a treatment plan that would
help me be cancer free and stand before you today. Thank goodness that
I live in a country where I could go and see my doctor and make
choices. And thank goodness I live in America where I didn't have to
get on a list to determine when I was going to be able to have the
surgery so that I could get rid of this cancer. Thank goodness I'm not
living in Canada or Europe, the very system that our colleagues on the
other side of the aisle are trying to model America's health care
system on.
I thought about during August a young lady named Candy Menville that
was crying in her wheelchair and begging me to make sure that we didn't
turn our health care system in America into the same system that's in
Canada and Europe. She said, Congressman, with tears running down her
eyes, don't take away my options.
Mr. Speaker, don't take away Cindy's option and don't take away my
options and others like me. Vote down this terrible bill.

Announcement By the Speaker Pro Tempore

The SPEAKER pro tempore (Mr. Salazar). The Chair will remind all
persons in the gallery that they are guests of the House and that any
manifestation of approval or disapproval of proceedings or other
audible conversation is in violation of the rules of the House.

Parliamentary Inquiry

Mr. BARTON of Texas. Parliamentary inquiry, Mr. Speaker.
The SPEAKER pro tempore. The gentleman is recognized for a
parliamentary inquiry.
Mr. BARTON of Texas. We respect the ruling and the admonition about
members of the gallery, but is it acceptable under the rules for the
Members of Congress to show approval or disapproval of a speech on the
floor?
The SPEAKER pro tempore. It is acceptable unless interrupting another
in debate.
Mr. BARTON of Texas. Thank you, Mr. Speaker. We approve the Speaker's
ruling.
Mr. Speaker, it is now my privilege to yield 1 minute to the
gentleman from the State of Oklahoma (Mr. Cole), and it is with great
pleasure that I announce that the entire Oklahoma and Nebraskan
delegation who disagree on the outcome of the football game are all in
agreement in opposing this bill.
Mr. COLE. I thank the gentleman for yielding.
Mr. Speaker, the Oklahomans I represent oppose this bill because they
know what it does and what it does not do.
They know that this bill will raise taxes, not lower them. They know
that this bill will grow government, not shrink it. They know that this
bill weakens Medicare, not strengthens it. They know that this bill
destroys jobs, that it doesn't create any. They know that this bill
will force State governments to cut services and raise taxes, and it
will put government bureaucrats rather than health care professionals
in charge of their health care system.
Oklahomans know this bill does nothing to reform our tort system.
They know it does nothing to give individual purchasers individual tax
deductions. They know it does nothing to establish national insurance
markets and association health plans that would allow small business to
provide affordable insurance to their employees.
Oklahomans know the Pelosi health care bill is a giant step backward.
And every Oklahoman in Congress will vote against this bill.
Mr. WAXMAN. Mr. Speaker, I yield 1 minute to the gentleman from
Maryland (Mr. Cummings).
Mr. CUMMINGS. Mr. Speaker, this afternoon we've heard a lot of people
saying we should do what our constituents say that we should do.
I ask them what do I say to the gentleman in my district who is
suffering from cancer and who is now trying to choose between eating
and paying a high copayment for chemotherapy?
What am I to say to the young writer who for years paid her premiums
and then, when she got pregnant and had her baby, they gave her a
present on the way out the door that she could not afford: a $22,000
bill?
What do I say to a lady who suffered from breast cancer in my
district and when she lost her job, lost her insurance, could not get
insurance, could not get it because of something called preexisting
conditions?
I would say to all those folks who are saying that we do not need
this and must not do this, we have a moral authority to our fellow
citizens. A moral authority.
Mr. BARTON of Texas. Mr. Speaker, I yield 1 minute to one of our pro-
life leaders, the Honorable Chris Smith of New Jersey.
Mr. SMITH of New Jersey. Mr. Speaker, today the House has an
opportunity to significantly limit public funding of abortion in a
manner that replicates the Hyde amendment and applies it to the two new
massive government health care programs created in the pending bill:
the public option and affordability credit program.
The Stupak-Pitts amendment ensures that pro-life Americans will not
be forced to fund, enable, or facilitate the killing of unborn children
and the wounding of their mothers.

[[Page H12850]]

Supermajorities, more than 67 percent, oppose public funding of
abortion. Protecting vulnerable unborn children and women from the
insidious violence of abortion is the human rights cause of our time.
So please let's not gloss over or trivialize the fact that abortion
dismembers, decapitates, starves to death, or chemically poisons
innocent babies, and that the abortion act itself, euphemistically
called ``choice,'' can in no way be construed to be compassionate,
benign, nurturing, or health care. Abortion is violence against women
and children. It is neither health care nor reform.
Support the Stupak-Pitts amendment
Mr. WAXMAN. Mr. Speaker, I continue to reserve the balance of my
time.

Parliamentary Inquiry

Mr. BARTON of Texas. Mr. Speaker, I have a parliamentary inquiry.
The SPEAKER pro tempore. The gentleman will state his inquiry.
Mr. BARTON of Texas. Who has the right to close this part of the
debate? Does Chairman Waxman have the right to close or does the
ranking minority member have the right to close?
The SPEAKER pro tempore. There is only one overall right to close,
and that will be the majority manager.
Mr. BARTON of Texas. Mr. Speaker, I yield 1 minute to Congressman Jeb
Hensarling from the great State of Texas for 1 minute.

{time}  1600

Mr. HENSARLING. Mr. Speaker, government-run health care is
government-rationed health care. Today in America when our loved ones
need health care, they wait hours, maybe days; but in Britain and
Canada, they wait weeks, months, perhaps even a year.
Mr. Speaker, since I have been age 5, I have gone fishing with my
father. Those are moments I treasure. But 15 years ago he went to see
his doctor about a chest pain; 48 hours later, he had triple bypass
surgery. And guess what? At age 81, we are still fishing. But had he
been in Britain, had he been in Canada, there might never have been
another fishing trip. My children might have never known their
grandfather because health care delayed is health care denied.
Government-rationed health care will mean our loved ones will suffer.
They will languish, and perhaps even perish. We should never support a
children-bankrupting, health care-rationing, freedom-crushing $1
trillion government takeover of our health care system.
Let's support the Republican plan to give the American people the
health care they need, when they need it, at a price they can afford.
Mr. BARTON of Texas. Mr. Speaker, I would like to recognize a Member
from the great State of Georgia (Mr. Kingston) for 1 minute.
Mr. KINGSTON. Mr. Speaker, in January, with unemployment at 8.5
percent, Speaker Pelosi passed an $800 billion pork-ladened stimulus
bill that was supposed to create jobs. In May, with unemployment up to
9.5 percent, Speaker Pelosi passed an energy tax of $1,500 on every
household in America that was supposed to create green jobs. Now in
November, unemployment is up to 10.5 percent, we have the highest
deficit in the history of the country, a $12 trillion national debt,
and Speaker Pelosi wants to spend $1 trillion on a government takeover
of insurance.
This bill raises premiums. It raises taxes. It cuts Medicare, and it
forces you to surrender your current health care coverage and puts a
thousand bureaucrats in between you and your doctor.
The government couldn't even run Cash for Clunkers, and now it wants
to take over 17 percent of the economy.
Let's vote ``no'' on the Pelosi plan and support the bipartisan
alternative.
The SPEAKER pro tempore. The gentleman from Texas has 1\1/2\ minutes.
The gentleman from California has 30 seconds.
Mr. BARTON of Texas. Mr. Speaker, I yield myself the balance of the
Energy and Commerce time.
(Mr. BARTON of Texas asked and was given permission to revise and
extend his remarks.)
Mr. BARTON of Texas. Mr. Speaker, first of all, let me tell you how
proud I am of the members of the Energy and Commerce Committee on both
sides of the aisle who have participated in this debate since January,
and who have participated on the floor debate today. It makes me proud
to be a member of that committee.
Mr. Speaker, we have heard all of the policy arguments pro and con
for this bill. I am going to end the Republican side of the Energy and
Commerce debate simply by saying that I think this bill should be
defeated because it is an imposition on personal freedom here in
America. I just simply don't think that it is right to tell people that
they have to have insurance, tells employers they have to provide
insurance, to set up a bureaucracy that advises a bureaucracy what that
insurance should be, that then determines what the insurance itself
should be, what the minimum premium should be, what has to be covered,
what shouldn't be covered, and then over time almost guarantees that
everybody, except the richest people in America, are in some version of
the public option.
I just think that is wrong in America, Mr. Speaker, and for that
reason alone I am against this bill.
There is an alternative. The Republican alternative covers many of
the things that my friends on the majority side say they are for. We
simply do it without mandating and imposing government will on the
American people. Please vote ``no'' on the majority bill, and vote
``yes'' on the minority substitute.
Mr. WAXMAN. Mr. Speaker, 37 million Americans do not have health
insurance because they can't afford it, their employers do not offer it
to them, or they have a preexisting condition and the insurance
companies deny it to them. We want them to buy the same policies that
our Republican Members have talked about in such glowing terms,
available to them and their families. Don't say ``no'' to 37 million
Americans and tell them they have freedom. They don't have freedom to
go without. In a country where people should not be forced into
bankruptcy when they get sick, let's let people buy private insurance
or a public option and get coverage.
The SPEAKER pro tempore. The gentleman from New York (Mr. Rangel) has
40 minutes and the gentleman from Michigan (Mr. Camp) has 40 minutes.
The Chair recognizes the gentleman from New York.
Mr. RANGEL. Mr. Speaker, I would like to take this time to recognize
the gentlewoman from Florida (Ms. Wasserman Schultz) for 1 minute.
Ms. WASSERMAN SCHULTZ. Mr. Speaker, we have heard a lot of discussion
in this debate about the uninsured and the uninsurable. Often it is
easiest to think about people with preexisting conditions who are
uninsurable as the poor, the sick, or the jobless.
Mr. Speaker, the face of the uninsurable stands before this House
today in this well. As a breast cancer survivor, the sad reality of
today's health care system is if I lost this job tomorrow, I could not
buy health insurance coverage because I have a preexisting condition.
This bill will end all that. The Affordable Health Care for America
Act will make it possible to rid our country of the angst of facing
illness without coverage. Passage will mean that Carol from south
Florida won't face the dual tragedy of a cancer diagnosis and the loss
of her job and, thus, the loss of her health care coverage. So instead
of putting all of her energy into fighting cancer, like I could, Carol
had to fight for her health care coverage, too.
It is time to deliver on the American promise not just of liberty,
but justice for all.
Mr. CAMP. Mr. Speaker, I yield myself 2 minutes.
Republicans have listened to the American people. It is clear from
the Speaker's health care bill the Democrats have not. The Speaker
crafted this bill behind closed doors and added 1,000 pages that have
never been before a committee or had any input from the American
people.
Just yesterday we confirmed that Americans could face 5 years in jail
if they don't comply with the bill's demands to buy approved health
insurance, and who knows what else we will discover over time. Simply
put, the health care of the American people is too important and too
complex to risk on this gigantic gamble. This bill will do lasting
damage to our economy and

[[Page H12851]]

force millions of Americans to give up their current health care
coverage.
With the national unemployment rate spiking to 10.2 percent, it
should be unthinkable to pass this bill which contains more than $730
billion in taxes that will destroy millions more American jobs. The
Democrats' bill cuts Medicare by one-half trillion dollars, slashing
health care benefits for seniors, a direct violation of the President's
pledge that Americans could keep what they have if they like it.
The Democrats' bill, when paired with an unpaid-for SGR fix,
increases the deficit, a violation of the President's pledge that
health care reform would not add one dime to the debt. The Democrats'
bill drives up the cost of health care and increases Federal spending
on health care by $600 billion, a violation of the President's pledge
that health care reform would bend down the cost curve.
So you can't keep what you like if you like it. The bill spends over
$1 trillion while raising taxes, cutting Medicare and increasing the
deficit, and it drives up the cost of health care. The Democrat
majority has not listened to the American people. Vote ``no'' on this
bill.
Mr. RANGEL. Mr. Speaker, I would like to recognize the distinguished
gentleman from Georgia (Mr. Scott) for 1 minute.
Mr. SCOTT of Georgia. Mr. Speaker, today the arc of history will
hover over this House of Representatives, and the question facing each
and every one of us today as 14,600 of our American citizens are losing
their insurance every day is: where are we going to stand on this arc
of history today? I ask you, are you going to stand with the negative
forces of ``no'' or ``kill the bill'' or ``I object''? Or are we going
to stand with the hope of America that has been expressed all of the
way down from Teddy Roosevelt to Franklin Delano Roosevelt to Harry
Truman to Lyndon Baines Johnson to Teddy Kennedy, and to John Dingell?
I say to you today, this House of Representatives, stand up and say I
am not afraid of the future because the key to our future is to make
sure that all Americans have access and have affordable health care
insurance. That's what the American people are expecting us to do, to
stand up for America.
Mr. CAMP. I yield to the gentleman from California for a unanimous
consent request.
(Mr. ROHRABACHER asked and was given permission to revise and extend
his remarks.)
Mr. ROHRABACHER. Mr. Speaker, I oppose this bill that will take
hundreds of billions of dollars out of Medicare and give billions of
dollars of health care to illegal immigrants.
Mr. Speaker, this attempt at sliding Americans into dependence on a
government-controlled health care system brings bait and switch to a
new low.
We have heard about the flaws of our current healthcare system, high
costs, lack of portability, lose a job--lose health insurance,
discrimination of those with preexisting conditions. Yes, many of the
heart-wrenching stories we are hearing to justify this legislation are
real. But correcting those maladies requires specific reform, not
transforming healthcare in America into a bureaucratically-managed
system that will cost hundreds of billions, including billions to
provide healthcare for illegal aliens, while at the same time cutting
Medicare by hundreds of billions of dollars. This so-called reform will
destroy the freedom of the American people to make health decisions
with a doctor of their choice. It will transform our system, rather
than reform it. And what we will end up with is a system that is
massively more expensive, less effective, and will be based on
government controls and rationing, rather than the patient-doctor
relationship.
You can touch our hearts with the stories of suffering brought about
by defects in our current system, but it doesn't follow that we have to
buy into this monstrous federal power grab. It is too benign to call
this scheme bait and switch.
Wake up America!!
This bill cuts healthcare for our seniors by hundreds of billions of
dollars while providing subsidized health care of illegal immigrants,
which will draw more illegals into our country.
Wake up America!!
This bill is structured so that private companies will find it
profitable to dump employees into the government-run option, rather
than continuing to offer private health insurance.
Wake up America!!
This ill-conceived power grab will bankrupt our country as it
destroys our freedom.
Mr. CAMP. Mr. Speaker, I yield 2 minutes to a distinguished member of
the Ways and Means Committee, a true American hero, the gentleman from
Texas (Mr. Sam Johnson).
(Mr. SAM JOHNSON of Texas asked and was given permission to revise
and extend his remarks.)
Mr. SAM JOHNSON of Texas. Mr. Speaker, today we are voting on Speaker
Pelosi's $1 trillion Washington takeover of health care. This bill
bulldozes individual liberty and puts the government just where it
doesn't belong, right smack dab in the middle of your personal health
care decisions. This bill forces every single person in this country to
purchase government-approved health care or go to jail. Businesses must
also offer government-approved health care or face hundreds of billions
of dollars in job-killing taxes.
Unfortunately, government-approved health care will be defined by a
handful of bureaucrats around a conference table in Washington. This
unprecedented Washington power grab eliminates an individual's right to
choose what kind of health care is best for them and their families.
Speaker Pelosi's 20-pound, 2,000-page bill costs $2.2 million per
word. The American public have made their voices heard. They are sick
and tired of the government sticking its nose where it doesn't belong.
They are fed up with Washington's trillion-dollar bailouts, free
handouts and special interest paybacks.
The Democrats in Congress need to listen and come up with a
bipartisan, patient-centered plan. We can do better with a targeted,
fiscally responsible approach that makes health insurance more
affordable, more accessible, and available. Real health reform protects
a patient's right to choose their own care. Real health reform gives
doctors the freedom to do what is best for their patients. We can do
all of this without piling trillions of dollars of debt onto our
children and grandchildren.
Vote down this deficit-ballooning, job-killing, Washington takeover
of health care today.
Mr. RANGEL. Mr. Speaker, I would like to recognize my friend and
colleague, the outspoken Member from New York, Mr. Nadler, for 1
minute.
(Mr. NADLER of New York asked and was given permission to revise and
extend his remarks.)
Mr. NADLER of New York. Mr. Speaker, I have spent much of my adult
life fighting for greater health care rights and for universal health
coverage. This historic bill goes a long way toward achieving those
goals.
Around the country, we see millions of people with inadequate or no
coverage. Families go to sleep at night knowing that they are one
serious illness away from bankruptcy. And the unemployed are people who
face going it alone in the prohibitively expensive individual coverage
market or, worse, going without insurance at all.

{time}  1615

While I would have preferred a single-payer system, I am happy to
support a bill that contains a public health insurance option that will
provide competition to the private insurance companies and will drive
down rates.
This bill will end discrimination against people with preexisting
health conditions, will end the practice of dropping patients when they
are sick, and will strengthen and enhance Medicare by ending the
doughnut hole and extending the solvency of the Medicare Trust Fund.
Mr. Speaker, the status quo is not an option. We have an opportunity
to get universal health care coverage in this country to implement the
competitive public health insurance option that puts the patient before
the quarterly financial report, and to ensure that just because you
lose your job, you won't lose your health insurance.
This is monumental and historic, and I am proud to support the
Affordable Health Care for America Act.
Mr. Speaker, I have spent much of my adult life fighting for greater
health care rights and universal health coverage. This historic bill,
H.R. 3962, makes great strides toward achieving those goals.
Around the country, we see millions of people with inadequate or no
coverage, with another 14,000 Americans joining the ranks of the
uninsured each day. We see families who go to sleep at night knowing
they are one serious illness away from bankruptcy, the reason

[[Page H12852]]

for 55 percent of all bankruptcies filed last year. We see the rising
ranks of the unmployed who face going it alone in the prohibitively
expensive individual coverage market--or worse, going without insurance
at all. And we see 20,000 people die every year because they have no
health insurance.
At the same time that this stark reality hits hardworking Americans,
insurance companies have conspired to keep costs high. These costs,
upward of 15-35 percent squandered on outrageously high administrative
costs, do nothing to make people healthier but do much to line the
pockets of insurance companies and help their corporate bottom line.
This is unacceptable. We must take action. That's why I support the
Affordable Health Care for America Act.
As with any legislation, there have been some compromises made along
the way. I would have preferred a single payer system, the most
effective and least costly way to implement a health delivery system.
But I, like so many of my colleagues, have come to see a competitive
public option as the best available way to refocus our misguided health
care approach. A public option will put patients and doctors, not
corporate bottom lines, at the forefront. This public option will add
much needed competition into an insurance market that must be kept
honest, and it will work to drive down rates.
Mr. Speaker, this past August, political pundits and TV-talking heads
had the public option dead on arrival. Yet, because of the efforts of
progressive Members in Congress, in which I was proud to join, we
succeeded in keeping the public option in this bill and ensured that
the American people would be given an alternative to corporate health
insurance. And make no mistake about it--the public option weathered
the storms of misinformation, slander, and downright lies because the
American people saw through the political game playing and saw the
public option for what it is--an option, not a mandate, that will help
stem the cost of ever-rising health care costs.
In addition to the public option, this national health reform bill
implements key insurance industry reforms, strengthens Medicare, and
immediately gives hope to the millions of Americans currently living
without health insurance.
It will end discrimination against pre-existing conditions, and end
the cruel practice of rescission, which allows insurance companies to
drop people from coverage if their illness is considered too expensive.
This bill also guarantees that people with insurance will not face
devastating costs when they get sick by placing limits on out-of-pocket
medical expenses, and creating, for the first time ever, a voluntary
long-term care program. And H.R. 3962 would end the blanket exemption
insurance companies currently enjoy from anti-trust laws. With this
change, we can now bring anti-trust enforcement against the egregious
practices of price-fixing and market allocation.
H.R. 3962 contains numerous provisions that help our seniors by
strengthening and enhancing the Medicare program. This bill reduces the
donut hole to $500 immediately and eliminates it entirely by 2019. It
allows the HHS secretary to negotiate prescription drug costs, which I
have long advocated for, eliminates out-of-pocket expenses for
preventive care for seniors, and extends the solvency of the Medicare
trust fund for at least five years.
Small businesses also receive desperately needed assistance from this
bill. Initially, businesses with up to 25 employees, then growing to
businesses with up to 100 employees by 2015, will be able to join the
health exchange, which will allow small business employees to take
advantage of group rates and a broader range of insurance options--a
key change that will go a long way toward helping small businesses keep
down their number one expense, which is the cost of providing health
care coverage.
For America's young people, who make up 29 percent of the uninsured
in America, H.R. 3962 will permit parents to extend coverage to their
children until their 27th birthday.
To help American families defray the costs of health coverage, this
bill extends assistance on a sliding scale to families earning up to
$88,000 per year. This will go a long way toward ending the cruel
choice between health care coverage and other necessities.
Mr. Speaker, there are some who have said that health care reform is
too hard. There are those who have allowed misinformation and politics
to push them to root against helping their fellow Americans to have
access to quality, affordable health care. There are even those who,
for reasons I fail to grasp, want to continue with the status quo.
To those people, Mr. Speaker, I say--the status quo is not an option.
We have a remarkable opportunity in front of us. We have an opportunity
to make fundamental changes to the way we view health care and deliver
services, to implement a competitive public health insurance option
that puts the patient before the quarterly financial report. And, with
passage of this bill, we will be able to say for the first time in this
country that just because you lose your job, you won't lose your health
insurance.
Mr. Speaker, this is monumental. This is historic. And I am proud to
cast my vote in favor of the Affordable Health Care for America Act.
Mr. CAMP. At this time, I yield 2 minutes to the distinguished
gentleman from the Ways and Means Committee, the gentleman from Texas
(Mr. Brady).
Mr. BRADY of Texas. Mr. Speaker, this is the Pelosi health care plan,
and it's wrong for America. Over 100 new Federal agencies, commissions,
and mandates standing between you and your doctor.
This huge, inefficient new bureaucracy makes your health care
insurance more expensive, forces millions of Americans into a
government-run plan, raises taxes on workers and small businesses,
increases Medicare drug costs for seniors, adds billions to our
frightening deficit, and after throwing $1 trillion at the problem,
still leaves 18 million Americans uninsured. Big government doesn't
mean better health care.
To pay for this massive new bureaucracy, Democrats slash Medicare for
our elderly by a half-trillion dollars. That means 660,000 Texas
seniors are going to lose their plan. It shuts 40 doctor-owned
hospitals in Texas, costing us 15,000 jobs. And 1.5 million Texans will
have their plans disappear.
This is not the reform families need. Instead, this is all about
taking the giant first step toward a single-payer national health care
system. If the Pelosi plan passes, Washington will ultimately decide
which doctors you can see, what treatments you deserve, and what
medicines you receive, and when you're sick, will you be worth their
cost?
House Republicans have a different vision. We listened. Ours is a
careful, step-by-step solution to the complex issue of health care,
focusing first on lowering your health care costs so more can afford
it. We have no tax increases, no Medicare cuts, no rationing, no
mandates, no huge intrusion of government into the most intimate parts
of your health care, just more choices, more fairness, less lawyers.
Best of all, our Republican plan is the only reform that actually
lowers your health care premiums and lowers the deficit.
We need to get health care reform right the first time. The Pelosi
plan is wrong.
Mr. RANGEL. Mr. Speaker, for another view of health care in Texas, I
yield 1 minute to Ms. Jackson-Lee.
(Ms. JACKSON-LEE of Texas asked and was given permission to revise
and extend her remarks.)
Ms. JACKSON-LEE of Texas. Mr. Speaker, today I am holding up a
concise, efficient, and effective health care plan for America, H.R.
3962, and I plan to stand with America and those who don't have health
insurance today as we cast our vote for affordable health care for
America.
Eighteen thousand people die every year because they do not have
health insurance. The State of Texas has 6 million people who don't
have health insurance. Several Republican Members from Texas, have in
their districts, some 29 percent, and 18 percent of individuals who
don't have health insurance.
So today I rise to say that the plan we have will immediately close
the doughnut hole for Seniors. It will provide the uninsured with a
bridge to the exchange program. It will extend the coverage for our
young people until the age of 27, and, yes, I'm proud of the language
on pages 22 and 23 that will begin to help save hospital beds in
physician-owned hospitals in the State of Texas and around the Nation.
This language is in the bill and we now can continue to work competent
quality hospitals in rural and urban areas.
We are ready to fight. We are ready to make sure that those who need
health insurance will have us on their side. I am standing with America
and voting for America for the first time in which a health care reform
bill passes the House with a Public Option to give more access to
Americans and lowers the costs of health care insurance. Vote for the
health care bill now.
I rise before you today in support of H.R. 3962, the Affordable
Health Care for America Act. On July 5, 1965, President Lyndon Johnson
said the following about the passage of Medicare, ``This bill is
sweeping in its intent

[[Page H12853]]

and impact. It will help pay for care in hospitals. If hospitalization
is unnecessary, it will help pay for care in nursing homes or in the
home. And wherever illness is treated--in home or hospital--it will
also help all Americans.'' My friends we can all say that about this
sweeping legislation. Madame Speaker, while some say that patients and
physicians oppose this bill I know otherwise. Today, I met with dozens
including physicians, medical students, patients, and advocates. This
group included representatives from Doctors for America, National
Physicians Alliance, American Medical Student Association, US PIRG,
Disciples of Christ, Episcopal Church, NETWORK--A Catholic Social
Justice Lobby, United Church of Christ, and United Methodist Church
along with a nationally renowned cardiac surgeon Dr. Salim Aziz of the
George Washington University Medical Center.
The health providers with whom I met are on the front lines of the
health care debate every day. As such, it is no surprise that they
enthusiastically endorse this bill, while holding out hope for
progressive changes to health reform legislation before it becomes law.
These health professionals see the pain and frustration of hardworking
Americans who face financial collapse, physical suffering, and
sometimes the loss of their life simply because they do not have decent
health care coverage.
Allow me to share with you some of the stories that I've heard from
these care givers. One story was that of Dr. ``Alex'', a Pediatrician
and Health and Evidence Policy Fellow at Mt. Sinai School of Medicine.
Dr. Alex told me of an illness he suffered himself while still a
medical student at Howard University College of Medicine here in
Washington, DC. One summer, during an internship at the Centers for
Disease Control in Atlanta, Dr. Alex became very sick, and was examined
at an emergency room. The examination revealed that Dr. Alex's ailment
arose from acute kidney failure.
Dr. Alex thankfully had health coverage through Howard University's
student health insurance plan. Yet he was faced a conundrum since the
university's plan only covered health services required by their
students in Washington, DC. It didn't cover him in Atlanta, thus Dr.
Alex qualified as under-insured. Aware that he could not afford out-of-
pocket payment for a renal dialysis unit as was being recommended, by
his physician, his father drove him through the night from Atlanta,
waking him every few minutes to make sure he was responsive, until they
finally reached Washington, DC, the next morning, where he could get
the treatment needed. This story is proof of the fact that even those
who chose to enter the profession of caring for others are not immune
to the dysfunction of our health care system. Dr. Alex also related
another interesting paradox that I'll share with you. He trained in
pediatric medicine at a county hospital outside of Los Angeles. At this
county hospital I cared for uninsured children, and those enrolled in
SCHIP and Medicaid. What he most enjoyed about working within that
system was that they provided high quality care to those who needed it
the most. His patients on Medicaid and SCHIP were able to easily see
sub specialists: Dermatologist, Ophthalmologist, and Gastro-intestinal
physicians. His patients who had private insurance often faced health
care barriers which his patients on SCHIP and Medicaid never had to
navigate. When children who had private medical insurance visited his
county hospital pediatric clinic, staff there had to seek preapproval
from the private insurance company so that patients' parents were not
billed and required to pay the cost of care out-of-pocket. In this
county pediatric clinic he once cared for a 9-month-old boy who had a
swollen face covered in a rash on his forehead and cheeks, and raw in
his neck folds. He sat before him and scratched his arms, trunk, and
face uncontrollably to the point of bleeding. Because of his constant
scratching his skin had started to harden. He had uncontrolled eczema
and his mother told him in tears how she had not been able to obtain a
referral to a dermatologist. The county pediatric dermatologist's one
afternoon a month clinic time was that same day. To prevent the
patient's mother from receiving a large medical bill, Dr. Alex did what
he normally did; he got on the phone to her private insurance company
and asked the insurance bureaucrat to agree to pay for the visit. As
his other patients had to wait for him, he wasted time on the phone
trying to solicit preapproval from her insurance company. But he could
not sway the insurance gatekeeper. He tried his hardest to make this
bureaucrat understand the child's bloody scabs, the mother's tears. But
to no avail. The dermatologist took pity on the child and did what we
physicians often do, he saw the patient for free.

Why have we allowed insurance bureaucrats to come between Dr. Alex
and his patients? We can do better than allow profit driven bureaucrats
decide what medicines my patients receive. He wants a health care
system where when he writes a prescription his patient does not have to
worry whether their insurance company will pay for it. An insurance
bureaucrat sitting in their cubicle should play no part in the
relationship between me and my patient. We need to reform our system.
Today is a historic day not only for the 39 million uninsured
Americans, but also for our great Nation. As Speaker Pelosi remarked
earlier today, we, Members of Congress, are ``humbled to stand here at
a time when we can associate ourselves with the work of those who
passed Social Security, those who passed Medicare, and now we will pass
health care reform.'' Many parallels exist between that history and
today. Today, we listened to a parade of Republicans warn that this
bill will bring the downfall of American society, of the American way
of life. This is not the first time that the Republicans have been on
the wrong side of history. In an interview in 1975, David L. Kopelman,
who played a prominent role in the early administration of the Medicare
Program, remarked that his colleagues were often criticized by
Republicans. ``Communist,'' he recalled, ``was the designation all too
liberally applied to anyone with a progressive idea. Well, after all,
when we went around making contact with employers in those early years
that was the designation not delicately applied by many, if not most of
them, to the social security program. It must be some communist scheme
foisted on the American people.'' Alf Landon, the Republican candidate
for President in 1936, even campaigned on the fact that not a dollar in
social security benefits would ever be paid.

Mr. Speaker, unfortunately, such ad hominem attacks are as prevalent
as ever. The Republicans want you to believe that our country is
descending into an abyss of socialism, but nothing could be further
from the truth. Today, I am proud to support a bill that is distinctly
American. We the people, Thomas Jefferson wrote in the Declaration of
Independence are endowed ``with certain unalienable Rights that among
these are Life, Liberty and the pursuit of Happiness.--That to secure
these rights, Governments are instituted among Men, deriving their just
powers from the consent of the governed . . .'' I believe that it is no
coincidence that life is listed first--for without it, the Founders
realized, no other rights can be realized. Over years, the millions of
Americans who could not access medical services were denied their most
basic right. The value of life is echoed in the Universal Declaration
of Human Rights as well as in the Hippocratic Oath taken by every
physician.
True, health insurance is not a human right by itself, but consider
the following: according to the National Academy of Sciences, Institute
of Medicine, there is a ``consistent and statistically significant
relationship between health insurance coverage and health outcomes for
adults. These factors, in turn, improve the likelihood of disease
screening and early detection, the management of chronic illness, and
the treatment of acute conditions . . .'' This year, a study published
in the American Journal of Public Health by researchers at Harvard
University Medical School concluded that nearly 45,000 excess deaths of
Americans can be linked each year to lack of health insurance. Forty-
five thousand is fifteen times the death toll at the World Trade
Center; 45,000 people are approximately equal to the population of
Texas A&M University; 45,000 is almost thirty times the number of
American soldiers killed in Iraq since 2001. The lives lost at the
World Trade Center and in Iraq will never be forgotten. Why then, do we
pretend that a far greater loss of life every year does not exist? Make
no mistake about it, health insurance can be a direct determinant of
whether somebody lives or dies.
According to the U.S. Census Bureau, 27 million American live without
health insurance, and an additional 1.1 million part-time workers lost
their health insurance in 2008. Implementing this legislation will
instantly improve the life expectancy of millions of Americans of all
ages. It is impossible to put a price on that. When we talk about the
right to healthcare, we are actually talking about the right to access
healthcare. In our current system people do not choose to be uninsured
but, instead, are priced out of insurance. These people cannot, as free
market proponents often argue, ``Pull themselves up by their
bootstraps.'' Instead, they and their families are too often cyclically
and systemically trapped in their economic situation. Texas, in
particular, with 6 million uninsured persons and 26 percent in the 18th
Congressional--H.R. 3962 must pass.

I am committed to working with the Speaker's office and Senatorial
leadership now that we are taking the first step in stemming the rising
tide of the many uninsured. The protection of physician-owned hospitals
is an issue of national interest. We have a lot of work to do as we
move toward the Senate and to the conference. I was gratified to meet
with the Speaker today to discuss the continued protection of the very
viable physician-owned hospitals.

[[Page H12854]]

I will continue to work to save physician-owned hospitals that are
currently treating patients or under significant development, to ensure
that Americans can continue to receive healthcare at the local
hospitals they have come to depend upon. Physician-owned hospitals take
care of patients covered by Medicare and Medicaid, as well as patients
who are uninsured or cannot pay for their care. They also provide
emergency departments access for their communities. At a time when we
are concerned about the shortage of hospital beds in the face of
epidemics like the swine flu, my amendment to this landmark bill will
make sure no hospital is forced to shut its doors or turn away Medicare
or Medicaid patients. The benefits that will come from our efforts to
protect physician owned hospitals are far reaching and will prevent any
further losses to local economies. Not only do physician hospitals
deliver high quality medical care to the patients they serve, they also
provide much needed jobs, pay taxes, and generate significant economic
activity for local businesses and communities. Existing physician-owned
hospitals employ approximately 51,700 individuals, have over 27,000
physicians on staff, pay approximately $2,421,579,312 in payroll taxes
and $512,889,516 in other federal taxes, and have approximately $1.9
billion in trade payables. Hospitals currently under development would
employ approximately 21,700 more individuals. With approximately 50
physician-owned hospitals, Texas leads the nation in the number of
physician-owned hospitals. The Texas economy could lose more than $2.3
billion and more than 22,000 jobs.
In my district, the 18th Congressional District of Houston, Texas,
St. Joseph Medical Center is a general acute care hospital that treats
all patients. In fact, its 40 percent Medicaid patient population is
double the average hospital's patient population in the entire State of
Texas and is one of the highest in the country. St. Joseph's was
operated by the Sisters of Charity for many years until it was
scheduled to be closed because the order could no longer support it.
The hospital was offered to for-profit and not-for-profit hospital
systems but no one would accept responsibility for operating St.
Joseph's. A plan was developed to convert the hospital into
condominiums. I refused to allow that to happen. It was only at that
point that the physicians who had practiced there for many years came
together to buy the hospital to save it from closing.
St. Joseph's takes care of patients covered by Medicare and Medicaid,
as well as patients who are uninsured or cannot pay for their care. The
emergency departments of many physician-owned ``specialty hospitals''
have been criticized for not having a true emergency department. St.
Joseph's has a department which is open 24 hours per day, 7 days per
week, providing an access point for patients in need of emergency
services. In fact, St. Joseph's admissions through the emergency
department are double the State average;
St. Luke's hospital in Houston, which is church-owned, has three new
facilities under development; the nonprofit religious mission has the
controlling interest. One full-service hospital has one phase already
operating, but would be under the growth restrictions; the hospital
cannot be completed if the new restrictions apply. The hospital brought
approximately 300 new jobs to the community; and
Baylor Health Care System, based in Dallas, has found that their
partnership with physicians has increased measurable quality, increased
patient satisfaction, and decreased the cost in the delivery of their
excellent care. This joint venture model has produced a heart hospital
that has the lowest readmission rate in the entire United States. And
yet this bill would deny Baylor Health Care System the right to add a
single operating room or procedure room to meet its community's need.
During the moratorium on physician-owned hospitals some years ago,
Baylor wanted to add a badly needed OB/GYN service at its Frisco,
Texas, hospital. This service is a money losing service, but there was
no such service within many miles for those people--Baylor fulfilled
the need. It was prohibited from adding this service simply because the
hospital had physicians holding a minority of the ownership of the
hospital. After the moratorium was lifted, the service was added and is
currently working at its capacity.
Mr. Speaker, can we imagine witnessing an impact, of no patient beds,
6- to 8-hour waiting times, to extend even to 10-hour waiting times,
turning emergency patients away at the door? Can we imagine the
dramatic case, when patients are not able to have access to quality
care? This is true of the most serious trauma, of the most serious
medical cases. Physician owned hospitals serve in many cases at least
40 percent of the city's population. I don't just mean the city's
population. We are discussing a population that is between 500,000,
which is the indigenous population, and the population of 1.5 million
that's in the city every day.
When a hospital downsizes in a particular city, it extends beyond the
boundaries of that city, and in doing so, with this hospital being
downsized, it's impacting all of the hospitals, not only in the city,
but those hospitals in nearby jurisdictions. We're seeing the epicenter
of a catastrophic event, and unless we realize the importance of this
one medical facility, but look at it not from the perspective that it
serves this city, but we have to realize that it serves the world. It
serves the Nation. At the very least, it serves the Nation; at the very
most, it most serves the world. So when you start looking at it from
those perspectives, then it becomes more than just a problem of
Houston, Texas, but a problem of this Nation. And it should be
addressed in that manner.

If we do not work closely together to look deeper at this issue, we
will face a number of medical facility closures that is a disservice to
the American people. So, we see that there seems to be a phasing-back
or cutback in all of the major services, but the most important of
those services, which directly affect the health and well-being of the
citizens, or again, those 1.5 million people who visit and work in the
city every day. So, we hear the same thing time and time again, even
though individuals are saying that the patient caseload can be handled
by the surrounding hospitals. You need but step into any emergency room
on any day, at any time, and just see the impact of this one hospital
being downsized. The impact will reach out throughout the city of
Houston.
Again, a true indication of the success of any city government, or
any country, is its ability to care for its weak, its injured, its
sick, its young, and its old. The ability to care--compassion. Let us
be honest--we see the faces of those individuals who we cannot help,
because the system has failed them, and they ask us for help. What do
we tell them? You never want to lie to a patient. You want to be honest
and up-front with this patient. But you reach a point where, in some
cases, it's best that you say nothing.
How can we tell a family member sitting across from me, in the back
of my ambulance, with their loved one lying on the cot as we do CPR,
cardiopulmonary resuscitation, on them, ``Ma'am, I'm sorry, we're going
to have to go on the other side of the city because St. Joseph's
Hospital is closed''? Then, when we get there, the doctors come to the
family member and say, ``I'm sorry, your husband, your son, your
daughter, your child, has died.''
How do we explain that to them: We passed the hospital that may have
made the difference in this case. The ability to care, to show
compassion: It's just apparent to me that that just doesn't exist now.
To sign off on anything less is to simply say, we turn our back on the
community; we turn our back on the Nation. To do that, is to give away
what makes us human. I think now is the time that we make that
decision: Whether we are unwilling to turn away from what makes us
human, or give in to those individuals who seek to benefit from others'
miseries. Those individuals know who they are. I think now is the
calling time. Now the horn is being blown, and we've got to answer. But
first, the failure of every part of civilization is first, the
inability to care for its population. From there, it tends to go
downhill.
This is a national problem, but we should be setting the trend, we
should set the example for the entire Nation that hospitals like St.
Joseph's Hospital do more than just care for our sick and injured. They
represent our capacity to care. There is a duty to act and a passion to
care.
H.R. 3962 is a bill that will change the health dynamics positively
for all Americans--but it is a work in progress. In the manager's
amendment after weeks of meeting with the leadership our efforts to
seek some relief for physician-owned hospitals was achieved. It is not
a winning formula, however on pages 22-23 of the manager's amendment we
secured language that says that all physician-owned hospitals should
not be treated alike. I have introduced two amendments to cover
extending the grandfathering in of physician-owned hospitals and on
criteria for other physician-owned hospitals. However, our work is not
finished--we must work with the Senate and in conference to keep
quality health care.
For the Record, I have attached a chart on Texas uninsured, benefits
for the 18th Congressional District, and physician-owned hospitals.
This is a vital issue which must be corrected or the bill moves
through Congress and for physician-owned hospitals to survive and grow.
Martin Luther King, Jr. often told the story of the priest, the Levite
and the good Samaritan. ``The first question that the priest and Levite
asked was ``If I stop to help this man, what will happen to me?'' But,
the Good Samaritan reversed the question ``If I do not stop to help
this man, what will happen to him?'' Today, we can be the Good
Samaritan--to help all Americans access good health care. Finally a
special thanks to Chairmen Rangel, Waxman, and Miller and a very, very
thank you to Congressman John Dingell and the late Senator Edward M.
Kennedy.

[[Page H12855]]

No insurance. Texas has the highest rate of uninsured with
about 6 million uninsured.
Texas Districts with the highest percentage of uninsured
constituents. Rank shows district ranking out of 435
nationally.
Rank, Representative, district No., and percent uninsured:
1. Ruben Hinojosa, District 15--46.4 percent.
5. Gene Green, District 29--36.4 percent.
6. Henry Cuellar, District 28--34.1 percent.
8. Silvestre Reyes, District 16--33.3 percent.
12. Eddie Bernice Johnson, District 30--32.3 percent.
19. Sheila Jackson Lee, District 18--29.7 percent.
22. Solomon Ortiz, District 27--28.6 percent.
23. Louie Gohmart, District 1--26.9 percent.
24. Jeb Hensarling, District 5--26.8 percent.
27. Ciro Rodriguez, District 23--26.4 percent.
Other South Texas Districts:
37. Lloyd Dogget, District 25--25.0 percent.
40. Charlie Gonzalez, District 20--24.7 percent.
48. Ron Paul, District 14--23.7 percent.
124. Lamar Smith, District 21--18.3 percent.

Benefits of the Affordable Health Care for America Act in the 18th
Congressional district of Texas

The Affordable Health Care for America Act will make health
care affordable for the middle class, provide security for
seniors, and guarantee access to health insurance coverage
for the uninsured--while responsibly reducing the federal
deficit over the next decade and beyond. This analysis
examines the benefits of the legislation in the 18th
Congressional District of Texas. Congresswoman Sheila
Jackson-Lee represents the district.
In Congresswoman Jackson-Lee's district, the Affordable
Health Care for America Act will:
Improve employer-based coverage for 279,000 residents.
Provide credits to help pay for coverage for up to 186,000
households.
Improve Medicare for 70,000 beneficiaries, including
closing the prescription drug donut hole for 5,300 seniors.
Allow 16,600 small businesses to obtain affordable health
care coverage and provide tax credits to help reduce health
insurance costs for up to 14,600 small businesses.
Provide coverage for 187,000 uninsured residents.
Protect up to 500 families from bankruptcy due to
unaffordable health care costs.
Reduce the cost of uncompensated care for hospitals and
health care providers by $49 million.

Affordable and Improved Health Care Coverage for the Middle Class

Better health care coverage for the insured. Approximately
41% of the district's population, 279,000 residents, receive
health care coverage from their employer. Under the
legislation, individuals and families with employer-based
coverage can keep the health insurance coverage they have
now, and it will get better. As a result of the insurance
reforms in the bill, there will be no co-pays or deductibles
for preventive care; no more rate increases or coverage
denials for pre-existing conditions, gender, or occupation;
and guaranteed oral, vision, and hearing benefits for
children.
Affordable health care for the uninsured. Those who do not
receive health care coverage through their employer will be
able to purchase coverage at group rates through a health
insurance exchange. Individuals and families with an income
of up to four times the federal poverty level--an income of
up to $88,000 for a family of four--will receive
affordability credits to help cover the cost of coverage.
There are 186,000 households in the district that could
qualify for these affordability credits if they need to
purchase their own coverage.
Coverage for individuals with pre-existing conditions.
There are 27,600 individuals in the district who have pre-
existing medical conditions that could prevent them from
buying insurance. Under the bill's insurance reforms, they
will now be able to purchase affordable coverage.
Health care and financial security. There were 500 health
care-related bankruptcies in the district in 2008, caused
primarily by the health care costs not covered by insurance.
The bill caps annual out-of- * * *.
Mr. CAMP. Mr. Speaker, at this time, I yield 2 minutes to the
distinguished ranking member of the Budget Committee and distinguished
member of the Ways and Means Committee, the gentleman from Wisconsin
(Mr. Ryan).
Mr. RYAN of Wisconsin. Mr. Speaker, I would like to place in the
Record a statement commending the people at CBO for their long hours
and hard work.
Mr. Speaker, I firmly believe that this is probably the most
consequential vote each of us will take in our service here, whether
you've been here for 40 years or for 1 year.
When you expose this bill's budget gimmicks, does it increase the
debt and deficit? Yes. Will it take coverage away from seniors, raise
premiums for families, and decrease health care innovation? Yes. Will
it raise taxes on small businesses and workers and cost us nearly 5.5
million jobs when our unemployment rate is 10.2 percent? Yes. Does this
bill mean the government will take over running our health care system?
Yes.
But what is worse is this bill replaces the American idea with a
European-style social welfare state. This bill, more than any other
decision we are going to make in this body, will do more to put
millions of Americans as dependents of a state rather than being
dependent upon themselves.
This is not about health care policy. If it were, we could pass a
bipartisan bill to fix what's broken in health care without breaking
what's working in health care. This is about ideology.
My friends, the choice is not whether you're going to stick with your
party leaders. The choice here is what side of history do you want to
be on? Will you be on the side of history where you stick with the
people and the principles that built this exceptional Nation? That is
the choice we are going to make with this bill, and I encourage you to
think it through.
It is unusual for the House to be in session working on a Saturday.
That has not been the case for the Congressional Budget Office's staff
that has been working on health care legislation. For the past several
months, CBO has worked non-stop to analyze health care legislation.
This legislation is enormously complex and far-reaching and CBO is
doing their best to fulfill their mission to provide objective non-
partisan analysis to the Congress. That analysis is critically
important to us and I want to acknowledge the hard work of Director
Doug Elmendorf and the following CBO staff in that endeavor:

Alexandra Minicozzi, Allison Percy, Andrea Noda, Anna Cook,
April Grady, Athiphat Muthitacharoen, Ben Page, Bruce
Vavrichek, Assistant Director for Health and Human Resources.
Carla Tighe Murray, Chapin White, Christi Hawley Anthony,
Colin Baker, Daniel Kao, David Auerbach, David Austin, David
Weiner, Doug Elmendorf, Director.
Elizabeth Bass, Ellen Werble, Heidi Golding, Holly Harvey,
Deputy Assistant Director for Budget Analysis, Jamease
Kowalczyk, James Baumgardner, Deputy Assistant Director for
Health, Janet Holtzblatt, Jean Hearne.
Jodi Capps, Joyce Manchester, Unit Chief, Long Term
Modeling Group, Julia Christensen, Julie Lee, Julie Somers,
Julie Topoleski, Kate Massey, Unit Chief, Low-Income Health
Programs and Prescription Drugs Cost Estimates.
Keisuke Nakagawa, Kirstin Nelson, Kurt Seibert, Lara
Robillard, Leo Lex, Unit Chief, State and Local Government
Cost Estimates, Lisa Ramirez-Branum, Lori Housman, Lyle
Nelson, Matt Schmit, Matthew Goldberg, Assistant Director for
National Security.
Mike Carpenter, Mindy Cohen, Noah Meyerson, Noelia
Duchovny, Patrick Bernhardt, Paul Burnham, Paul Jacobs, Pete
Fontaine, Assistant Director for Budget Analysis.
Phil Ellis, Unit Chief, Health Policy Analysis, Rebecca
Yip, Robert Stewart, Sarah Jennings, Sean Dunbar, Sheila
Campbell, Stephanie Cameron, Stuart Hagen, Sunita D'Monte,
Susan Labovich, Tom Bradley, Unit Chief, Health Systems and
Medicare Cost Estimates.

Mr. RANGEL. Mr. Speaker, I couldn't agree with the last speaker more.
This is an historic moment, and I certainly hope you, your friends, and
colleagues think this through for the American people.
At this time, I have the pleasure to present to the body Mr. Lacy
Clay, the gentleman from Missouri, and yield him 1 minute.
Mr. CLAY. I thank the distinguished chairman for yielding.
Mr. Speaker, I rise today to support a monumental piece of
legislation that will expand health care coverage and reduce cost.
Currently, 46 million Americans are uninsured, and by 2019 the number
could reach over 65 million. Too many are denied access to care, often
when they need it most. No one should be denied coverage because of a
preexisting condition, and no one should have to fear losing their
coverage after they get sick. Even individuals who have health
insurance suffer. Millions of underinsured Americans pay exorbitant
fees for procedures and treatments that their insurance plan should
cover.
The status quo is not working for Americans. It is time to take
action. Each Member in this body should ask themselves one question
before they vote, and that is: Am I my brother's keeper? And my answer
is: Yes, I am.
Mr. CAMP. I yield 2 minutes, Mr. Speaker, to the distinguished member
of the Ways and Means, the gentleman from California (Mr. Herger).
Mr. HERGER. Mr. Speaker, today I rise not only on behalf of my
constituents in northern California, but on behalf of all Americans.
They have made

[[Page H12856]]

their opposition to government-run health care known. They have come
out by the thousands to town halls, called our offices, and held
peaceful rallies, but, unfortunately, congressional Democrats have
refused to listen.
The legislation being considered today is one of the most damaging,
destructive bills ever to come before this Chamber. A government
takeover of health care won't bring down cost, but it will bring down
quality of care. It will explode the national debt at the expense of
future generations. It raises taxes by $750 billion and guarantees
middle class tax increases down the road.
We all agree that we need health care reform, but we don't need to
put the government in charge. Mr. Speaker, I believe in the free
market, I believe in choice and competition, and I believe in freedom
to choose your doctor and to get the treatments you need. America was
built on these principles, and the Pelosi health care plan will take us
in the opposite direction.
I urge every Member of the House to live up to our obligation, listen
to the people and say ``no'' to government-run health care.
Mr. RANGEL. I yield myself 30 seconds, Mr. Speaker, because the
gentleman who just spoke said that the Democrats didn't listen to the
Republicans. Having had the honor to serve with outstanding Republicans
on the Ways and Means Committee and having, as chairman, had hearings
last year and throughout, quite frankly, there wasn't much to listen to
until last Tuesday when, for the first time, you presented a bill. In
any event, I appreciate the gentleman's contribution.
The SPEAKER pro tempore. The time of the gentleman has expired.
Mr. RANGEL. I yield myself such time as I may consume.
We have been designated as one of the three committees to work on
this bill for the President and for the House of Representatives. And
we were privileged to work with Chairman Waxman as well as Chairman
Miller. I don't think in the history of the Congress we have found
three separate committees working in such cooperation. But as I said
earlier, we had such hardworking, dedicated members and such a strong
support staff that it's almost embarrassing that they are so limited in
sharing with you the work and the time and support that they've given
to this important issue for the Congress and for our country.
In any event, I have to admit, as Chair, there was one member that I
relied on so much. He is the gentleman from California who since 1984
served and continues to serve as the chairman of the Health Committee.
And so it is with a great deal of pride that I yield 3 minutes to the
gentleman from California (Mr. Peter Stark).
Mr. STARK. Mr. Speaker, today's vote will be the most important of
our careers. History will mark which side we're on: providing quality,
affordable coverage for all Americans, or the status quo.
I would remind my friend from Wisconsin that former Senator Bob Dole
voted against Medicare, and that vote has haunted him ever since. It
probably prevented him from becoming President.
Since my first election, I have worked to see that government serves
our people. My top priority for 37 years has been to provide quality,
affordable health care for all. I wish we had done it sooner, but at my
age, you learn to take what you can when you can get it.
The bill is not the bill that many of us would have created on our
own. That is the legislative process. The compromise before us today is
the right thing to do for the American people.
The bill guarantees health coverage to 96 percent of Americans. It's
fully paid for. People who like their coverage indeed can keep it. It
reforms health insurance regulation and requires shared responsibility
by individuals, businesses, and government. It assures that health care
is affordable for lower- and middle-income families. It fills the
Medicare prescription drug doughnut hole, and it provides free
preventive services in Medicare.
It has the support of consumers, doctors, nurses, senior citizens,
children, people with disabilities, farmers, and small business
owners--organizations that represent virtually every segment.
In my district, like every other district, Republican or Democrat,
I've got 67,000 uninsured people who will be helped; 8,000 people with
preexisting conditions; 14,000 businesses will get tax credits; 8,300
seniors will have the doughnut holes filled. And every district in the
country has similar numbers. I defy you to go home and tell those
people you voted to deny them quality, affordable health care.
I am proud to have helped author this legislation. I encourage each
of my colleagues to join me in voting ``yes.'' I can assure you, these
guys aren't going to have to pay for it in the future.

{time}  1630

Announcement By the Speaker Pro Tempore

The SPEAKER pro tempore. Members on both sides of the aisle are
reminded not to use guests of the House as props.
Mr. CAMP. Mr. Speaker, I yield 2 minutes to the distinguished member
of the Ways and Means Committee, the gentleman from Georgia (Mr.
Linder).
Mr. LINDER. I thank the gentleman for yielding.
Mr. Speaker, we have been listening ad nauseam for months from the
Democrats, who have been saying that anybody who doesn't support a
government takeover of health care is supporting their insurance
friends or their friends in the pharmaceutical industry.
Guess who contributes to political campaigns? Lawyers contribute more
than all the rest together. To who whom do they give their money?
Surprise. Surprise. Ninety-six percent was given to Democrats in this
year. Is that why they are left out of the health care reform bill?
Everyone who has looked at this issue for years has said to start
with tort reform. Start with tort reform. The three most recent studies
all this year said that Americans are spending $200 billion a year on
tests and procedures that are unnecessary, defensive medicine, because,
if they are not done, the doctors will be sued. That's $2 trillion over
10 years. That would pay for this $1.5 trillion behemoth.
It is ignored except in one fashion: there is mention in this bill
that, if your State has already reduced jury awards and has gotten
control over tort reform, you will be punished.
Ladies and gentlemen, this is not about health care. This is about
rewarding your friends and about punishing your enemies. It has been
going on all year, and it is a huge mistake.
Mr. RANGEL. Mr. Speaker, it is my pleasure to yield 1\1/2\ minutes to
the gentleman from Michigan (Mr. Levin). If there is a moral issue, I
would like to be on his side.
(Mr. LEVIN asked and was given permission to revise and extend his
remarks.)
Mr. LEVIN. Mr. Speaker, most Americans--and I emphasize that--most
Americans want to keep the insurance they have and do not want to lose
it because of skyrocketing costs; to be sure they are not denied
coverage because of preexisting conditions; and to be sure if they have
major illnesses, they are not bankrupted by unaffordable costs. Most
Americans also want other citizens to have their health care needs
covered by insurance.
Democratic health care reform responds to these concerns, and like
Social Security and Medicare, it is as American as apple pie.
Consider this letter from a constituent of mine from Fraser,
Michigan: ``I am ashamed to let my family and friends know that I have
no health insurance. I have refused hospital treatment I know I needed
because I could not afford to pay for any type of medical procedure.''
She closes her letter with this simple message: ``Please don't let
anything or anyone stop you from reforming health care. I hope you will
think of me. I need you to do the right thing. Health care for all
Americans now.''
That's what we are doing: health care for all Americans now.
Mr. CAMP. Mr. Speaker, I yield 2 minutes to a distinguished member of
the Ways and Means Committee, the gentleman from California (Mr.
Nunes).
Mr. NUNES. Mr. Speaker, as we consider this massive government-run
health care bill currently before the House, I would like to remind my
colleagues of a few things that have happened over the last year.

[[Page H12857]]

We spent $1 trillion to bail out banks, investment companies and car
companies. We spent another $1 trillion on a stimulus bill that has yet
to produce any jobs as promised. This record spending doesn't count the
omnibus spending bill that we had and the fact that we grew our budget
to $3.6 trillion all in one year.
If this weren't enough, we are being asked now to create a new
trillion-dollar, government-run health care program despite the fact
that we can't pay for the two existing government programs that we have
today--Medicare and Medicaid. These two programs have at least $62
trillion in debt that this Congress refuses to recognize. Let me repeat
that again: $62 trillion in debt that we face with our two existing
government-run health care programs. Mr. Speaker, with $1 trillion here
and $1 trillion there, pretty soon, you are talking about real money.
What is worse is that, despite all of this spending during record
times of high unemployment, this bill will kill American jobs,
exporting them overseas. In the meantime, our government leaders
continue to run over and grovel to the Chinese to borrow more money to
finance the spending.
Mr. Speaker, Rome is burning while this Congress fiddles. This
Congress is so irresponsible, so reckless, it's like watching a broke,
drunk gambler continuing to double down, just trying to break even.
Vote ``no.''

Announcement By the Speaker Pro Tempore

The SPEAKER pro tempore. The Chair will remind persons in the gallery
that they are here as guests of the House and that any manifestation of
approval or disapproval thereof of proceedings or other audible
conversations is in violation of the rules of the House.
Furthermore, occupants of the gallery are guests of the House. Those
in violation of these rules of the House may be removed.
Mr. RANGEL. Mr. Speaker, I yield 90 seconds to the gentleman from the
sovereign State of Georgia (Mr. Lewis), the true voice of justice in
this Congress.
Mr. LEWIS of Georgia. Mr. Speaker, I want to thank my chairman,
Chairman Rangel, for yielding.
Mr. Speaker, this is a historic day. As President Kennedy said in his
book ``Profiles in Courage,'' there comes a time when men must act
according to the dictates of their conscience and not according to
political expediency.
We have a mission. We have a mandate. We have a moral obligation to
lead this Nation into a new era where health care is a right and not a
privilege. Now is the time. Be on the right side of history, the right
side of the sick, the right side of the vulnerable. We have been
tracked down by the spirit of history. If we fail to act on health
care, if we fail to do what we must do, history will not be kind to any
of us.
So I say to you, my colleagues: be not afraid. Be not afraid. Be of
the courage. The time is always right to do what is right. On this day,
at this moment, answer the call of history, and pass health care
reform, and pass it today. Pass it now for the people of this country.
Mr. CAMP. Mr. Speaker, I yield 2 minutes to the gentleman from Texas
(Mr. Carter).
Mr. CARTER. Mr. Speaker, a couple of weeks ago, I was doing a town
hall meeting, and I got an email from a friend. He said, There's an old
saying: control a man's purse, and you control half the man. Control a
man's health, and you control all the man.
We are talking about a massive change in the lives of every human
being in America today. That massive change is because we've already
turned over to the Federal Government most of our financial system for
them to manage it, so they control our purse. This government controls
the purse of America, and we have done that this year. It's there. We
bailed people out. We are now voting members of financial organizations
and businesses, like automobile firms. Now we want to control the
American people's purse.
Now we have to ask ourselves: Well, what's going to happen when we
do? When we create this great system, how do we know what it's going to
look like?
Maybe there's a lot of talk here. I think we've got a fairly
independent vision. I want to use this vision, quite frankly, but it's
not fair because it's one-sided, and this document is two-sided, but
this document printed in smaller font is two-sided. So here is what we
have in the way of what the government needs to create for a health
care plan.
These are government ideas.
This is the substitute: the people's ideas.
It's the difference, ladies and gentlemen, between liberty and
government. You know, this week, a whole lot of people came an awful
long way so that they could express their opinions, and they were
called radicals.
Vote against this bill.
Mr. RANGEL. Mr. Speaker, I yield 90 seconds to a true expert on our
country's law system and tax system, the gentleman from Massachusetts
(Mr. Neal).
Mr. NEAL of Massachusetts. Thank you, Chairman Rangel.
Mr. Speaker, let me stand in support of this health care bill today.
Reforming this health care system has not been easy, but we come here
today after deliberating for countless years, weeks, months--and as
recently as this morning more hours added--because we are building a
baseline of health care for the American family.
We've worked hard to reform this health care system because, if we do
nothing, family premiums will increase $1,800 a year; and by 2020, 61
million Americans will be uninsured. We have analyzed, and we have
debated the details of the bill line by line and section by section.
To the critics, yes, we've read the bill.
For all of the misinformation that has surrounded this legislation,
there is a great deal that we all here today agree upon: this bill ends
discrimination based on preexisting medical conditions; it limits out-
of-pocket expenses for families; it bans lifetime limits on health care
coverage that a family with a critically ill child can bump up against
in no time at all.
Limiting out-of-pocket expenses is something we do all agree on. Half
the bankruptcies in America are health care-related. This bill removes
the uncertainties of our health care system for families and for
businesses, for young adults who are no longer eligible for their
parents' insurance coverage, and for senior citizens in the Medicare
part D doughnut hole. This is a solid piece of legislation.
As I close, remember the party that stood with Social Security, and
remember the party that stood with Medicare as we proceed to this vote
this evening.
Mr. CAMP. Mr. Speaker, I yield 3 minutes to the distinguished
minority leader, the gentleman from Ohio (Mr. Boehner).
Mr. BOEHNER. I thank my colleague for yielding.
Mr. Speaker, one of the issues in the underlying bill allows for the
taxpayer funding of abortion, and the leadership of the majority party
did see fit to allow Mr. Stupak of Michigan and others to offer an
amendment that would restore what has been a 30-year effort, that no
taxpayer funds should be used for abortion.
If that amendment were to pass, Mr. Rangel, and when this bill comes
back from committee and if the House does, in fact, pass the Stupak
language of outlawing taxpayer funding for abortion, will you guarantee
me, when it comes back, it will be in the bill?
I would be happy to yield.
Mr. RANGEL. Mr. Leader, you've been here long enough to truly
understand how this system works.
As soon as we pass this bill, then we would expect the Democratic-
controlled Senate to pass their bill. Then we will go into conference,
and we will work the will of the majority in the House.
We had no idea that you would expect that a Member, especially one
that you spoke in such glowing terms of as you have about me--that you
would expect me on this floor, in front of all of my friends and
colleagues, to guarantee you anything. I think any Member who gives a
guarantee might be in violation of our ethics laws, so I wish you would
kind of take a look at this before you would ask these questions.
Mr. BOEHNER. In reclaiming my time, Mr. Rangel, if the House does, in
fact, vote for the Stupak language, in

[[Page H12858]]

conference, do I have your guarantee that your vote will be in favor of
the Stupak language?
Mr. RANGEL. Well, I haven't normally cut any deals with you as a
Republican, but why don't you talk to someone on your level in the
House leadership as you have in the past?
Mr. BOEHNER. Reclaiming my time, Mr. Speaker.
Mr. RANGEL. You asked me a question.
Mr. BOEHNER. This is exactly the point I've been trying to make.
While the House is expected to take up the Stupak language later on
this evening, language which would outlaw the taxpayer funding of
abortion, it's pretty clear that this could be a shell game that's
underway, that it gets to pass here in the House, helping to ensure
that this bill passes; but we have no guarantees that when it comes
back from conference that that language stopping the taxpayer funding
of abortion will be in the bill.

{time}  1645

Mr. RANGEL. All I am asking, as long as you have been here, have you
ever had any Member--
Mr. CAMP. Regular order, Mr. Speaker. Regular order. No time has been
yielded.
The SPEAKER pro tempore. The Chair recognizes the gentleman from New
York.
Mr. RANGEL. Have you ever gotten a guarantee like that from anybody
since you have been here? No.

Announcement by the Speaker Pro Tempore

The SPEAKER pro tempore. Members will please direct their remarks to
the Chair.
Mr. RANGEL. Mr. Speaker, it is my pleasure to yield 1\1/2\ minutes to
Mr. Thompson of California. I thank him for the great contribution he
has made to this bill that we present.
Mr. THOMPSON of California. Thank you, Mr. Chairman, for yielding.
Mr. Speaker and Members, for far too long too many Americans have not
had access to quality, affordable health care. Because of this
legislation, the millions of Americans who don't have health care or
who are struggling to pay their health care bills will be able to get
the care they need when they need it. Families, small businesses, and
individuals will save money.
There will be no copays or deductibles for preventive care services.
If you change jobs, you can take your coverage with you. You will not
be denied coverage for preexisting conditions and families won't be
bankrupted by high medical bills.
The bill will also help inject competition into the marketplace to
help bring down the rising costs of health care insurance. The Medicare
doughnut hole will be closed and the bill reduces the deficit by at
least $30 billion over the next 10 years.
There is still a lot more work to be done, and we are going to fix
the doctor reimbursement to ensure the best access for our seniors in
regard to getting health care. Today is a historic day for all
Americans. It moves us one step closer to quality, affordable health
care for all Americans.
Mr. CAMP. Mr. Speaker, I yield 2 minutes to a distinguished member of
the Ways and Means Committee, the gentleman from Ohio (Mr. Tiberi).
Mr. TIBERI. Mr. Speaker, the American people do not want their health
care replaced by government-run health care.
This bill is flawed in many ways. It cuts benefits to seniors. It
increases taxes. It's the largest expansion of Medicaid ever at a time
when State governments across our land are cutting services. It creates
and extends 43 entitlement programs and 111 new offices, bureaus,
commissions.
The Ohio State Medical Association that represents doctors in my
district is opposed to the bill. They write, ``Medicaid eligibility
expansion is a troubling trend for the physician community as payment
for these services often fails to cover the cost of providing care.''
They go on to say, the legislation ``lacks many of the critical
elements necessary for successfully reforming Americans' health care
delivery system and strengthening the physician-patient relationship.''
The bill does not address medical liability reform, which causes
defensive medicine to be practiced. Medicare is cut by over $500
billion. Five million seniors could lose the coverage they have today.
It turns out that you can't keep what you have if you like it. In fact,
one of three seniors in my district could lose the benefits they enjoy
today.
I am also concerned about the negative impacts on small businesses
and employers. Under the ``pay or play'' mandate in this bill, Mr.
Speaker, $135 billion in new taxes will be thrust upon those
businesses. This could cause over 5.5 million Americans to lose their
jobs.
Mr. Speaker, we have a better way, a better alternative that will
lower health care premiums, guarantee health care to affordable health
care for those with preexisting conditions, allow States flexibility to
provide more coverage, and protect the benefits of our seniors.
Americans deserve better, Mr. Speaker. There is a better way. Let's
reject this bill and start over.
Mr. RANGEL. Mr. Speaker, I yield 1\1/2\ minutes to the gentlewoman
from Nevada (Ms. Berkley) and thank her publicly for the great
contribution she has made to this bill.
Ms. BERKLEY. I thank the chairman for his kind words and his
leadership on this issue.
Mr. Speaker, I rise today in support of this historic piece of
legislation that will expand health care coverage to millions of my
fellow Americans.
The way we provide health care in this country is unsustainable. In
Nevada, the cost of a private family health insurance plan is expected
to grow from over $11,000 in 2009 to more than $19,000 10 years from
now. If we do nothing, we will reach a point in this country where
hardly anyone will be able to afford health insurance.
This bill is good for Nevada. Over 400,000 uninsured Nevadans will be
able to get health insurance because of this bill. This bill is good
for Nevada's seniors. It closes the doughnut hole, eliminates copays
for preventive services and extends the life of Medicare over 5 years.
The bill isn't perfect. It doesn't contain a provision to protect
bone density tests that I fought for, and it doesn't fix the Medicare
physician payment system, and we must do both. But I support this bill
today for the needed reforms that are included. They are very
important. It's a great first step.
Faye Schwartzer in Las Vegas, Nevada, this vote is for you.
Mr. CAMP. At this time I yield 2 minutes to a distinguished member of
the Ways and Means Committee, the gentlewoman from Florida (Ms. Ginny
Brown-Waite).
Ms. GINNY BROWN-WAITE of Florida. I thank the gentleman.
Mr. Speaker, the bill before us creates 111 different offices,
bureaus, commissions, programs and entitlements, but it only cuts one--
Medicare. This bill steals more than $500 billion from our Nation's
seniors to fund new entitlement programs for the young, the healthy and
the wealthy.
My colleagues in the majority have boldly decided that cutting $500
billion from Medicare is a good idea. They actually are telling seniors
that these cuts will improve Medicare in the future.
Well, Grandpa and Grandma might be old, but they are not stupid. You
are not going to cut Medicare and tell them that it's a good thing.
The bottom line is that this bill is not real reform. Congress should
be strengthening Medicare, not weakening the program. Just look at how
bad the Federal Government has been historically in predicting health
care costs. This bill will increase health care costs for all Americans
and cut Medicare funding. Americans don't believe that yet another
trillion-dollar program will cost them nothing.
Mr. Speaker, we all hear Speaker Pelosi say that she is a mother and
a grandmother. Like Speaker Pelosi, I too am a mother and a
grandmother. I can tell you that my constituents believe that this bill
is bad for the middle class, bad for parents and grandparents and, even
worse, for future generations.
I cannot support this bill. I urge my colleagues to reject it as well
so that we can work together truly on a bipartisan solution. The
President's own economic advisors have said that this bill will kill
5.5 million jobs. Americans back home are watching this and saying,
What is Congress thinking? Why would they want to further sabotage our
economy? This bill clearly is

[[Page H12859]]

not what America wants. They want an incremental approach. Nobody is
defending health care as we know it. We are saying, let's fix what's
broken.
I urge my colleagues to vote against this bill. It is dangerous for
our economy. It is not something that every American needs, wants or
can afford at this time.
Mr. RANGEL. I yield 1\1/2\ minutes to the gentlewoman from
Pennsylvania (Ms. Schwartz) and I would like to publicly thank her for
the many hours that she put in on H.R. 3200.
Ms. SCHWARTZ. Thank you, Mr. Chairman.
Finding a uniquely American solution to ensure that all Americans
have access to meaningful, affordable health coverage has been an
unfulfilled goal for decades.
Today we have the opportunity to make this moral and economic
imperative a reality. I want to acknowledge the extraordinary
leadership of our chairman and of the cooperation of three committees
in the House and all of the Members who were so engaged in developing
the bill before us today.
The Affordable Health Care for America Act meets the goals of health
care reform: enhanced consumer protection for those with health
coverage, eliminating preexisting condition exclusions; new, affordable
choices for individuals and small business; strengthened Medicare for
our seniors with better prescription drug coverage and greater access
to primary care; improved delivery of care with better health outcomes
for all Americans; and the containment of rapidly rising costs of
health care.
It builds on America's public-private system and is paid for, now and
into the future. The status quo is unaffordable, unsustainable and
unacceptable.
Now is the time to act on behalf of the millions of Americans without
insurance and the millions more who are underinsured, on behalf of
small and large businesses who struggle every day to pay the rising
cost of insurance for their employees, on behalf of seniors. In fact,
on behalf of all Americans who worry about our families getting the
health care they need and then being able to pay for it, today is a
great day for America.
Mr. CAMP. Mr. Speaker, I yield 2 minutes to a distinguished member of
the Ways and Means Committee, the gentleman from Kentucky (Mr. Davis).
Mr. DAVIS of Kentucky. Mr. Speaker, we all agree we need to improve
health care quality and increase access, but this bill fails to do so.
Republicans know health care reform can be accomplished without raising
taxes for families and small businesses, without increasing the size of
government, without cutting Medicare benefits.
This week, tens of thousands of Americans traveled to Washington,
D.C., to demand a health bill that would increase access, reduce cost,
save jobs and keep the government out of our health decisions.
Instead of listening, Democrats squelched over 45 health care bills
in favor of a tyrannical bill that cuts senior benefits, creates 118
new agencies, boards and programs, kills jobs and raises taxes by $730
billion.
Unemployment has reached a staggering 26-year high and Speaker
Pelosi's health care bill will cost another 5.5 million jobs. Americans
don't want reform that comes with higher cost and unemployment.
This is a misguided effort by the majority, making it more
complicated and expensive to create jobs. The Northern Kentucky Medical
Society and thousands of doctors nationwide are opposed to this bill,
H.R. 3962. They know that government takeover of health care will put
bureaucrats between doctors and patients.
We can craft responsible health care legislation, and that's exactly
what my Republican colleagues have done in H.R. 4038, the Common Sense
Health Care Reform and Affordability Act. Our substitute reduces
premium costs for every American to make health insurance more
affordable and accessible, without raising taxes and without cutting
Medicare benefits on our seniors.
Under our bill, insurance premiums are $5,000 cheaper per family than
the cheapest Democratic bill. This bill takes waste and costs out of
the system instead of adding to it. The Republican bill heeds the pleas
of the people without spending $1.3 trillion, without killing jobs and
without hurting seniors.
Madam Speaker, H.R. 3962 is not reform; it is tyranny. Give the
people health reform, health freedom, and kill this bill.
Mr. RANGEL. Mr. Speaker, I yield 1\1/2\ minutes to my friend and
leader from the great State of New York (Mr. Crowley).
(Mr. CROWLEY asked and was given permission to revise and extend his
remarks.)
Mr. CROWLEY. I thank my good friend, the gentleman from New York, for
yielding me this time.
I rise today in support of the Affordable Health Care for America
Act, which will provide millions of hardworking American families the
quality, affordable health care they deserve. In the past decade, the
cost of health care for American families has skyrocketed. Premiums
have doubled, yet wages remain stagnant at best.
Last year, more than half of Americans postponed care or skipped
their medications because they simply could not afford them. The status
quo is no longer acceptable nor affordable, and the status quo is
changing today. Today Democrats are taking action and delivering to the
American people real change, a better, safer, more affordable way of
life.
The Affordable Health Care for America Act will give American
families peace of mind, peace of mind that health care is not just a
luxury for some but an affordable, accessible benefit for all of us.
I urge all of my colleagues to make history today and vote ``yes'' on
this bill to make health insurance affordable and accessible for each
and every American.

{time}  1700

Mr. CAMP. Mr. Speaker, at this time I yield 2 minutes to a
distinguished member of the Ways and Means Committee, the gentleman
from Washington State (Mr. Reichert).
Mr. REICHERT. I thank the gentleman for yielding.
Mr. Speaker, we have heard yesterday's announcement: unemployment
eclipses 10 percent. Yet today we are considering a health care bill
that will cost even more jobs and will raise taxes on families, on
small businesses, on seniors, and takes away freedom.
This bill especially hurts our seniors, our greatest generation, by
cutting their benefits, raising their premiums, and, on top of that,
taxing wheelchairs, taxing pacemakers, taxing hearing aids.
This bill is not right for America, it is not right for families, it
is not right for small businesses, and it is not right for seniors. We
need real solutions.
Let's focus on reducing the costs maybe, offer tax incentives, enact
medical liability reform, allow people to buy insurance across State
lines. These solutions bring lower costs and bring health care to those
who really need it.
Mr. Speaker, the most troubling aspect, though, of this bill is that
it takes away freedom, and this freedom came through great sacrifice,
the sacrifice of men and women throughout the history of this great
Nation so that we could choose and live a free life. This bill takes
away that freedom, the freedom to choose the health care that is right
for you and your family. This bill takes away that freedom, requiring
every American to purchase a government-approved health plan, pay a
tax, or even go to jail. This bill takes away the freedom of patients
to consult with their doctors without government interference. And this
bill takes away that freedom, the freedom of our seniors to choose
their own health care plan.
So, Mr. Speaker, this is not only a job-killing bill. Mr. Speaker,
sad to say, this is a freedom-killing bill.
Mr. RANGEL. Mr. Speaker, I yield 90 seconds to the gentleman from New
Jersey (Mr. Pascrell), and thank him for the great job he has done for
the committee.
Mr. PASCRELL. Mr. Speaker, no one believes the loyal opposition that
Democrats don't care about seniors. Need I provide a history lesson 101
here?
Today is when we must ask ourselves the real reason we came to
Congress. Was it to fulfill the hopes of the people, or to take the
path of least resistance? The easy thing would be to say the problem is
too big, the interests are too aligned, and then maintain the status
quo. The hard thing is to bring everybody together, make the
compromises that need to be made, and

[[Page H12860]]

give the American people true health care reform that will carry our
country through for generations.
This is the same choice that was laid before the Members of the 89th
Congress when they voted on the creation of Medicare and Medicaid. And
where would we be today as a nation had those Members simply succumbed
to the difficulty of making real change? Where would we be today? Where
would we be in mortality? Where would we be with the seniors who were
sick and poor at that time without those two programs?
We are now 40th among the industrial nations in infant mortality.
When will we wait to have our consensus? We need this reform. Let us
not leave another generation to wonder what we could have been.
Let's pass historic legislation that provides the promise of
affordable health care for every American today and the generations to
come.
Mr. CAMP. Mr. Speaker, I yield 2 minutes to a distinguished member of
the Ways and Means Committee, the gentleman from Louisiana (Dr.
Boustany).
Mr. BOUSTANY. Mr. Speaker, today we will have a vote on a flawed,
massive, and irresponsible health care takeover by government, pushed
by Speaker Pelosi and House Democrats, that will cost more than $1
trillion. This bill will increase health care costs for most Americans,
increase taxes while Americans struggle to find work, and hurt seniors'
quality care.
Mr. Speaker, as a heart surgeon, I saw the amazing innovation in my
20 years in practice in our system. In fact, in the early 1950s, an
American surgeon, hopelessly observing the death of a patient from
blood clots to the lungs, was inspired and invented the first heart-
lung machine that made open heart surgery possible. Many thousands of
patients worldwide have benefited from this innovation, this innovation
right here in the United States, innovation that will be stifled by the
Pelosi health care bill.
There is another way. We can do better. House Republicans have
solutions that will lower costs by creating real choice and
competition. We will help those with preexisting conditions to get
meaningful health care coverage, we will preserve U.S. leadership in
medical innovation and education, and we will reduce frivolous lawsuits
in medicine that needlessly drive up the costs for families.
As a heart surgeon, I know that we can achieve real health care
reforms to bring down costs. But the Democrats' current bill will only
lead to higher costs for millions of Americans and destroy what is
currently working in our system.
There is a better way. There is a different way. There is a way to
lower health care costs, help more people achieve a high quality
doctor-patient relationship in this country and improve health care for
all Americans.
Vote down this bill and support the Republican plan.
Mr. RANGEL. Mr. Speaker, I now yield 1\1/2\ minutes to the gentleman
from Illinois (Mr. Davis).
Mr. DAVIS of Illinois. Mr. Speaker, passage of this bill will move us
closer to the realization that all men, women, and children in this
country can have access to quality health care. It will reduce the
waiting time in emergency rooms and shorten the length of time you have
to wait to see a doctor. It makes it possible for people to have health
insurance who have never had any before in their lifetime and to see a
doctor on a regular basis. It recognizes the needs of people with
disabilities. It seriously increases the number of community health
centers, protects disproportionate share and teaching hospitals, and
promotes health awareness and education. But, most importantly, it
prolongs and enhances life, as well as its quality.
This is the most significant health legislation passed in this
country since Medicare and Medicaid. Residents of my district have been
calling all day asking that I would vote for them, that I would vote
for Illinois, that I would vote for America. I tell them, yes, I will,
because I believe that health care ought to be a right and not a
privilege.
I wanted a single-payer system, but I will vote for H.R. 3962 because
it is good for Illinois, it is good for me, it is good for you, and it
is good for America.
Mr. CAMP. Mr. Speaker, I yield 2 minutes to the distinguished member
of the Ways and Means Committee, the gentleman from Nevada (Mr.
Heller).
Mr. HELLER. Mr. Speaker, I thank the ranking member for his
exceptional hard work in producing a Republican alternative that does
not raise taxes, raise premiums, increase our debt or increase health
care costs.
In a recent article, the Democratic leadership stated that getting
votes today will be easier because Democrats want to go home.
Mr. Speaker, the Pelosi health care bill will cost Americans more
than 5 million jobs. Despite national unemployment at 10.3 percent, and
in my home State of Nevada, over 13 percent unemployment, we are moving
forward with this bill. For the majority, this is fine, if Members of
Congress get to go home.
This legislation raises billions in new taxes on small businesses and
increases health care premiums by $15,000 per family on average. But,
as I said, as long as the majority gets to go home, this doesn't
matter.
This bill cuts $500 billion from Medicare, affecting more than 20,000
seniors in my district and over 100,000 Statewide, and also avoids
meaningful medical liability reform. But the majority will support it,
because they get to go home.
This bill's individual mandates will result in 9 million Americans
paying a new tax or facing criminal penalties. These penalties include
$250,000 fines and/or 5 years in jail for failure to pay the tax.
However, this doesn't matter, as long as the majority gets to go home
today.
Mr. Speaker, this bill lacks enforceable citizenship verification
provisions. As many as 8.5 million illegal immigrants will be eligible
for taxpayer-subsidized health care under this legislation. But, of
course, if the majority gets to go home, it simply doesn't matter.
Yet the height of hypocrisy is that Members are not required to
participate in this government-run health care program.
Unfortunately, the strategy to pass this massive bill hinges upon
Members of Congress wanting to go home, instead of passing legislation
that will help the American people.
Mr. RANGEL. Mr. Speaker, I yield 90 seconds to a hardworking member
of the Ways and Means Committee from the sovereign State of New York
(Mr. Higgins).
Mr. HIGGINS. Mr. Speaker, the American health care industry is a $2.5
trillion industry. It represents 17 percent of the American economy, as
measured by the gross domestic product. Yet our outcomes, according to
the World Health Organization, are pathetically falling behind. We are
37th in overall quality. Unacceptable in America. We are 41st in infant
mortality. That means in 40 other countries, from birth to 1 year of
age, kids live by a higher percentage than they do in the United
States. Unacceptable in America. We are dead last of any industrialized
country in preventable deaths. Unacceptable in a good and generous
Nation.
This is a uniquely American problem with a uniquely American
solution. We look to not-for-profit plans, like the Cleveland Clinic,
the Mayo Clinic and Johns Hopkins. They are early adapters of new
innovation, and they are providing the highest quality health care, not
only in the Nation, but throughout the world, at the lowest possible
cost. That is the health care that I want for my family, that is the
health care that I want for my community, and that is the health care I
want for my Nation.
We have been debating this issue not for seven months, but for seven
decades. It is time for change. I understand that reform is tough. The
reformer, said Machiavelli, has enemies in all those who profit by the
older order, and only lukewarm defenders in all those who would profit
in the new order. On health care, most Americans are rooting for the
reformer.
Mr. CAMP. Mr. Speaker, at this time I yield 2 minutes to a
distinguished Member of the Ways and Means Committee, the gentleman
from Illinois (Mr. Roskam).
Mr. ROSKAM. I thank the gentleman for yielding.
Mr. Speaker, if you are at home and you are sort of flipping channels
between the football games and C-SPAN,

[[Page H12861]]

and you flipped on and only heard the majority party, you would think,
wow, what a great plan. I mean, really, you would think people are just
going to fall all over themselves, and all these adjectives and
declarative statements just sound wonderful. Until you look inside that
bill and you find handcuffs.
Now, I am not talking about figurative handcuffs. I am talking about
criminal penalties; criminal penalties that have been mentioned by the
gentleman from Texas, criminal penalties that have been mentioned time
and again on this floor. We have heard from the best and the brightest
all afternoon, and not a one of them have answered why it is you have
to criminalize people to coax them into a plan that is fabulous. It
makes no sense.
And these aren't my words. This is actually coming from the Joint
Committee on Taxation, in a letter that was written, ironically, with
Chairman Charlie Rangel as the chairman of that committee, released 48
hours ago, that says in fact if you don't comply with the individual
mandate, what happens to you? You can be subject to 5 years in prison
and you can be subject to a quarter of a million dollars in fines.

{time}  1715

And the other side, with all due respect, with all the adjectives and
all the flourishing speech, has failed to answer that question.
I submit to you, if we listen today, if we listen to the remainder of
this debate, they will be silent in terms of a good answer as to why it
is you need to criminalize people to coax them into a plan. It's a
failure, and we ought not stand for it.
The small businesses, the entrepreneurs, and the self-employed that
this would have an impact on, they say, ``Look, don't criminalize us.
Give us relief. Let us purchase across State lines.'' Not in the
Democrats' bill. ``Give us real tort reform, real liability reform.''
Not in the Democrat bill in any substantive way. ``Let us purchase and
work together to pool to lower costs down.'' The right to remain silent
shouldn't be the word from the government.
Mr. RANGEL. At this time, I yield 90 seconds to the gentleman from
Kentucky (Mr. Yarmuth).
Mr. YARMUTH. Mr. Speaker, 3 years ago today, the citizens of
Louisville, Kentucky, sent me to this body. They sent me here largely
to help bring us to this moment.
I was sent by a recent college graduate who had to give up her
coverage under her parents' health insurance policy and couldn't get
her own coverage to cover her lifelong allergic condition.
I was sent by the family of a 10-year-old little boy who wrote me,
begging for help to help pay for the $50,000 they have to pay annually
to care for their autistic brother.
I was sent by the Louisville woman whose insurance was dropped in the
middle of her cancer treatment.
I was sent by thousands of seniors, struggling to pay their
prescription drug costs.
I was sent by people like the local realtor who is trying to figure
out right now how to pay his next year's insurance bill he just
received with a 32 percent increase.
Today is the day those Americans get the help they have been praying
for. It is the day we take a giant step toward that more perfect Union
that we all seek. I am very proud to be a part of this historic day,
and I am also very proud for the all-too-patient citizens of America
who sent me here, along with many of my colleagues, in 2006 to cast
votes for the Affordable Health Care for Americans Act.
Mr. CAMP. Mr. Speaker, at this time, I yield 1 minute to the
gentlewoman from Michigan (Mrs. Miller).
Mrs. MILLER of Michigan. Mr. Speaker, during the past year, the
Democratic majority has passed so many bills that have done absolutely
nothing to help our economy. Instead, they've raised taxes, they've
exploded the deficit, and they actually have killed off jobs. Then,
yesterday, the national unemployment rate went up past 10 percent--
actually, to 10.2 percent, with no end in sight.
So it is incredible that today this House may pass a job-killing,
tax-hiking, deficit-exploding government takeover of our health care.
And one of the most disingenuous things that has been said is that if
you like your current health care, that you can keep it. Well, not so
fast.
In my county, Macomb County, Michigan, the Chamber of Commerce just
did a survey of all of their members. They asked them that if, rather
than continuing to provide good health care plans for their employees,
they would instead take the 8 percent penalty that is included in this
bill, and guess what? No surprise. The overwhelming majority said they
would of course dump their employees out into the public plan.
Mr. Speaker, we are going to have a complete government takeover of
our health care system faster than you can say, ``This is making me
sick.'' Vote ``no.''
The SPEAKER pro tempore. The gentleman from Michigan has 8 minutes
remaining. The gentleman from New York has 14\1/2\ minutes remaining.
Mr. RANGEL. Mr. Speaker, I would like to yield 1 minute to the
Congresswoman from California (Ms. Lee), who is the chairperson of the
Congressional Black Caucus and has done such a great job on the
question of diversity as well as other parts of the bill for women.
Ms. LEE of California. Mr. Speaker, on behalf of the Congressional
Black Caucus, I rise in strong support of this bill. Known historically
as the conscience of the Congress, we recognize that it is our moral
responsibility to pass this today.
I want to thank the gentleman and commend him and the other Chairs of
the tri-committees as well as our leadership and our Speaker for
bringing us to this point today.
The strong public option in this bill will provide our constituents
with the choice and competition they want. It will help improve health
equity and help eliminate health disparities, and this bill recognizes
that an ounce of prevention is worth a pound of cure. It will help
people who choose to keep their private plans by limiting annual rate
increases by insurance companies.
Today's historic vote is another step forward in our quest for social
justice. It really is about life and death, but it's not the end of the
process. The Congressional Black Caucus will keep fighting until a
final bill is on the President's desk.
Today, finally, health care will become a basic human right for all,
rather than a privilege for the few. We all have been called today for
such as this. Let us rise to the occasion and vote ``yes'' on
affordable health care for all.
Mr. CAMP. At this time, Mr. Speaker, I yield 1 minute to the
gentlewoman from Oklahoma (Ms. Fallin).
Ms. FALLIN. Mr. Speaker, the American people understand the need for
health care reform. They just don't want socialized medicine. They
don't want the Federal Government taking over our health care
decisions, taking away our freedoms of choice about health care. They
don't want more Federal deficit spending on the backs of our children
and future generations of our children, and they don't want more taxes
upon small business, especially in this recession.
They don't like the Federal Government taking away our freedoms
guaranteed under this Constitution, and they don't want the Federal
Government interfering in our States' rights. They don't want unfunded
mandates upon the States, and they don't want government-funded
taxpayer abortions upon our families.
Mr. Speaker, men and women have fought for our freedoms for this
Nation for generations, but this health care bill will change the face
of our Nation and put our Nation on a trajectory of a Federal
Government takeover in so many areas of our freedoms and our lives.
Let's reject this health care bill, and let's start all over and pass
real, meaningful health care reform.
Mr. RANGEL. I yield 1 minute to the gentlewoman from New York,
Congresswoman Velzquez.
(Ms. VELAZQUEZ asked and was given permission to revise and extend
her remarks.)
Ms. VELAZQUEZ. For too long, millions of Americans have suffered
without access to the medical treatment they need. Right now, as we
debate this measure, too many Americans are worrying about how they
will find health care coverage if they lose their jobs. On this day
alone, 14,000 Americans will lose their coverage, and millions of other
citizens, including one in every

[[Page H12862]]

three Hispanics, lack health insurance coverage.
Today all of that changes. This is the moment. No longer will
insurance companies abandon Americans when they most need help. This
bill will end the practice of denying Americans coverage because of
preexisting conditions. The 36 million uninsured Americans will finally
have coverage. Choice, competition, and transparency will be brought to
the insurance market, meaning better care at lowered costs.
I say this to my colleagues: It has been too long. Let us pass this
bill.
Mr. CAMP. Mr. Speaker, I yield 1 minute to the gentleman from Florida
(Mr. Crenshaw).
Mr. CRENSHAW. Mr. Speaker, a lot of the men and women that I
represent in northeast Florida are members of the military, and we've
been working for 15 years to make sure they have adequate health care.
They deserve it. They defend us every day.
They asked me, How is this new Democratic plan going to affect my
TRICARE and my TRICARE for life? The answer is nobody really knows what
this slippery slope with the public option is going to do to existing
coverage. If you take this Democratic plan, you will see it's
complicated, 2,000 pages long. It's unproven. It's untested. It's
filled with uncertainty.
At the end of the day, this Democratic plan is a dangerous experiment
on the backs of the American people without their consent. If this were
the medical field, that would be unethical. It would be malpractice.
There is a better way, Mr. Speaker. There is a better way.
Mr. RANGEL. I yield 1 minute to the gentlewoman from Michigan,
Congresswoman Kilpatrick.
Ms. KILPATRICK of Michigan. I thank the gentleman for yielding.
Mr. Speaker, this is a historic day. Choice, competition, quality,
and peace of mind. I want to commend the Speaker for her leadership and
our chairman in our caucus for putting together a bill that will help
American families.
The 36 million Americans who do not now have insurance will be
insured. Your premium costs will go down. The quality of all insurance
will be increased. No longer will insurance companies be able to
examine and cut you off when you get ill. Prescription drugs will be
cheaper. The AARP supports this bill. Medical doctors and nurses
support this bill. The Consumers Union supports this bill. The UAW
supports this bill.
It's a great historical day for our country. I predict it will be, as
we go forward, as strong and as popular as Social Security, Medicare,
and now our new national health care program.
Thank you. Thank you, Madam Speaker. Thank you, Democrats, for
standing strong.
Mr. CAMP. Mr. Speaker, at this time, I yield 1 minute to the
gentlewoman from West Virginia (Mrs. Capito).
Mrs. CAPITO. Mr. Speaker, I rise today to voice the concerns of my
constituents who believe the Speaker's trillion-dollar 1,990-page bill
is simply the wrong solution for West Virginia's families. We were told
that under the President's plans, those who like their health care
would be able to keep it. Well, we now know that is simply not true. It
is certainly not true for the 72,000 West Virginians on Medicare
Advantage who will see the program slashed by $170 billion under this
plan.
Consider one of my elderly constituents from Dunbar, West Virginia,
who called just today. She relies on the enhanced benefits of Medicare
Advantage to cover her rheumatoid arthritis and her diabetes. She
suffered a stroke, a brain aneurysm, and she is on more than a dozen
prescriptions. She relies on these services, and she fears that this
bill will put them at risk. Sadly, she is right, because this bill will
change her health care.
Mr. Speaker, we need health care reform, but we can do better than
this.
The SPEAKER pro tempore. The gentleman from Michigan has 5 minutes
remaining. The gentleman from New York has 11\1/2\ minutes remaining.
Mr. RANGEL. Thank you. I yield 1 minute of that to the gentleman from
the great State of New York, Gregory Meeks.
Mr. MEEKS of New York. The camera of history is rolling, and I am so
happy to play a part in it, because just as we created history in the
thirties with Social Security and in the sixties with Medicare, we will
create history tonight in passing H.R. 3962.
Dr. King once asked the question, How long? Well, because of H.R.
3962, how long before all Americans have access to affordable and
quality health care? Not long. How long before we end discrimination
for preexisting conditions? Not long. How long before we ensure that no
Americans fear bankruptcy or financial ruin due to illness? Not long.
How long before we close the doughnut hole, helping all of our senior
citizens? Not long. How long before we begin to control the escalating
prices of insurance and health care? Not long. How long before all
Americans, all of us, can have access to quality health care? Not long.
Mr. CAMP. At this time, Mr. Speaker, I yield 1 minute to the
gentleman from Virginia (Mr. Goodlatte).
Mr. GOODLATTE. Mr. Speaker, what's in this 2,000-page monstrosity
that's costing the taxpayers over $1 trillion in costs? Well, we're
going to see tax increases of $800 billion, and $500 billion in cuts
from Medicare.
Well, take a look on page 94. Section 202(c) prohibits the sale of
private health insurance policies beginning in 2013, forcing
individuals to purchase coverage through the Federal Government.
On page 225, however, section 330 permits, but does not require,
Members of Congress to enroll in government-run health care.
Page 122, section 233(a)(3) requires the commissioner, a new health
insurance czar, to issue guidance on best practices of plain language
writing. This from the same people who wrote this 2,000-page health
care bill.
Page 183, section 305(a) gives the commissioner the power to enlist
appropriate entities, like Planned Parenthood and ACORN, to engage in
outreach to specific vulnerable populations about the bill's new
programs.
Oppose this bill.
Mr. RANGEL. Mr. Speaker, at this time, I yield 1 minute to
Congressman Conyers, the distinguished dean of the Congressional Black
Caucus, senior Member of this great House of Representatives, and
someone that had indicated his concern about health care from many,
many years ago.

{time}  1730

Mr. CONYERS. Thank you, Chairman Rangel, and all of our colleagues
that have supported single-payer health care. Eighty-six other Members
are now working to make sure that we get this bill passed. I single out
my colleagues Dennis Kucinich and Anthony Weiner for their particularly
effective work.
But I want to say that this is the same battle that some people went
through when we passed Social Security. We had the same naysayers. The
same people when we passed Medicare, the same naysayers. The same
people when we passed Medicaid, the same naysayers. And now we try to
reform health care today, and what do we get? The same people saying
``no'' again.
So I'm proud to bring all of the support that I can to make sure that
this bill becomes law, that more people are covered, and that
preexisting conditions no longer will be an excuse to get rid of
people.
Mr. CAMP. Madam Speaker, at this time I yield 1 minute to the
gentleman from Georgia (Mr. Kingston).
Mr. KINGSTON. I thank the gentleman for yielding.
Madam Speaker, what we have today is another Pelosi plan for America.
But let's remember the Pelosi plan for jobs: an $800 billion stimulus
plan that caused unemployment to go from 8.5 percent to over 10
percent.
Let's remember the Pelosi plan for automobiles: Cash for Clunkers, a
$3 billion program that even the Democrats agreed did not work and was
killed after 3 weeks.
The Pelosi plan for fiscal discipline: a $1.4 trillion debt this
year, the highest in history.
And let's don't forget the Pelosi plan for national security:
dithering in Afghanistan.
Now we have the Pelosi plan for health care: it kills small
businesses and jobs. It raises taxes. It raises premiums. It cuts
Medicare. It takes away your current health care coverage and spends $1
trillion.
Vote ``no'' on the Pelosi plan for a government takeover of health
care and join the bipartisan Members of this Congress who plan to
promote an alternative which is far better.

[[Page H12863]]

Mr. RANGEL. Madam Speaker, I yield for the purpose of making a
unanimous consent request to Mr. Faleomavaega, my friend from Samoa.
(Mr. FALEOMAVAEGA asked and was given permission to revise and extend
his remarks.)
Mr. FALEOMAVAEGA. Madam Speaker, God is good. I rise in full support
of the health care needs of all our fellow Americans. God bless
America.
Madam Speaker, I rise in strong support of H.R. 3962, legislation to
provide affordable, quality health care for all Americans and reduce
the growth in health care spending, and for other purposes. This bill
will control rising medical costs and also extend health care coverage
to uninsured American citizens throughout the United States and its
Territories.
I want to thank Speaker Nancy Pelosi for her leadership and my
colleagues in Congress for their support on this important bill.
Especially, I extend my gratitude to the Chairmen of the House
Committee on Energy and Commerce, Congressman Henry Waxman; and the
House Committee on Ways and Means, Congressman Charles Rangel for
listening to the concerns of the Territories and for their willingness
to work with the Territorial delegates on resolving their concerns.
I also want to commend my fellow Territorial delegates for their hard
work and efforts, in working hand-in-hand to reduce health disparity
facing the Territories. I especially want to recognize Congresswoman
Donna Christensen for her work in the House Committee on Energy and
Commerce, Congressman Pedro Pierluisi and Congressman Gregorio Sablan
for their advocacy in the House Committee on Education and Labor and to
Congresswoman Madeleine Bordallo for her leadership as the Chairwoman
of the Congressional Asian Pacific American Caucus Healthcare Task
Force.
Madam Speaker, the Affordable Health Care for America Act, or H.R.
3962, will improve health care for Americans living in the insular
areas. Under the provisions of this legislation, from FY2011 through
FY2019, American Samoa will receive additional Medicaid funding in the
amount of $239.5 million. Moreover, its Federal Medical Assistance
Percentage (FMAP) will be raised to the highest FMAP applicable to any
of the 50 States and District of Columbia. As a result American Samoa
will assume an FMAP no less than 75 percent, the FMAP for Mississippi
which has the highest among the 50 States.
American Samoa will also work together with the Secretary of Health
and Human Services on a plan to transition the Territory to full parity
by 2020. And to make this transition, the Secretary will also assist to
make appropriate modifications to the Territory's existing Medicaid
programs. This will require comprehensive assessment of the existing
Medicaid program and health care services in American Samoa.
I am pleased that American Samoa and the insular areas will have the
opportunity to become part of the Exchange program, the centerpiece of
the Health Care Reform legislation. Again I thank my Territorial
delegates for their hard work to ensure that Congress continues to
recognize the need and unique set of circumstances we have in the
Territories. To help carry out the Exchange program, $300 million is to
be allocated among American Samoa, the CNMI, Guam, and the USVI, based
on consultation with the Secretary of Health and Human Services. If
American Samoa or any Territorial government chooses not to join the
Exchange, its allocation will be added instead to that Territory's
Medicaid funding.
Madam Speaker, H.R. 3962 will bring much needed improvement to the
health care system in American Samoa. The fact of the matter is rising
medical costs and limited health care coverage, exacerbated by American
Samoa's remote location and exponential rate of chronic diseases, have
led to a high number of people in the Territory with minimal or no
access to quality health services. Indeed, findings from the American
Samoa Health Survey conducted in 2005 estimated only 25 percent of the
population have insurance. Subsequently, there is a tremendous need to
address these concerns in a viable health care policy for the
Territory.
For this reason, in a letter sent June 22, 2009, I wrote members of
the Fono (American Samoa Legislature) to address the need to improve
the health care system in the Territory. I specifically requested that
the Fono should take advantage of the report from the Coverage for All
in American Samoa (CAAS) project, which includes policy recommendations
on ways to improve the Territory's health care system.
I commend the American Samoa Government especially the Office of the
Lieutenant Governor and staff for their dedication and commitment to
the CAAS project that was completed in 2007. I also want to commend the
Health Resources and Services Administration (HRSA) of the U.S.
Department of Health and Human Services (DHHS) for committing total
funding of $1.2 million from 2004 to 2007 to complete the CAAS project.
My hope is for the American Samoa Government to follow through on the
policy recommendations in the CAAS report and adopt the framework for
health care reform that is now in place and supported by H.R. 3962.
The Affordable Health Care for America Act, H.R. 3962, carries with
it our expectations and hopes for quality and affordable health care
for our people and with it a commitment; a commitment to ensure that
every American is provided quality health care that they are entitled
to and to receive health services that they so critically need.
I urge my friends and colleagues to support H.R. 3962 and pass this
historical health care reform legislation.
Mr. RANGEL. I yield myself 2 minutes.
This is it for the members on the Ways and Means Committee and others
that have demonstrated such outstanding leadership to be a part of
history.
It's unfortunate that we were unable to create an atmosphere of
bipartisanship because, certainly, the 40 million people that are
without health insurance, we can't distinguish between those who are
Republicans and those who are Democrats. Clearly, we had enough
information of the number of people that were in the congressional
district, all of our congressional districts, that had no insurance at
all.
I am more than certain that my colleagues on the other side of the
aisle have heard the very same stories we have: people who thought they
were insured and they were not; people who wanted insurance and they
would not insure them because they had some condition; other people who
worked hard every day of their lives, but were not given insurance and
they can't afford to buy it.
No, this isn't the Pelosi plan. This is a plan for all America, a
plan to make us proud to know that our country is concerned about us
and our children and our grandchildren. And, yes, the American Medical
Association, AARP, and everyone is throwing papers around. But these
are the groups, the national groups, that have asked America and this
Congress to step up and fulfill our responsibility.
And it's not just for our constituents. It's for our great country,
to have her as strong as she can be, to be able to know that we can
compete with any other nation no matter what part of the world that
we're in; and that our workforce will not only be educated and talented
in order to compete, but we will be healthy.
Every industrialized country takes care of their people. It's not a
political thing. Certainly here it's not a Republican or Democratic
thing. It's, Are we going to be healthy? Are we going to be strong? Are
we going to be certain that when you count America, count her among the
healthy.
Madam Speaker, I want to bring to the floor an outstanding Member of
Congress who is the subcommittee Chair on the Education and Labor
Committee. As you know, three committees had jurisdiction and Education
and Labor had jurisdiction. We had three chairmen. But we had one
subcommittee chairman who has just been outstanding. He's been a friend
of those without insurance, a friend of those who look forward to this
bill's being passed.
So it is with great distinction that I yield the balance of my time
to Mr. Robert Andrews from New Jersey, and I ask unanimous consent that
he be allowed to control that time.
The SPEAKER pro tempore (Ms. Edwards of Maryland). Without objection,
the gentleman from New Jersey will control the balance of the time.
There was no objection.
Mr. CAMP. Madam Speaker, at this time I yield 1 minute to the
gentleman from Texas (Mr. Gohmert).
Mr. GOHMERT. Madam Speaker, this is well intended. But you read
section 501, and it basically says if you make too much to get free
health care but you make too little to be able to buy it, you're going
to get taxed under this bill. It means well. But it does damage.
For those who have paid into Medicare for 40 years or so, who
expected to have it, they get cut hundreds of billions of dollars, but
illegals are going to get covered. Come on now.
In the 1960s they meant well with the Great Society, but they offered
a check for every child a woman could have out

[[Page H12864]]

of wedlock. Meaning well, wanting to help them, but they lured them
into a rut with no way out, and they came to my court to be sentenced.
We hurt people when we do the wrong things. For the Declaration of
Independence, our Founders pledged their lives, their fortunes, their
sacred honor. This is a ``declaration of dependence'' that pledges
Americans' lives, Americans' fortunes, and there is no honor in that.
Mr. ANDREWS. Madam Speaker, I yield myself 3 minutes.
Madam Speaker, the people of the country and Members of the House
deserve a vigorous debate. They also deserve an accurate record. And I
think the time has come to begin to clarify and correct some of the
series of assertions that have been made here that are simply not
correct.
There was an assertion made from the minority side a few minutes ago
that no one knows what will happen to those who are on TRICARE or
veterans health benefits. The gentleman may not know, but we do.
Nothing will change for a person under TRICARE or veterans benefits if
they do not wish to have it changed.
There was a statement made on the other side that the bill will
``cover illegal aliens.'' That is incorrect. There is no subsidy and
there is no coverage for an undocumented person.
There have been numerous statements made on the other side that there
will be massive tax increases on the American people. Here is the fact:
the fact is that there is a surtax in this bill that helps to pay for
coverage of uninsured people and for better quality care. It affects
the top .3 percent of households in this country. If you're an
individual and you make more than $500,000 a year adjusted gross
income, if you're a couple and you make more than $1 million a year
adjusted gross income, it affects you.
The statement has been made repeatedly the bill will add to the
deficit. That's not the truth. That's not what the Congressional Budget
Office says. They say the contrary. They say that the net effect of
this bill is it will reduce the deficit in the first 10 years by in
excess of $100 billion and that in the second 10 years, the bill will
reduce the deficit by somewhere in the neighborhood of one-quarter of 1
percent of GDP.
The statement has been repeatedly made that it is a crime not to have
health insurance. Here's the accurate statement: because there is a
penalty imposed on individuals who don't meet the individual mandate,
and, by the way, that individual mandate has within it very generous
subsidies and it has a hardship exemption, but it has been said it is a
crime not to have health care. That is not accurate. It is a crime to
willfully and intentionally evade taxation, just as it is with every
other tax.
It has been said this is a government takeover of health care. That
is false. This is a consumer takeover of health care. And those who
would be apologists for the insurance industry don't like that. The
American people do and will.
Madam Speaker, I reserve the balance of my time.
Mr. CAMP. Madam Speaker, at this time I will place in the Record a
letter from the Joint Committee on Taxation, which on page 3 indicates
that both misdemeanor and felony penalties with imprisonment of up to 5
years will be imposed.

Congress of the United States,

Joint Committee on Taxation,

Washington, DC, November 5, 2009.
Hon. Dave Camp,
House of Representatives,
Washington, DC.
Dear Mr. Camp: This is in response to your request for
information relating to enforcement through the Internal
Revenue Code (``Code'') of the individual mandate of H.R.
3962, as amended, the ``Affordable Health Care for America
Act.'' You specifically inquired about penalties for a
willful failure to comply.

Tax on individuals without acceptable health care coverage

H.R. 3962 provides that an individual (or a husband and
wife in the case of a joint return) who does not, at any time
during the taxable year, maintain acceptable health insurance
coverage for himself or herself and each of his or her
qualifying children is subject to an additional tax. The tax
is equal to the lesser of (a) the national average premium
for single or family coverage, as applicable, as determined
by the Secretary of Treasury in coordination with the Health
Choices Commissioner, or (b) 2.5 percent of the excess of the
taxpayer's modified adjusted gross income over the threshold
amount of income required for the income tax return filing
for that taxpayer. This tax is in addition to both regular
income tax and the alternative minimum tax, and is prorated
for periods in which the failure exists for only part of the
year. In general, the additional tax applies only to United
States citizens and resident aliens. The additional tax does
not apply to those who are residents of the possessions or
who are dependents, nor does it apply to those whose lapses
in coverage are de minimis or those with religious conscience
exemptions. The additional tax does not apply if the
maintenance of acceptable coverage would result in a hardship
to the individual or if the person's income is below the
threshold for filing a Federal income tax return.

Range of civil and criminal penalties for noncompliance

You asked that I discuss the situation in which the
taxpayer has chosen not to comply with individual mandate and
not to pay the additional tax. The Code provides for both
civil and criminal penalties to ensure complete and accurate
reporting of tax liability and to discourage fraudulent
attempts to defeat or evade tax. Civil and criminal penalties
are applied separately. Thus, a taxpayer convicted of a
criminal tax offense may be subject to both criminal and
civil penalties, and a taxpayer acquitted of a criminal tax
offense may nontheless be subject to civil tax penalties. In
cases involving both criminal and civil penalties, the IRS
generally does not pursue both simultaneouly, but delays
pursuit of civil penalties until the criminal proceedings
have concluded.
The majority of delinquent taxes and penalties are
collected through the civil process. In determining whether a
penalty applies along with an adjustment to a tax return, the
examining agent is constrained not only by the applicable
statutory provisions, but also by the written policy of the
IRS not to treat penalties as bargaining points but instead
to develop the facts sufficiently to support the decision to
assert or not to assert a penalty. The goal is consistency,
fairness and predictability in administration of penalties.
If the government determines that the taxpayer's unpaid tax
liability results from willful behavior, the following
penalties could apply.

Civil penalties

Section 6662(a)--an accuracy related penalty of 20 percent
of the underpayment attributable to the health care tax,
based on negligence or disregard (the former includes lack of
a reasonable attempt to comply and the latter includes any
intentional disregard of rules or regulations) or substantial
understatement, if the understatement of tax is sufficiently
large.
Section 6663--a fraud penalty of 75 percent of the
underpayment, if the government can prove fraudulent intent
to avoid taxes by clear and convincing evidence.
Section 6702--a $5,000 penalty for taking a frivolous
position on a tax return, if the underpayment is intended to
delay or impede tax administration and the return on its face
indicates that the self-assessment is substantially
incorrect.
Section 6651--delinquency penalty of .5 percent of the
underpayment, each month, up to a maximum of 25 percent of
the underpayment.

Criminal penalties

Prosecution is authorized under the Code for a variety of
offenses. Depending on the level of the noncompliance, the
following penalties could apply to an individual:
Section 7203--misdemeanor willful failure to pay is
punishable by a fine of up to $25,000 and/or imprisonment of
up to one year.
Section 7201--felony willful evasion is punishable by a
fine of up to $250,000 and/or imprisonment of up to five
years.

Application of penalties under current practice

The IRS attempts to collect most unpaid liabilities through
the civil procedures described above. A number of factors
distinguish civil from criminal penalties, in addition to the
potential for incarceration if found guilty of a crime.
Unlike the standard in civil cases, successful criminal
prosecution requires that the government bear the burden of
proof beyond a reasonable doubt of all elements of the
offense. Most criminal offenses require proof that the
offense was willful, which is a degree of culpability greater
than that required in a civil penalty cases. For example, a
prosecution for willful failure to pay under section 7203
requires proof beyond a reasonable doubt both that the
taxpayer intentionally violated a known legal duty and that
the taxpayer had the ability to pay. In contrast, in applying
the civil penalty for failure to pay under section 6651, the
burden is on the taxpayer: the penalty applies unless the
taxpayer can establish reasonable cause and lack of willful
neglect with respect to his failure to pay.
Criminal prosecution is not authorized without careful
review by both the IRS and the Department of Justice. In
practice the application of criminal penalties is infrequent.
In fiscal year 2008, the total cases referred for prosecution
of legal source tax crimes were as follows.
Investigations initiated--1,531.
Indictments and informations--757.
Convictions--666.

[[Page H12865]]

Sentenced--645.
Incarcerated--498.
Percentage of those sentenced who were incarcerated--77.2.
Of the 666 convictions reported above for fiscal year 2008,
fewer than 100 were convictions for willful failure to file
or pay taxes under section 7203. Civil penalties outnumber
criminal penalties imposed. For example, in fiscal year 2008,
compared to the 666 convictions, approximately 392,000
accuracy related penalties were assessed on individual
returns. Also in fiscal year 2008, the IRS assessed 5,502
penalties under section 6702 for frivolous positions taken on
returns.
I hope this information is helpful for you. If I can be of
further assistance, please contact me.
Sincerely,
Thomas A. Barthold.

Madam Speaker, at this time I yield 1 minute to the gentleman from
Texas (Mr. Poe).
Mr. POE of Texas. Madam Speaker, in my prior life I was a judge for
22 years. I tried only criminal cases.
This bill forces everyone that can to buy insurance whether they want
to or not. If they don't, they're taxed. But that tax is really a fine.
Be that as it may, if they don't pay the fine, they're in violation of
the IRS Code and they can pay another $250,000 fine and go to a Federal
penitentiary for 5 years.
That is government oppression of the people, forcing them to buy
insurance whether they want to or not. That is repressive government
control, and that's the way that I see it. If they don't submit, they
are forced to go to jail.
You know, this bill is about government control. It's not about
choice. It's oppression. It's not about liberty. The Constitution
starts out with ``We the people.'' If this bill passes, especially that
section, let's scratch out ``We the people'' and write in the phrase
``We the subjects of Big Government.''
And that's just the way it is.
Mr. ANDREWS. Madam Speaker, I'm pleased at this time to yield 1\1/2\
minutes to the gentlewoman from Ohio (Ms. Fudge), who's one of the
authors of the small business provisions in the bill.
Ms. FUDGE. There comes a time, Madam Speaker, when we must choose
that which benefits the greater good or look for selfish reasons to
support the status quo. Now is that time and I choose the greater good.
When I go home, Madam Speaker, I will be able to say that I was asked
to make health care more affordable and I said ``yes.'' This bill makes
health care affordable for 36 million more Americans by ensuring that
working-class citizens will never have to pay more than 12 percent of
their income on health care premiums and that people whose incomes are
400 percent of poverty or less will receive their premiums in the form
of subsidies. More than 163,000 households in my district alone will
benefit from these subsidies.
When asked to increase access to care, I said ``yes.'' ``Yes'' to the
people of America who will no longer worry about being denied coverage
because of preexisting conditions. ``Yes'' to the people of America
whose families can now have regular checkups and free preventative
care. Madam Speaker, I said ``yes'' to those who for the first time
will have a family doctor instead of using the emergency room for
routine matters.
When asked to help the laid-off worker, the small business owner, the
working poor, and those who can't make ends meet in this very
struggling economy, I said ``yes.'' When asked to ensure that those who
have health care today but may be dropped tomorrow are taken care of, I
said ``yes.'' When asked to exhibit the courage needed to fight for
change, I said ``yes.''
When the history of the 111th Congress is written, I choose to be in
that number that said ``yes'' to the people of America.

{time}  1745

Mr. CAMP. Madam Speaker, I yield 1 minute to the gentleman from
California (Mr. Rohrabacher).
Mr. ROHRABACHER. Madam Speaker, this attempt at sliding Americans
into dependence on a government-controlled health care system brings
bait-and-switch to a new low. We have heard about the flaws of our
current health care system: high cost; lack of portability; lose a job,
lose insurance; and discrimination against those with preexisting
conditions. Yes, many of the heart-wrenching stories we are hearing to
justify this legislation are real. But correcting those maladies only
requires specific reform. It doesn't require transforming health care
in America into a bureaucratically managed health care system that will
cost hundreds of billions of dollars more, including billions to
provide health care for illegal aliens while at the same time cutting
Medicare by hundreds of billions of dollars.
This so-called reform will destroy the freedom of the American people
to make health decisions with their doctor and the doctor of their
choice. It will transform our system rather than reform it, and what we
will end up with is a system that is massively more expensive, less
effective, and will be based on government controls and rationing,
rather than the patient-doctor relationship.
Mr. ANDREWS. Madam Speaker, nurses make a great contribution to our
health care system, and a gentlewoman who is a nurse has made a great
contribution to this bill. I yield 2 minutes to the gentlewoman from
New York (Mrs. McCarthy).
Mrs. McCARTHY of New York. I thank my colleagues, Mr. Andrews, and I
also thank George Miller for also working with us.
We have known for years that we have a shortage of doctors,
especially primary care doctors, and we have had a shortage of nurses.
This bill is going to help that.
You know, when we talk and I hear some of the charges coming from the
other side, I am wondering where have I been all of these months when I
sat through the committee hearings and heard what we are doing.
I want to say with the Education and Labor Committee, the Nurse
Training and Retention Act and the Student-to-School Nurse Ratio
Improvement Act is in this bill, H.R. 3962. The Nurse Training and
Retention Act will provide grants so we can have more new nurses, but
to have more new nurses, we have to have those who are educated to
teach those nurses. We have that in this bill, too.
I also want to say that for years I have been fighting with the
insurance companies to make sure that children who are born with
disfigurements on their face can have corrections so long term they
won't have those scars, physically and mentally, and to help those
families adjust to the child. In this bill, we will be able to say that
the plastic surgeons can work on these children.
Think about a child who is born without an ear. The insurance
companies say that is cosmetic. That is not cosmetic. The ear is
actually part of the body so you can actually hear better. But the
emotional scars that happen to the children that are born with these
deformities, that is wrong.
If we can't take care of our children in this country, if we can't
make sure our seniors on Medicare get the kind of care that they need--
I will tell you, I just went through surgery. I went to get my
prescriptions filled, and my pharmacist said to me, How lucky, you
don't have to pay anymore for your prescriptions until January 1. Why?
Because I have coverage, because I have health care from the Federal
Government. We can do better, and we should.
The SPEAKER pro tempore. The Chair recognizes the gentleman from
Minnesota (Mr. Kline) for 40 minutes.
Mr. KLINE of Minnesota. Madam Speaker, I yield myself such time as I
may consume.
Madam Speaker, we have before us today more than 2,000 pages of
legislative text that will give us public policy that costs more than
$1 trillion and creates a huge morass of government bureaucracies. Over
a hundred new offices, bureaus, commissions, and programs. Let's look
briefly at just one of these new offices.
The Democrats empower a new super bureaucrat with unprecedented
authority over personal health care decisions, the health choices
commissioner, heading up the Orwellian health choices administration.
In the short time we have had since this legislation was made public,
we have combed these pages--in the first part of these 2,000 pages--to
see if we could get a picture of the responsibilities, authorities, and
powers that were granted to this individual. As you can see, Madam
Speaker, we actually had to go back to the supply store to get enough
of these tabs.

[[Page H12866]]

This super bureaucrat, this health choices commissioner, it turns out
will have powers to define, deny, deem, determine, assess, administer,
and establish our health care benefits for all Americans.
It is no wonder that millions of Americans are afraid of a government
takeover of our health care. How can they not fear such a thing? This
is unprecedented, this amount of power granted to one bureaucrat. And,
of course, there are other bureaucrats in this bill.
I don't believe that this bill should see the light of day. It
certainly should not pass. It is a recipe for job losses. It is a clear
power grab by Washington bureaucrats. It is a power grab. We ought to
discard it altogether. Press the reset button, start over. We can do
better. The American people deserve better. Let's vote ``no'' on this
power grab by Washington bureaucrats.
I reserve the balance of my time.
The SPEAKER pro tempore. The gentleman from New Jersey has 1\1/2\
minutes remaining.
Mr. ANDREWS. Madam Speaker, at this time I would like to yield to a
gentleman who authored a very key provision about saving money through
medical records technology, the gentleman from Oregon (Mr. Wu) for 1\1/
2\ minutes.
Mr. WU. Madam Speaker, I rise today in strong support of health
insurance reform. In 20, 40, 60 years, this legislation will stand
beside Social Security, the GI bill, and Medicare as a pillar of
American health care and humane values. The bill creates a new health
insurance exchange or marketplace to expand access and provide people
with a menu of quality health insurance options so they can choose the
plan that best meets their own needs.
The bill would create affordability credits to ensure that all
Americans have more affordable health care coverage.
The bill will set a yearly limit on how much you can be charged for
out-of-pocket expenses because no one should go broke because you get
sick.
In short, what health insurance reform means for Americans is more
security and stability. Americans should not have to wait any longer
for these reforms. We have been waiting since Theodore Roosevelt. We
have been waiting since Franklin Roosevelt. We have been waiting since
Harry Truman. We have been waiting since Lyndon Johnson. We have been
waiting since Jimmy Carter. We have been waiting since Bill Clinton. It
is time to stop the waiting and it is time to act.
The SPEAKER pro tempore. The time of the gentleman from New Jersey
has expired.
Mr. KLINE of Minnesota. Madam Speaker, I yield for the purpose of a
unanimous consent request to the gentleman from California (Mr. Lewis).
(Mr. LEWIS of California asked and was given permission to revise and
extend his remarks.)
Mr. LEWIS of California. Madam Speaker, I rise to oppose H.R. 3962.
Madam Speaker, our health care system is the envy of much of the
world. That does not mean it is perfect.
Major challenges such as pre-existing conditions and portability can
be dealt with by breaking down barriers between states and through
nationwide underwriting.
California-style liability reform provides a model to reduce the cost
of defensive medicine and can significantly reduce the cost of health
care.
Tax incentives can be used to encourage broader participation by
families, without federal mandates.
The Speaker and her congressional advisors are committed to
government-run health care. We can solve existing problems without
adding a trillion dollars on the backs of average American taxpayers.
Vote ``no'' H.R. 3962. Help save us from single payer healthcare.
Mr. KLINE of Minnesota. I reserve the balance of my time.
The SPEAKER pro tempore. The gentleman from New Jersey (Mr. Andrews)
is recognized for 40 minutes.
Mr. ANDREWS. Madam Speaker, at this time it is my honor to yield 4
minutes to a person who has spent a distinguished career in this House
fighting for this day, who is one of the principal authors of this
bill, the leader of our committee, the chairman of the Committee on
Education and Labor, the gentleman from California (Mr. George Miller).
Mr. GEORGE MILLER of California. Madam Speaker, I thank the gentleman
so much for his contribution to this legislation, to the debate in this
House, and to the role he has played in informing our Members and the
public about this bill.
I want to begin by giving thanks, Madam Speaker, particularly on my
committee, I want to thank the staff that have worked so terribly hard,
Michele Varnhagen, Megan O'Reilly, Jody Calemine, Aaron Albright,
Meredith Regine, and Rachel Racusen, who have all supported this
tremendous team and the professional staff of the Committees on Ways
and Means and Energy and Commerce, and certainly to my colleagues,
Chairman Rangel and Chairman Waxman, and to our subcommittee chairmen,
Mr. Andrews, Mr. Pallone and Mr. Stark. It has truly been an honor to
have been involved in this debate and sit in the same room with the
dean of our House, John Dingell, and to be able to craft this
legislation. It is an honor I will remember the rest of my life, and I
thank the Democratic leadership for giving us the space to bring
President Obama's bill to this House so we can pass it and change
America. And I want to thank Speaker Pelosi. Without her leadership,
her tenacity and her passion, we would simply not be here today.
We are about to make history, and the reason we are about to make
history is because many of us have so much confidence in the great
things that America is capable of achieving. America has been
challenged throughout its history to achieve great things on behalf of
Americans, on behalf of the world community. We have risen to that
challenge. But throughout that history, one challenge has eluded us:
the challenge to come and to finally provide access to affordable
health care for all of our citizens, for all Americans, to provide them
the kind of security that they would know with this legislation, to
provide them the understanding that never again will they live in fear
that they will be without health care, for whatever circumstances take
place in their lives.
And every Member in this Chamber on both sides of the aisle have
encountered our constituents over our public careers as they have told
us terrible stories, dramatic stories, painful stories, sad stories,
about how their family has been crushed, or their friends or their
neighbors that they care about or work with, by circumstances beyond
their control. How, when one circumstance leads to another, how in
America today when the layoff notice comes, you are also on notice that
you will lose your insurance. Your world is turned upside down
immediately. You struggle to find employment or retraining. You
struggle to refigure your family's finances. And you know if your
children are sick, they won't be able to go to the doctor--you won't be
able to afford it. If your spouse is in the middle of treatment, that
treatment can be curtailed, no matter what the illness, no matter how
important the treatment is. It can go in a flash.
We cannot continue to ask American families to continue to live on
that edge of uncertainty, of insecurity, of the possibility of fiscal
ruin. A small event, because of the lack of health care, can explode
into the life of a family, into the life of a community when it happens
over and over and over again.
But this legislation says that's not going to happen again in our
future. We are going to become the architects and the builders of a
system that will provide care to these people, will provide services to
these people, will provide security for these people so that these
American families can go to work with confidence. They can buy a home
with confidence. They can think about their kids' education with
confidence, and know it will not be all wiped out in a flash because
their insurance was canceled.
The SPEAKER pro tempore. The time of the gentleman has expired.
Mr. ANDREWS. I yield the gentleman an additional 1 minute.
Mr. GEORGE MILLER of California. That is what this legislation is
about. We can talk about all of the internal merits and the back and
forth. But at the end of the day, for the first time in our history, we
deliver to all Americans the security that their family will have an
opportunity to continue on a stable financial track and that they can
make the kinds of plans that we want to make for our children, our
grandchildren, that their neighbors might be able to make.

[[Page H12867]]

But in America today, because of the absence of this policy, because
of the absence of a comprehensive health care bill that provides
universal access, because of the failure of a bill that will help
families that are struggling to meet the demand to pay the premiums,
because of that failure, as The Wall Street Journal said, we pay a huge
price in innovation because people know they will be penalized if they
start a new business, if they take an idea and try to take it to
fruition, if they switch jobs for a better opportunity maybe career-
wise but that doesn't have insurance, if they want to go to work for a
start-up where they can't provide insurance.
Let's give America for the first time health care security for their
families, their friends, their kids, and their neighbors.
Madam Speaker, I rise in support of this historic legislation to fix
our broken health insurance system and finally bring affordable health
coverage to every American.
We are truly on the verge of making history.
Never before has the House or Senate approved a bill to guarantee
every American access to affordable health care.
Never.
Not that we haven't tried.
The fight to reform this Nation's health care system has spanned
nearly 100 years, across generations and many great leaders, from Teddy
Roosevelt to Franklin Roosevelt to John F. Kennedy to President Clinton
to my own personal hero, Ted Kennedy.
But time and again these efforts were stymied by special interests.
The need for reform is dire.
Hundreds of thousands of people are losing insurance each month.
At least 36 million Americans have no coverage at all--including
nearly 50,000 people in my district in Northern California.
Over half of all personal bankruptcies are due to a medical incident.
Businesses are choking on bloated health care costs.
Innovation is being stifled. Our competitiveness is undermined.
But this year is different. This time is different.
The American people literally cannot afford to wait any longer, and
today we will cast a history-making vote to guarantee all Americans
access to quality, affordable health insurance.
We must not fail again.
An unprecedented effort by the House led us to this milestone.
Three committees and our diverse Caucus worked together in an
extensive and coordinated fashion, with one purpose--to fulfill a
decades-old and yet still urgent promise.
We engaged the public in one of the most transparent debates of
federal legislation in history, including over 2,000 events across the
U.S. since July alone.
The result is a bill that reflects what we have heard from workers
and families, from small business owners and economists, from seniors
and college students, from doctors and nurses.
The Affordable Health Care for America Act will directly meet the
needs of Americans and the goals that President Obama set for reform:
It lowers costs for families and businesses,
Protects people's choices of doctors and health plans, reduces the
deficit, and
Ensures access to quality, affordable health insurance for all
Americans.
For the first time in U.S. history, all uninsured Americans will be
able to purchase quality, affordable coverage through a new Health
Insurance Exchange, where they will be able to choose from a menu of
options: a public health insurance option or several private plans.
And for those that already have insurance, our bill will grant them
the security of knowing that their coverage will always be there.
Never again will Americans worry about losing their health care if
they change or lose their job.
Never again will someone be denied health care coverage because of a
pre-existing condition.
Never again will a patient have to worry about their insurance
company rescinding their policy when they need coverage the most.
Never again will a small business owner have to worry about
unpredictable and unaffordable premiums.
Our bill, H.R. 3962, will end the many injustices that workers,
families, and businesses face in today's system.
It will finally make health insurance work for consumers--not
insurance CEOs.
Let me be specific about what our reforms will mean for the American
people:
No more co-pays or deductibles for preventative care;
No more rates increases because of a pre-existing condition, gender,
or occupation;
An annual cap on out-of-pocket expenses;
Guaranteed affordable dental, hearing and vision care for children;
Lower prescription drug costs for seniors;
Young people will be able to stay on their parents' insurance through
their 27th birthday; and
A ban on lifetime caps on what insurance companies will pay, so
patients will never again be one treatment away from medical
bankruptcy.
As I mentioned earlier, this legislation meets our commitment to
fiscal responsibility.
Every piece of this bill is fully paid for through a combination of
revenue raised by placing a surcharge on the wealthiest Americans and
savings generated by making Medicare and Medicaid more efficient.
These reforms will strengthen Medicare for seniors and shift our
system's focus from quantity of health procedures to quality of care
and producing healthier outcomes for patients.
The Congressional Budget Office reports that our bill will reduce the
deficit by more than $100 billion over the next decade and slow the
growth of health spending, leading 11 chief health care economists to
declare our legislation ``vital to the Nation's fiscal and economic
future.''
As with previous efforts to reform health care, this bill received an
enormous amount of public scrutiny.
In the last few months, opponents of health reform have conjured up
every falsehood imaginable about this bill in an effort to scare the
American people and once again try to stymie reform.
But as I said, I believe that this year is different. Our legislation
has been tested in public and the momentum continues to grow in support
of the bill.
The American people have seen through the lies and distortions.
And they are not fooled by the hoax of an 11th hour Republican bill
that is nothing more than a cruel rebuke to the needs of the American
people.
Their bill would do nothing but maintain the status quo and guarantee
insurance profits at the expense of tens of millions of hard working
Americans.
The public understands the true meaning of our bill.
They know it will cover 96 percent of Americans.
They know that, under our bill, if they lose their job they will
continue to have health coverage for their children, spouses and
families.
They know that this bill means that if they have cancer, the
insurance company can no longer pull the rug out from under them while
they're in the middle of treatment.
They know that this bill will protect them, through any economic
cycle.
Nearly 50 years ago, as he was fighting to expand health care
benefits, President Kennedy said,

All of the great revolutionary movements of the Franklin
Roosevelt Administration we now take for granted. But I
refuse to see us live on the accomplishments of another
generation. I refuse to see this country and all of us shrink
from the struggles which are our responsibility in our times.

We must not shrink from the struggle for health reform, which is our
responsibility in our time. This is our moment to revolutionize health
care in this country.
We have arrived at this historic moment thanks to the hard work of so
many people.
I would like to thank my good friends and colleagues, Chairman Rangel
and Chairman Waxman, and our three subcommittee chairs, Rob Andrews,
Frank Pallone and Pete Stark, and especially Dean Dingell. We could not
have had better teammates in this journey.
I would also like to thank the Democratic Leadership, our Speaker,
Ms. Pelosi, the Majority Leader, Mr. Hoyer, our Whip, Mr. Clyburn, and
all the members of leadership for the countless hours they spent
working with the committee chairs to arrive at this point today.
And of course we could not have completed the work on this bill
without the work of our incredibly talented staff, who worked long
nights and weekends for months on end. They are the unsung heroes of
this process, and I know all our colleagues join me in thanking them
for their extraordinary work.
From my staff I would like to thank Mark Zuckerman, Alex Nock, Danny
Weiss, Michele Varnhagen, Megan O'Reilly, Jody Calemine, Tico Almeida,
Meredith Regine, James Schroll, Rachel Racusen, Aaron Albright, Amy
Peake, Courtney Rochelle, and Mike Kruger.
Finally, I'd like to pay tribute to my mentor and friend, Sen. Edward
M. Kennedy.
Health care was the cause of Ted's lifetime. Our effort would have
been impossible had he not carried the torch of justice and equality
for all those years.
I know I am not alone when I say that I sincerely wish Ted Kennedy
could be with us today to see his dream of quality, affordable health
care for all become a reality.
Madam Speaker, this is the most important bill I have ever worked on
during my many years of service in Congress.

[[Page H12868]]

I could not be prouder to have helped to write this bill, to
encourage each of my colleagues to support it, and to cast my vote in
favor of the Affordable Health Care for America Act.
We stand at the doorstep of history.
Let us go in.

{time}  1800

Mr. KLINE of Minnesota. Madam Speaker, at this time, I yield 3
minutes to the ranking member of the Health Subcommittee, certainly a
member of the committee, the gentleman from Georgia (Dr. Price).
Mr. PRICE of Georgia. Madam Speaker, health care at its very core is
a compassionate and a moral human endeavor. As a physician, I can tell
you that I never saw a Democrat or a Republican disease. The medical
decisions that each American makes for themselves and for their
families are some of the most important and personal decisions ever
made, and there are principles of health care that we should follow.
Think about those principles of accessibility and affordability and
quality and responsiveness and innovation and choices. Think about
those principles. None of those principles are improved by the further
intervention of the Federal Government, which is why we should adopt
and concentrate on positive, patient-centered health care reform.
It is so very important that principles be in place that will ensure
that patients and their families and their doctors are able to make
those personal medical decisions unencumbered by a stifling and
oppressive Federal Government. But sadly, this bill will not allow
those independent decisions and is wrong in so many ways.
This bill, on page 94, will make it illegal for any American to
obtain health care not approved by Washington. This bill, on page 301,
will force Americans to purchase health coverage that Washington picks,
not that you select for yourselves. This bill, on pages 297 and 313,
places job-killing taxes on virtually every single business. This bill,
on page 211, will force millions of Americans to lose their current
personal private health coverage.
This bills comes with a price tag of $1.3 trillion, which will be
borne by our children and our grandchildren. This bill, on page 520,
slashes billions of dollars from Medicare that will necessitate health
care rationing for seniors. And this bill, on page 733, empowers the
Washington bureaucracy to deny lifesaving patient care if it costs too
much.
This bill is not a health care bill. This bill is an affront on the
morality of the provision of American health care.
As a physician, when patients and their families and their doctors
are not allowed to independently decide what care should be provided,
we lose more than our health care system; we lose our morality and we
lose our freedom.
This bill, whether known or not, is an oppressive affront to every
single American. The positive vote, the bipartisan vote on this bill is
``no.''
Mr. ANDREWS. Madam Speaker, I am pleased to yield to a Member who
understands the immorality of 47 million uninsured. The gentleman from
Michigan (Mr. Kildee) is recognized for 1 minute.
Mr. KILDEE. I thank the gentleman.
Madam Speaker, I rise today in strong support of H.R. 3962, the
Affordable Health Care for America Act.
Choices regarding health care are some of the most personal decisions
we make. The ability to choose one's doctor and decide on a course of
treatment with one's physician is an undeniable American right, and so
is access to quality affordable health care.
Most of us can agree that our current health insurance system is
broken. The cost of health insurance has skyrocketed in recent years,
leaving many families struggling to afford coverage or forcing them to
go without. Others are denied insurance due to preexisting conditions,
saddling them with terrible medical debt when they need treatment.
These treatments, along with other factors, Madam Speaker, have led
to nearly 50 million Americans without any health insurance; 71,000
live in my district.
I urge the passage of this bill.
Lack of adequate health coverage leads many people to wait until an
emergency to seek medical treatment, turning what could have been a
simple doctor's visit into a costly trip to the E.R. What many people
do not realize is that when patients cannot pay their bills, the
American taxpayer is charged for a portion of that cost. Medical
providers also absorb some of the costs, forcing them to raise the
prices of services and thereby increasing costs for everyone and
driving up health insurance premiums. This problem will only get worse
over time, and health care will continue to become more and more
expensive.
The House health insurance reform legislation addresses this issue by
increasing competition between insurers, thereby lowering costs. It
also prevents insurers from denying or dropping coverage due to pre-
existing conditions. By treating conditions earlier at a doctor's
office, instead of at the emergency room, it will save money for the
patient, the taxpayer and the medical providers, ultimately bringing
down health care costs for everyone.
This is an issue that Congress has been tackling since the days of
Harry Truman and even before and I am proud to stand with my colleagues
in passing this long awaited bill.
Mr. KLINE of Minnesota. At this time, I am very pleased to yield 1
minute to the gentlelady from North Carolina, a former member of this
committee and now a member of the Rules Committee, Dr. Foxx.
Ms. FOXX. I thank my colleague from Minnesota.
The people of America are struggling with 70 percent effective
unemployment brought on by actions of this Democratically controlled
government. And what do the Democrats want to do? Give us more
government. They expect us to believe that more government control of
our lives is good. More government control is not good.
We've been successful as a Nation because of our freedom. Taking away
freedom will weaken us as a people and a country. The American people
know that and have told us that. They're opposed to this bill.
Medicare, the kind of treatment they want us to have, denies
treatment more than twice as often as most private insurance. That will
be our future: rationed health care and destruction of freedom.
My colleagues should say no to the Pelosi-Obama freedom-killing, job-
killing H.R. 3962.
Mr. ANDREWS. Madam Speaker, when people were about to be deprived the
freedom to choose a public option, the Progressive Caucus stood up. The
leader of the Progressive Caucus that led that effort will now be our
next speaker.
The gentlewoman from California (Ms. Woolsey) is recognized for 2
minutes.
Ms. WOOLSEY. Thank you to Congressman Rob Andrews, who kept this
clear and made it understandable for every single person in this
country. Thank you, Congressman.
Well, let's put aside all the numbers and fuzzy terminology and let's
talk about what this bill really means to average Americans.
Madam Speaker, I will never forget 40 years ago waking up in the
middle of the night with a start night after night after night because
I did not have health insurance for my three small children, and it was
not anything that had to do with anything that we had caused. I would
wonder what would happen, what if my children got ill or one of them
was injured because of no health insurance? Well, this bill that we're
talking about today, with it, our family would have been secure. We
would have been much healthier because we would have known that we had
health insurance.
So, Madam Speaker, let's take a family of two, two working parents,
two children. With this bill, if one of the children gets sick, the
parents won't have to worry about arguing with the health insurance
company for treatment. If the mother gets breast cancer, the family
won't have to worry that their health insurance company will cancel
their coverage because it doesn't want to pay for her treatment. If one
of the parents loses his or her job, and along with it the family's
health insurance, they will be able to go into the health exchange and
choose between private and public plans. If the family can't afford to
pay the premiums, there will be affordability credits to help them.
That security would have meant a better life for me. It would have
meant a better life for my children that year. We want to make sure
that every child has that security.
Mr. KLINE of Minnesota. At this time, I am very pleased to yield 1

[[Page H12869]]

minute to a very important member of the committee, the gentleman from
Wisconsin (Mr. Petri).
(Mr. PETRI asked and was given permission to revise and extend his
remarks.)
Mr. PETRI. I thank my colleague from Minnesota.
Madam Speaker, unemployment is 10.2 percent, the highest in 26 years,
yet here we are being asked to vote on a bill which will radically
alter and disrupt one-sixth of our economy, hit businesses with costly
new regulations, ratchet up monstrous Medicaid mandates on the 50
States, raise taxes on job creators, impose skyrocketing insurance
premiums on individuals and families, and destroy popular Medicare
Advantage plans, all this while failing to bend the cost curve down and
providing no real liability reform.
At a time of record deficits, this bill spends over $1 trillion to
provide health insurance to less than 15 percent of Americans. To pay
for this budgetary train wreck, it imposes $730 billion in new taxes
and relies on a series of budget gimmicks in a slippery attempt to
claim it won't contribute to our deficit tsunami.
This legislation will bring about a radical intrusion of government
into every sector of health care. It puts bureaucrats between patients
and their doctors. It doesn't make sense, isn't very smart.
Let's not pass this monstrosity.
I certainly agree that it is time to fix the health care system in
the United States so that all Americans have access to quality,
affordable health care. In order to achieve this goal, I strongly
believe that any bill that is approved by Congress must institute
reforms that will address the rising cost of health care.
The majority of Americans have some kind of health insurance they are
generally satisfied with. What they really care about is rising costs.
Spending on health care services already accounts for about 17 percent
of gross domestic product (GDP)--an expected total of about $2.6
trillion in 2009. Health care inflation has outpaced general inflation
by approximately 2.5 percent a year. Government spending on health care
continues to grow exponentially and without action, spending on
Medicare and Medicaid will rise from 4 percent to 19 percent of GDP in
2082.
However, the bill we are considering today takes us in the entirely
wrong direction by instituting reforms that will increase health care
spending while doing little to bend the cost curve. This legislation is
best categorized as an entitlement expansion rather than health care
reform. At a time of record deficits, H.R. 3962 spends $1.055 trillion
to provide health insurance to less than 15 percent of Americans.
Furthermore, almost 15 million of these individuals will receive
insurance coverage by expanding the eligibility of Medicaid. This
results in the largest expansion of Medicaid since its inception almost
forty years ago. In fact, according to the Congressional Budget Office,
the bill will increase the federal budgetary commitment to health care
by $598 billion in the first ten years alone!
To pay for this budgetary train wreck, H.R. 3962 imposes $729.5
billion in new taxes on small businesses, individuals who cannot afford
health insurance, and employers who cannot afford to provide coverage
that meets new insurance standards. In Wisconsin, the ``surtax'' that
provides the largest source of funding for the bill will hit 11,900
small businesses--at a time when unemployment is hovering around nine
percent. Individuals who are dependent on medical equipment such as
wheelchairs and hearing aids will also face increased costs because of
additional taxes in this bill--at a time when many families are
struggling to pay their monthly bills.
Furthermore, H.R. 3962 relies on a series of budget gimmicks to make
it appear that the bill would not increase the federal deficit. First,
the legislation fails to account for this year's projected 21 percent
cut to Medicare physician reimbursements, which if allowed to go
through would severely threaten seniors' access to physicians. However,
preventing this and future cuts will cost over $200 billion. Instead of
making this fix in H.R. 3962 and accounting for its cost, the
Democratic House leadership introduced it as a stand-alone bill without
offsets--despite the fact that the Senate already rejected this
approach. H.R. 3962 also proposes over $400 billion in cuts to
Medicare. However, as many acknowledge, Congress has a history of
reversing itself on unpopular cuts to Medicare, so it is very
questionable as to whether these savings will be realized. The
legislation also authorizes a new long-term care program which is
funded through a voluntary payroll tax. H.R. 3962 uses these pay roll
contributions for other spending priorities in the bill, instead of the
benefits that will eventually have to be paid out under the new
program. Even the Democratic Chairman of the Senate Budget Committee,
Kent Conrad, called the inclusion of this program a ``Ponzi scheme.''
Finally, only 7/10th of a percent of new spending occurs in the first
three years, while most of the tax increases begin at enactment,
representing a debt and ``tax'' time bomb.

Besides increasing taxes and adding to the exploding deficit, this
legislation represents a radical intrusion of government into every
sector of health care. H.R. 3962 gives the government unprecedented
authority over the regulation of health insurance. The top-down
bureaucratic model of mandating extensive cost sharing and coverage
requirements will do very little to ensure high quality care and will
certainly lead to increased costs.
We should be doing the exact opposite and giving consumers, rather
than government bureaucrats or insurance companies, more responsibility
for decisions regarding their health care. This bill does nothing to
incentivize consumer driven health plans which encourage individuals to
take care of themselves, save for future medical expenses and
comparison shop to find the best health care at the most reasonable
cost. Most importantly, consumer driven plans put into motion the
incentive structure throughout the health care delivery system that
will slow the rising cost of health care.
In fact, many of the reforms and new mandates in H.R. 3962 will
actually raise the cost of health insurance for those that are now
covered. Multiple studies have demonstrated that younger and healthier
Americans could see their health care premiums triple, and a family of
four could see its health care premiums more than double. While H.R.
3962 mandates that all citizens purchase ``acceptable coverage,'' in
reality many young and healthy individuals may find it more economical
to forego coverage and pay the penalty which is less expensive than the
cost of buying health insurance. Should younger and healthy people
forego coverage, premiums for everyone else will increase. In fact,
because of the bill's ban on insurance companies discriminating against
pre-existing conditions, younger healthier people will have even more
of an incentive to wait until they are sick to purchase health
insurance.
The legislation also breaks the President's promise that if you like
your health insurance you will be able to keep it. The legislation
makes significant cuts to Medicare Advantage Plans which will surely
eliminate or reduce benefits to the 216,000 beneficiaries in Wisconsin.
Furthermore, the legislation places an 8 percent tax on businesses
that don't offer acceptable coverage, as defined by federal
bureaucrats. According to the Galen Institute, a non-profit think tank,
``data from a 2009 Kaiser Family Foundation survey suggest that at
least 30 percent of firms with fewer than 200 employees that now offer
insurance would fail the test for family coverage, and about 20 percent
would fail individual coverage.'' However, instead of complying with
the new mandates, many employers will likely stop offering health
insurance to their employees because the 8 percent payroll tax penalty
is less than the cost to provide coverage. Furthermore, the extensive
new federal record keeping and audit requirements provide further
incentives to stop offering coverage. In fact, a study by Blue Cross
and Blue Shield demonstrated that ``complying with the new actuarial
standards in the bill would increase average costs by 17 percent for
individuals and almost 10 percent for small employers.''

Over 80 percent of the money spent on health care in the United
States today is spent on the delivery of health care. Yet, what we see
in today's bill is just ``more of the same'' in the delivery of care
instead of making fundamental changes to reward high quality, low cost
care. The bill authorizes hundreds of Medicare pilot programs to test
different ways to pay doctors and hospitals for quality of care. But
once again, these pilots are governed from the top-down and typically
take years to initiate and rarely result in reforms applied throughout
the system. Instead, we should be supporting efforts that are coming
out of both the states and multi-collaborative projects between
networks of hospitals, businesses and physicians. Wisconsin hospitals
such as ThedaCare, Marshfield Clinic, Gunderson Lutheran, and Aurora
Health Care have long been engaged in transforming the delivery of care
to get rid of the inefficiencies and provide low cost, high quality
care. We should be supporting these reforms from the bottom-up, instead
of repeating the work that has already been done.
And finally, I have grave concerns that the legislation will allow
for government funding of abortions and threaten current conscience
protections for health care providers. I strongly believe that the Hyde
Amendment should be codified in this legislation.
Today, I will vote in support of Congressman Boehner's substitute
amendment which is a good step forward in lowering health care premiums
for families and small businesses,

[[Page H12870]]

increasing access to affordable high quality care, and promoting
healthier life styles--without adding to the deficit.

Announcement by the Speaker Pro Tempore

The SPEAKER pro tempore. Members are reminded to heed the gavel.
Mr. ANDREWS. Madam Speaker, I yield myself 30 seconds before the next
introduction.
There is a credibility issue here. The minority says the bill doesn't
have enough prevention, but the American Cancer Society supports the
bill. The minority says it destroys the doctor-patient relationship,
but the American Medical Association supports the bill. The minority
says it's bad for America's seniors and for Medicare, but the AARP
supports the bill. I think there is a credibility issue, and it doesn't
work for the minority.
At this time, I would be happy to yield 1\1/4\ minutes to the
gentleman from Pennsylvania (Mr. Sestak).
Mr. SESTAK. Madam Speaker, a little shy of 3 years ago, I came to
this Congress to pay back a debt. After three decades in the U.S.
military, my young 4-year-old was struck with the same brain tumor
Senator Ed Kennedy had. Because of the wonderful health care plan that
this Congress provides our families in the military, she was given a
chance.
I was taken in the U.S. military by how and why we do that. It's not
because we're generous. It's because we reap great dividends for this
Nation. This Congress sent me off for 11\1/2\ months to a war, and
while I was gone, my daughter and my wife were taken care of and my
mind was on the mission. In the military, we reap the benefit of
healthy, focused warriors.
I am taken with this bill. It gives us healthy, productive workers.
It actually combines, in my mind, the best of America's character--
rugged individualism allied with the common enterprise of this Nation.
It gives us the quality of life that in the military reaps such great
dividends. This bill, to me, is no different, and it's time.
Mr. KLINE of Minnesota. Madam Speaker, at this time, I yield 2
minutes to the ranking member of the Armed Services Committee and the
former ranking member of the Education and Labor Committee, the
gentleman from California (Mr. McKeon).
Mr. McKEON. Madam Speaker, I thank the ranking member for yielding.
It's been said that Abraham Lincoln said, ``You cannot bring about
prosperity by discouraging thrift. You cannot strengthen the weak by
weakening the strong. You cannot help the wage earner by pulling down
the wage payer. You cannot further the brotherhood of man by
encouraging class hatred. You cannot help the poor by destroying the
rich. You cannot keep out of trouble by spending more than you earn.
You cannot build character and courage by taking away man's initiative
and independence. You cannot help men permanently by doing for them
what they could and should do for themselves.'' Madam Speaker, what
we're doing here violates all of these principles that Abraham Lincoln
spoke so eloquently about.
I rise today in strong opposition to this Pelosi bill of over 2,000
pages. At a time when we are suffering the highest unemployment in this
country since 1983, the American people can't afford these massive new
spending increases, and I refuse to pass this great burden on to my
children and grandchildren.
I offered two amendments to try to improve this bill: one to require
Members of Congress to enroll in the public option like we're going to
require all of you to do, and one that said that illegal immigrants
would not receive new benefits under this new bill; commonsense
provisions that were voted down by the Democrats in the Rules
Committee. In fact, Democrats voted down every single Republican
amendment but one. How is that for bipartisanship?
This legislation increases taxes, kills jobs, and costs over $1
trillion in money we don't have. The Republican plan will cut costs
through tort reform, negotiating across State lines, and through
purchasing power.
Support the Republican alternative and oppose the Pelosi plan. This
is an absolute disaster.

{time}  1815

Mr. ANDREWS. Madam Speaker, before I yield to my next speaker, I
yield myself 30 seconds.
With all due respect, what is an absolute disaster are the repeated
misrepresentations of certain things that are in this bill, and we just
heard one. No one is forced to join the public option. No one. It is
not in the bill; and I would, frankly, invite the minority to show us
where it is.
Secondly, Members of Congress are positioned exactly the way everyone
else is with the public option. When and if the time comes that the
Federal Government is a participating employer in the exchange, we can
either choose the public option or not. The House deserves an accurate
record.
I yield 1\1/2\ minutes to a woman who stood for fiscal soundness not
only here in Washington but in New Hampshire for her State budget, the
gentlewoman from New Hampshire, Carol Shea-Porter.
Ms. SHEA-PORTER. Madam Speaker, I rise today to support the
Affordable Health Care for America Act. This is a historic moment for
our Nation.
In my district, this bill will provide coverage for 37,000 uninsured
residents; 128,000 households will qualify for credits to help them
afford the coverage of their choice. We will invest more in community
health centers. We make Medicare stronger, which is why AARP has
endorsed this bill. We start to close the Medicare part D doughnut hole
in 2010, and it will be completely closed by 2019. We will provide a 50
percent discount for name-brand drugs for those in the doughnut hole,
and we eliminate copayments for preventative care.
Today, we make history for our seniors, for our children, for the
middle class--for all Americans. Today, we vote for an America where
discrimination based on preexisting conditions is a thing of the past.
Today, we vote for an America where getting sick doesn't mean losing
your home. Today, after decades of debate, we finally vote for a
healthier America.
Mr. KLINE of Minnesota. Madam Speaker, before I yield to the
gentlewoman from Washington, I yield for a unanimous consent request to
the gentleman from Kentucky (Mr. Rogers).
(Mr. ROGERS of Kentucky asked and was given permission to revise and
extend his remarks.)
Mr. ROGERS of Kentucky. Madam Speaker, I rise in opposition to this
freedom-taking bill.
We can all agree that health care costs are too high and that we need
to open up access for more Americans. That being said, we need to pass
a bill that actually cuts costs and increases access rather than a
government-run takeover of health care. I cannot support Speaker
Pelosi's monstrosity of a bill because it puts a Washington bureaucrat
between individuals and their doctor, it adds to our enormous debt in
Washington, and, even more frightening, it will limit health care
availability in rural regions like southern and eastern Kentucky.
In these challenging economic times, with double digit unemployment,
out of control government spending sprees, and bailout after bailout,
we should not pass a bill that will kill jobs and raise taxes. Speaker
Pelosi's government-run health care bill not only imposes new penalties
and taxes on small businesses, it raises taxes on already struggling
individuals and families. Whether someone wants health insurance or
not, they'll be forced to purchase it, and the federal government will
garnish wages or send them to jail if they don't comply. Even more
troubling, the more vulnerable and ailing one is, the more they'll pay,
as this bill imposes new taxes on critical medical supplies, like
wheelchairs, oxygen tanks, hospital beds, and prosthetic limbs. As if
that wasn't enough, the bill opens the floodgates of taxpayer money for
illegal immigrants to abuse the system and obtain free government
health insurance--all on the backs of law-abiding Americans. Lastly, I
am scared for our seniors as this bill makes devastating cuts to the
Medicare program to the tune of $500 billion, and puts the popular
Medicare Advantage program on life support, virtually eliminating its
existence.
I support the Republican alternative health care bill that focuses on
lowering health care premiums for families and small businesses,
increases access to affordable high-quality health care, and promotes
healthier lifestyles without adding to Washington's crushing debt. The
plan I support guarantees access to affordable care for those with pre-
existing conditions, ends junk lawsuits against our doctors, allows
small businesses to band together to purchase insurance for their
employees and allows individuals to shop for insurance across state
lines. Simple and less costly initiatives such as these will lower
insurance premiums by at least 10 percent, and provide health insurance
to millions more Americans.

[[Page H12871]]

This bill reflects a fundamental and drastic change in our way of
life, and is the largest government intrusion into the private lives of
our citizens ever. I, for one, am truly frightened by the potential
consequences.
Mr. KLINE of Minnesota. I am now pleased, Madam Speaker, to yield 2
minutes to a member of the committee, the ranking member on a
subcommittee, the gentlewoman from Washington, Cathy McMorris Rodgers.
Mrs. McMORRIS RODGERS. I thank the gentleman for yielding.
Madam Speaker, we just need to slow down. The American public has
made it clear that they want the right health care reform bill enacted,
not just any bill.
Look at the stimulus bill that was rushed through Congress. Look at
what has happened. They said, Oh, unemployment won't go over 8 percent.
We are now at 10.2 percent. We have lost 3 million jobs, and we have a
$1.4 trillion deficit.
Like my mom used to say, You rush, you make mistakes.
This health care reform bill will be no different. It spends $1.3
trillion. It taxes employers $750 billion, many of whom are small
business owners, at the very time that we need these small business
owners to be creating jobs. We need jobs. Isn't it interesting that
even the administration's own economic adviser has estimated that this
bill will cost America an additional 5.5 million jobs.
Other reforms in the bill all but eliminate Medicare Advantage,
hurting 20,000 seniors in eastern Washington and millions across the
country. For rural communities, the bill calls on the Institute of
Medicine to study payment disparities in rural regions. So we are
spending $1.5 trillion, and the only relief we get is another study? My
list of concerns goes on and on.
The Republicans have a better way, one that lowers premiums for
families by as much as 10 percent; one that saves billions in medical
liability reform, allowing people to purchase health insurance across
State lines; one that continues the continuity and coverage; and it's a
solution that doesn't indebt our children and our grandchildren.
Madam Speaker, just this week, thousands of people stood on the
Capitol steps. They called on Congress to oppose this legislation. I
urge us to heed their warning. Vote ``no.'' Let's slow down the
process, and let's get the right kind of reform, not just any kind of
reform.
Mr. ANDREWS. Madam Speaker, I yield myself 15 seconds.
The gentlewoman just quoted an unnamed phantom Obama administration
adviser. Christina Romer, the CEA chairperson for the Obama
administration, says this bill will increase the GDP between 1-2
percent and will add several million jobs.
I am pleased to yield 1\1/2\ minutes to a strong voice for working
families in this country, the gentleman from Illinois (Mr. Hare).
Mr. HARE. Thank you, Congressman Andrews.
Madam Speaker, when I was growing up as a young boy, my parents lost
their home. My father was ill. He couldn't make the payments. I
remember coming home the day of my older sister's wedding to see a
process server with a notice to evict and 30 days to leave.
Two days before my father died, I sat by his bed, and he told me,
There are two promises I want you to make to me: take care of the girls
and your mother, and no matter what you do, please see that this will
not happen to another family.
Tonight, in a few hours, I will have the opportunity to keep that
promise to my dad and to the tens of thousands of other people who have
lost their homes and everything they had simply because they were sick.
All the fear-mongering. All the misstatements of facts and figures.
Health care in this country, my friends and fellow citizens, is a
right. It is not a privilege.
So, tonight, for my father and for the people who came after him, I
will stand proud for this bill no matter the amount of shouting, of
tearing this down and of calling the bill whatever you want to call it.
I call it getting people exactly what this country promises them: life,
liberty, and the pursuit of happiness.
Mr. KLINE of Minnesota. Madam Speaker, I am pleased to yield 1 minute
to a member of the committee, the gentleman from Michigan (Mr.
Hoekstra).
Mr. HOEKSTRA. I thank my colleague for yielding.
Madam Speaker, today, I met Theresa. Theresa had a sign that read: I
love my country. On the other side, it read: My future. Her brother,
Xavier, had a sign that read: Give me liberty, not debt.
If we pass Pelosi health care tonight, tomorrow morning, we will
still all love our country; but we will have jeopardized Theresa's
future. A bailout, a stimulus, cap-and-trade, and Pelosi health care
have jeopardized her future. For Xavier, we will have given him debt:
another $1.2 trillion on top of the $1.4 trillion we gave him last
year.
I will vote ``no'' because I believe that that's the vote that says:
I love my country. I will vote ``no'' because I believe that that is
the vote that preserves our future. I will vote ``no'' because I know
that that will preserve Xavier's liberty and not give him more debt.
With that, I urge my colleagues to vote ``no'' on this bill.
Mr. ANDREWS. Madam Speaker, I am pleased to yield 1\1/2\ minutes to a
member who fought tirelessly for equality in Medicare reimbursement for
the State of Iowa, the gentleman from Iowa (Mr. Loebsack).
Mr. LOEBSACK. Thank you, Mr. Andrews.
Madam Speaker, I am proud to be a part of this effort to improve
health care in America, and I will support the bill before us because I
have heard from countless Iowans about the desperate need to change the
current system, and I believe this legislation before us today will
provide true and comprehensive reform.
However, since coming to Congress, I have told just about everyone I
could and everyone who would listen to me that comprehensive reform
could not be achieved without addressing geographic disparities in the
Medicare payment system. Many other Members agreed, and we formed the
Quality Care Coalition, and we brought about that change.
There is much needed language in this bill to fix a broken Medicare
payment system. By focusing now on the quality of services provided to
patients instead of the quantity of services, this provision will
provide a significant cost savings to Medicare, and it will benefit
patients in Iowa and all across America.
In particular, I want to thank my leadership; my chairman on the
committee, George Miller; my friend Rob Andrews; Chairman Waxman; and
Chairman Rangel for their work on this issue.
I urge everyone to vote for this bill before us.
Mr. KLINE of Minnesota. Madam Speaker, I yield 1 minute to a member
of the committee, the gentleman from South Carolina (Mr. Wilson).
Mr. WILSON of South Carolina. Madam Speaker, America's leading voice
for small business, the National Federation of Independent Business,
the NFIB, opposes H.R. 3962, the Pelosi takeover bill. The NFIB has
sounded the alarm about the employer mandate, payroll tax penalty and
unnecessary paperwork mandate crippling small businesses.
The opposition letter from the NFIB warns that the Pelosi takeover
includes multiple mandates. Economic research shows mandates are
ultimately borne by the worker through job loss and lower wages. The
NFIB also warns how the payroll tax penalty is a tax on jobs and job
creation. Additionally, the unnecessary paperwork mandate will place a
new paperwork burden on all small businesses at a time when they are
struggling to stay afloat. The NFIB has estimated the takeover effort
will kill 1.6 million jobs at a time of record unemployment.
We should support health insurance reform, not a government takeover.

November 5, 2009.

Letter to House Opposing H.R. 3962

Dear Representative: On behalf of the National Federation
of Independent Business (NFIB), the nation's leading small
business advocacy group, I am writing in opposition to the
Affordable Health Care for America Act (H.R. 3962). The
Affordable Health Care for America Act does not reflect the
access or affordability needs of NFIB's small businesses, and
a vote against H.R. 3962 will be considered an NFIB Key Vote
for the 111th Congress.

[[Page H12872]]

NFIB has been a constructive participant in the healthcare
debate and has spent more than a decade voicing our need for
reform. With healthcare costs ranking as the No. 1 issue
facing small business, our employers must carefully weigh the
potential benefits of reform against the new costs imposed on
business owners in the legislation. NFIB members have
identified specific areas in H.R. 3962 that will raise those
costs:
Employer Mandate: H.R. 3962 includes an employer mandate
that will require employers to pay for healthcare for full-
time and part-time employees. An employer mandate does not
address the No. 1 issue facing small businesses:
unsustainable costs. This mandate affects those who do not
offer coverage today as well as those who already do provide
insurance, but aren't making contributions at contribution
levels outlined in the bill (72.5% for individual plans and
65% for family plans). Rather than help, this will penalize
employers already offering healthcare and force them to make
hard choices about how to afford the new government
requirements. Economic research has shown time and again that
mandates such as these are a ``one-two punch'' where the cost
is first borne by the employer, but is ultimately borne by
the employee--through job loss and lower wages.
Payroll Tax Penalty: A payroll tax penalty is a tax on jobs
and job creation because they tax labor. The legislation
requires that all employers with a payroll of $500,000 or
more pay a payroll tax of up to 8 percent if they do not
provide ``qualified'' health insurance to their employees. No
matter how profitable or unprofitable a business might be,
they are forced to pay this tax. In addition, because the
exemption thresholds in H.R. 3962 are not indexed for
inflation, the exemption will become a healthcare equivalent
of the alternative minimum tax, hitting more and more
employers until there is no one exempted at all.
Paperwork Mandate: H.R. 3962 places a new tax-compliance
paperwork burden on all small businesses. The ``corporate
reporting'' provision is an expansion on reporting
requirements (for transactions of more than $600), which
increases the cost of operating a small business and diverts
resources away from growing and creating jobs.
Big Benefit Package and More Mandates: Small employers need
a guarantee that plans offered in an exchange will be less
costly, not more expensive, than what they are paying today.
Today, small businesses pay an average of 18 percent more for
their healthcare, leaving them continuously searching for
more affordable choices.
H.R. 3962 gives a political board the power to define
``coverage'' and will determine whether an employer plan is
``acceptable.'' However, the bill does nothing to ensure that
the new plans will be less costly than what small employers
are paying today. In some cases, the legislation will also
require some small employers to cover benefits that are not
currently mandated under federal law.
Takes Away Small Business Solutions: Small employers need
more, not fewer, affordable health insurance options.
However, the prohibition of HSA, FSA and MSA funds to
purchase over-the-counter medications, along with the $2,500
limit on FSA contributions, threatens to further limit the
ever-shrinking options employers have to provide meaningful
healthcare to their employees.
Public Option: A government-run plan cannot compete fairly
with the private market, and threatens to destroy the
marketplace, further limiting choices. We believe that with
proper reforms the private market can be held accountable to
provide greater competition and lower-cost solutions where
insurers compete based on their ability to manage, rather
than shed risk. Instead, the excessively prescriptive
insurance reforms in H.R. 3962 will drive up costs.
Surtax: Seventy-five (75) percent of small businesses are
structured as pass through entities and pay their business
taxes at the individual level. More than one-third of small
businesses employing 20 to 250 employees could face the tax.
Finally, since the tax is not indexed for inflation, the
effect of the tax will creep downward, making more and more
businesses vulnerable to a tax increase.
Poorly-Structured Tax Credit: There are two reasons the
credit in H.R. 3962 is of limited value. First, the
availability of the credit is too short. A credit that is
only available for two years means that every small business
owner that claims the credit will see a large spike in their
out-of-pocket costs for health care in year three. Second,
the wage limits are too restrictive. Phasing the credit out
based on average wages of $20,000 or less severely reduces
the amount of a tax credit available for most small
businesses.
NFIB will continue to advocate for reform because, as both
democratic and republican lawmakers have said, the status quo
is not acceptable. Our small business owners agree, but
reform must make the problem better, not worse. Because H.R.
3962 will not lower healthcare costs and threatens our
economic recovery, NFIB will consider a NO vote a vote in
support of small business. This will be an NFIB KEY VOTE FOR
THE 111TH CONGRESS.
Sincerely,

Susan Eckerly,

Senior Vice President,
Federal Public Policy.

Mr. ANDREWS. Madam Speaker, I yield 2 minutes to a gentlewoman who
authored a provision to expand small business opportunities for
affordable health insurance, the gentlewoman from Nevada (Ms. Titus).
Ms. TITUS. Thank you, Mr. Andrews.
Madam Speaker, for more than 6 months, I've discussed the need for
health care reform with my constituents; and time and again I've heard
from small business owners who are struggling to afford health care
coverage.
Over the last decade, the average health insurance premium has more
than doubled for Nevada's small businesses. Without comprehensive
reform, Nevada's small business health premiums are projected to again
double over the next decade. In this year alone, small businesses
across the country are being hit with a 15 percent average increase in
premiums. It is clear that the status quo is unacceptable and
unsustainable.
I had concerns about earlier versions of this bill, but I am pleased
that H.R. 3962 before us today is significantly improved and takes
important steps to help make health insurance more affordable.
I worked to raise the income level at which people are assessed a
health care surcharge. The new threshold is significantly higher, up
from $350,000 for couples to $1 million. This means that 98.8 percent
of all small businesses will be exempt from paying any surcharge.
The bill also now exempts small businesses with payrolls below
$500,000 from the employer mandate. That means that 86 percent of all
employers are exempt, and many small businesses which choose to offer
insurance to their employees will be eligible for a tax credit to help
offset those costs.
I am especially proud that the provision I championed, which was to
expand the health insurance exchange so that more businesses could
participate, was included and strengthened in this bill. This will
ensure that small businesses have additional options for purchasing
health insurance at a lower cost.
All of these improvements combined will strengthen small businesses
so they will be critical engines of growth in our communities. It is
time small businesses knew who really stood up for them and cared about
them and their employees.
I urge my colleagues to support this bill and to stand up for small
business.
Mr. KLINE of Minnesota. Madam Speaker, I yield 1 minute to a member
of the committee, the gentlewoman from Illinois (Mrs. Biggert).
Mrs. BIGGERT. I thank the gentleman for yielding.
Madam Speaker, I rise in strong opposition to this $1.3 trillion
government takeover of health care.
Time and again, the President promised the American people that, if
they like the health insurance they have, they can keep it. So I
introduced an amendment in the Education Committee that said what he
said: if you like the health insurance you have, you can keep it.
The Democrats defeated this amendment with a unanimous vote.
This bill does not keep the President's promise. Instead, it would
allow a group of unelected government bureaucrats to determine if the
health insurance you have is up to government standards. If they say
it's not and if you don't buy what they say you should buy, you will be
fined. If you don't pay the fine, it's jail time.
I urge my colleagues to defeat the bill and to, instead, vote for the
GOP alternative. Not only does it expand access to those who lack it
and not only does it lower costs for everyone, but it cuts the deficit,
preserves the doctor-patient relationship, and ensures that you can
keep the coverage you have.

{time}  1830

Mr. ANDREWS. Madam Speaker, a number of great and visionary men have
stood at the podium where you stand now as Speaker of the House. Many
of them tried to achieve significant health care reform; each of them
failed. A lot of strong visionary men failed, so we will succeed with a
strong, visionary woman.
It is my privilege to yield 1 minute to the Speaker of the House of
Representatives, Congresswoman Nancy Pelosi.
Ms. PELOSI. I thank the gentleman for yielding, for his kind remarks
and for his tremendous leadership on bringing this legislation to the
floor. Thank you, Congressman Rob Andrews.

[[Page H12873]]

Madam Speaker, today as we all know is an historic moment for our
Nation and for America's families. For nearly a century, leaders of
every party and political philosophy have, as far back as Teddy
Roosevelt, called for health care for the American people.
For generations, the American people have called for affordable,
quality health care for their families. Today, the call will be
answered. Today, we will pass the Affordable Health Care for America
Act.
This legislation is founded on key principles for a healthier
America: innovation, competition and prevention. It improves quality,
lowers cost, expands coverage to 36 million more people, and retains
choices.
Our innovation began in the recovery package in January with $19
billion for health IT, the first step in lowering cost and improving
quality, and $8 billion in investments for biomedical research. This
legislation will mean affordability for the middle class, security for
our seniors and honors our responsibility to our children, adding not
one dime to the deficit.
For all Americans, this legislation makes a big difference: no
discrimination for preexisting medical conditions; no dropped coverage
if you are sick; no copays for preventive care. There is a cap on what
you pay in, but there is no cap on the benefit that you receive.
It works for seniors, closing the doughnut hole, offering better
primary care and strengthening Medicare for years to come. It works for
women, preventing insurance companies from charging women more than men
for the same coverage. No longer will being a woman be a preexisting
medical condition.
It works for young people, offers affordable choices and copays for
preventive care to stop problems before they start, and allows young
people to stay on their parents' insurance until their 27th birthday.
It works for small business owners, providing access to affordable
group rates and creating a tax credit to help them insure their
employees. It works for consumers, keeping insurance companies honest
and encouraging competition with a public option.
This legislation puts you and your doctor in charge. No longer will
the insurance companies come between you and your doctor.
President Obama has said that health care reform is entitlement
reform, and this legislation proves that point. It is fiscally sound,
it is paid for, and it reduces the deficit by tens of billions of
dollars over the next 10 years.
This legislation is the result of extensive deliberation here in the
Congress, where we have held more than 100 hearings and is the product
of extensive input from the American people. Members of Congress have
held over 3,000 town meetings. It has resulted in a better bill than
H.R. 3200. However good or excellent that was, this bill is a better
one with significant differences, and my colleagues have pointed them
out, as did Congresswoman Dina Titus, who just spoke before me at the
podium.
We are brought to this historic moment in our Nation for our families
because of the work of our chairmen: Chairman Henry Waxman of the
Energy and Commerce Committee, Chairman Charlie Rangel of the Ways and
Means Committee, Chairman George Miller of the Education and Labor
Committee, and Chairwoman Louise Slaughter of the Rules Committee. I
thank all of those committees, including the Rules Committee, for being
in so late so that we could have this legislation on the floor today
and for their ongoing service to the Congress.
More than 300 groups representing tens of millions of Americans have
expressed their support for the bill: the AARP, American Medical
Association, the American Nurses Association; the list of medical
groups goes on and on. The American Cancer Society Cancer Action
Network, American Heart Association, American Diabetes Association. And
I am particularly proud the Consumers Union has endorsed the
legislation. My colleagues, this morning we were part of history, and
we are this evening as well.
But a particularly poignant moment occurred when Chairman Dingell
took the Chair to preside over the debate, the beginning of the debate
for health care. When he was a young man as a Member of Congress, he
gaveled Medicare into law. It had been, as one of our colleagues said,
in his DNA, this pursuit of health care for all Americans. His father
had introduced the bill over and over again when he was in Congress
and, as his successor, he continued that great legacy. Today he will
see a lifelong dream of generations in his family come true as we begin
the process of making this a reality.
It's impossible to talk about health care reform in America without
talking about Senator Edward Kennedy. His leadership and his
contribution to this debate is boundless. Health insurance reform was
the cause of his life. He called it ``the great unfinished business of
our society.'' On this issue he said what is at stake ``is the
character of our country.'' When the President came to address the
joint session, he quoted those comments by Senator Kennedy from a
letter that the Senator had sent to him. What the Senator also said in
the letter that was sent to President Obama before he died was this:
``I entered public life with a young President who inspired a
generation and the world. It gives me great hope that as I leave,
another young President inspires another generation and, once more on
America's behalf, inspires the entire world.''
He acknowledged President Obama's ``unwavering commitment and
understanding that health care is a decisive issue for our future
prosperity.''
President Obama's leadership gives our Nation hope. Today, with this
legislation, we will give them health. President Obama has said, ``We
will measure our success in the progress that is made by America's
working families.''
Today, with the passage of the Affordable Health Care for America
Act, we will make history. We will also make progress for America's
working families.
I urge my colleagues to support this important legislation.
Mr. KLINE of Minnesota. Madam Speaker, at this time I am pleased to
yield 1 minute to someone who tells me that he is, in fact, very proud
he doesn't have a section in this bill, a member of the committee, the
gentleman from Indiana (Mr. Souder).
Mr. SOUDER. This is indeed a historic day. It's a crossroads in
America. What you just heard from our distinguished Speaker was we, the
government, will do this. We, the government, will do that. We, the
government, will do this. We, the government, will do that. Instead of
having the private sector do this, instead of having competition,
instead of having capitalism do this, we, the government, will fix
everything. We, the government, will provide everything.
We are in an economic crisis in this country. Just yesterday, for the
first time, an over 10 percent unemployment. In my eight counties, over
half are over 15 percent unemployment.
So what are we doing today? Taxing small business, the number one
producer of jobs, adding regulations to those businesses, adding
expenses to those businesses, taxing medical technology, which will
reduce R&D, reduce jobs, reduce quality of health care.
What are we doing today? We are not going to require identification
for illegal immigrants. We are going to hope that they self-report.
With 1,990 pages of ignoring the voices of American people, you get
higher taxes, fewer jobs, an unconstitutional takeover of 17 percent of
our economy, a trillion dollars of debt, and free health care for the
illegals who took your jobs.
Mr. ANDREWS. Madam Speaker, I am pleased to yield 2 minutes to the
gentleman who made sure that the ban on discrimination based on
preexisting conditions will take effect as soon as this bill does, the
gentleman from Connecticut (Mr. Courtney).
Mr. COURTNEY. Madam Speaker, 45 percent of Americans suffer from some
form of chronic disease, leaving them exposed to preexisting condition
discrimination. The Commonwealth Fund found that 12.6 million non-
elderly adults were, in fact, discriminated against by insurance
companies because of preexisting conditions in the last 3 years.
This health care reform bill will abolish the barbaric discriminatory
practice of denying insurance and charging more for insurance to
Americans based on medical underwriting. Like Jim Crow laws, like
separate but equal laws, like laws denying women

[[Page H12874]]

the right to vote or own property, the practice of denying coverage
because of a person's internal biology, high blood pressure, diabetes
or cancer will be forever abolished.
Section 211 of this bill ends this practice permanently in 2013; and
section 106, which I wrote with Mr. Andrews' help, immediately provides
relief by amending existing law to shorten the look-back period for
group health plans from 6 months to 30 days and reduces the exclusion
of coverage for preexisting conditions from 18 months to 90 days.
This balanced, well-thought-out reform of the Health Insurance
Portability and Accountability Act of 1996 will provide tangible, real
change for Americans terrified of losing their coverage because of a
layoff or a job change.
What does the Republican plan do? Does it adopt section 106 or 211?
No. On page 145 of the Republican bill, they call for--are you ready--a
GAO study of the issue of preexisting conditions. The time for delay
and dilatory studies is over. It is time to act.
As U.S. President Abraham Lincoln once said, it is time to make a
more perfect union, and pass the Affordable Health Care for America
Act.
Mr. KLINE of Minnesota. Mr. Speaker, at this time I yield 1\1/2\
minutes to a distinguished member of the committee, the gentleman from
Delaware (Mr. Castle).
Mr. CASTLE. Mr. Speaker, I rise in opposition to the legislation but
in strong belief that the vast majority of us in Congress are committed
to reducing the skyrocketing costs of health care today and expanding
access to insurance coverage for those in need.
Additionally, I am certain that if we focused on the on the many
shared bipartisan goals, we could pass a health reform package that
took commonsense steps without making financial commitments that this
country is unable to afford. Such items include insurance market
reforms such as preventing denial of care for preexisting conditions,
purchasing insurance across State lines, encouraging regional exchanges
between States and portability, small business pooling and tax credits,
negotiating drug prices, eliminating the $60 billion in Medicare fraud
each year, rewarding efforts to prevent common disease and illness,
enrolling those who qualify into existing programs like Medicaid and
SCHIP, tax benefits for needy individuals for help purchasing
insurance, and limiting abusive lawsuits.
Instead, we are confronted with a bill that overreaches by creating
new government programs costing over $1 trillion paid for from tax
increases and cuts to Medicare which are more gimmicks than real
entitlement reform. Independent analysis of H.R. 3962 continues to show
that reforms will result in higher costs for too many patients in
addition to increasing the Federal debt which continues to rise
dramatically under this Democratic administration and Congress.
Universal health care will not happen overnight. An incremental
approach that expands access to health care coverage, contains costs
and limits government involvement should be at the forefront of lasting
and meaningful program. The process to date has been driven by
politics. It is not too late to enact policies that enjoy broad
bipartisan support.
Mr. ANDREWS. Mr. Speaker, our next speaker fought hard to make sure
the vast majority of entrepreneurs in small businesses were exempt from
any taxes under this bill. I am pleased to yield 1 minute to the
gentleman from Colorado (Mr. Polis).

{time}  1845

Mr. POLIS. Mr. Speaker, I would like to thank Mr. Andrews, the
committee staff, and Chairman Miller for their hard work on this bill.
Where are we today? Our country spends more and gets less from health
care. We spend more and get less. Many small businesses and individuals
are unable to afford insurance. Americans are fed up with 15 to 20
percent increases in costs every year, and that is for those of us
lucky enough to have insurance. People with preexisting conditions
often can't get coverage, or the very condition they need coverage for
is excluded.
Where does this bill take us? It encourages competition among
insurance companies, giving us more choices and more stability so we
can choose from hundreds of different policies, including shopping
across State lines.
It covers most of the uninsured by empowering them to choose the
provider of their choice. It prevents pricing discrimination based on
preexisting conditions. It allows small businesses to have the same
purchasing power as large corporations and saves them money. It reforms
our legal system to reduce the cost of frivolous lawsuits. It supports
doctor and nurse training, reduces the deficit by over $10 billion, and
applies free market principles to establish a playing field for health
care that is good for practitioners and consumers.
I encourage my colleagues to support health care.
Mr. KLINE of Minnesota. Mr. Speaker, I yield 1 minute to a member of
the committee and the ranking member of the subcommittee, the gentleman
from Kentucky (Mr. Guthrie).
Mr. GUTHRIE. Mr. Speaker, I have heard from many of my constituents
who are worried and anxious about Speaker Pelosi's health care bill.
Speaker Pelosi's bill spends $1.2 trillion, cuts Medicare benefits,
includes a $34 billion unfunded Medicaid mandate and increases premiums
for those already struggling to pay for health insurance. On top of all
of that, the bill raises taxes for just about everyone. The bill taxes
individuals who choose not to purchase health insurance, taxes small
businesses, taxes medical devices, and taxes health savings plans. The
bill is the exact opposite of what the American people said they
wanted.
The Republican alternative addresses Americans' number one priority
for health care reform: lowering the cost for premiums they pay now.
The Congressional Budget Office has confirmed that our plan will lower
health care premiums and reduce the deficit without taxing families and
small businesses.
I am voting ``no'' on Speaker Pelosi's bill because of the
devastating consequences it will have on Kentucky's families, seniors,
and small businesses.
Mr. ANDREWS. Mr. Speaker, I am pleased to yield 1 minute to a
gentleman who has led the fight to help small businesses in this bill,
the gentleman from New York (Mr. Bishop).
Mr. BISHOP of New York. Mr. Speaker, we all know that our fiscal
future presents enormous challenges. The skyrocketing costs of our
health care system puts constraints on our Federal budget, on our
family budgets, and it prevents necessary investments in our future and
the future of our children.
The key to fiscal stability is entitlement reform. The key to
entitlement reform is health care reform, and the first step in health
care reform is the legislation before us. With nearly one-fifth of our
national spending going towards health care, reducing the rate of
increases in health care costs is an absolute necessity.
Let's be honest with our constituents. Reducing corporate welfare and
promoting efficiencies in Medicare spending is not equivalent to
cutting benefits or covering fewer services. Rather, the Affordable
Health Care for America Act is a thoughtful approach to ensuring
Medicare works better for seniors and for those who provide care.
Most importantly, the Affordable Health Care for America Act promotes
stability and peace of mind for the family who just learned their child
has diabetes or the husband whose wife has just been diagnosed with
breast cancer. No longer will such devastating news be followed by the
fear of impending bankruptcy.
Vote ``yes'' on H.R. 3962.
Mr. KLINE of Minnesota. Mr. Speaker, I yield 1 minute to the
gentlewoman from Kansas (Ms. Jenkins).
Ms. JENKINS. Mr. Speaker, the health care system in America needs
reform, but the Pelosi plan is the wrong prescription. Unlike the
Republican plan, this bill does nothing to reduce health care costs.
While there are many reasons I am opposed to this bill, the most
glaring is we can't afford it. Unemployment has hit 10.2 percent, the
highest level since 1983; yet Democrats are forcing through yet another
job-killing bill that, according to modeling created by the President's
own economic advisers, will kill an additional 5.5 million jobs.
Kansas just announced it is facing a $460 million budget shortfall;
yet this

[[Page H12875]]

body is set to send my State another unfunded mandate estimated to cost
$230 million.
And the deficit just exceeded $1.4 trillion; yet the majority wants
to pass this $1.3 trillion government takeover of health care.
Let's reject this fiscally irresponsible legislation.
Mr. ANDREWS. Mr. Speaker, may I inquire as to how much time each side
has left?
The SPEAKER pro tempore (Mr. Pastor of Arizona). The gentleman from
New Jersey has 18 minutes remaining, and the gentleman from Minnesota
has 21 minutes remaining.
Mr. ANDREWS. Mr. Speaker, I am very pleased to yield 1 minute to the
newest member of our committee, who has made a tremendous contribution
to this bill already, the gentlelady from California (Ms. Chu).
Ms. CHU. Mr. Speaker, I rise in strong support of the Affordable
Health Care for America Act. The clock is ticking for Americans and the
children of my district. Families have been suffering, waiting for
changes in our health care system so they can care for their children.
They have been waiting for Congress to act.
They are mothers like Maria, whose child has leukemia and worries
that excessive copays will make her go bankrupt.
They are children like Stacey, who has been waiting to get glasses
and can't see the chalkboard at school, but she can't get them because
her parents' insurance doesn't provide vision care.
They are parents like Barbara and Jim, whose 20-year-old has diabetes
and is no longer eligible for health insurance since he graduated from
college.
With the passage of this bill, out-of-pocket expenses will be capped
at $10,000, vision care for children will be covered, and older
children will be covered up until age 26. Maria will not go bankrupt,
Stacey will get glasses, and a son with diabetes can get treated.
Children and families will get the quality health care they deserve.
Let's pass this health care bill now.
Mr. KLINE of Minnesota. Mr. Speaker, at this time I am pleased to
yield 1 minute to a member of the committee, a practicing physician
himself, the gentleman from Louisiana (Dr. Cassidy).
Mr. CASSIDY. Mr. Speaker, as a practicing physician, I know that this
bill has tremendous consequences for patients and for the economy. It
is estimated that the $730 billion in new taxes in this bill will kill
5.5 million jobs. The CBO estimates that this will have an annual
inflation rate of 8 percent, an annual inflation rate that more than
doubles costs in 10 years.
The Republican bill expands access by lowering premiums 10 percent.
This bill expands access by forcing businesses and individuals to
purchase, and if they do not, the long arm of the State reaches out and
grabs them and shakes out fees and penalties.
Now, it was said this morning by a Democratic colleague that we need
to redefine freedom. We are going to need all kinds of new definitions.
We are going to redefine freedom as the ability to do what the
government tells you to do. We are going to redefine helping the
economy as higher taxes and destroying jobs. We are going to redefine
bending the cost curve as more than doubling costs in 10 years.
Consider not the rhetoric, but the facts. Please reject this bill.
Mr. ANDREWS. Mr. Speaker, I am pleased to yield 1\1/2\ minutes to the
gentleman from New Jersey, my neighbor and friend, Mr. Holt.
Mr. HOLT. Mr. Speaker, the question so many are asking is, Can we
afford this health care reform? I would say not only can we afford it,
we can't afford not to pass it.
Consider where we are today: Businesses, large and small, feel a
heavy weight around their necks trying to afford health care for their
employees. It hurts our economy. It costs jobs. Businesses and families
are paying a hidden tax of over $1,000 each per year for the care of
the uninsured. Costs continue to go up because our procedure-based
system rewards the ordering of unnecessary and expensive tests that not
only don't help the patient, they can be detrimental. Any family, even
well-off families who think they have good health coverage, can find
themselves in bankruptcy from a bad accident or arbitrary actions of
the insurers.
All of this would change under this bill. This bill would reduce
costs in a number of ways: By reducing the ranks of the uninsured,
whose more expensive care we all pay for; by increasing the insurance
competition through the new marketplace with a large interstate risk
pool; by removing the antitrust exemption; and by moving toward more
efficient record-keeping and by moving toward outcome-based, health
outcome-based, patient-centered care.
In addition to all this, the revenues raised by this bill exceed the
expenditures, so passing this will reduce the deficit by billions of
dollars below what it would be if we do not pass this tonight.
We can't afford not to pass this health care reform. The bill will
reduce the costs individuals, families and businesses face and reduce
the government deficit.
Mr. HOLT. Mr. Speaker, I rise today in strong support of the
Affordable Health Care for America Act, H.R. 3962, legislation that
would provide secure and stable health coverage regardless of whether
one changes jobs or is between jobs, ensure Americans will never be
denied care if they get sick, and extend coverage to those Americans
not well served by the current health care system.
This is a historic debate we are having. For the past century, since
Teddy Roosevelt ran for President in 1912, our nation has been debating
how to ensure that sick Americans can access the care they need. As a
U.S. Representative and the husband of a primary care physician, I have
heard many stories from hard-working New Jerseyans about the need for
reform. Some Americans have access to excellent care, often thanks to
the advanced biotechnology and pharmaceutical products created in New
Jersey, while others lack even basic care. One of the goals of the
health care reform is to help all Americans gain stable access to
medical care and life-saving medicines.
At a July roundtable in Trenton, a spouse of a cancer patient told me
that when she and her husband came home from the hospital after one
extensive treatment, they returned to foot-high stacks of insurance
paperwork and $150,000 of out-of-pocket charges for her husband's
needed care. A self-employed woman from East Brunswick wrote to me
recently to let me know she pays $2,000 a month for her family's
coverage and still has to pay out-of-pocket to see many of her
physicians. These stories are a reminder that health care reform is
about real people who are disserved by the broken health insurance
system.
These are not isolated stories. While in the U.S., we will spend over
$8,000 per person this year for health care, 16 percent of New
Jerseyans lacked insurance in 2007 and family insurance premiums are
projected to rise from $14,000 in 2009 to $24,000 in 2019. In a country
where we are projected to spend 18 percent of our Gross Domestic
Product ($2.6 trillion) this year on health care, we can do better.
The Affordable Health Care for America Act would improve the American
health care system for all Americans, regardless of how they currently
receive their health coverage. First, the legislation would lead to
stable health costs that do not threaten family finances by
establishing consumer protections for those purchasing private
insurance. The bill would eliminate insurance benefit caps to ensure
families do not have to worry about leaving the hospital with bills too
big to pay because their benefits have run out. The bill would set an
annual cap on out-of-pocket health expenses to eliminate cases where
one disease forces a family into bankruptcy.

Second, the bill would provide stable coverage for those between jobs
or the self-employed by creating an insurance marketplace, where they
could get insurance at group rates. Most of the policies in this
insurance marketplace would be private insurance, while one of the
plans would be a non-profit public plan. This public plan would be
subject to the same requirements and regulations as the for-profit
plans in the marketplace. The public option would be just that--an
option in which no one would be forced to enroll. The bill also would
eliminate the practice where patients with a pre-existing condition
like diabetes or cancer or pregnancy cannot purchase insurance.
According to a Congressional committee report, the bill would help
10,000 uninsured individuals in Central New Jersey gain access to
affordable health insurance.
Third, the bill would strengthen Medicare by starting to pay
physicians for treating the whole patient and by encouraging doctors to
coordinate a patient's medical care instead of paying for each test or
procedure. The legislation would strengthen the long-term health of the
Medicare trust fund by increasing the efficiency of the program,
expanding its ability to fight waste, fraud, and abuse, and eliminating
wasteful subsidies to private insurance companies.

[[Page H12876]]

It is worth repeating: not only would Medicare remain intact under
this legislation, it would become better. The legislation would
strengthen the Medicare trust fund by increasing the efficiency of the
program, expanding its ability to fight waste, fraud, and abuse, and
eliminating wasteful subsidies to private insurance companies. No
standard Medicare benefits would be cut. In fact, Medicare would be
improved by eliminating the ``doughnut hole'' in the prescription drug
benefit. Each year in Central New Jersey, 8,300 seniors face the
Medicare ``doughnut hole'' and are forced to pay their full drug costs,
despite paying for Part D drug coverage every month. H.R. 3962 would
provide these seniors with immediate relief by cutting brand name drug
costs in the ``doughnut hole'' by 50 percent and ultimately eliminating
the ``doughnut hole'' altogether. Further, the legislation would help
seniors by eliminating co-payments and deductibles in Medicare for
preventative services to ensure that diseases would be treated at their
earliest stages and to keep seniors well. The legislation creates new
Medicare incentives to encourage physicians and hospitals to coordinate
medical care and seek to reduce duplicate tests, x-rays, and labs.
These and other provisions are why AARP, among several others, has
endorsed this health care reform legislation.
This bill was created from one of the most open and deliberative
processes in recent memory. During the past few years, Congressional
committees held more than 53 committee hearings, debated and voted on
almost 240 amendments, and considered health reform for 167 hours. Many
of the amendments reflected concerns raised by constituents and have
improved this bill further.
While there are strong humane and moral reasons to pass this health
reform bill, the economic reasons are equally strong. Businesses, large
and small, feel a heavy weight in trying to afford health care for
their employees--hurting the economy and costing jobs. Any family,
regardless of their income, can find themselves in bankruptcy from one
accident or expensive illness. All of this would change under this
reform bill. The bill would lower health costs for families by
increasing competition across all states through a new marketplace and
eliminating the antitrust exemption. It would reduce costs by promoting
coordinated medical care to eliminate duplicative tests, by simplifying
insurance paperwork and electronic records. The bill would decrease
costs by expanding research on which treatments work best for different
patients, helping physicians and nurses provide effective medical care.
Long term, the legislation would limit costs by shifting to a focus on
health outcomes and rewarding physicians for treating the whole
patient.
It would do all this without adding one penny to the debt. Instead,
it will lower the debt and, according to the Congressional Budget
Office (CBO), produce a $109 billion surplus over a decade. We cannot
afford not to pass health care reform and reduce the crippling health
costs facing our nation, our businesses, and our families.
Sadly, there is a great deal of misinformation about the proposed
health reform bill. I have heard from some the myth that Members of
Congress would be exempt from health care reform. It is worth noting
that Members of Congress receive their health insurance like any other
of the eight million federal employees and we pay premiums just like
any other worker. The health insurance reform bill includes several
improvements to the overall insurance marketplace, all of which would
apply to the federal employee health insurance plans. I welcome the
fact that the reform legislation would apply to Members of Congress,
just like employees of other large companies.
Opponents of reform also claim that the House health reform bill
would encourage euthanasia or insert the government into end-of-life
conversations between patients and their physician. This claim is
false. The truth is that the legislation would provide doctors with
better payment for talking with their patients. This bi-partisan
provision would provide payment for a doctor's time if a patient
chooses to have a conversation about the care that the patient prefers
if he or she becomes very ill, but it does not require anyone to use
this benefit. These conversations would not involve any government
employee, but would be solely between the patient and his or her
physician. As noted by the AARP, ``[t]his measure would not only help
people make the best decisions for themselves but also better ensure
that their wishes are followed.''
There is no reasonable basis for concern that seniors' conversations
with their doctors on personal requests for end-of-life care would do
anything to promote assisted suicide, which is illegal in New Jersey
and 47 other states, or euthanasia, which is illegal in all states.

Discussions between the sick or the elderly and their doctors about
end-of-life care have long been an accepted part of modern patient care
as a way to ensure that the patient's wishes are carried out. In 2003,
under the Bush administration, the Agency for Healthcare Research and
Quality issued a report outlining a five-part process for physicians to
discuss end-of-life care with their patients. Unfortunately, doctors
are not paid for such discussions and thus are not encouraged to have
them. According to the National Hospice and Palliative Care
Organization, which supports this provision, the bill simply would
allow for counseling on decisions that require time and consideration.
Another myth is that health reform would provide federal benefits for
undocumented aliens. Undocumented immigrants currently may not receive
any federal benefits except in specific emergency medical situations.
There are no provisions in the House health reform bill that would
change this policy. In fact, the legislation explicitly states that
federal funds for insurance would not be available to any individual
who is not lawfully present in the United States.
I have heard from many constituents concerned about the inclusion or
exclusion of family planning services in health insurance reform. The
legislation would exclude federal funding of abortion, and maintain
existing federal laws protecting conscience rights in health care. In
fact, the amendment adopted tonight, which I believe is in error, would
go further than existing law and even prevent women from using their
personal funds from purchasing coverage for family planning services. I
hope the conferees will revisit this issue to ensure women have the
freedom to purchase the policy that best serves their needs and
conscience.
I am pleased that health reform will help small businesses. According
to a report issued from the Council of Economic Advisors in July 2009,
the current health care system places a heavy burden on small
businesses through high premiums, fixed administrative costs, adverse
selection, and comparative disadvantage with larger businesses in
America and with businesses in other countries. This is why small
businesses pay up to 18 percent more per worker for the same health
insurance plan than a large firm. The House legislation would help
small business employees purchase insurance at group rates through an
insurance marketplace, and by providing a tax credit to help small
businesses that purchase insurance. Almost 18,000 small businesses in
Central New Jersey would receive this tax credit.
The bill further recognizes the constraints facing small businesses
and exempts many small employers from the shared responsibility
requirement to provide insurance for their employees. The Congressional
Budget Office and respected Massachusetts Institute of Technology
health care economist Jonathan Gruber have pointed out that for the
large majority of small businesses, the reform legislation would be a
great improvement and would provide real savings.
For years, small businesses have asked me and other Members of
Congress to allow them to get better rates by pooling their employees
in large numbers, which is currently available to only larger
companies. The newly-created marketplace would allow insurance plans to
pool the health risks of millions of people and thus get lower rates.
In addition to the marketplace for small businesses created by the
House health reform bill, I worked with my colleagues Rep. Phil Hare
(D-IL) and Rep. Rob Andrews (D-NJ) to include language in this
legislation that would allow affiliated small businesses to join
together to purchase insurance. This proposal for helping small
businesses was brought to me by a small businessman in my district.
I also was pleased to write a section of the bill that would create
an online job training programs for health care workers, modeled after
a successful program originating at Rutgers University. This program is
needed to help meet the increasing need for health care workers, which
was indicated by a July report by the Council on Economic Advisors. The
demand for health workers soon will exceed the supply with 48 percent
growth in health support occupations such as medical record, clinical
laboratory, and health information technicians. My amendment, included
in H.R. 3962, would provide new training opportunities to meet this
additional demand for health professionals.
While I support the Affordable Health Care for America Act, I look
forward to working with my colleagues to improve this bill as the
legislative process moves forward. I have heard from home care and
hospice providers in my district and across New Jersey who are
concerned about the reductions in Medicare home health payments. I have
spent time with home care organizations and with individual patients at
home and have gained a deep understanding of the challenges and
successes that occur each day. I fear that additional cuts to home
health would make it harder to do the essential job that home care and
hospice workers perform each day. I also am concerned that several
provisions of the bill may impede biomedical research and innovation,
as this research has improved patient care

[[Page H12877]]

and fostered a successful life sciences industry in New Jersey.
While the bill we are considering is strong, I know this bill will
continue to improve as we move through the legislative process. Today's
vote in the House of Representatives marks an important step in this
process and is the furthest we have come toward providing affordable
and quality health coverage to all Americans. I look forward to working
to the completion of meaningful health care reform legislation and
sending it to the President for his signature.
I urge my colleagues to vote in favor of this bill to reform our
nation's health insurance system and improve.
Mr. KLINE of Minnesota. Mr. Speaker, before I recognize the gentleman
from California, I yield myself such time as I may consume.
There has been quite a bit of discussion here about how this bill is
going to help small businesses and reduce their taxes. I think it is no
accident that business group after business group, small business after
small business, large business after large business across this country
is opposing this legislation. It is the businesses who are going to
bear the first brunt of the taxes, bear the costs, and that is going to
be relayed to lost jobs.
For example, I have a whole list of organizations: the Associated
Builders and Contractors; the Associated General Contractors; the
International Franchise Association; the National Association of
Manufacturers; the National Federation of Independent Businesses; the
U.S. Chamber of Commerce; and on and on, oppose this bill because it
does not help business. It puts a burden on them.
Now I am pleased to yield 1 minute to the gentleman from California
(Mr. McClintock).
Mr. McCLINTOCK. Mr. Speaker, the question before us comes to this:
Will Congress force American families to surrender control of their
health care to the Federal bureaucracy? There is nothing optional about
this law. The word ``shall'' appears 3,400 times in it, each time
backed with the full force of the government.
You shall only get your health care through the government exchange.
You shall only select among the health care plans that the government
czar has approved for you, whether they fit your family's needs or not.
You shall buy a government-approved plan and pay for every
government-imposed mandate in it through higher premiums, lower wages
or higher taxes, and you will face steep fines and even Federal prison
if you decline to do so.
You ``shall'' 3,400 times.
Whenever such a system is imposed, the result is always the same:
massive cost overruns, followed by a brutal rationing of care.
Instead of destroying everything that is good about American health,
shouldn't we first repair what is wrong? Primum non nocere--first, do
no harm.
Mr. ANDREWS. I am honored to yield 1 minute to a gentleman who has
done an extraordinarily effective job of representing his constituents,
the gentleman from the Commonwealth of the Northern Mariana Islands
(Mr. Sablan).
Mr. SABLAN. Mr. Speaker, I rise today in support of H.R. 3962, the
Affordable Health Care for America Act. The need for health care reform
has never been greater nor more urgent. This is true for my district,
as it is for our Nation. We cannot wait another day. We must seize the
moment and pass a law that will go a long way toward providing quality,
accessible, and affordable health care for all Americans.
I urge my colleagues to support the bill.
Mr. KLINE of Minnesota. Mr. Speaker, I would like to yield 2 minutes
to another physician, a member of the committee who is not only a
doctor, but a small businessman, the gentleman from Tennessee (Dr.
Roe).
(Mr. ROE of Tennessee asked and was given permission to revise and
extend his remarks.)
Mr. ROE of Tennessee. Mr. Speaker, I thank the gentleman for
yielding.
I rise in opposition to this bill before us. I came to Congress to
enact health care reform. As a physician, I have seen firsthand the
problems insurance companies created for my patients. I have seen
firsthand how the government programs have made beneficiaries worse
consumers of health care, and I have seen how the cost of health care
has exploded and made insurance unaffordable. I want to fix these
problems. But this bill will not fix these problems; it will make them
worse.
The Democrats have ignored evidence that this program won't work. I
asked President Obama three separate times since July to sit down and
talk about the health care bill and what I know its effects will be,
and I have yet to receive a call from the White House. It is one thing
to disagree with the evidence that undermines the premise of reform you
are pushing, but to not even consider it is unbelievable.
So here we are today with a health care bill that is over 2,000
pages. It is a Christmas tree of special interests. Sewer systems for
Indian tribes, biofuel tax credits, nutrition standards for chain
restaurants, and references to pizza and donuts all made it into this
bill. But somehow the Democrats could not come up with a real solution
for medical malpractice reform.
This bill taxes everyone and everything. It taxes medical devices, it
taxes individuals, it taxes employers. It taxes small business owners
who could be creating jobs and getting us out of this recession,
instead forcing them to cut wages for jobs. It taxes medical savings
accounts. It cuts Medicare. Home health care, skilled nursing
facilities and Medicare Advantage would all be cut. And seniors with
prescription drug coverage will have their premiums increased. Seniors
oppose this bill because they get it. Their care is going to decrease
and their costs are going up.
The bill spends all that money even faster. The bill dramatically
expands Medicaid, despite the fact that I haven't heard anyone who had
an option say they want to be on Medicaid. It creates a huge new
Federal bureaucracy to navigate through. And it funds a government
competitor to private insurance companies that will siphon people off
the private insurance market onto a Medicaid-like program, just like
Tennessee did with Tenncare.
Mr. Speaker, I came to Congress to enact health care reform. As a
physician, I've seen firsthand the problems insurance companies created
for patients. I've seen firsthand how government programs have made
beneficiaries worse consumers of health care. I've seen how the cost of
health care has exploded, so much so that many can't afford insurance.
I've seen all these problems and I want to fix them.
When I first heard that the Democrats were proposing to insert a
government competitor in the insurance marketplace, I thought, surely
they can't be serious. When I realized they were, I thought I could
change their opinions by telling them about the real-life failures I've
seen under our state's program known as TennCare and how H.R. 3200 and
now 3962 is simply a bad extension of these mistakes.
For months I've gone to the House floor with many of my physician
colleagues to talk about the problems with this plan. The TennCare plan
tried to provide universal coverage and make health insurance
affordable, and in the end it nearly bankrupted the state as the
program tripled in cost. It created an incentive for beneficiaries to
seek unnecessary care because it cost them nothing. It shifted costs to
the private plans, who were forced to make up the underpayments of the
government program, increasing everyone's premiums. In the end, 45
percent of those on the public plan previously had private insurance
and either dropped their coverage or were dropped by their employer.
Our Democratic Governor, Phil Bredesen, saved our state's budget by
doing something hard--he cut the rolls. He controlled costs and he
introduced an alternative plan called Cover Tennessee, which requires
an equal contribution from employers, individuals and the government,
which is a model for shared responsibility. Incidentally, Governor
Bredesen has called this bill on the floor the mother of all unfunded
mandates.
Democrats continued to ignore this evidence. I asked President Obama
three separate times since July to sit down and talk about the health
care bill and what I know its effects will be, and I have yet to
receive a call from the White House. It's one thing to disagree with
evidence that undermines the premise of the reform you're pushing, but
to not even consider it is unbelievable.
So here we are today with a health care bill that is over two
thousand pages. It's loaded up like a Christmas tree of special
interest provisions. Sanitation facilities for Indian tribes, biofuel
tax credits, nutrition standards for chain restaurants, and references
to pizza and doughnuts all made it into this bill, but

[[Page H12878]]

somehow, Democrats could not come up with a real solution for medical
malpractice reform except to try to protect trial lawyers' share of
jury awards. Malpractice is proven to cost the health care system
billions of dollars every year, but the reforms being proposed make the
current system worse.
This bill taxes everyone and everything. It taxes medical devices. It
taxes individuals who choose not to purchase insurance, and drives up
premiums for individuals who do purchase insurance. It taxes employers
who fail to offer health insurance, then taxes them further if they try
to increase their employees' wages. It taxes small business owners, who
could be creating jobs and getting us out of the recession, and instead
forces them to cut jobs or wages. It taxes health savings accounts,
which reduces the use of catastrophic health insurance coverage.
It cuts Medicare. Home health care, skilled nursing facilities and
Medicare Advantage would all be cut, and seniors with prescription drug
coverage will have their premiums increased. Seniors oppose this bill
because they get it--their care is going to be decreased and costs are
going up.
After the bill finishes up taxing everything and everyone, it spends
all that money even faster. The bill dramatically expands Medicaid,
despite the fact that I've never heard of anyone saying they want
access to the program. It creates a huge new federal bureaucracy to
navigate through. And it funds a government competitor to private
insurance companies that will siphon people off of private insurance
onto a Medicaid-like program, just like Tennessee did with TennCare.
After the Democrats finish spending $1.5 trillion, they say the bill
is quote unquote deficit neutral. But they ignore that every major
government health care expansion before it--Medicare, Medicaid, SCHIP
to name a few--have cost more than originally estimated. And they
completely ignore the fact that they use 10 years of revenue to pay for
7 years of new spending. In the second decade, this program will become
an enormous unfunded mandate on state governments, on individuals and
on the federal government. Despite the largest deficit in our nation's
history, the Democrats are irresponsibly going to make it harder to
ever balance the budget.
Here's the bottom line: this bill costs too much. It taxes too much.
It does nothing to improve health care, and will result in the majority
of Americans left with decreased access, decreased quality and
increased costs. It is, as the Wall Street Journal called it, the worst
bill ever and deserves to be rejected.

{time}  1900

Mr. ANDREWS. Mr. Speaker, I am pleased to yield 1 minute to the
gentlewoman from New York (Ms. Clarke), one of the leading voices for
senior citizens, resulting in the AARP endorsing our bill.
Ms. CLARKE. I thank the gentleman from New Jersey very much.
Mr. Speaker, today I rise to support H.R. 3962, the Affordable Health
Care for America Act. As we approach the dawning of the second decade
of the new millennium, this evening we will usher in a new assurance of
the health and well-being of all Americans. Our children will have the
health and peace of mind to exceed the productivity of our generation.
Our willingness to do what it takes to transition into the 21st century
health care delivery system will guarantee future generations the
advancement of a productive civil society.
Every American has a right to adequate physical and mental health
care, and I believe that we, as a national government, have a
responsibility to assist our citizenry in securing quality health care.
It is unfortunate that there are those amongst us who just couldn't
care less; those who were satisfied with the status quo of rising
premiums, satisfied with individuals being denied coverage because of
preexisting conditions, satisfied with ignoring the pain and suffering
of the 47 million Americans who are uninsured.
Mr. Speaker, I urge all of my colleagues to vote for this measure.
Mr. Speaker, today, I rise in support of H.R. 3962, Affordable
Healthcare for America Act. This evening, as we approach the dawning of
the second decade of the new millennium, we will usher in a new
assurance of the health and well being of all Americans. Our children
will have the health and peace of mind to exceed the productivity of
our generation. Our willingness to do what it takes to transition to a
21st century healthcare delivery system will guarantee future
generations the advancement of a productive civil society.
In the United States, one of the richest countries in the world,
nearly 47 million Americans lack health insurance, 13.5 percent of whom
are New Yorkers. Last year alone, New York City's hospitals spent $1.2
billion in charity costs. Tragically, people who are either uninsured
or underinsured often have to go without vital healthcare simply
because they cannot afford it.
Every American has a human right to adequate physical and mental
healthcare, and I believe that we as a national government have a
responsibility to assist our citizens in securing quality healthcare.
Unfortunately, my Republican colleagues don't seem to fully grasp the
dire situation our healthcare system is in. Maybe they would have come
up with a bill that actually addressed the deficiency in our broken
healthcare.
It is unfortunate that there are those amongst us who just could care
less--those who are satisfied with the status quo of rising premiums,
satisfied with individuals being denied coverage because of pre-
existing conditions, satisfied with ignoring the pain and suffering of
the 47 million Americans who are uninsured.
Instead of working with us to fix the problem, they capitalize on
people's fears and doubts. It is meant to distract, delay, confuse, and
engender fear among our citizens. Today we will not allow the voices of
fear to dominate the healthcare reform debate.
This bill provides healthcare coverage to 96 percent of Americans and
includes a strong public option that will provide the needed
competition to lower premium costs. That is why I support H.R. 3962,
Affordable Healthcare for America Act.
With preventative care as the cornerstone of the 21st century
healthcare delivery system, eliminating the disparate treatment of
women, eliminating discrimination based on pre-existing conditions,
creates a new health exchange for access to quality affordable health
insurance and turns medical visits from a broken volume based system to
a 21st century value based system. I will cast my vote this evening in
memory of a distinguished New Yorker, Brooklynite and friend Jackie
Ward, who died of heart failure as a young woman in her early 50s.
In my district, the 11th Congressional District of Brooklyn, the
Affordable Healthcare for America Act will: First, improve employer-
based coverage for 367,000 residents. As a result of the insurance
reforms in the bill, there will be no co-pays or deductibles for
preventative care; no more rate increases or coverage denials for pre-
existing conditions, gender, or occupation; and guaranteed oral,
vision, and hearing benefits for children. Second, it will provide
credits to help pay for coverage for up to 160,000 households, if they
need to purchase their own coverage. Third, under the bill's insurance
reforms, 11,900 individuals in the district who have pre-existing
medical conditions will now be able to purchase affordable coverage.
Finally, this bill will allow 11,300 small businesses to obtain
affordable healthcare coverage and provide tax credits to help reduce
health insurance costs for up to 11,400 small businesses.
Healthcare is a fundamental human right, rather than a commodity. A
year ago, Americans cast a historic vote to change the course of this
Nation. Today, we cast this historic vote, to finally manifest the
change they demanded: Access to Affordable Healthcare. I am proud to
cast my vote in favor of this bill.
Mr. KLINE of Minnesota. Mr. Speaker, may I inquire as to the time
remaining on each side?
The SPEAKER pro tempore. The gentleman from Minnesota has 16 minutes.
The gentleman from New Jersey has 14 minutes.
Mr. KLINE of Minnesota. Thank you, Mr. Speaker.
At this time I am pleased to yield 1 minute to the gentleman from
Pennsylvania (Mr. Thompson), a member of the committee.
Mr. THOMPSON of Pennsylvania. Mr. Speaker, I rise today in opposition
to H.R. 3962. I came to Congress this past January following 28 years
in nonprofit health care. In January, the Democratic majority quickly
moved the SCHIP reauthorization. I supported the final passage of the
bill. SCHIP was modeled after Pennsylvania's CHIP program, a bipartisan
public-private partnership to offer private insurance to my State's
most vulnerable population. CHIP works in Pennsylvania.
Mr. Speaker, I am dismayed to learn that this bill will scrap the
SCHIP program. This will jeopardize coverage and increase costs for
scores of Pennsylvania's needy children. Families who rely on
Pennsylvania's CHIP program will faces higher costs when their children
are forced into plans offered through the exchange. We have heard from
my colleagues about cuts to our seniors, small businesses, family
farms, and agriculture. Now you are hearing about the cost to our
children.

[[Page H12879]]

As a health professional, I urge my colleagues to vote ``no'' on this
measure, and I would like to submit a letter from five of my Republican
colleagues from Pennsylvania on this issue.

Congress of the United States

Washington, DC, November 7, 2009.
Hon. Nancy Pelosi,
Speaker, House of Representatives, The Capitol, Washington,
DC.
Dear Speaker Pelosi: We are writing to express our grave
concerns with provisions included in H.R. 3962, the
Affordable Health Care for America Act, that would eliminate
the Children's Health Insurance Program (CHIP) and require
all children above 150 percent of the federal poverty level
(FPL) who are not covered under a Medicaid CHIP (M-CHIP)
expansion program to be moved into the new health insurance
exchange. These extremely troubling provisions will add an
undue cost burden on children and families in Pennsylvania as
well as delays in care and coverage gaps when CHIP plans are
terminated.
Members of the Pennsylvania General Assembly strongly
advocated for the creation of Pennsylvania's CHIP law in
1992, and improvements to the program in 1997. Our program
served as a model for the federal CHIP law, and it has been
an overwhelming success in our state. There is no better
example of a public-private health partnership that has
contributed to the lives of Pennsylvania families. We often
hear from our constituents that their children are healthy
and active because of CHIP.
Now, only months after you championed for the
reauthorization of CHIP, it is surprising that the bill you
are ushering through the House is proposing to eliminate this
successful program. These provisions would jeopardize
coverage and increase costs for scores of Pennsylvania's
children since Pennsylvania operates CHIP as a separate
program and makes coverage available to children beyond 150
percent of FPL.
A recent actuarial analysis demonstrates that CHIP benefits
are superior for low-income families than the House health
care legislation. Families who rely on Pennsylvania's CHIP
program will face higher costs when their children are forced
into the plans offered through the exchange. For instance,
for children living in families earning 175 percent of FPL,
the study finds that the median CHIP plan covers 100 percent
of medical expenses covered by CHIP. Under the House bill,
that family will pay nearly 400 dollars. For children in
families earning 225 percent of FPL the median CHIP plan
covers 98 percent of medical expenses, exposing children to
only 2 percent of costs. Comparable exchange plans would
expose families to 5 percent to 35 percent of out-of pocket
costs.
We have witnessed first hand that CHIP is an efficient
program that provides Pennsylvania children with affordable,
quality care. H.R. 3962 is a step in the wrong direction for
our children--imposing higher costs and delivering fewer
benefits to our most vulnerable population.
For several additional reasons, we will vote against H.R.
3962. Protecting children, especially those most in need,
should be one of Congress's top priorities in the context of
health care reform. We urge you to reconsider the direction
H.R. 3962 will lead this country and the consequences of
eliminating CHIP for Pennsylvania's children.
Sincerely,
Charles W. Dent,
Member of Congress.
Todd Russell Platts,
Member of Congress.
Bill Shuster,
Member of Congress.
Jim Gerlach,
Member of Congress.
Glenn Thompson,
Member of Congress.

Mr. ANDREWS. Mr. Speaker, I yield myself 3 minutes.
(Mr. ANDREWS asked and was given permission to revise and extend his
remarks.)
Mr. ANDREWS. I would like to thank my friends on both sides of the
aisle. This has been a stressful time for Americans, and today may have
been a very stressful day for Americans.
This might have been the day that someone thought they were going to
get a job but found out that they won't get the job because they had
breast cancer 5 years ago and can't get health insurance because of
their preexisting condition. It has not been their day.
Or it might be the day that a senior citizen decides that they don't
have the money this week to renew their prescription because they're in
the doughnut hole under Medicare. So they're going to pay their rent
instead of their prescription bill, and they're going to get very sick.
It's just not their day.
Or it might be the day that someone is lying awake in bed, churning
about the fact that their child seems a little sicker than usual. But
if they take them to the doctor, they might get sent to the hospital,
and they can't pay the hospital bill because they have no health
insurance, and it might mean bankruptcy or foreclosure or losing their
home. It's just not their day.
If we pass this bill and it gets to the President's desk, a new day
will come to this country, because no person with a preexisting
condition will ever suffer discrimination again; because effective next
year, eventually no senior will run out of drug coverage at any time
during the year because they work for it and they deserve it. The new
day will come to that uninsured person because no hardworking American
will ever go without health insurance in this country.
You know, the special interests and the lobbyists and the health
insurance industry, they have all had their day. They have been around
here for a very long time. And I hate to disappoint them, but today is
not their day. It is the day for uninsured Americans. It is the day for
hardworking Americans. This is the day when we will begin the change,
and every American will get the health care they so richly deserve.
Stand up for those who cannot be heard, and vote ``yes'' for this
bill.
Mr. KLINE of Minnesota. Mr. Speaker, I yield 2 minutes to the
gentleman from Michigan (Mr. Ehlers), a member of the committee.
Mr. EHLERS. Mr. Speaker, I certainly support making health care more
affordable and accessible for all Americans. Perhaps I'm naive, but I
had hoped that we would have been able to produce a bipartisan bill
that I could gladly vote for. Such is not the case. We were not even
given the courtesy by the other party of taking part in writing this
bill and presenting ideas which could be included in the bill.
The status quo in the health care system is unacceptable. We must
make health care more affordable and accessible than it is. But this
bill is even less acceptable than the current health care system. This
bill will result in large tax increases, as we've heard, which is
absolutely the last thing that my State of Michigan needs because we
are struggling so hard with the economy the way it is. This proposed
bill is basically a government takeover.
What am I looking for? I'm looking for health care quality. That, to
me, means getting the treatment you need, when you need it, from the
doctor you choose. This bill does nothing to provide that.
Time is a great health care killer among governments. We looked at
other countries. They may have very good plans, but if you need an MRI
today and you have to wait for 6 months, you are not getting good
health care. We want to make sure that the plan we develop provides the
health care you need, when you need it, from the doctor you choose.
I truly hope that, in the future, as we go through the conference
process with the Senate, that our Republican ideas will be incorporated
as well as the Democratic ideas, and that we really produce the best
bill we can. We did that with Medicare. We tried to do it with Medicare
part D, and I would hope that the Democratic Party, instead of just
glorying in their bill, and doing their own thing, and ignoring the
Republicans, would, in fact, work with us and try to produce a bill
that is good for the country, for the people, and especially for those
who need medical care.
The SPEAKER pro tempore. Without objection, the gentleman from
California (Mr. George Miller) will control the remainder of the time.
There was no objection.
Mr. GEORGE MILLER of California. I yield 1 minute to the gentleman
from Ohio (Mr. Wilson).
Mr. WILSON of Ohio. Mr. Speaker, as we wind down the clock on the
health care debate, I have thought long and hard about what's best for
my district back in Ohio, and I have concluded that the Affordable
Health Care for America Act is an important step forward in fixing our
broken health care system.
While this legislation is not perfect, there are benefits that are
simply too hard to ignore. For example, in my district, 13,000 small
businesses will have the opportunity to provide their employees better
health care. We will close the drug doughnut hole for over 9,000
seniors just in my district alone, and it will help 174,000 households
in the Sixth Congressional District afford better coverage.
I have always promised the people that I work for back home that I
will vote in their best interest and that I will stand up for what is
right. I am

[[Page H12880]]

proud to be here this evening on this issue, and I believe that this
bill is the right thing to do to provide stability and security for the
families in Ohio in my district.
Mr. KLINE of Minnesota. Mr. Speaker, I am pleased to yield 1 minute
to my colleague, the gentlewoman from my home State of Minnesota (Mrs.
Bachmann).
Mrs. BACHMANN. Mr. Speaker, the American people overwhelmingly reject
the government takeover of our health care. Last Friday, a couple from
Hawaii decided the time is so short they needed to get on a plane, come
to Washington to beg their Representative to vote ``no'' from Hawaii.
What sacrifices freedom-loving Americans are making to get their
government's attention and how big our government has gotten.
They brought me this beautiful, precious lei, and I am reminded that
the one who created this lei also created our freedom. Are we so
insensible to the high cost our forebears paid to purchase our freedom?
Tonight, would we foolishly bargain those freedoms away? The American
people, our forebears, generations yet unborn, are crying out to us
tonight for us to preserve their freedoms.
Vote ``no'' on the government takeover of health care.
Mr. GEORGE MILLER of California. I yield 1 minute to the gentlewoman
from Pennsylvania (Mrs. Dahlkemper).
Mrs. DAHLKEMPER. Mr. Speaker, the American people overwhelmingly have
called on us, their Representatives, to enact real change in our
country and in their lives. The Affordable Health Care for America Act
embodies the positive change the American people have demanded.
This bill creates effective, affordable, and quality reform for all
Americans. Seniors will benefit from a stronger Medicare system, no
longer subject to the prescription drug doughnut hole or have to pay
out of pocket for their primary care needs. Small businesses will no
longer be burdened by skyrocketing health care costs. Tax credits and
greater competition in the health care market will make coverage
affordable for these small businesses, and no individual will ever
again be denied health insurance because of preexisting or chronic
conditions.
My colleagues, the need for reform is clear, and the time for reform
is now. I urge Members on both sides of the aisle to vote for the
Affordable Health Care for America Act for our seniors, for all women,
for small businesses, and mostly for our precious children and
grandchildren.
Mr. KLINE of Minnesota. Mr. Speaker, at this time, I yield 1 minute
to the gentleman from Texas (Mr. Smith), the ranking member of the
Judiciary Committee.
Mr. SMITH of Texas. Mr. Speaker, I thank the gentleman from
Minnesota, the ranking member of the committee, for yielding me time.
According to CBO estimates, this bill will cost $1.3 trillion and
includes $750 billion in new taxes and $500 billion in Medicare cuts.
It increases premiums, increases taxes, cuts benefits, and leads to
health care rationing. The government, rather than patients and
doctors, will make many health care decisions. The bill represents a
loss of freedom and more government control for the American people.
I support health care reform to help the long-term, low-income
uninsured, but it can be achieved without a government takeover of
health care. The House Republicans have a better health care bill that
lowers premiums for families and small business owners, cuts the
deficit by $68 billion, and includes tort reform.
Mr. GEORGE MILLER of California. If I could inquire of the Chair as
to how much time is remaining on both sides.
The SPEAKER pro tempore. The gentleman from California has 10
minutes. The gentleman from Minnesota has 11 minutes.
Mr. GEORGE MILLER of California. I yield 1 minute to the gentleman
from Missouri (Mr. Carnahan).
Mr. CARNAHAN. Mr. Speaker, ``millions do not now have protection or
security against the economic effects of sickness. The time has arrived
for action to help them attain that opportunity and that protection.''
President Truman delivered these words in a special message to Congress
in 1945, calling for comprehensive health care in America.
Health care in America has been broken far too long, unavailable and
unfair for too many, becoming more unaffordable every year. Health care
premiums have doubled in 10 years. Health care bills are the number one
reason for personal bankruptcies in our country. Health care costs are
the number one contributor to our deficit. We spend more on health care
than any other country, yet we rank near the bottom in terms of health
care results.
This bill builds upon the best parts of our private employer-based
system and fixes what's broken to lower costs, increase competition,
promote preventive medicine, and protect seniors. Many ideas and
concerns from Missourians I represent have been included in this bill
to make it even better. History and the American people are calling us
to action. The time is now to fix health care in America.
Mr. KLINE of Minnesota. Mr. Speaker, now I yield 1 minute to the
gentleman from Alabama (Mr. Aderholt).

{time}  1915

Mr. ADERHOLT. Mr. Speaker, there is no question we need to address
health care problems in this Nation. That is something both Democrats
and Republicans both agree on.
However, the government takeover of health care that we are debating
tonight adds up to way too much spending, too much government
bureaucracy, too many unfair mandates, too much government control in
an area with where government just doesn't belong.
The Republican substitute is about to be debated tonight, and it will
attempt to fix the broken aspects of health care in the United States.
There will be many of us tonight in this Chamber who will vote ``yes''
on that Republican substitute because there needs to be changes.
However, we will vote ``no'' on final passage because we don't want to
throw the baby out with the bath water in order to fix the problems.
Mr. GEORGE MILLER of California. Mr. Speaker, I yield 1 minute to the
gentleman from Michigan (Mr. Schauer).
Mr. SCHAUER. Mr. Speaker, because of rising medical costs, families
in America are literally going broke. Yes, broke. The American Journal
of Medicine reported that 62 percent of American bankruptcies are
linked to medical bills. These medical bankruptcies have increased by
50 percent in just 6 years. The shocking fact is that 78 percent of
these people actually had health insurance, but gaps and inadequacies
in the current system left them unprotected when they were hit by
devastating bills.
Important insurance reforms in this bill will fix this, and as a
result of this bill, 36,000 of my constituents will finally be able to
afford quality health coverage and peace of mind for their families.
Perhaps more than in any other State, people in Michigan know that
the current system is broken. It's time for us to fix it. It's time for
us to pass H.R. 3962.
Mr. KLINE of Minnesota. Mr. Speaker, at this time I yield 1 minute to
the gentleman from Indiana (Mr. Burton).
Mr. BURTON of Indiana. I thank the gentleman for yielding.
Government can't give until it takes. There is no such thing as a
free lunch.
You know, we have 10.2 percent unemployment right now. This bill is
going to cost about 5.5 million jobs. It's going to cost $730 billion
in new taxes and $1.2 trillion for the program over the next decade. We
can't afford that at this time with unemployment being at the rate that
it is.
We face a $1.4 trillion deficit this year alone, and you're going to
add $1.2 trillion to that and a $730 billion tax increase with 10.2
percent unemployment?
You're going to cost jobs. And the American people want jobs right
now, first and foremost. Jobs. Jobs. Jobs. And then deal with some of
these things in a more responsible way.
Mr. GEORGE MILLER of California. Mr. Speaker, I yield 1 minute to our
new Member from New York (Mr. Owens).
Mr. OWENS. Mr. Speaker, my district needs one thing: jobs.
In Upstate New York small businesses are the jobs engine. Over the
past 15 years, they have been responsible for nearly two-thirds of all
jobs

[[Page H12881]]

created in America. But the cost of health care is grinding the engine
down. Over the last decade, small business insurance premiums are up
129 percent. That means much higher expenses, more businesses dropping
coverage, a sicker, more financially strapped workforce, and enormous
pressure on small business owners from competitors overseas and big
businesses at home.
The bill can change that. It creates a competitive marketplace where
individuals and small businesses can shop for policies at fair rates.
It guarantees free preventative care for a healthier, more productive
workforce. And it encourages Americans to start businesses of their own
because the cost of health care will no longer tie them to the same
job.
The people of my district need jobs. They need me to vote ``yes.'' I
came to Congress to move America forward. This will do that.
Mr. KLINE of Minnesota. Mr. Speaker, at this time I yield 3 minutes
to the distinguished Republican leader, the gentleman from Ohio (Mr.
Boehner).
Mr. BOEHNER. I thank my colleague for yielding.
For many of us on both sides of the aisle who believe in the sanctity
of human life, the underlying bill allows for taxpayer funding of
abortion. The Speaker has allowed Mr. Stupak and others to offer an
amendment tonight.
And, Mr. Miller, if that amendment were to pass and this bill were to
get to conference and there were a vote in the conference on this,
would you guarantee me that you would support the House-passed version?
Mr. GEORGE MILLER of California. Will the gentleman yield?
Mr. BOEHNER. I'm happy to yield.
Mr. GEORGE MILLER of California. As he has already acknowledged, when
he was Chair and he went to conference many times, he could not
guarantee anything. You will take into this House, if that amendment
should pass, that will be an expression of this House on that subject,
on that amendment. We will take that with the full dignity of that vote
into that conference committee.
Mr. Boehner, if you can speak for the Senate--nobody else has been
able to.
Mr. BOEHNER. Reclaiming my time, the question was this: If the House
is to pass the Stupak amendment and this bill is to pass tonight and
there is a vote in the conference on this issue, would you guarantee me
that you will support the House-passed version?
Mr. GEORGE MILLER of California. I will not guarantee that. You know
the nature of the conference committee.
Mr. BOEHNER. Reclaiming my time, this is the third chairman tonight
who will provide no guarantees that if the House were to pass the
Stupak amendment that they would vote in committee to support the
House-passed version.
This is the point of why I've been down here making this an issue:
just because we pass an amendment to help facilitate the passage of
what I think is a bad bill does not mean that the language that this
House votes on is committed to by the Democrat leaders in this House.
Mr. GEORGE MILLER of California. Mr. Speaker, I yield 1 minute to our
new Member to the Congress from California, Congressman Garamendi.
Mr. GARAMENDI. Mr. Speaker, 3 days ago I had the great honor of
joining this august body, which for more than a century has debated
health care.
Two hours ago a dear friend Chic Dambach and his adult son came to my
office. At the age of 2, Kai's kidneys failed. Chic and his family had
health insurance. Their insurance company refused to cover transplants.
Chic and his wife, Kay, were faced with a choice: enormous personal
debt or their son's life. They chose life.
A decade of battles with their insurance company together with
crushing debt, Kai, when he becomes 23, will be uninsurable. He has a
preexisting condition.
H.R. 3962 is America's opportunity to end this despicable situation.
The bill has strong comprehensive insurance reform and creates the
penultimate enforcement mechanism: the public option. Americans should
not be at risk any longer. The bill deserves our support.
Mr. Speaker, three days ago I had the great honor of joining this
august body that for 220 years has debated the momentous issues of the
day, wars, industrial and labor policy, civil rights, environmental
protection, and social security, and for more than a century--health
care policy.
Today we are faced with a choice. Do we vote no health insurance
reform and continue the current situation that has placed in jeopardy
every person in America who is not yet 65 years of age? Or do we vote
today to provide every American with a comprehensive, affordable, and
available health care policy?
One example of why we must vote yes on H.R. 3962 and end the health
care crisis that millions of Americans face each year is Chic Dambach
and his son Kai.
Some of you may know Chic as the former President of the Returned
Peace Corps Association. Chic and his family had a comprehensive family
health insurance policy. At the age of two, Kai's kidneys failed.
Their insurance company refused coverage for kidney transplants. Chic
and his wife Kay were faced with a choice, more than a hundred thousand
dollars of personal debt or their son's life. They chose life.
Today, Kai is a freshman at the University of Maryland. More than a
decade of battles with their insurance company has ensued together with
a crushing burden of debt. When Kai becomes 23 he will be uninsurable.
Like millions of other American's he has a preexisting condition.
H.R. 3962 is America's opportunity to end this despicable situation.
The bill has strong comprehensive insurance reform and creates the
penultimate enforcement mechanism--The public option--that in its
fullness would allow all of us to walk away from the clutches of the
profit before people private insurance companies whose first operating
commandment is ``Pay as little as late as possible.''
This must end. Americans should not be at risk any longer. H.R. 3962
is the solution. It deserves our support.
Mr. KLINE of Minnesota. Mr. Speaker, I yield for the purpose of
making a unanimous consent request to the gentleman from Pennsylvania
(Mr. Dent).
(Mr. DENT asked and was given permission to revise and extend his
remarks.)
Mr. DENT. Mr. Speaker, I rise in opposition to this government
takeover bill.
Mr. Speaker, I rise today to ask unanimous consent to revise and
extend my remarks and have them submitted to the Congressional Record.
I have spent the past week reviewing the 1,990 page health-care
bill--H.R. 3962--that was introduced last Thursday and the manager's
amendment that was filed late Tuesday night. I oppose this legislation
which will exacerbate rather than solve the problems in our health care
system and take our Nation in the wrong direction.
Although I believe health care reform is needed, diminishing
Americans' control over their health care decisions, cutting Medicare
benefits for seniors, eliminating SCHIP coverage for low-income
children, imposing punitive taxes on small businesses and increasing
health care costs for all Americans in order to create an unsustainable
entitlement program that will bury our Nation in debt is not the way to
do it. Fundamentally, this bill moves the United States in the
direction of a European style welfare state which is accompanied by
much higher European style tax rates, slower economic growth and
structurally higher unemployment rates. The bottom line is that this
legislation will lead to fewer opportunities for our children and
grandchildren.
H.R. 3962 is bad for Americans because it won't reduce health care
costs--in fact many will see increased costs--and it will cause
millions of working Americans to lose their current coverage.
It's bad for seniors. The bill includes nearly a half-trillion
dollars in cuts to Medicare benefits. It will mean less choices, as
well as increased premiums and prescription drugs costs for thousands
of seniors in the 15th District.
It's bad for Pennsylvania's children, who will be forced out of the
State's successful CHIP program into plans offered through the health
insurance exchange where families will face higher costs.
It's bad for Pennsylvania's already struggling budget, forcing an
unfunded Medicaid mandate of at least $2.2 billion on our cash-strapped
Commonwealth.
It's bad for small businesses. It will stifle innovation and job
creation by imposing punitive surtaxes. It's bad for the Pennsylvania
economy in particular, with a $20 billion tax on the makers of medical
devices, an industry that employs thousands in my district and the
surrounding region.
And above all it's bad for America, spending more than $1 trillion in
taxpayer dollars to create an unsustainable new Federal program and
saddling our children and grandchildren with debt. Only in Washington
can someone say with a straight face that by creating a new

[[Page H12882]]

trillion dollar program that we will not add a dime to the deficit now
or in the future.
If we are serious about enacting meaningful health care reform that
will ensure that all Americans have access to quality care, we must
address the issue of cost. American families are struggling to afford
increasing health care costs and health care spending is taking up a
larger and larger portion of Federal, State, and local governments'
budgets.
Regrettably, H.R. 3962 fails to address one of the key reforms that
will save billions of dollars and reduce health care costs--medical
liability reform. In fact, the provisions in H.R. 3962 will actually
heighten the medical liability crisis facing our Nation.
The medical justice system is one of the major drivers of cost in our
health care system. Doctors practice defensive medicine--ordering tests
and treatments that are not truly needed but prescribed to ward off
frivolous lawsuits. We have all been in our doctor's office and
thought, ``Do I really need this?'' This defensive medicine doesn't
mean better care; it just means more expensive care. The litigious
environment has caused medical liability insurance premiums to
skyrocket. In turn, patients pay more for health care because the costs
are passed down.
The practice of defensive medicine costs the United States more than
$100 billion per year--some studies have estimated the cost may be as
high as $151 billion to $210 billion annually. In Pennsylvania, not
only are medical liability insurance rates increasing costs for
patients, they are driving qualified doctors out of the Commonwealth.
Recently, the Congressional Budget Office, CBO, released an analysis
indicating that medical liability reforms would save the government $54
billion over 10 years and cut national healthcare spending by 0.5
percent a year. These savings would be the result of direct savings
from lower premiums for medical liability insurance and also indirect
savings from reduced utilization of health care services.
The original House health care bill, H.R. 3200, was silent on medical
liability reform. Just 3 of the 1,990 pages of H.R. 3962 address the
issue. Tragically, the language in H.R. 3962 actually discourages
States from making the medical liability reforms that CBO has said will
save $54 billion. This is politics at its worst--protecting trial
lawyers at the expense of patients.
Yesterday, I offered an amendment to the Rules Committee that would
have inserted significant medical liability reform provisions into H.R.
3962. My amendment would enact nationwide reforms aimed at ending the
costly practice of defensive medicine and encourage States to adopt
effective alternative medical liability laws that will reduce the
number of health care lawsuits initiated, reduce the average amount of
time taken to resolve lawsuits and reduce the cost of malpractice
insurance. Specifically, I believe we must stabilize compensation for
injured patients, hold parties responsible for their degree of fault,
ensure that meritorious claims are swiftly resolved, encourage
compliance with accepted clinical practice guidelines, and guarantee
that medical care is available to those who need it the most by
providing protections to safety-net providers.
Unfortunately the leadership in the U.S. House of Representatives
made the choice to prohibit meaningful reform from being debated on the
House floor today. I sincerely regret that the majority decided to
bulldoze ahead without considering practical policy that will reduce
costs and produce significant savings in our health care system.
With common sense, bipartisan discussion, we can make straightforward
reforms to our health care system that will address the most pressing
problems. We can enact strong insurance market reforms that provide
consumer protections and promote transparency. We can ensure that those
with chronic conditions and preexisting conditions have coverage
through high-risk pools and reinsurance models. We can actually lower
the cost of health care and increase access to affordable coverage by
removing restrictive barriers on competition across state lines,
allowing businesses to pool together and get the same buying power as
their larger competitors, equalizing tax treatment for individuals
buying health insurance, and enacting meaningful medical liability
reform. We can put our Nation on the path to a healthier future by
focusing on prevention and wellness.
Today, the House majority has failed the American people. Now the
Senate has an opportunity to prevent this ill-conceived measure from
moving forward, and embrace the calls of the American people to unite
behind meaningful reforms that will reduce cost and increase access
without fundamentally altering the American economy.
Mr. KLINE of Minnesota. Mr. Speaker, at this time I yield 1 minute to
the gentleman from Florida (Mr. Bilirakis).
Mr. BILIRAKIS. Mr. Speaker, I rise today to oppose the Democrats'
government takeover of health care.
This bill will raise taxes on individuals and small businesses, cut
Medicare for seniors, and raise health care premiums. The bill raises
taxes by $730 billion and costs nearly $1.3 trillion. We literally
cannot afford this plan.
There is a better way, however. The Republican health care plan is a
responsible, targeted approach to reform. It doesn't raise taxes during
a recession or cut Medicare. It will lower premiums, making coverage
more affordable for families and employers while reducing the deficit
by $68 billion. Commonsense ideas like medical liability reform,
strengthening association health plans, and allowing people to purchase
health insurance across State lines will make health care more
affordable without breaking the bank.
The choice is simple. Mr. Speaker, I urge my colleagues to oppose
Speaker Pelosi's health care bill and support the Republican
alternative.
Mr. GEORGE MILLER of California. Mr. Speaker, I yield 1 minute to the
gentlewoman from Maryland (Ms. Edwards).
Ms. EDWARDS of Maryland. I thank the gentleman for yielding.
Mr. Speaker, I rise today in support of this historic legislation. It
is the most historic in a generation. H.R. 3962 will indeed change the
face of health care in this country. This bill really is not about
partisanship and it's not about politics, but it is about the American
people; and it's time for us to deliver on our promise to them.
As I've listened to my colleagues today talk about why this bill is
good for their districts for the uninsured, for men, for women, for our
seniors, I'm reminded that I was indeed once one of those uninsured. As
a young mother, I became so sick that I collapsed in a grocery store,
and I was taken to an emergency room. Without health care insurance, I
was treated. I was one of those uncompensated. Now it's time for me to
pay the American people back with a vote for comprehensive health care
reform.
This bill will take the burden off providers and Americans for paying
the cost of uncompensated care and safeguards for the health of all
Americans. It lowers costs and ends discriminatory insurance industry
practices such as denying women coverage for pregnancies or a history
of domestic violence.
Mr. Speaker, it's time for us to have the courage to rise above our
pecuniary interests.
Mr. KLINE of Minnesota. Mr. Speaker, at this time I'm very pleased to
yield 1 minute to my friend and colleague, the gentleman from Ohio (Mr.
Jordan).
Mr. JORDAN of Ohio. I thank the gentleman for yielding.
Mr. Speaker, how bad does it have to get? How bad does it have to get
before we stop the out-of-control spending? A $1.4 trillion deficit, a
$12 trillion national debt, a trillion dollars in bailouts and
stimulus, and now here we come again with $1.3 trillion takeover of our
health care system.
One of the things that makes this country so special, one of the
things that makes this country the greatest Nation in history is this
simple concept, that parents make sacrifices for their children so that
when they grow up, they can have life a little better than we did, and
then they in turn do it for the next generation, and each generation in
this country has done it for the one that succeeds them.
And now, unfortunately, what we are doing is borrowing and spending
and living for the moment and passing the bill on to our kids. It's
wrong and it should stop here.
Vote this bill down. Support the Republican alternative.
Mr. KLINE of Minnesota. Mr. Speaker, can I inquire as to exactly the
time remaining for each side.
The SPEAKER pro tempore. The gentleman from Minnesota has 5 minutes
remaining, and the gentleman from California has 5 minutes remaining.
Mr. KLINE of Minnesota. Mr. Speaker, I am pleased at this time to
yield 1 minute to the gentleman from Kansas (Mr. Moran).
Mr. MORAN of Kansas. Mr. Speaker, the Pelosi health care bill creates
111 new bureaucracies and it only cuts one program: Medicare.
I chair the Rural Health Care Coalition. I care about health care
especially as it affects rural States, rural

[[Page H12883]]

Americans like Kansans. And I have concluded that this bill will not
make health care more affordable or more accessible for rural America.
The standard by which I judge this is not a Republican plan or a
Democrat plan, but what is good and right for America.
I've concluded that coupled with all the other bad ideas of this
Congress--stimulus packages, bailouts, Cash for Clunkers, cap-and-
trade--we will be leaving our children with more debt, less freedom,
diminished personal responsibility, and fewer economic opportunities.
Worse, we will have failed to honor the dreams for a better life for
another generation of Americans. This I will not, cannot support.
Mr. GEORGE MILLER of California. Mr. Speaker, I yield 1 minute to the
gentlewoman from Texas (Ms. Eddie Bernice Johnson).

{time}  1930

Ms. EDDIE BERNICE JOHNSON of Texas. Mr. Speaker, I rise in strong
support of this bill, H.R. 3962, the Affordable Health Care for America
Act. It is a long time we should have been here. We have been trying
this for so very long.
You know, if this bill said anything as bad as what I have heard from
the Republicans, I wouldn't support it. But it does not do that. I
don't know what bill they are reading.
I want to share, though, that I know this will bring relief to my
constituents. In my district, there are 35.6 percent of the residents
uninsured, and the adjoining district, District 32 of Texas, has about
the same number, but we are on different sides for bringing that
relief.
The American people have heard so many untruths, they must be
confused. Having access, though, to better coverage will show them what
the truth is. This bill is a win for all Americans. I stand in strong
support of this legislation and urge my colleagues to vote in favor of
this bill.
Mr. KLINE of Minnesota. Mr. Speaker, I am pleased to yield 1 minute
to another physician, the gentleman from Louisiana (Dr. Fleming).
Mr. FLEMING. It has been mentioned many times during this debate that
the AMA and the AARP have endorsed this. However, the polls show that
the majority of physicians oppose this. And the polls say that the
majority of seniors oppose this bill, the Pelosi health care takeover.
Who is going to be hurt in this? Individuals will be required to pay
2.5 percent taxes or go to jail; 5.5 million of them will be
unemployed. Businesses will be required to pay 8 percent payroll tax,
and then an additional excise tax of 5.4 percent, bringing the marginal
rate to 45 percent. States will have an increase in unfunded Medicaid
mandate. Who is going to pay for that?
Mr. Speaker, seniors will see $500 billion, half a trillion dollars,
removed from their access to care.
I urge my colleagues to vote ``no'' on Pelosi health care.
Mr. GEORGE MILLER of California. Mr. Speaker, I yield 1 minute to the
gentlewoman from California (Mrs. Davis).
Mrs. DAVIS of California. Mr. Speaker, as chair of the Consumer
Protection Committee in the California State Assembly, I worked hard to
maintain and improve the protections and the rights that Americans
deserve.
In the health care industry, which is really the most important of
all sectors that deal with people's basic needs, millions of consumers
are being taken advantage of on a daily basis and have few rights.
This bill changes that. It changes that and it puts us on the track
of giving Americans and their families the peace of mind that they will
never lose their health coverage.
I look forward to voting on this historic bill which puts consumers
and puts Americans first.
Mr. KLINE of Minnesota. Mr. Speaker, I am very pleased to yield 1
minute to the distinguished gentleman from Oklahoma (Mr. Cole).
Mr. COLE. Mr. Speaker, I respect, like all Members do, everybody in
this House, from the Speaker and the minority leader right down to the
most junior Member. But the reality is, this isn't our House; this is
the people's House. As I have listened to my friends on the other side,
I have wondered, frankly, did you listen to what the people had to say
in August in meeting after meeting after meeting? Have you taken the
time to look at what they say in poll after poll after poll?
This is not an issue that has come on us suddenly. It is not a
crisis. The American people have had a chance to study the issue, read
the bill, and listen to the debate, and quite frankly, register an
opinion. If we listen to them today, Mr. Speaker, we will follow their
loud and insistent voice and vote ``no.''
Mr. GEORGE MILLER of California. Mr. Speaker, I yield 1 minute to the
gentleman from California (Mr. Farr).
(Mr. FARR asked and was given permission to revise and extend his
remarks.)
Mr. FARR. Mr. Speaker, I am ashamed on this great day of hope to hear
so much fear, fear outside and fear inside. And I don't think they know
fear. I know the fear of a woman carrying a baby dying because she has
no access to health care. I saw that over and over again as a Peace
Corps volunteer in Latin America.
Without health care, you can't start the day. You can't get up. You
can't cope. You can't go to work. You need health care.
Combat that fear. Combat those fearmongers out there. Stand up for
hope. Say ``yes'' to health care for all Americans. Vote ``yes'' for
compassion. Vote ``yes'' for care. Vote ``yes'' for healing and health.
Vote ``yes'' for my grandchildren.
Mr. FARR. Mr. Speaker, I rise in support of this historic bill and
ask unanimous consent to revise and extend my remarks.
My first exposure to real poverty was as a Peace Corps volunteer in
Medellin, Colombia. People there lived hard-scrabble existences, barely
eking out subsistence-level lives.
My role as a Peace Corps volunteer was to help the community organize
and petition its government for basic resources to improve the lives of
the people. What I learned in that barrio is that unless people have
shelter, unless they have food, and unless they have health care,--
yes--health care, there can be no stability in the community and no
confidence in the future. People need to have their health in order to
cope and to be productive.
The lesson I learned in Colombia 45 years ago is still true today in
the U.S.A., people in health care limbo can't focus on the future. They
are too busy worrying about today.
History teaches us that America was built on neighbor helping
neighbor. Colonists clung together in the New World and protected each
other. Settlers out West never turned away a traveler. I am ashamed and
amazed at the tone of debate today that would deny our fellow Americans
access to health care coverage. That is not the American way. When did
we become so selfish? At a time of historical hope why are we hearing
so much about fear?
There is nothing to fear--tomorrow or a year from tomorrow you will
still have you insurance policy, hospitals and doctors will be doing
their jobs of caring and healing and for the first time the hope for
health care for all will come true.
Tonight we are asked to make history--leadership is about getting
results. To make just law we have to vote yes. I am proud to say
``yes'' to health care for all in America. ``Yes'' to compassion and
care. ``Yes'' to healing and health. ``Yes'' to my grandchildren's
future.
Mr. KLINE of Minnesota. Mr. Speaker, at this time I yield 1 minute to
the gentleman from South Carolina (Mr. Inglis).
Mr. INGLIS. Mr. Speaker, I identify with the sentiments of the
gentleman who just spoke. The only problem is if you look at Martin
Feldstein's article yesterday in The Washington Post, what you see is
that we are going to have another problem with the cost of this, that
as folks have a problem with the cost shift continuing, we are actually
going to make insurance more expensive, and actually people are going
to lose coverage because they are going to decide to go bare until they
get sick, then access the guaranteed issue, then cause premiums to
rise, which will actually cause more people to be uninsured.
So the mandate here doesn't work because the penalties aren't high
enough in the mandate to keep people from deciding to go bare until
they are diagnosed with a problem.
The result will be that we actually end up with more people uninsured
and higher premiums. The bill needs to be rethought. That is the kind
of thing that we could develop in a collaborative process. That's not
the process here. That's why we have this problem.

[[Page H12884]]

Mr. GEORGE MILLER of California. I yield to the gentleman from
Massachusetts (Mr. Olver) for the purpose of making a unanimous consent
request.
(Mr. OLVER asked and was given permission to revise and extend his
remarks.)
Mr. OLVER. Mr. Speaker, I rise in favor of H.R. 3962.
Mr. Speaker, we often hear that America has the best health care
system in the world.
But, our health care system largely takes care of those who are lucky
enough to be able to afford it.
In the past decade, the premiums charged by private health insurance
companies have risen more than 75 percent while workers' wages have
risen less than 25 percent.
To add insult to injury, the profits of the 10 largest health
insurers have risen by 400 percent, and the salaries of their CEO's
have tripled.
America now has 50 percent higher health care costs than the highest
of the next 20 most industrialized nations.
Yet, Americans suffer the highest infant mortality rate among the G-7
countries. Our infant mortality rate is 50 percent above the average
for the other 6 countries.
American life expectancies are more than 2 years lower than the
average for the other 6 countries.
Clearly, we have the most expensive health care system in the world,
but, equally clearly we don't have the best.
We can and must do better. We must reverse these trends.
This is our chance to fix a broken system.
I am proud to vote in favor of H.R. 3962, the Affordable Care for
America Act.
For the 50 million Americans who still do not have health insurance,
this historic legislation guarantees you will have good insurance--
insurance that you can afford--which provides a sliding scale of
credits available to families that earn up to 400 percent of the
federal poverty standard, or $88,200 for a family of 4.
For those of us that are lucky enough to have health insurance, this
legislation LL provides added stability by immediately banning lifetime
caps and by 2013 eliminating pre-existing condition exclusions and
annual caps on insurance coverage. You cannot be denied coverage.
For those who are concerned about losing or having to switch jobs--
especially important in our current economy--this bill brings you added
stability. You will always have access to affordable, quality health
insurance.
For senior citizens on Medicare, H.R. 3962 protects your benefits. We
know that seniors live on largely fixed incomes. As such, this bill
puts money back into your pockets by reducing the donut hole
immediately by $500 and immediately cuts the cost of brand name drugs
in half for those who still find themselves in the hole. Furthermore,
the donut hole is completely closed by 2019. The bill provides free
Prevention and Wellness care and saves seniors money by reducing
copayments and cost-sharing.
Finally, H.R. 3962 makes major investments in primary care so that we
will have the critical infrastructure in place to efficiently combat
the steady rise of deaths from preventable illness in this country.
Between 1997 and 2002, when researchers compared preventable deaths--
from diabetes, cancer, and heart disease amongst others--in 19
industrialized countries, the United States placed last. During those
years alone, at least 75,000 men, women and children died because they
lacked access to quality preventive care. Furthermore, H.R. 3962 makes
new critical investments in training primary care providers, helping
them with overwhelming student loan debt and paying them well for their
service.
This is a historic time in our country's history. This bill makes the
critical investments that are needed to turn our health care system
around and provide the health care that our citizens deserve.
I am proud to cast my vote in favor of this monumental legislation.
Mr. GEORGE MILLER of California. Mr. Speaker, I yield 1 minute to the
gentleman from Tennessee (Mr. Cohen).
Mr. COHEN. Mr. Speaker, this debate in the House is part of a 97-
year-old debate in America. It started with a Republican, Teddy
Roosevelt, and continued with Democrats Harry Truman and Lyndon
Johnson, then a Republican, Richard Nixon, who, while short on
veracity, was great on policy and government. It continued through Bill
Clinton, and now we are in a day when we have a chance to accomplish
something worthwhile, something Daniel Webster tells us we should do
while we are here in our generation and our time, to do something
worthy of being remembered.
Theodore Roosevelt said, In this world the only thing supremely worth
having is the opportunity, coupled with the capacity, to do well and
worthily a piece of work, the doing of which is of vital consequence to
the welfare of mankind.
I plan to take my voting card, along with hopefully at least 218
others, and do something that Teddy Roosevelt would see as proper, and
provide health care for Americans.
The SPEAKER pro tempore. The gentleman from Minnesota and the
gentleman from California each have 1 minute remaining.
Mr. KLINE of Minnesota. Mr. Speaker, I yield myself the balance of my
time.
Mr. Speaker, let me just say that what we have before us here is a
true loss for American families seeking quality health care and
American workers seeking quality jobs. It is remarkable that our
colleagues believe 2,000-plus pages of more red tape, more power in the
hands of the super bureaucrat, more taxes will do anything other than
make health care more costly and more complicated and kill more jobs in
this country.
Why, when we have a 10.2 percent unemployment rate, the highest in a
quarter century, would we ever want to pass legislation that will
destroy millions of jobs? It defies logic. Why would we want to strip
Medicare from the seniors who depend upon it? Why would we want to pile
debt on our children and grandchildren? Why would we want to raise
health care costs? Why would we want to raise taxes? I have yet to hear
an answer to these questions.
This bill is not health care reform. The American people deserve
better than this. We can do better than this. Let's make the right
decision. Stop this Big Government takeover of health care and return
to the table for real reform.
I yield back the balance of my time.
Mr. GEORGE MILLER of California. Mr. Speaker, I yield to the
gentleman from Pennsylvania for the purpose of a unanimous consent
request.
(Mr. FATTAH asked and was given permission to revise and extend his
remarks.)
Mr. FATTAH. Mr. Speaker, I support this bill, and I thank the
chairman for yielding me the time.
Mr. GEORGE MILLER of California. Mr. Speaker, I yield 1 minute to the
gentleman from Minnesota (Mr. Oberstar).
Mr. OBERSTAR. Mr. Speaker, I have advocated a national health care
system as long as I have served in Congress. Today we take a decisive
step toward that goal.
This is not a perfect bill but a good bill. The three committees have
worked hard to address the needs of the people of my district, and my
own concerns, regional disparities in Medicare reimbursement that
penalize Minnesota health care providers, and ensuring taxpayer dollars
are not used to fund abortion services.
Last summer I met with the Skare family in Cloquet. Their son, born
with a congenital liver disease, required a liver transplant as a
child. Today he is 20 years old. The family is buried under mountains
of medical bills, despite having health insurance. They constantly have
to fight the insurance providers to make them live up to their
commitments. This bill will ensure that families like the Skares will
not be held hostage to insurance companies. It will protect all
Americans from being denied coverage due to preexisting conditions.
Today, we keep faith with the American people. Today we ensure that
quality, affordable health care is available to everyone. Support this
bill.
Mr. OBERSTAR. Mr. Speaker, throughout my service in the House of
Representatives, I have been a strong proponent for a national health
care system to ensure that all Americans have access to affordable
health care. Our current health care system is paradoxical. While our
nation can take credit for having the best trained health care
professionals and the most advanced medical devices, far too many
Americans do not have access to essential health care. Our current
health care system has failed this fundamental fairness principle, and
as a result, health care has been rationed in this country with more
than 46 million Americans without health insurance.
Long before the November 2008 elections and the beginning of this
Congress, there has been near universal agreement that health care
reform is necessary, and that the cost of inaction is unacceptable.
Today represents an important opportunity to make health care more
affordable and more accessible to more Americans.

[[Page H12885]]

Comprehensive health care reform involves more than just extending
access to the uninsured. The explosion of health care costs has created
tremendous challenges for the private sector that has hindered our
ability to compete in the global marketplace. Additionally, it is
imperative to constrain health care spending that consumes an
unsustainable percentage of our federal budget. Health care reform is
vital to the nation's economic recovery and fiscal responsibility.
I commend the leadership of the three committee chairman who have
worked tirelessly to craft legislation to repair what is not working
well and preserve what is working in our health care system. Thank you,
Charlie Rangel, Henry Waxman, and George Miller for your dedicated
efforts to seize this historic opportunity and produce a sensible
health care bill that builds upon and improves the employer-provided
and private health insurance market.
I am very pleased that the House health care bill (H.R. 3962)
includes many essential reforms that will improve health care. The
health insurance provisions to ensure that Americans will not be denied
coverage due to a pre-existing condition, the requirement for
guaranteed issue and renewal, and the limit on out-of-pocket spending
are much needed reforms that will make health insurance more available
and affordable. For seniors, I strongly support the funding to close
the donut hole in the Medicare Part D prescription drug program.
I am also delighted that H.R. 3962 contains provisions to address the
historic disparities in Medicare reimbursement that have long penalized
Minnesota and other high-quality, low-cost states. I greatly appreciate
the dedicated work of my colleagues in the Quality Care Coalition
(Betty McCollum, Ron Kind, Bruce Braley, Jay Inslee) to include
language that will promote Medicare geographic equity. I believe that
the requirement for the Secretary of Health and Human Services to
implement the recommendations of an Institute of Medicine study will
lead to Medicare payment reform that will reward value, not volume.
This payment reform is one of my biggest priorities because in 2007,
Medicare paid Minnesota hospitals $1 billion below the actual cost of
care.
While I am very pleased that the House will have the opportunity to
vote on amendment to ensure that taxpayer dollars are not spent for
abortion, I am disappointed that several important amendments were not
made in order. It was expected that the House would consider an
amendment that would create a single-payer system for health care.
While I continue to have great concerns about a single-payer system
based on Medicare rates, I would have supported the single-payer
amendment. I am disappointed that the Kucinich amendment which was
supported in the committee mark-up to enable states to develop their
own innovative state programs was stricken from the bill, and we do not
have the opportunity to restore this language.
I am also disappointed, however, that the House health care bill does
not contain a number of important policy reforms recommended by the
National Rural Health Association (NRHA). The NRHA made more than ten
specific recommendations regarding longstanding payment inequities that
were unfortunately not addressed in this bill. I am especially troubled
that several rural health improvements that were accepted in committee
mark-up were not included in the updated House bill. It is essential
that provisions to ensure rural representation on MedPac, and
improvements in the 340B Drug Pricing program and the super rural
ambulance reimbursement are restored in conference. I am also hopeful
that the final conference report will include legislation that
Minnesota's Senators and I have authored to provide Critical Access
Hospital designation for a hospital in Cass County, Minnesota which I
hope the Senate will include in their bill.
I strongly believe that Minnesota's leadership in health care reform
should serve as a model for national reform. Minnesota is unique in
requiring all health maintenance organizations (HMOs) to be nonprofit
as a condition of licensure. Minnesota extended health care coverage to
lower-income children long before the enactment of the federal SCHIP
program, and Minnesota has done a better job in expanding access to
care through its MinnesotaCare program than the rest of the nation.
Minnesota has led the nation on integrated health systems to coordinate
care, and a new partnership between Fairview Health and the Medica
health insurance company that provides payment incentives to invest in
health care rather than paying for ``sick care'' demonstrates
Minnesota's continued leadership that is far ahead of national
policymakers.
Even with the expected improvement in Medicare reimbursement that
will benefit Minnesota, I am concerned in many respects that Minnesota
is picking up the tab to pay for national health reform. While I
understand and support the need to reduce the excessive payments in the
Medicare Advantage program, it is far easier for high-cost states to
absorb a 14 percent cut than for Minnesota which receives significantly
less in Medicare Advantage payments. I am also concerned with the
addition of a tax on medical devices that will negatively impact
Minnesota's important medical device industry, as well as changes in
the second generation biofuel producer credit that will preclude
``black liquor'' from eligibility for this biofuel credit that will
impact the wood product industry in Minnesota. I will strongly
encourage modifications in the financing in the final version to ensure
fairness for Minnesota.
During the thorough discussion and debate regarding health care this
year, I have greatly appreciated the opportunity to visit with
constituents in Minnesota and in Washington. From seniors and health
care providers to organized labor, the small business community and the
faith community, I have gained valuable insights and recommendations to
improve this legislation.
While I recognize and understand there are still many issues that
need to be addressed, I am prepared to support this legislation today
to move this necessary process forward.
Mrs. LOWEY. Mr. Speaker, I rise in support of the Affordable
Healthcare for America Act.
Over the last eight months, I have communicated with tens of
thousands of my constituents in Westchester and Rockland Counties in
meetings, conference calls, round-tables, telephone town halls, and
neighborhood office hours.
Among people from of all walks of life--small business owners,
doctors, patient advocates, and seniors--one constant is the passion
which most agree on the need for health care reform despite different
opinions on how best to achieve reform.
Since 2000, personal premiums have more than doubled.
Since 1987, the cost of the average family health insurance policy
has risen from 7 percent of the median family income to 17 percent.
In 2007, 60 percent of all U.S. bankruptcies were due to medical
costs.
The U.S. is on track to spend nearly $33 trillion on health care over
the next decade.
The financial security of our families, businesses, and our overall
economy depends on meaningful health care reform.
That's why I will support this bill today to:
Provide health coverage to approximately 36 million Americans,
including 39,000 residents in my congressional district.
Help small businesses who are struggling to provide coverage to their
employees while exempting 86 percent of the smallest businesses from
the requirement to do so.
Ensure that reform is fully paid for while exempting 99.7 percent of
all American households from paying a health care surcharge.
Guarantee additional protections to those who have insurance,
including ending discrimination for pre-existing conditions; limiting
annual out-of-pocket costs; and preventing health insurance companies
from dropping your coverage if you become sick.
Improve and strengthen Medicare.
Now, this bill is not perfect. I am deeply disappointed that the
House approved language which puts new restrictions on women's access
to abortion coverage in the private health insurance market even when
they would pay premiums with their own money.
If we want to reduce abortions we should give millions of women
health coverage so they can get regular reproductive care,
contraceptives to prevent unintended pregnancies, and prenatal care to
ensure healthy pregnancies.
Despite this damaging provision, we must move forward in improving
health coverage for those who have it, providing coverage for those who
don't, and controlling costs throughout the system.
I urge my colleagues to support this legislation.
Mr. LOEBSACK Mr. Speaker, this August and September I held 16 town
halls across the 2nd District of Iowa. I heard from countless Iowans
about the need to change the current health care system. Though some
disagreed with provisions in the original House proposal, almost
everyone agreed that the fact that a family in Iowa pays an extra
$1,100 per year in premiums to support a broken system was
unacceptable. So I am proud to be a part of a Congress that decided the
status quo is no longer acceptable. Iowa families want stable health
care coverage that can't be taken away, they want greater choices, and
they want to know that if they get sick they won't be forced into
bankruptcy. The Affordable Health Care for America Act answers these
calls to action and I'm proud to support a bill that is good for
Iowans.
This legislation keeps what works in the current system and fixes
what doesn't. If you like your current health insurance and you like
your doctors you can keep them. If you don't have health insurance, you
will be able to acquire it. In fact, some of the greatest changes from
the original House proposal to the bill we are considering today are
the immediate reforms. We aren't saying wait for coverage, we

[[Page H12886]]

are saying the status quo is not fair and we will no longer tolerate it
starting right now.
There will be help for hardworking families now. The revised bill
immediately creates an insurance program with financial assistance for
those who have been uninsured or denied coverage because of pre-
existing conditions, and fills the gap until the Health Insurance
Exchange is up and running. The bill immediately prohibits health
insurance companies from rescinding coverage. If you find out you are
sick one day, you don't have to worry that your health insurance will
be taken away the next.
The revised legislation also immediately prohibits health insurers
from utilizing lifetime limits on benefits, and extends COBRA
eligibility to permit individuals to remain in their COBRA policy until
the Health Insurance Exchange is up and running. America's Affordable
Health Care for America Act also makes immediate changes to improve the
health and well being of our seniors. The legislation begins closing
the Medicare Part D Donut Hole in January. There will also be an
immediate 50 percent discount for brand name drugs in the donut hole.
In addition to the immediate benefits, this legislation takes a
comprehensive approach to long-term reform. I am a native Iowan, and
since I came to Congress I have been committed to fixing the broken
Medicare payment system. The geographic disparities in the system have
caused problems not only for providers in my District, but also for the
patients.
I have always been proud of how hospitals in my District have
achieved so much under the constraints of the current Medicare payment
system. With some of the lowest reimbursement rates in the country,
they provide some of the highest quality care. However, the current
system is broken and now I'm proud to say that the Affordable Health
Care for America Act reforms Medicare payments so that they are based
on the quality of services rather than the quantity of services. This
fix benefits not just Iowa, but all of America.
I also want to mention another provision with direct benefit to Iowa
in this legislation. According to a 2008 Institute of Medicine report,
Retooling for an Aging America: Building the Health Care Workforce, in
the near future, the nation will be aging dramatically, leading to an
increase of older adults from 12 percent of the U.S. population in 2005
to almost 20 percent by 2030.
As the population ages, their health care needs will increase, and
they will need additional supports. In the same report, it's stated
that meeting the demand that is expected in coming years will require
expansion of the roles of many members of the health care workforce,
including technicians, direct-care workers and informal caregivers, all
of whom already play significant roles in the care of older adults.
I was very pleased to have language included in this bill that takes
much needed steps towards meeting these workforce demands, as well as
other projected long-term health needs. The provision encourages the
identification, promotion, and implementation of investments in the
long-term care workforce and assists States in developing comprehensive
state workforce development plans.
It also creates a Workforce Advisory Panel which will identify core
competencies for long-term care workers and recommends training
curricula and resources for these workers. The bill also creates a
demonstration project to evaluate the Panel's recommendations. In
addition, this legislation improves assistance to family and informal
caregivers, and improves the dissemination of information to seniors
regarding their long-term care health insurance options.
In a recent guest column in the Des Moines Register, John Hale from
the Iowa Caregivers Association, highlighted the efforts that Iowa has
already undertaken on long-term care workforce shortages and spoke
about the national need to address these issues. Mr. Hale stated that,
``Access to coverage does not equal access to care.'' I could not agree
more.
Federal support is essential in helping all states continue to look
at both workforce shortages and the core competencies that should be
required of those in the field. I have said many times in the past
weeks and months that quality health care is the key to patient
outcomes. I am glad this legislation takes much needed steps to support
our long-term care workforce.
There are many more important provisions in this legislation and in
the coming days, weeks, and months I look forward to discussing this
bill, and what it does for Iowans, with my constituents. I look forward
to voting for the Affordable Health Care for America Act, and
abolishing the status quo.
Mr. WESTMORELAND. Mr. Speaker, on this bill the Congress is scheduled
to vote on today will cost more than $1.3 trillion over the life of the
bill.
It'll expand entitlement spending, it'll raise taxes on small
business payrolls, it'll cost jobs by mandating coverage that some
businesses can't afford, it'll put government in between the doctor and
the patient, and it'll cut Medicare funding. By expanding Medicaid
eligibility, the legislation puts new burdens on states that already
are struggling to pay their bills. The states share the cost of the
Medicaid program, and this could cost my home state $2 billion to $4
billion over the next 10 years. That's a huge share of Georgia's state
budget, and it's a cost we simply can't bear.
But, luckily, there is a better way. Republicans are providing that
alternative, although the Democrats continue to insist we're not
offering ideas. We are. They just don't want Americans to know it.
Ms. SPEIER. Mr. Speaker, today, I look forward to keeping my promise
to the voters and taxpayers who sent me to Congress by casting a vote
for a historic health care reform bill that has been sixty years in the
making.
Still, with any effort as far-reaching as reforming health care,
Americans are right to ask: ``What's in it for me?''
Well, I'll tell you.
If you are a woman, this bill has plenty for you. You know, far too
well, that our fight for equality is not limited to the board room. We
must fight for our rights in every line of fine print in every
insurance contract. The fact is that women's health care premiums cost,
on average, more than 145 percent of the price of a similar man's
policy. Even then, women are more likely to be denied coverage for a
pre-existing condition, including for things as common as getting
pregnant (or the inability to get pregnant) having a c-section, even
being a survivor of domestic violence. With the passage of this health
care reform bill, these practices will be tossed on the ash-heap of
history atop corsets, chastity belts and other limitation on women's
rights and equality. In fact, with this bill, America's mothers, wives
and sisters will finally enjoy the same health care coverage that their
fathers, sons and brothers have.
If you are an American of retirement age, this health care reform
legislation contains provisions that ensure high quality, effective
health care throughout your retirement years. We have heard your
frustrated calls to end the ill-conceived Medicare Part D donut hole
and responded by immediately reducing the hole by $500 and, by 2019,
getting rid of it once and for all. The bill also cuts in half the cost
of name-brand drugs. No older American should ever have to decide
between purchasing food or the life-saving medicine prescribed by their
doctor.
When Congress voted for Medicare nearly 45 years ago, this House
promised seniors quality, affordable health care in their retirement.
They did this despite a future president, Ronald Reagan, decrying
Medicare as socialism--sound familiar?
Well, by cutting waste, fraud and abuse, eliminating the out-of-
pocket payments for preventative care and banning overpayments, this
Congress is making good on that promise and extending the Medicare
trust for future generations.
If you are one of the 14,000 Americans who lose their health
insurance coverage every day, this bill offers comfort and hope when
you are most in need. Just last night during a telephone town hall a
constituent told me how, at 55 years old, she lost her job and her
health coverage. She wonders if, even after the economy recovers, she
will be able to get a job--at her age--that provides health care.
Today, when workers like her lose their job and their coverage, they
are forced into the snake pit that is the individual insurance market
where insurance company practices like denying coverage because of a
preexisting condition are common. Fortunately this practice, along with
dropping customers once they fall ill, has been outlawed in this bill.
Also, while the health care exchange--which will provide access to
affordable, quality health care--is being set up, a high-risk insurance
pool will be available so that you have coverage in the meantime.
For the majority of Americans who have health insurance through their
employer, you get the best news of all. I don't have to tell you that,
since 2000, employer-sponsored health insurance premiums have more than
doubled. Your employer's real health care costs have risen at a rate
that is three times faster than wage increases and business profits.
This is, quite simply, unsustainable. If we took a page from the
opposition party and did nothing, the cost of employer-sponsored family
health insurance plans would reach $24,000 in less than ten years. This
same price spike would result in families spending 45% of their income
on health insurance. Also, the insurance exchange will allow you or
your employer to purchase coverage from health plans that meet
guaranteed benefit levels, cap annual out-of-pocket spending and end
annual and lifetime benefit limits. There will also be a public option
that is completely self-supported by premiums.
This is not a decision that has been made in haste. No issue has been
studied, scrutinized and debated more than health care reform. And,
like every time in our nation's history when sweeping changes are
proposed--

[[Page H12887]]

whether it be Social Security, Medicare, civil rights, women's suffrage
or the creation of the Veterans Administration--emotions have run high
in this debate and there has been no shortage of opinions on every
side.
The bill we are set to vote on is a compromise between many different
points of view. It is the result of the most exhaustive and transparent
review process of any bill in our nation's history, with hundreds of
hours of bipartisan committee meetings being devoted to it and the
final text being posted on-line more than three days prior to a vote
being taken. Compare that to the Republicans Medicare Part D bill in
2003 which was forced to a vote just hours after the bill was printed.
It will be a proud day for this Congresswoman--and for America--when
Congress finally sets our nation on a path toward greater access,
greater equality and greater accountability and competition in our
health care system.
This is what my constituents sent me here to do. And I am happy to
oblige.
Mr. LATHAM. Mr. Speaker, everyone agrees that health care costs too
much in this country, but we can fix the problem without a trillion-
dollar government takeover of health care. The bill before us now takes
us in the wrong direction. It slashes Medicare and pins small
businesses with job-killing taxes and mandates, at a time when our
economy is struggling and unemployment is over 10 percent.
More federal controls on the content of insurance policies have
nothing to do with covering the uninsured and will increase costs for
most families rather than decrease them. If you have coverage through
an employer, your premiums will go up. If you have an individual
policy, you will have to switch to a federal exchange plan in 2013 or
face a fine or, possibly, jail time for not having federally qualifying
coverage that you may not be able to afford. Younger people in
particular could see their premiums increase by more than 70 percent.
Instead of taking the approach we are taking today, we should
implement common-sense reforms that focus on covering the uninsured and
lowering health care costs. We must ensure those with pre-existing
conditions get quality coverage. We can lower costs by requiring
insurance companies to compete nationwide, and we can clamp down on
frivolous malpractice lawsuits. Most of the uninsured work for small
businesses that cannot afford health insurance for their employees, and
we should allow small businesses to pool together for lower premiums.
Such reforms have bipartisan support and could be enacted immediately
to provide relief for millions of Americans struggling with health
insurance costs.
On another note, this bill contains no guarantee that Iowa's
Medicare reimbursement rates--which are among the lowest in the
country--will see any sort of increase. At the same time, this bill
specifically increases Medicare payments in 14 counties in California,
the home state of Rep. Henry Waxman, one of this bill's main authors.
This may be viewed as reform by some, but it is certainly uneven reform
for those counties in our districts that do not benefit from such
increases.
Throughout the summer and early fall, more than 12,400 residents of
Iowa's 4th Congressional District responded to my health care survey. A
majority were unsatisfied with the state of health care in America, and
rightly so. More than 70 percent of respondents ranked cost as the most
pressing concern regarding health care in the United States, followed
by access at 14.6 percent and quality at 8.4 percent. However, 86
percent described the quality of their personal health care as either
``excellent'' or ``good'' and they do not want to be forced to give up
coverage they are satisfied with. Some 65 percent said the government
should play ``no role'' or a ``minor role'' in determining health
insurance options for Americans. My constituents support common sense
solutions. Approximately 64 percent support doing away with exclusions
for preexisting conditions, 75 percent thought people should be allowed
to purchase health insurance across state lines, and 69 percent support
small business health plans.
To sum it all up, this bill is clearly not what is advertised by its
supporters and it is not what my constituents want. We need to go back
to the drawing board and produce a bill with common-sense solutions
that the vast majority of Americans support.
Mr. CASSIDY. Mr. Speaker, I have spent 20 years caring for the
uninsured in Louisiana's public hospital system.
Skyrocketing costs put quality care out of reach for too many
Americans, and I appreciate that everyone agrees the status quo is
unacceptable.
All agree on the goals of reform: lower costs and expand access to
quality care.
Unfortunately, this bill does not achieve our goals.
The Congressional Budget Office says it raises costs.
Without lowering costs, access or quality will suffer.
Its effects will be radical, but this is not a radical bill.
It turns insurance bureaucrats into federal bureaucrats.
There's no innovation, just nationalization.
Real reform would revolutionize health care.
Real reform would give patients, not bureaucrats, the power.
Unless patients are empowered with control over health care dollars
and decisions, costs will not be lowered and access will not be
expanded without sacrificing quality.
The road to real health reform begins with stopping this bill today.
I urge my colleagues to join me in this effort.
Mr. PRICE of North Carolina. Mr. Speaker, as the House of
Representatives approaches this historic vote, my mind travels back to
the formative years when I first became engaged in politics, and also
to hundreds of meetings I have had with constituents since the citizens
of North Carolina's Fourth district first sent me to Congress.
I came of age as the civil rights movement of the late '50s and early
'60s swept across the country. It shaped and transformed my social,
religious, and political views. I remember the culminating moment in
1964 when, as a Senate staff member, I crowded into the gallery and
witnessed the dramatic passage of the Civil Rights Act of 1964.
That momentous bill marked an expansion of democracy and of access to
opportunity for millions of Americans. Today's vote is also momentous,
and it also marks an expansion of democracy's promise. Today we resolve
that never again will American citizens be denied access to health
insurance, and that one of life's most basic needs--health care--will
be available to all of our people.
As I think back on my years of congressional service, I remember
meetings with parents terrified at the prospect that their children
with serious illnesses would not be able to obtain coverage when they
reach adulthood. I remember maddening stories of families coping with
illness while simultaneously fighting with insurance companies. I
remember young adults unable to buy affordable insurance, often because
of allergies or other minor conditions. I remember retirees not yet
eligible for Medicare being quoted rates of thousands per month because
of their health history.
Mr. Speaker, we have all heard these stories. They are unworthy of
our country. And today we have the opportunity to bring such hardship
and heartache to an end. The American people deserve a health care
system that works for them--one that provides access to stable
coverage, quality care, and affordable premiums and copayments. The
legislation before us today will correct the failures of the American
health care system without compromising its many strengths or adding to
the budget deficit.
If you have coverage at work, you'll be able to keep it--but the loss
of a job will no longer mean the loss of affordable coverage. And your
insurance company will no longer be able to impose lifetime benefit
limits; discriminate on the basis of age, gender, or pre-existing
conditions; or cancel your policy if you get sick.
If you have coverage through Medicare, you'll have more benefits and
lower out-of-pocket costs, including no more copayments for preventive
and many diagnostic services, and a 50 percent discount on your brand-
name prescriptions, and a progressive closing of the gap in coverage
known as the ``doughnut hole.''
If you don't have coverage at all, you'll be able to buy it on the
National Health Exchange at the same affordable group rates that big
companies have always been able to negotiate for their employees. And
you'll have more than one choice, so that companies will have to
compete for your business instead of the other way around.
Landmark reforms--Social Security, Medicare, Medicaid--these things
do not come easily. We were sent to Congress this year to do what is
difficult. Despite the efforts of some shrill voices, we are on the
verge of overcoming the special interests that halted reform more than
a decade ago, to deliver on landmark legislation that will make a
positive difference in the life of every American. It is an historical
moment, an essential investment in our nation's long-term fiscal and
economic well-being, and it's long overdue. I urge my colleagues to
vote yes on the Affordable Health Care for America Act.
Mr. BACA. Mr. Speaker, today is a historic day for all of us.
As Members of Congress, it is our duty to pass real healthcare reform
this year.
The American people are suffering.
47 million people lack even the most basic care, and for those lucky
to have insurance--their premiums have more than doubled over the last
10 years.
Perhaps no state is in greater need of this reform than my home state
of California.
217 thousand people in my Congressional District go everyday without
insurance.

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And for California as a whole--we have 13 million uninsured
residents.
The people of California, and people across the United States need
health care reform that: ends discrimination based on pre-existing
conditions; ends dropped healthcare coverage because you get sick; ends
co-pays for preventative care; and ends skyrocketing costs for
individuals and families.
The Republican alternative does none of these things.
It simply keeps the status quo! It does nothing to provide quality,
affordable health care to the American people.
The 217,000 people living in my District without insurance cannot
afford inaction any longer.
The 13 million people in California without insurance cannot live
with the status quo.
The 15 hundred families in my District who went bankrupt because of
health costs cannot afford the status quo.
Now is our opportunity to make history--and to move America forward.
We must not be short-sighted and focus only on politics and polls.
As a Christian--my faith teaches me we must love and care for our
fellow man, as if they were our brother or sister.
I know that fixing our broken health care system is not just an
economic issue--it is also a humanitarian and a moral issue.
I am especially pleased that today's bill includes the Indian Health
Care Improvement Act.
As a Member of the House Native American Caucus and the Natural
Resources Committee--I have been a strong supporter of ending the
health disparities that exist on our reservations.
I will close my statement by again stressing the importance of this
historic moment.
We passed Social Security in 1935. We passed Medicare in 1965.
I urge my colleagues to stand with the American people and pass
legislation in 2009 that will make quality, affordable health care a
right for all Americans.
Mr. LANCE. Mr. Speaker, this evening members of the U.S. House of
Representatives are being asked to vote on legislation that
dramatically revamps our Nation's health care system.
This 2,000-plus page, $1.3 trillion Democratic health care proposal
is a measure that raises individual and business taxes and reduces
funding for Medicare.
H.R. 3962 increases spending by more than $1 trillion at a time when
our levels of debt and deficits are at all-time highs.
The bill imposes a 5.4 percent ``surtax'' on thousands of individuals
and families in my congressional district during an economic recession
and when New Jerseyeans are paying some of the highest federal, state
and local property taxes in the country.
The health care bill levies at 2.5 percent tax on the Garden State's
medical device industry that employs more than 300,000 in New Jersey
alone at a time when New Jersey's unemployment rate is nearly 10
percent.
The measure ignores common-sense malpractice reforms while cutting
Medicare by nearly $500 billion leading the Medical Society of New
Jersey and its doctors and medical professionals to come out in
opposition to H.R. 3962.
In short, this bill, If signed into law, will be harmful to New
Jersey's taxpayers, seniors and businesses. As such, I rise in strong
opposition to this measure.
But make no mistake--I support health care reform.
Like the majority of my colleagues I strongly support health care
reform. But not the reform we will be voting on this evening.
I stand in support of common sense steps to broaden health care
access and responsible solutions that address the rising cost of health
care.
I believe reform ought to include portability--allowing people to
keep their health insurance whether they change jobs or move to a
different state. And no one should be denied coverage for preexisting
conditions.
Yet the call for common sense health care reform should be one that
our Nation can afford.
The Republican substitute offered by House Republican Leader John
Boehner is a fiscally responsible alternative health care reform
measure that reduces costs and expands insurance coverage without
raising taxes, rationing care or putting the government between patient
and doctor.
The Republican reform bill includes medical liability reform that
will seek to end junk lawsuits that force doctors to practice defensive
medicine driving up health care costs.
The GOP alternative will allow families and businesses buy health
insurance across state lines while also allowing individuals, small
businesses and trade associations to pool together and purchase health
insurance at lower prices.
It levies no taxes on New Jersey's medical device industry and
includes important safety provisions concerning innovative biologic
drugs by requiring research and clinical trials before the Food and
Drug Administration can approve generic biologics.
To maximize safety, I believe that research and those clinical trials
should be conducted within the United States. By creating this process
for approval of innovative biologic drugs we protect the health and
safety of patients, lower health care costs and provide adequate
incentives for innovation to ensure that New Jersey continues to be the
``Medicine Chest of the World.''
These are ideas that have strong, bipartisan support but most are
absent from the Democrats' new reform legislation.
Instead of focusing on fiscally responsible reforms that have
bipartisan support, the Democratic Leadership has chosen a path that
ignores good ideas from the Republican side of the aisle.
The Republican substitute is the only health care reform measure that
improves what is working in our health care system and fixes what is
broken in a fiscally responsible manner without raising taxes or
increasing our ever-growing debt and deficit.
Mr. WILSON of South Carolina. Mr. Speaker, I have criticized many of
the provisions of this bill (H.R. 3962) and rightfully so. But in
fairness, I do believe the sections relating to the creation of a
market for biosimilar products is one area of the bill that strikes the
appropriate balance in providing lower cost options to consumers
without destroying a healthy and functioning industry in this country.
These provisions were one of the few areas in the bill adopted on an
overwhelming bi-partisan vote for the Eshoo-Inslee-Barton (EIB)
amendment in the Energy and Commerce Committee.
Creating a pathway for new products that doesn't destroy the ability
or the incentives for innovator companies to develop breakthrough
technologies and at the same time providing a safe and effective way to
bring competition to benefit patients is a laudable achievement. I wish
we could remove this provision from this fatally flawed piece of
legislation and consider it separately because it would pass with the
kind of overwhelming bi-partisan support that Americans across the
country wish to see.
However, these provisions are only the first step in a long path to
the marketing of these new products. New research and clinical testing
will have to occur and the FDA will write rules that will ensure this
research is done safely and effectively. One of the reasons I have long
supported the U.S. biotechnology industry is that it is a homegrown
success story that has been an engine of job creation in this country.
Unfortunately, many of the largest companies that would seek to enter
the biosimilar market have made their money by outsourcing their
research to foreign countries like India. With this weeks devastating
news that unemployment has reached 10.2 percent it is critical that we
preserve jobs in the United States. While the innovator's have created
jobs here, these generic companies have shipped them overseas, so they
can turn around and sell cheap knockoffs of innovative American
products.
As this new market launches in the U.S., we need to ensure that we
foster innovative products in this country for the creation of jobs and
research that will go into proving whether these products are
interchangeable with the innovators products. I have my doubts that
these companies can create such interchangeable products, but I am
certain that the research and testing of whether or not they can should
occur in this country and not somewhere across the globe. Testing and
research on these interchangeable biosimilars should occur in this
country to ensure that it is done properly and safely and to benefit
our economy.
Mr. SMITH of Texas. Mr. Speaker, although the Democratic Leadership
has had several months to address the concerns voiced by countless
Americans, the latest health care reform bill is no better than the
last.
I support health care reform; however, this bill goes far beyond
fixing the problems we all know need to be addressed and it fails to
enact true health care reform.
Skyrocketing costs have crept into our health care system, creating
uncertainty about the future of health care for employers, working
Americans, and the uninsured. Americans need more, not fewer, choices
for something as important and personal as health care.
Americans are concerned with cost, choice, quality and access of
health care and Congress should work to address these concerns. Any
legislation considered should attempt to make our health care system
more accountable and accessible to patients.
This legislation expands coverage with a government takeover of the
health care industry funded by new taxes and massive cuts to Medicare.
The nonpartisan Congressional Budget Office and Joint Committee on
Taxation estimate that H.R. 3962 would require over $550 billion in new
taxes on individuals and small businesses.
CBO also estimates that this legislation will lead to $33 billion in
penalties for uninsured

[[Page H12889]]

individuals and $135 billion in penalties for employers under the
government mandate or ``pay or play'' requirements.
Raising income taxes on hard-working Americans and threatening small
businesses with penalties to fund a government takeover of health care
is a terrible prescription for a troubled economy.
In order to pay for this government takeover of health care,
Democrats also have proposed cutting more than $500 billion in Medicare
spending. The plan also includes an expansion of Medicaid that will
cost cash-strapped States $34 billion over the next 10 years.
I believe Congress should pursue reform in terms of costs and access,
but the legislation advanced by Democratic leaders is equal parts
faulty premise and flawed logic. Their legislation will increase health
care spending, limit choice, and cut Medicare benefits.
The current health care proposal being considered by Congress will
lead to higher costs, rationing of care, higher taxes on families and
small businesses, elimination of jobs through punitive taxes on small
businesses, granting of unchecked power to a new ``health care choices
commissioner,'' elimination of choices for patients, tax-payer funded
abortions and a government panel placed between doctors and patients.
Americans deserve the freedom to choose the type of health care that
is best for them and their families.
During his campaign, then-Senator Obama promised that he would ``have
all the negotiations around a big table'' and ``televised on C-SPAN''
to ``allow people to stay involved in this process.'' Yet the
negotiations and decisionmaking process have taken place behind closed
doors with the media and American people shut out.
That is why the bill lacks bipartisan support. In fact, there is
bipartisan opposition to the House Democrats' government take-over.
Rather than increasing taxes and rationing care, the President needs
to address medical liability reform, which is one of the biggest
sources of waste and added cost.
Frivolous lawsuits force physicians to practice defensive medicine
and carry expensive malpractice insurance, the cost of which is passed
on to patients. Uncapped lawsuit awards paid by insurance companies
also get passed on to patients as higher premiums.
It is a disservice to the American people that this legislation fails
to include the legal reforms that are necessary to make any expansion
of health care coverage financially sound.
Unlimited lawsuits enrich trial lawyers while increasing the cost of
health care for everyone. Unfortunately, we now know that opposition by
trial lawyers is the reason tort reform has been excluded from all the
Democrats' health care proposals, including the one we will be voting
on today. Former Democratic National Committee Chairman Howard Dean
said the following publicly at a recent town hall meeting: ``[T]he
reason why tort reform is not in the bill is because the people who
wrote it did not want to take on the trial lawyers . . . and that is
the plain and simple truth.''
That political opposition, which Governor Dean admitted is not based
on the merits but on raw self-interest, flies in the face of the facts.
The CBO estimates that enacting tort reforms nationwide would result
in a reduction of medical malpractice insurance rates by 25 percent to
30 percent. And according to the Government Accountability Office,
rising litigation awards are responsible for skyrocketing medical
professional liability premiums.
Lower premiums mean Americans will pay less to have better health
care.
The President of the American Medical Association said ``If the
[health care] bill doesn't have medical liability reform in it, then we
don't see how it is going to be successful in controlling costs.''
And the President's own doctor of over two decades supports tort
reform. He said regretfully that ``I once briefly talked to [the
President] about malpractice, and he took the lawyers' position.''
In the handful of States that have enacted tort reform, health care
costs have fallen, and the availability of medical care has expanded.
In my home State of Texas, premiums fell by 30 percent, and more than
14,000 doctors returned or set up new practices in the state.
To give just one example, a charitable hospital group in Texas that
serves the poor and underserved reported that since Texas enacted tort
reform, its legal costs have gone from $153 million per year to just
$2.3 million last year.
Doctors are so concerned about frivolous lawsuits that they order
unnecessary--and expensive--tests and procedures that are of no benefit
to the patient.
HHS estimates the national cost of defensive medicine is more than
$60 billion. The Congressional Budget Office just issued a report that
concludes it costs $54 billion. The costs of litigation and defensive
medicine are then passed off to the patient in the price of health
care.
If tort reform were enacted, trial lawyers would stand to lose one of
their primary sources of income: medical malpractice suits, which are
often just a form of legalized extortion. But all Americans would gain,
and tens of billions of dollars would suddenly be freed up and could be
used to help provide health insurance to the uninsured.
Regrettably, the Democrats' health care bill not only fails to
contain any of the tort reforms the CBO concluded would save at least
$54 billion in health care costs, but also contains a provision that
bribes States with Federal taxpayer dollars not to enact such reforms
in the future. It explicitly prohibits tort reform ``demonstration
project'' funds from going to States that put limits on damages or
attorneys' fees.
Section 2531 of the Democrats' bill states that ``the Secretary [of
HHS] shall make an incentive payment . . . to each State that has an
alternative medical liability law in compliance with this section,''
but then goes on to say a state can take advantage of such funds only
if ``the law does not limit attorneys'' fees or impose caps on
damages,'' which are exactly the tort reforms the CBO concluded yield
real health care costs savings.
That is not only a blow to State reform efforts. It is a federally
funded bribe discouraging states from enacting real reform and a giant
bailout for trial lawyers.
H.R. 3962 also contains two antitrust provisions that are within the
House Judiciary Committee's jurisdiction: Sec. 262, which repeals the
McCarran-Ferguson Act for health and medical malpractice insurers, and
Sec. 2573, which codifies a ban on settlements between name brand and
generic pharmaceutical manufacturers in the context of Hatch-Waxman
litigation. Neither provision was given due consideration in the
Judiciary Committee, and their unintended consequences could have
significant negative impacts on the cost and availability' of both
insurance and medications.
My basic concerns with Sec. 262 are its breadth, the possible
unintended consequences, and the fact that the provision will do no
good and may do much harm. For more than 60 years, the States have
regulated the business of insurance and built a record that provides
guidance about permissible activity. By inviting Federal intervention,
this bill creates a dual regulatory system that only confuses the
health insurance and medical malpractice industry.
The bill presents a wholesale repeal of McCarran-Ferguson for health
insurers and medical malpractice insurers. Further, the protections for
information gathering by a State insurance commission or other State
regulatory entity that were included in the similar bill (H.R. 3596)
reported by the Judiciary Committee over my opposition have been
completely eliminated from the legislation.
The uncertainty caused by this provision threatens small and large
insurers alike, but the smaller ones that depend on sharing
information, under oversight by State regulators, are most at risk.
Thus the bill threatens to reduce competition among health and medical
malpractice insurers. With no demonstrable benefits and many potential
adverse effects, Sec. 262 should not have been included in the bill.
Section 2573 raises different concerns. When a generic drug
manufacturer files an Abbreviated New Drug Application under the Hatch-
Waxman Act with the Food and Drug Administration, it indicates its
intention to infringe on a brand manufacturer's patent. This means that
the generic company is trying to enter into the brand manufacturer's
drug market before the branded pharmaceutical's existing patent has
expired. This notice usually results in a lawsuit by the brand company
that leads to a settlement about the date on which the generic
manufacturer can begin selling a generic version of the branded
company's drug. This is nothing new. Most cases in the United States,
whether civil or criminal, antitrust or patent, settle. The reasons for
this are simple: litigation is expensive and its outcomes are
uncertain.
The supposed problem is when a settlement in the Hatch-Waxman context
involves a payment in lieu of or in addition to an agreement on the
date of entry into the market by the generic manufacturer. Such
payments are said to frustrate the intent of Hatch-Waxman by allowing
the brand company to ``pay to delay'' entry of the generic competitor.
The proposed solution to this problem, incorporated in Sec. 2573,
goes too far. The bill calls for a ban on all Hatch-Waxman settlements
that feature any consideration, such as cash or an exchange of patents,
in addition to the date of entry. Such a ban dramatically reduces the
ability of companies to settle these cases. After all, if the parties
could not agree on date of entry, then they would effectively be forced
to litigate the case to the bitter end. This means that, in some cases,
a settlement would have resulted in generic entry into that particular
drug market much earlier than if the brand company wins its patent
suit.
I fear this ban will itself frustrate the intent of Hatch-Waxman by
limiting the incentives for

[[Page H12890]]

generics to challenge these patents and for brand companies to
innovate.
The best way to reach the appropriate balance is through a case-by-
case analysis by a neutral third party of the competitive effects of
these settlements using the rule of reason. This, in essence, is the
conclusion that the majority of the Courts of Appeals, including the
Second, Eleventh, and DC Circuits, have reached in these cases, and we
should uphold the judgment of these courts.
The only saving grace of Sec. 2573 is that it creates a cause of
action separate and apart from the antitrust laws and will not affect
how those laws are interpreted in the future. This also means that the
provision, as written, did not come before the Judiciary Committee,
even though it remains, at heart, a competition issue. By keeping the
Judiciary Committee from considering this legislation, we are
eliminating the incentives for drug invention and generic competition
that have served American consumers so well. Innovative new drugs,
after all, are created in the laboratory, not the courtroom.
Sec. 1640 of the bill also contains a provision that allows the
Department of Health and Human Services to issue administrative
subpoenas to insurance companies during investigations of decisions to
exclude benefits. The standard for issuing an administrative subpoena
under the bill is extremely low. The information sought must simply
``relate to'' the matter under investigation.
It is highly ironic that we are considering this bill with this
administrative subpoena language during the same week the Judiciary
Committee approved the Democrats' revision of the FBI's authority to
issue National Security Letters, which are the functional equivalent of
administrative subpoenas used in foreign intelligence and terrorism
investigations.
The Democrats' bill reported this week by the Judiciary Committee
replaces the current ``relevance'' standard for issuing a National
Security Letter with a heightened standard, requiring the FBI to show
``specific and articulable facts'' in order to seek particular
information using a National Security Letter. House Democrats want to
make it easier for the government to investigate insurance companies
than to investigate terrorists plotting to kill Americans.
In the end, this 1,990-page bill will raise premiums and health care
costs on all Americans. It imposes mandates and new taxes on the middle
class and small businesses. It fails to address tort reform and it
dumps a huge unfunded expansion of Medicaid on the states. Combined
with budget gimmicks to hide $245 billion in costs and massive cuts to
senior benefits, this is simply bad medicine.
Mr. MORAN of Kansas. Mr. Speaker, after reviewing H.R. 3962, the
Affordable Health Care for America Act, listening to the concerns of
Kansans, and visiting Kansas hospitals to speak with doctors, nurses,
patients, and administrators, I have concluded that this bill will be
harmful to Kansas and I strongly oppose it. However, I do believe the
sections relating to the creation of a market for biosimilar products
is one area of the bill that strikes the appropriate balance in
providing lower cost options to patients without destroying a healthy
and functioning industry in this country. These provisions were one of
the few areas in the bill adopted on an overwhelming bipartisan vote
for the Eshoo-Inslee-Barton, EIB amendment in the House Energy and
Commerce Committee.
Creating a pathway for new products that does not destroy the ability
or the incentives for innovator companies to develop breakthrough
technologies and, at the same time providing a safe and effective way
to bring competition to benefit patients and encourage treatments, is a
necessary objective. New biosimilars have the potential to
fundamentally change the course of many diseases. We need to promote
patient safety and ensure incentives to encourage the continued
development of a critical weapon to fight diseases such as Alzheimer's,
Parkinson's and cancer. I wish we could remove these specific
provisions from H.R. 3962 and consider them separately because it would
most likely pass with the kind of overwhelming bipartisan support.
However, these provisions are only the first step in a long path to
the marketing of these new biosimilar products. New research and
clinical testing will have to occur and the FDA will implement
regulations that will ensure this research is done safely and
effectively. Biopharmaceuticals represent a tremendous growth
opportunity for our burgeoning bioscience industry in Kansas, and we
need to work to see that new biotechnology products continue to reach
patients and medical professionals.
As this new biosimilar market develops in the United States, we need
to ensure that we foster innovative products in this country for the
creation of jobs and research that will go into determining whether
these products are interchangeable with the innovator's products.
Testing and research on these interchangeable biosimilar products
should occur in this country to ensure that it is done properly and
safely and to benefit our patients and our economy.
Ms. GRANGER. Mr. Speaker, I have criticized the majority of the
provisions in H.R. 3962, the Affordable Health Care for America Act,
and I will vote against it. However, I am pleased that H.R. 3962, as
well as the Republican Substitute Amendment that I support, both
include language relating to biosimilar products.
The provisions related to the creation of a market for biosimilar
products is one area of the bill that strikes the appropriate balance
in providing lower cost options to consumers without destroying a
healthy and functioning industry in this country. These provisions were
one of the few areas in the bill adopted in a bipartisan vote for the
Eshoo-Inslee-Barton amendment in the Energy and Commerce Committee.
Creating a pathway for new products that doesn't destroy the ability
or the incentives for innovator companies to develop breakthrough
technologies and at the same time providing a safe and effective way to
bring competition to benefit patients is a laudable achievement. I wish
we could remove this provision from this bill so that I could vote for
it on its own. I believe that if this provision was considered on its
own it would pass the House of Representatives with bipartisan support.
The biosimilar provisions in this bill are only the first step in a
long path to the marketing of these new products. New research and
clinical testing will have to occur and the FDA will write rules that
will ensure this research is done safely and effectively.
One of the reasons I have long supported the U.S. biotechnology
industry is that it is a homegrown success story that has been an
engine of job creation in this country. With this week's news that
unemployment has reached 10.2 percent, it is critical that we preserve
jobs in the United States. Testing and research on these generic
biosimilars should take place in the United States to ensure that it is
done properly and safely while benefitting our economy.
Innovative biotechnology companies have created jobs here in the
United States and we must continue to support them.
Mr. PAYNE. Mr. Speaker, I an others have spoken at length on the ways
that this bill will improve health care for all of our constituents.
Another significant benefit of this legislation which has not received
as much attention will be the creation of new high-paying jobs in this
country. Let me repeat that for some of my friends on the other side of
the aisle, this bill will create high-paying, high-quality jobs in
healthcare delivery, technology and research in the United States.
First, this bill will create enormous demand for healthcare workers,
especially in the area of primary care. Insuring the millions of
Americans in this country who currently have no insurance will allow
them to see primary care providers and receive the wellness and
preventive care they have been denied for too long. This influx of new
patients will need doctors, nurses and technicians for their care,
while reducing overall healthcare costs because they will not need much
more expensive hospitalizations. I support channeling resources that
for too long have been used to treat people once they become sick into
jobs and services that will prevent people from getting sick in the
first place.
Second, this bill will continue the efforts we began in the stimulus
package to deploy new health information technologies that better
manage both the quality of care people receive and the cost at which
they receive it. New health care exchanges and new demands on the
health system to provide high-quality and cost-effective health care
will create new opportunities and markets for our brightest technology
minds. They will be incentivized to create and develop products that
will be a win/win for Americans: high quality health care at an
affordable price.
Third, this bill will create high quality research opportunities in
this country. The Energy and Commerce Committee enacted a framework for
allowing biosimilar competition in this country. This new class of
medicines will help lower costs and bring competition to one area that
is key to the future of our healthcare system. Biotechnology is on the
cutting edge of efforts to reducing costly invasive procedures and
allowing our constituents to live healthier and more productive lives.
The creation of this new class of medicines comes with requirements for
new clinical research and testing, especially in the area of whether a
new biosimilar can be interchangeable with an innovator's product. This
research will create high quality and high paying jobs and it is
imperative that we keep this research and these jobs in this country.
We cannot allow these research opportunities to leave this country,
and I intend to work with the Secretary of HHS and the Commissioner of
the FDA to ensure they stay in the United States.

[[Page H12891]]

I do not look at this bill as one of cost or drain on the economy of
our country like so many of its opponents on the other side of the
aisle. I see this bill as an exciting opportunity to create the kind of
jobs we so desperately need in this country while at the same time
improving the lives of ALL Americans. This bill will improve health
care, create jobs and grow our economy.
Mr. TERRY. Mr. Speaker, I have criticized many of the provisions of
this bill and rightfully so. But in fairness, I do believe the sections
relating to the creation of a market for biosimilar products is one
area of the bill that strikes the appropriate balance in providing
lower cost options to consumers without destroying a healthy and
functioning industry in this country. These provisions were one of the
few areas in the bill adopted on an overwhelming bi-partisan vote for
the Eshoo-Inslee-Barton (EIB) amendment in the Energy and Commerce
Committee.
Creating a pathway for new products that doesn't destroy the ability
or the incentives for innovator companies to develop breakthrough
technologies and at the same time providing a safe and effective way to
bring competition to benefit patients is a laudable achievement. I wish
we could remove this provision from this fatally flawed piece of
legislation and consider it separately because it would pass with the
kind of overwhelming bi-partisan support that Americans across the
country wish to see.
However, these provisions are only the first step in a long path to
the marketing of these new products. New research and clinical testing
will have to occur and the FDA will write rules that will ensure this
research is done safely and effectively. One of the reasons I have long
supported the U.S. biotechnology industry is that it is a homegrown
success story that has been an engine of job creation in this country.
As this new market launches in the United States, we need to ensure
that we foster innovation and ensure the safety of any new product
brought to the market.
Ms. CLARKE. Mr. Speaker, I ask unanimous consent to revise and extend
my remarks in support of this legislation because it eliminates gender
rating that allows young women to be charged 45% more than men for
identical coverage.
Mr. POE of Texas. Mr. Speaker, H.R. 3962 forces businesses and
individuals to purchase health insurance. It raises at least two
constitutional issues. Congress should never pass an unconstitutional
bill, and I will vote against H.R. 3962.
The Constitution doesn't give the Federal Government direct authority
to compel the purchase of health insurance. The Supreme Court would
once again have to come in and by judicial edict give the government
the intrusive power to do what it obviously cannot do now: stretch the
meaning of the Commerce Clause.
Can the Federal Government force people to buy health insurance
whether they can afford it or not? Can the Federal Government then
impose a criminal fine on them under the guise of calling it a tax if
they fail to buy the insurance?
What happens if the citizen doesn't pay the fine? Do they go to jail
without the benefit of trial by jury? Do they lose their right to
confront witnesses and have a lawyer?
Congress forcing mandatory health insurance on Americans and then
imposing criminal sanctions without due process is a violation of the
Constitution. This action would shock the Framers of our Constitution.
These serious constitutional issues cannot be ignored and I strongly
oppose H.R. 3962 and any other bill that violates our Constitution.
Mr. Speaker, I am strongly against H.R. 3962, and I will vote against
it should it come to a vote on the House floor. However, I do believe
the sections relating to the creation of a market for biosimilar
products is one area of the bill that strikes the appropriate balance
in providing lower cost options to consumers without destroying a
healthy and functioning industry in this country. These provisions were
one of the few areas in the bill adopted on an overwhelming bipartisan
vote for the Eshoo-Inslee-Barton (EIB) amendment in the Energy and
Commerce Committee.
Creating a pathway for new products that doesn't destroy the ability
or the incentives for innovator companies to develop breakthrough
technologies and at the same time providing a safe and effective way to
bring competition to benefit patients is a laudable achievement. I wish
we could remove this provision from this fatally flawed piece of
legislation and consider it separately because it would pass with the
kind of overwhelming bi-partisan support that Americans across the
country wish to see.
However, these provisions are only the first step in a long path to
the marketing of these new products. New research and clinical testing
will have to occur and the FDA will write rules that will ensure this
research is done safely and effectively. One of the reasons I have long
supported the U.S. biotechnology industry is that it is a homegrown
success story that has been an engine of job creation in this country.
Unfortunately, many of the largest companies that would seek to enter
the biosimilar market have made their money by outsourcing their
research to foreign countries like India. With this week's devastating
news that unemployment has reached 10.2% it is critical that we
preserve jobs in the United States. While the innovators, have created
jobs here, these generic companies have shipped them overseas, so they
can turn around and sell cheap knockoffs of innovative American
products.
As this new market launches in the U.S., we need to ensure that we
foster innovative products in this country for the creation of jobs and
research that will go into proving whether these products are
interchangeable with the innovators products. I have my doubts that
these companies can create such interchangeable products, but I am
certain that the research and testing of whether or not they can should
occur in this country and not somewhere across the globe. Testing and
research on these interchangeable biosimilars should occur in this
country to ensure that it is done properly and safely and to benefit
our economy.
Mr. KIRK. Mr. Speaker, our goal in health care reform should be to
lower the cost of health care, making it more affordable for Americans
to purchase coverage. Many young adults from Illinois and elsewhere
will be hit very hard under this legislation if they do not have
coverage provided by their employers. We should not force young
Americans to purchase coverage that costs them more because of reform.
This is a new expensive tax targeted to young workers--and I oppose it.
According to the Department of Health and Human Services, 29 percent
of individuals between the ages of 18 and 24 are uninsured and 27
percent of individuals between the ages of 25 and 34 are uninsured.
Prices in the individual insurance market are already so high they do
not think it is worth it. The misnamed ``Affordable Health Care Act''
that we are debating now will make this coverage even more expensive.
The reason is that this bill requires that insurers may not charge
64-year-olds more than twice what they charge healthy 19-year-olds.
This mandate will raise premiums on young adults tremendously. Young,
healthy people who lack coverage, mostly because they find it too
expensive at a current cost of $1,700 to $2,000 for it, will be forced
to buy policies that cost $3,000, even after federal subsidies. The
House bill's ``age rating'' of 2 to 1 is far below the 5 to 1 ratio
currently prevalent in the insurance market. Why does this ratio exist?
Simply because the medical bills of healthy young people are a fraction
of what older Americans spend. Comparisons of the House bill with an
estimate of what is available on the individual market now using data
provided by the Kaiser Family Foundation demonstrate that a 25-year-old
single individual making $30,000 will pay a premium of $3,169 under the
House bill after subsidies, while similar standards with a 4:1 age
rating cost $2,258. It is almost a $1,000+ leap. This is a big deal for
those earning only $30,000.

The Kaiser Family Foundation provides a way to estimate how insurance
premiums will rise for young workers and their families:

------------------------------------------------------------------------
House     Current     Higher
Salary      bill      market    premium
------------------------------------------------------------------------
Single Policy:
21......................    $30,000     $2,724     $2,258       $466
25......................    $35,000     $3,169     $2,258       $911
28......................    $40,000     $3,169     $2,435       $734
30......................    $42,000     $3,169     $2,676       $493
Family of Four:
28......................    $75,000     $8,102     $7,402       $700
30......................    $90,000     $8,543     $7,862       $681
------------------------------------------------------------------------

I proposed an amendment to this bill that would ensure that anyone
purchasing insurance coverage after January 1, 2013 is exempt from the
individual mandate if a less expensive insurance plan than those
available under today's bill Act was available six months prior to its
enactment. Unfortunately, this amendment was not made in order by the
Rules Committee.
In health care reform, we should do no harm. We must enact reforms
that will actually lower the costs of insurance premiums so Americans
can afford to purchase coverage. Enacting a bill that makes it more
expensive for young workers to buy insurance coverage and then forcing
them to buy such coverage is wrong.
In closing, I want to commend Shauna McCarthy of my staff for the
many months she has committed to health reform, contributing to this
amendment as well as the Medical Rights and Reform Act, which seeks to
prevent government intervention in the important relationship between
patients and their doctors.
Mrs. MALONEY. Mr. Speaker, Sunday, 42,000 people gathered in my
hometown of New York City to run the NYC marathon while 2 million more
people watched, cheered, and marveled at those who accepted the
challenge of running 26.2 miles. It is likely that each participant had
a different reason for running, but the ultimate goal was the same: to
finish, to

[[Page H12892]]

succeed, and to accomplish a goal. As Greek legend explains, the
concept of the marathon comes from the long distance a messenger ran to
deliver the important news that the battle had been won. Mr. Speaker,
as we stand here today to debate a historical bill that will
substantially improve the delivery of health care in America, we are
the runners at mile 25. The cheers are the loudest, the anticipation is
the greatest, and the end, while near, seems very far away. Despite all
of the noise, the message is clear: now is the time for health care
reform, now is the time to take care of all Americans, now is the time
to make sure that families are not forced to see loved ones die because
they did not get the care they need and deserve.
I'd like to thank and commend the leadership of Speaker Pelosi,
Majority Leader Hoyer, Chairmen Waxman, Miller and Rangel and of
course, Chairman Emeritus Dingell who has been working on health care
reform since he first came to Congress. H.R. 3962, the Affordable
Health Care for America Act, is a significant and important step toward
securing affordable, accessible, and quality health care for all
Americans. Our current health care system is broken. Costs continue to
increase at unsustainable rates and too many families and businesses
are feeling the debilitating burdens brought on by these expenses. Too
many Americans have inadequate coverage or lack coverage entirely and
are suffering or dying as a result.
H.R. 3962 is critical to the health of our families, to the health of
our economy and to the health of our nation;
H.R. 3962 lowers costs for every patient, reins in premiums, co-pays,
and deductibles, limits out of pocket costs, and lifts the cap on the
amount that insurance companies cover each year;
H.R. 3962 strengthens Medicare, securing the financial stability and
solvency of Medicare for years to come, and provides seniors with
better benefits and guaranteed access to their doctors;
H.R. 3962 reduces the deficit by over $100 billion in the first 10
years, and likely by even more in the following decade, according to
the Congressional Budget Office;
H.R. 3962 provides affordable coverage to those who cannot get health
insurance because of pre-existing conditions, including domestic
violence and pregnancy, and protects consumers from higher rates due to
gender or other factors;
And, very importantly, I am proud that H.R. 3962 includes a public
health insurance option that will increase competition and reform our
current system. I am grateful to Speaker Pelosi for her steadfast
support of this important provision and am confident that it will
expand access to care to the many people in need. When 14,000 Americans
are losing their health care coverage each day, it is clear that a
public option is needed. It will bring down costs, increase access, and
improve care for all Americans. The richest country in the world should
not have people who go without the basic necessity of health care. The
public option will hold health insurance companies accountable for the
practices that price people out of the health care they need and
deserve.
Health care is the most important public policy issue of our
generation that will affect generations to come. I am grateful for the
opportunity to be a part of this momentous reform and would like to
take the time to highlight some areas of the bill that specifically
impact my Congressional district.
H.R. 3962 will improve employer-based coverage for 440,000 residents
in my district and will provide credits to help pay for coverage for up
to 120,000 households. It will also improve Medicare for 88,000
beneficiaries, including closing the prescription drug donut hole for
8,100 seniors. H.R. 3962 will allow 33,300 small businesses to obtain
affordable health care coverage and provide tax credits to help reduce
health insurance costs for up to 31,300 small businesses and will cover
26,000 uninsured residents. In short, H.R. 3962 will make health care
affordable for the middle class, provide security for seniors, and will
guarantee access to health insurance coverage for the uninsured while
reducing the federal deficit over the next ten years and beyond.
In addition to representing the residents of the 14th Congressional
District of New York, I am proud to represent 14 hospitals. Many of
these are the jewels of American medicine, training our nations'
doctors, and facilitating cutting edge research that identifies cures
and gives hope to millions of Americans and their families. I am
pleased that H.R. 3962 recognizes the importance of teaching hospitals
and preserves Graduate Medical Education. New York's teaching
hospitals, while training our future physicians, are treating the
sickest of the sick and poorest of the poor. These payments, including
Direct Medical Education and Indirect Medical Education are critical to
the survival of these hospitals and to the greater good of medicine.
H.R. 3962 takes into account diverse patient populations, the cost of
goods and services, and the higher costs incurred by teaching
hospitals. Teaching hospitals tend to treat the most complex cases and
are the first to adopt innovative technologies and techniques that
advance patient outcomes, so their costs are often higher than average.
A policy that reduces spending arbitrarily runs the risk of stifling
innovation which is why I am pleased that the bill is sensible on how
it addresses geographic variation. This bill recognizes the pitfalls of
a blanket overhaul. It requires the Secretary of HHS to contract with
the Institute of Medicine to conduct two studies. The first is a study
of wage levels which will look at the hospital wage index and the
physician geographic practice cost index and will recommend changes to
the methodologies, if necessary. The second study looks at the
geographic variation associated with volume and intensity of services
in Medicare, Medicaid, and private sector spending per capita. The IOM
is encouraged to understand and separate out higher-than-average
spending due to unavoidable or desirable factors (e.g., patient
demographic and clinical risk factors and wage levels) from higher-than
average spending due to avoidable or undesirable factors (e.g.,
excessive medical errors, and practice patterns differing from best
practices). The bill wisely includes specific prohibitions against
recommendations to reduce graduate medical education, disproportionate
share, and health information technology payments.

While I am pleased with the bulk of the bill, I am concerned that
H.R. 3962 does not extend the 340B discounts to drugs purchased for
inpatient use, a provision that was included in an earlier version of
the bill. Currently, the 340B Drug Pricing Program requires
pharmaceutical manufacturers that participate in Medicaid to sell
outpatient drugs at discounted prices to disproportionate share
hospitals (DSH) that serve a high threshold of low-income, uninsured
and underinsured patients. Under current law, DSH hospitals
participating in the 340B Drug Pricing Program pay approximately thirty
percent more for their inpatient drugs than their outpatient drugs,
although the drugs are frequently the same. The inpatient and
outpatient settings serve the same low-income population that the 340B
Drug Pricing Program was designed to assist. These discounts lower
costs for patients and taxpayers. At a minimum, extending the 340B Drug
Pricing Program to inpatient drugs would reduce inpatient drug costs by
fifteen percent. These new resources could be better used to provide
direct patient care. I am hopeful that during Conference, the House
will cede to the Senate language and extend the 340B drug pricing to
inpatient drugs. After all, now is not the time to deprive safety net
hospitals from millions of dollars in savings needed to treat the most
vulnerable in our communities.
Mr. Speaker, the task is huge and the rewards even bigger. Today we
will vote to cover 96 percent of Americans without adding a dime to the
deficit. We will be doing what's right for our families, what's right
for our economy, and what's right for our future. I urge my colleagues
to look at the larger picture and remember that today we will make a
lasting difference in people's lives.
Mr. TERRY. Mr. Speaker, I rise today to make the House aware of a
seemingly silent crisis facing millions of Americans and to offer a
potential solution. I am talking about the problem of personal medical
debt, and the critical need for medical debt counseling. As a result,
thousands of Americans in my state of Nebraska and throughout our
nation are facing extremely difficult choices that severely impact
their quality of life, and sometimes life itself.
Mr. Speaker, I am sure my colleagues are aware that medical debt is
the number one cause of personal bankruptcy in this country. Let me say
that again: 60 percent of all personal bankruptcies are the result of
crushing medical debt. I know that my colleagues would agree that this
is an astonishing, and indeed, an embarrassing statistic for our
country.
In most cases, those who suffer from serious medical debt are people
with chronic diseases who have just enough insurance to be considered
insured. While they may technically be insured, the fact of the matter
is that in reality they are severely underinsured. Simply put, they are
faced with some extremely difficult choices between whether to pay
their medical bills or pay for their basic needs. For example, someone
with a chronic disease who is saddled with extremely high medical debt
may have to choose between paying their mortgage or putting food on the
table and paying the bill for life-saving treatments for their disease.
It is not hard to understand that when faced with these kinds of
options more than half the time people chose to declare bankruptcy.
That means that hospitals take a loss, individuals who have declared
bankruptcy ruin their credit, and the American people in the end
typically pay for it all.
Mr. Speaker and my colleagues, we can help fix this crisis with
medical debt counseling.

[[Page H12893]]

The idea behind medical debt counseling is simple: Create a network
of non-profit organizations that provide counseling services
specifically for medical debt. The nonprofit counselors will provide
the participants with a number of options long before the idea of
bankruptcy is even considered. This is a win-win for everyone. A person
can avoid bankruptcy, and a health care provider such as a hospital or
doctor, can receive payment for their services.
Nonprofit organizations with expertise in helping under-insured
people with chronic diseases manage their burden, such as the Chronic
Disease Fund which assists people in my state, should be put on the
front lines of providing effective medical debt counseling. They are
the experts which are best equipped to provide effective counseling so
that individuals will not be forced into declaring bankruptcy because
of their medical debt.
To my knowledge, there is nothing in the pending health care reform
legislation that would help encourage medical debt counseling. This
brings me to an important point. Because we have moved so fast on
health care reform legislation, good ideas like medical debt counseling
are not part of this bill. We need options like this for health care
reform because it will work to save the American taxpayer money.
Medical debt 2 counseling will reduce the cost burden on the health
care system, not increase it. And medical debt counseling is
innovative. It is innovation like this that made America's health care
the best in the world.
Mr. Speaker, my constituents, like yours, provide for their families
but they live on a tight budget. When faced with the reality of making
a huge medical bill payment or putting food on the table, what do you
think they are going to do? We can help them avoid this terrible
scenario. Again, 60 percent of bankruptcies in this country are because
of crushing medical debt. We can help lower the number of personal
bankruptcies across this great nation, but to do so we need to
encourage a system of medical debt counseling.
Ms. KILPATRICK of Michigan. Mr. Speaker, I rise today in support of
H.R. 3962, Affordable Health Care for America Act, offered by Rep. John
Dingell of Michigan and ask all of my colleagues to support this
historic bill before us that will expand coverage to 36 million
uninsured Americans, ensure that patients and physicians make their own
health care choices, reduces administrative costs, invests in wellness
and prevention, reforms the insurance industry by ending discriminatory
practices, especially pre-existing conditions and health disparities,
and allows young adults to remain on their parents' insurance policy
until the age of 27.
I have held numerous town hall meetings in my district to listen to
the views of my constituents. My office has received numerous calls,
emails, and letters on this subject, with an overwhelming majority
asking me to vote YES on the bill because America cannot wait any
longer for health care insurance reform. More than 300 groups,
representing millions of Americans, have expressed their support for
the bill, including the American Association of Retired Persons, the
American Cancer Society, the United Auto Workers, the AFL-CIO, the
SEIU, Families USA and the National Committee to Preserve Social
Security and Medicare. The groups expressing their support include a
broad range, including groups representing doctors, seniors, small
business, youth, women, persons with disabilities, consumers and
patients.
Health care insurance reform is not a Republican or Democratic issue,
it is an American issue. Under a Democratic President, we witnessed the
beginnings of health care reform with Medicaid and Medicare in the
1960s. Under another Democratic President, we will witness the second
coming of true health care reform.
Today's vote will mark a change in our country where every American
will know that health care is a top priority for this country. When I
was a newly elected Member to the U.S. House of Representatives,
Congress was in the throes of reforming health maintenance
organizations or HMOs. While this was well intended, at the time, I
asked, ``what about those millions of people who go to work each and
every day, who care for our senior citizens in nursing homes, who clean
our bathrooms, cook our food, clean our streets, and send their
children to college, but whose employers do not provide health care?''
What happened is that those individuals did not have health care
coverage, period. Now is the time to help those janitors, street
sweepers, short-order cooks, child care workers, home health care
providers, and small businesses so that those workers, too, will be
able to have health care.
The 111th Congress has taken bold steps to provide more access to
health care for Americans. While we have expanded health coverage to
more than five million uninsured children through the passage of the
State Comprehensive Health Improvement Plan or SCHIP, we must complete
what we started. Access to health care is vital to the health of not
only individual Americans but to the American economy.
Even before our recent economic crisis, health care was getting more
expensive, what few benefits were offered were eroding, and even more
people were losing coverage. In 2007, according to various sources, 45
million Americans were uninsured; this number is an increase over
2000's 38.7 uninsured Americans. And this is the uninsured; we are not
even discussing the millions more senior citizens, working poor and
families who are underinsured. I am talking about seniors who have to
choose between eating or their prescriptions. I am talking about those
families who have to choose between taking their child to the doctor or
food for the week. The economic crisis has only made this situation
worse.
The bankruptcy of the automobile industry, the closing of auto
dealerships, and the crisis faced by automobile suppliers have caused
thousands more in our Nation and in particular the state of Michigan to
lose their employee health benefits.
Our version of health care reform, the Affordable Healthcare for All
Americans Act, has four key highlights for Americans and American
businesses: lower costs; greater choice; higher quality and peace of
mind. As Health and Human Services Secretary Sebelius said earlier, if
we do nothing to reform health care, we will continue to live sicker,
die faster and pay twice as much.
Health care reform legislation should require coverage of the full
range of women's reproductive health services. H.R. 3962 protects these
rights and ensures that all women have access to a health care plan
that meets their needs while respecting current law. The Stupak
amendment would limit access to reproductive care in the private and
public options, and does not allow citizens to pay for the procedure
out of their own pockets. I voted against the Stupak amendment.

Health care reform will provide lower health care costs

Under the America's Affordable Health Care Act, there will be no more
co-pays or deductibles for preventive care. No more rate increases or
exclusions for pre-existing conditions, gender or occupation. There
will be an annual cap on the out of pocket expenses for individuals and
businesses. Finally, for the first time, there will be guaranteed and
affordable oral, hearing, and vision care for children.
By having a public health care plan, the bill will ensure competition
for Americans to have the best health care at the most affordable cost.
Also, since everyone will have health care, no one industry or business
will be at an advantage over another one.

Health Care reform will provide greater choice for all Americans

Americans will be able to keep their doctor, and their current plan,
if you like what you have. With a high quality public health insurance
option competing with private insurers, there will be more choice of
providers and more benefits. The important aspect is this--every
American will have a choice of providers, versus today's choice,
for the uninsured, of the emergency room or no care at all. No one will
be forced into a public option. This will just be one of many choices.

Health care reform will provide higher quality health care for all
Americans and businesses

You and your doctor--not insurance companies--will make health care
decisions. As more primary care, family doctors, and nurses enter the
workforce, even more access is guaranteed for all Americans. Also, the
bill mandates coverage for mental health care, a key issue that will
affect, in particular, the families of our service members who are
returning from the wars in Iraq and Afghanistan.

Health care reform will provide peace of mind

The bill provides a cap on catastrophic coverage--coverage for
traumatic injuries such as spinal cord injuries and long-term health
care. There will be no more denial of coverage for preexisting
conditions, and no reason to make a life or job decision based on
whether or not you or your family will have health care coverage.
We need health insurance reform now. Access to quality, affordable
health care is critical to the well-being of all Michiganders and all
Americans, today and tomorrow. Central to all of this is addressing the
needs of uninsured Americans, strengthening our Medicare system,
providing health insurance to low-income children and families, funding
research into diseases like diabetes and cancer, and giving patients
the ability to make decisions with their doctors, not health insurance
companies. An estimated 1,400 families lose health insurance every day
that we do not pass health insurance reform.
One aspect of this legislation of which I am most proud is its fiscal
responsibility. According to a letter dated November 5, 2009 from the
non-partisan, objective Congressional Budget Office, this bill adds not
one dime to

[[Page H12894]]

the deficit. Furthermore, this bill reduces the deficit by an estimated
$109 billion. This is not only fiscally responsible, it allows us to
provide health care to the least of our sisters and brothers.
When this bill is signed into law, ten provisions of the bill will
take effect immediately:
It will begin to close the Medicare Part D ``Donut'' Hole. The bill
reduces the donut hole by $500 per Medicare recipient and also
institutes a 50-percent discount on brand-name drugs.
It gets health insurance to the uninsured. By creating a temporary
insurance program, health care will be available for people who have
been denied a policy due to preexisting conditions or who have not had
health care for several months.
It bans lifetime limits on health care coverage. The bill prohibits
health insurance companies from placing lifetime caps on coverage--
traditional coverage or catastrophic care coverage.
It provides health insurance for young people. It requires health
insurance plans to allow young people through age 26 to remain on their
parents' insurance policy at their parent's choice.
It eliminates cost-sharing for preventive services in Medicare. It
eliminates co-payments for preventive services and exempts preventive
services from deductibles under the Medicare program.
It ends health care rescissions. It prohibits insurers from
nullifying or ``rescinding'' a patient's policy when they file a claim
for benefits, except in cases of fraud.
It bans copayments and deductibles. It eliminates copayments for
preventive services and also exempts preventive services from
deductibles under the Medicare program.
It increases funding for community health centers. It increases
funding for Community Health Centers to allow twice the number of
patients seen by Community Health Centers for the next 5 years.
It increases the number of primary care doctors. It increases the
investment by the Federal Government in training programs to increase
the number of primary care doctors, nurses, and public health
professionals.
Creates long-term health care for disabled adults. The bill creates a
longterm care insurance program to be financed by voluntary payroll
deductions to provide benefits to adults who become functionally
disabled.
As with Medicare and Medicaid, the Federal Government has the
Constitutional power to reform our health care system. The 10th
amendment to the U.S. Constitution states that the powers not delegated
to the federal government by the Constitution, nor prohibited by it to
the states, are reserved to the states . . . or to the people. Article
One, Section Three, also known as the Commerce Clause, says the same
thing. The Constitution gives Congress broad power to regulate
activities that have an effect on interstate commerce. Congress has
used this authority to regulate many aspects, from labor relations to
education to health care to agricultural production. Since virtually
every aspect of the heath care system has an effect on interstate
commerce, the power of Congress to regulate health care is essentially
unlimited.
The Affordable Health Care for America Act is good for small
businesses. Under this legislation, many small businesses will be
eligible for a new tax credit to help them provide coverage for their
workers and their families--and they or their workers will get access
to a new comparison shopping marketplace with low rates and good
benefits like large groups get. Without health insurance reform, small
businesses would pay nearly $2.4 trillion over the next 10 years in
health care costs for their workers. According to the nonpartisan Joint
Committee on Taxation--only 1.2 percent of the wealthiest Americans
will be subject to the surcharge and it would only apply to dollars
earned over $1 million for a couple and $500,000 for an individual.
Furthermore, 86 percent of all businesses are exempt from the
requirement to provide health insurance coverage to their workers.
Nothing in the House bill will cut basic Medicare benefits. The
Affordable Health Care for America Act strengthens and improves
Medicare benefits for older Americans and helps eliminate waste, fraud
and inefficiency from Medicare--including gross overpayments to
insurance companies providing Medicare Advantage plans which do nothing
to improve care for Medicare Advantage beneficiaries.
The Affordable Health Care for America Act is comprehensive health
insurance reform that covers 96 percent of Americans, ensures
affordability for the middle class, provides security for our seniors,
ends discrimination by insurance companies against the sick, caps what
Americans pay out-of-pocket and protects our children's future by not
adding to our deficit.
Finally, health care reform will allow the United States to catch up
to the rest of the industrialized world. We are the only nation that
does not provide universal health care coverage to its citizens. This
puts the health of not only individual Americans at jeopardy, it puts
the health of our economy in jeopardy. Businesses that have to compete
with China, India, Europe and other countries are doing so on an
uneven, unfair playing field, because while China, India and European
businesses do not have to pay for health care, American businesses do.
Health care reform will allow these businesses to truly compete on a
global plane.
I applaud my colleagues in the House of Representatives for
supporting this legislation in ensuring that health care reform is
accessible, available, and affordable for all Americans and American
businesses. Two generations is long enough for the American people to
wait for comprehensive health care reform. Health care is the key moral
and economic imperative for our Nation and this Congress. We must
reform health care now.
Ms. CLARKE. Mr. Speaker, today, I rise in support of H.R. 3962,
Affordable Healthcare for America Act. In the United States, one of the
richest countries in the world, nearly 47 million Americans lack health
insurance, 13.5 percent of which are New Yorkers. Last year alone, New
York City's hospitals spent 1.2 billion dollars in charity costs.
Tragically, people who are either uninsured or underinsured often have
to go without vital healthcare simply because they cannot afford it.
Every American has a human right to adequate physical and mental
healthcare, and I believe that government has a responsibility to
assist its citizens in securing quality healthcare. Unfortunately, my
Republican colleagues don't seem to fully grasp the dire situation our
healthcare system is in. Maybe they would have come up with a bill that
actually addressed the deficiency in our broken healthcare.
It is unfortunate that there are those who just don't care. Those who
are satisfied with the status quo of rising premiums, satisfied with
individuals being denied coverage because of preexisting conditions,
satisfied with ignoring the pain and suffering of the 47 million
Americans who are uninsured. Instead of working to fix the problem,
they capitalize on people's fears and doubts. It is meant to distract,
delay, confuse, and engender fear among our citizens. Today we will not
allow the voices of fear to dominate the health care reform debate.
This bill provides healthcare coverage to 96 percent of Americans and
includes a strong public option that will provide the needed
competition to lower premium costs. That is why I support H.R. 3962,
Affordable Health Care for America Act.
In my district, the 11th Congressional District of Brooklyn, the
Affordable Health Care for America Act will:
First, improve employer-based coverage for 367,000 residents. As a
result of the insurance reforms in the bill, there will be no co-pays
or deductibles for preventive care; no more rate increases or coverage
denials for pre-existing conditions, gender, or occupation; and
guaranteed oral, vision, and hearing benefits for children.
Second, it will provide credits to help pay for coverage for up to
160,000 households, if they need to purchase their own coverage.
Third, under the bill's insurance reforms, 11,900 individuals in the
district who have pre-existing medical conditions will now be able to
purchase affordable coverage.
Finally, this bill will allow 11,300 small businesses to obtain
affordable health care coverage and provide tax credits to help reduce
health insurance costs for up to 11,400 small businesses.
Healthcare is a fundamental human right, rather than a commodity. A
year ago, Americans cast a historic vote to change the course of this
Nation. Today, we cast this historic vote, to finally manifest the
change they demanded. Access to Affordable Healthcare. I am proud to
cast my vote in favor of this bill.
Mr. Speaker, I believe that H.R. 3962, the Affordable Health Care for
America Act, will improve health care for all of our constituents.
Another significant benefit of this legislation, which has not received
as much attention, will be the creation of new high paying jobs, high
quality jobs in healthcare delivery, technology and research in the
United States.
First, this bill will create enormous demand for healthcare workers,
especially in the area of primary care. Insuring that the millions of
Americans, who currently have no insurance, will have access to primary
care providers so that they can receive the preventive care they have
been denied for too long. This influx of new patients will create a
need for doctors, nurses and technicians, while reducing overall
healthcare costs because of the new focus on preventative medicine. I
support channeling resources, that for too long have been used to treat
people once they become sick, into jobs and services that will prevent
people from getting sick in the first place.
Second, this bill will continue the efforts we began in the stimulus
package to deploy new health information technologies that better

[[Page H12895]]

manage both the quality of care and the cost of it. New health care
exchanges and new demands on the health system to provide high quality
and cost-effective health care will create new opportunities and
markets for our brightest technological minds. They will be
incentivized to develop high quality healthcare products at an
affordable price.
Third, this bill will create new research opportunities in this
country. The Energy and Commerce Committee enacted a framework for
allowing biosimilar competition in this country. This new class of
medicines will help lower costs and bring competition to one area that
is key to the future of our healthcare system. Biotechnology is on the
cutting edge of efforts to reduce costly invasive procedures, thereby
allowing our constituents to live healthier and more productive lives.
The creation of this new class of medicines comes with requirements for
new clinical research and testing. This research will create high
quality, high paying jobs. It is imperative that we keep this research,
and these jobs in this country. We cannot allow these research
opportunities to leave this country, and I intend to work with the
Secretary of HHS and the Commissioner of the FDA to ensure they stay in
the United States.
I do not look at this bill as a drain on our economy, like so many of
its opponents on the other side of the aisle. I see this bill as an
exciting opportunity to create the kind of jobs we so desperately need
in this country, while at the same time improving the lives of all
Americans. This bill will improve health care, create jobs and grow our
economy.
Mr. FATTAH. Mr. Speaker, in my fourteen years representing the people
of Philadelphia and Montgomery County, Pennsylvania, I have had few
opportunities as significant as this one to stand up for my
constituents, their families, the future of our city and the destiny of
our nation. This healthcare bill is the result of months of legislative
negotiation and collaboration and answers the calls made for decades by
mothers who could not alleviate the suffering of their children,
conscience-minded small business owners who could not provide the
healthcare coverage they knew their employees deserved and doctors and
nurses who fought creatively to provide treatments they knew their
patients needed and could never afford. I am proud that today we will
take the most significant step in a century towards joining the rest of
the industrialized world in assuring every American has access to the
healthcare they need.
It is the nature of democracy that this bill contains some provisions
which I do not support. I believe women deserve access to the full
range of legally assured health services on equal footing with men. I
believe it is our responsibility to vigorously address the pernicious
health disparities which disadvantage Americans of color and linguistic
minorities. I believe overzealous efforts to deny some people
healthcare on the basis of their immigration status will inadvertently
limit care for native-born and legal residents as well. I believe a
stow public option is the only way to ensure competition, choice and
affordability in the American private insurance market. At the end of
the day, we, as the Representatives of the people are called to speak
for them. Rarely do we have the opportunity to so directly improve
their standard of living. It is with the people of the Second District
in mind, and the generations to come, that I enthusiastically vote yes
for the Affordable Health Care for America Act.
Ms. WOOLSEY. Mr. Speaker, at least 46 million Americans are uninsured
right now. More than 85% of the uninsured are in working families. Even
if you have health insurance now, without reform, the cost of health
care for the average family of four is projected to increase by almost
$2,000 a year. The need for health reform is urgent and that's why I
rise in strong support of this historic bill.
Many Members of Congress, myself included, continue to believe that
the best way to provide high quality, affordable healthcare to everyone
is to create a single payer health insurance system. However, while we
would prefer single payer, we united behind a health reform bill with a
robust public option.
We believed, and still believe, that the robust public option, a
public option based on medicare plus 5% rates is the best way to
increase competition, bring down the costs of premiums, and provide
everyone with a real choice between a private and public health
insurance plan.
In August, many thought the public option was dead. But the
Progressive Caucus, Tri Caucus, and many in our leadership, made sure
that the robust public option was very much a part of the debate in
September and October.
Because of the work of so many Members, we have a public option in
the bill we are considering today. While it's not the plan I would have
preferred, this public option will increase competition with private
plans and provide a real choice in health insurance plans.
In addition, there is language in the manager's amendment that will
ensure that any increase in health insurance premiums must be
justified, which will help make premiums more affordable for our
Nation's working families.
As we move into conference with the Senate, I look forward to
continuing to work with my colleagues to ensure that we have the best
possible bill. Therefore, Mr. Speaker, to increase competition and
provide choice, any bill reported out of conference must retain a
strong national public option that goes into effect when the health
exchange begins, and, is not based on any triggers. I urge my
colleagues to support this bill.
Mr. HARE. Mr. Speaker, I wish to strongly voice my support for the
Affordable Health Care for America Act on behalf of all hard working
men and women across this great country and certainly in the State of
Illinois.
For decades, our government has debated the issue of extending
healthcare to all, yet too many Americans still lack it and the
security and peace of mind that comes with it. For those fortunate
enough to be insured, rising costs are making it harder and harder to
stay afloat. We, as members of this body, have the opportunity today to
take a historic step toward passing the Affordable Health Care for
America Act, so that quality health care can be more affordable and
accessible to all Americans and their families. This bill will
drastically reduce the number of uninsured, increase competition and
lower costs through a public option, reform the insurance industry so
Americans don't see their coverage unfairly denied or dropped, and put
more money in our seniors' pockets by closing the Medicare Part D
doughnut hole, all while reducing the deficit by $104 billion over 10
years.
With unemployment at its highest level since 1983, another
significant benefit of this legislation that should be highlighted is
the creation of new high-paying jobs in this country. Let me repeat
that for some of my friends on the other side of the aisle, this bill
will create high-paying, high-quality jobs in healthcare delivery,
technology and research in the United States. This bill creates a
framework for allowing biosimilar competition in this country, which
has the potential to lead to a new class of generic biologic medicines
that will help lower costs and bring competition to one of the areas
that will be key to the future of our healthcare system. The
development of generic biologics or biosimiliars has the potential to
create much needed jobs here at home in clinical research and testing.
I intend to work with the Secretary of HHS and the Commissioner of the
Food and Drug Administration to ensure that this new work is conducted
here at home, in places like my home state of Illinois.
This bill will additionally create enormous demand for healthcare
workers, especially in the area of primary care. Insuring the millions
of Americans in this country who currently have no coverage will allow
them to see primary care providers and receive the wellness and
preventive care they have been denied for too long. This influx of new
patients will need doctors, nurses and technicians for their care,
while reducing overall healthcare costs because they will receive care
based around prevention as opposed to hospitalization. I support
channeling resources, that for too long have been used to treat people
once they become sick, into jobs and services that will prevent people
from getting sick in the first place.
The Affordable Health Care for America Act will continue the efforts
this Congress first undertook in the Recovery Act that deployed new
health information technologies throughout our healthcare system. These
technologies help to better manage both the quality of care people
receive and the cost at which they receive it. New health care
exchanges and new demands on the health system to provide high-quality
and cost-effective health care will create new opportunities and
markets for our economy. Workers and industry together will be
incentivized to create and develop products that will be a win/win for
Americans: high quality health care at an affordable price.
I was proud to work with my colleagues on the Education and Labor
Committee to help shape this bill. I was pleased to have had the
opportunity to add two critical pieces to this bill that are of great
importance to my constituents: allowing for Small Employer Benefit
Arrangements (SEBA), which facilitate the participation of small
businesses and the self-employed in the Health Insurance Exchange; and
protecting the ability of our nation's veterans to be able to enter
into the Health Insurance Exchange to attain additional insurance for
their dependents while retaining their VA health coverage. These
provisions were common-sense improvements that make this great bill
even better.
I have cited many, but not all, of the reasons why I think this
historic bill is worthy of my vote. I now ask that my colleagues join
me in protecting American families from coast to coast in supporting
this historic legislation. Mr. Speaker, thank you for your strong
leadership on this issue and I look forward to proudly voting in favor
of this bill in honor of the 39,000 uninsured residents of my District
who would

[[Page H12896]]

finally have the ability to receive the quality health care they
deserve.
Mr. PASCRELL. Mr. Speaker, I and others have spoken at length on the
ways that the Affordable Health Care for America Act will improve
health care for all of our constituents. Another significant benefit of
this legislation which has not received as much attention will be the
creation of new high-paying jobs in this country. Let me repeat that
for some of my friends on the other side of the aisle: this bill will
create high-paying, high-quality jobs in health care delivery,
technology, and research in the United States.
First, H.R. 3962 will create enormous demand for health care workers,
especially in the area of primary care. Expanding meaningful health
insurance coverage to the millions of Americans in this country who are
currently uninsured or underinsured will allow them to see the primary
care providers and receive the wellness and preventive care they have
been denied for too long. This influx of new patients will need the
doctors, nurses, and technicians necessary to deliver the care they
need--while reducing overall health care costs as we prevent more
expensive emergency care and hospitalizations. I support channeling
resources that for too long have been used to treat people once they
become sick into jobs and services that will prevent people from
getting sick in the first place.
Second, the Affordable Health Care for America Act will continue the
efforts we began in the stimulus package to deploy new health
information technologies that better manage both the quality of care
people receive and the cost at which they receive it. New health care
exchanges and new demands on the health system to provide high-quality
and cost-effective care will create new opportunities and markets for
our brightest minds in technology. They will be incentivized to create
and develop products that will be a win-win for Americans--high quality
health care at an affordable price.
Third, H.R. 3962 will create high quality research opportunities for
America. The legislation under consideration establishes a framework
for allowing biosimilar competition in this country. This new class of
medicines will help lower costs and bring competition to an area that
is a key to the future of our health care system. Biotechnology is on
the cutting edge of efforts to reduce costly invasive procedures and
allow our constituents to live healthier and more productive lives. The
creation of this new class of medicines comes with requirements for new
clinical research and testing, especially in the area of new
biosimilars' interchangeability with innovator products. This research
will create high quality and high paying jobs, and it is imperative
that we keep this research and these jobs in this country. The
Inspector General of Health and Humans Services is currently
investigating the amount of data received from overseas clinical
trials. We cannot allow these research opportunities to leave this
country, and I intend to work with the Secretary of HHS and the
Commissioner of the Food and Drug Administration to ensure that the
clinical studies to support the safety and interchangeability for this
new class of follow-on biologics is conducted in the United States.
Mr. Speaker, I do not view this legislation as a cost or drain on the
economy of our country like so many of its opponents on the other side
of the aisle. Instead, the Affordable Health Care for America Act is an
exciting opportunity to create the kinds of jobs we so desperately need
in this country while improving the lives of ALL Americans. H.R. 3962
will improve health care, create jobs, and grow our economy.
Mr. PASCRELL. Mr. Speaker, I am pleased to support the Affordable
Health Care for America Act. I could not be prouder that H.R 3962
expands coverage to 96 percent of Americans in a fiscally responsible
manner. I strongly believe that all interested parties should indeed
have a stake in this necessary effort, but I would like to recognize
the contribution asked of the biopharmaceutical industry.
New Jersey has often been called the Medicine Chest for the World and
for good reason. Last year, the biopharmaceutical and medical
technology industries employed nearly 60,000 individuals in the state
of New Jersey--with another 88,000 ``spin-off' jobs through the
purchase of goods and services, capital construction projects, and
other industry activity.
H.R. 3962 extends Medicaid rebates to Medicare dual-eligible and low-
income subsidy beneficiaries while instituting a new 50 percent
discount for Part D beneficiaries who find themselves in the
prescription drug benefit coverage gap--the so-called ``donut hole.''
Pharmaceutical sales represent about 10 percent of national medical
expenditures, but the savings generated from these provisions represent
a disproportionately larger share of the legislation's savings and
revenues.
There is little doubt that these industries are sure to see increased
sales both as millions of previously uninsured Americans and millions
more who were underinsured are given access to meaningful health
insurance that covers prescription medications and as seniors with
expanded Part D coverage better adhere to the prescription regimens
prescribed by their doctors. However, I have lingering concerns that a
single industry may be paying more than their fair share and that this
may have unfortunate consequences in New Jersey. The biopharmaceutical
manufacturers in my state have estimated that as many as 12,300 jobs
could be lost in New Jersey.
I believe that H.R. 3962 is an effort that will indeed create new
jobs in the health care sector both as the demand for health care
providers increases and as the result of a new pathway for the
development of follow-on biologics, and I applaud the legislation for
taking steps to close the Medicare Part D donut hole. However, we must
recognize there will be consequences for New Jersey's biopharmaceutical
industry, and I express my hope that these consequences will be
minimized as the House and Senate come together to formulate a
compromise health reform package.
Mr. PASCRELL. Mr. Speaker, in my capacity as co-chair of the
Congressional Brain Injury Task Force, I would like to share my
understanding of the intent of the provisions of H.R. 3962--the
Affordable Health Care for America Act--regarding the coverage of the
treatment continuum for persons with brain injury.
News reports of returning veterans and recent high profile brain
injury stories indicate what researchers have been reporting for years:
brain injury is a leading public health problem in U.S. military and
civilian populations. I believe that any health care reform initiative
must recognize that brain injury is not an event or an outcome but is
the beginning of a lifelong disease process that impacts brain and body
functions. These impacts of brain injury can result in difficulties in
physical, communication, cognitive, emotional, and psychological
performance, undermining health, function, community integration, and
productive living. Brain injury is also disease causative and disease
accelerative because it predisposes individuals to re-injury and the
onset of other conditions.
The Brain Injury Association of America (BIAA) has developed a series
of guiding principles for assessing any health care reform bill from a
brain injury perspective. I believe, consistent with policy statements
by the BIAA, that health care reform must address the unique health
care needs of individuals with brain injury by recognizing that brain
injury is the start of a lifelong disease process. As such, individuals
with brain injury require access to a full continuum of medically
necessary treatment--including rehabilitation furnished by accredited
programs in the most appropriate treatment setting as determined in
accordance with the choices and aspirations of the patient and family
in concert with an interdisciplinary team of qualified and specialized
clinicians.
I am pleased to conclude that the Affordable Health Care for America
Act reflects and is consistent with these principles.
Principle 1: An individual with a brain injury should have an
individualized medical treatment plan that documents specific
diagnosis-related goals for individuals with a reasonable expectation
of achieving measurable functional improvements through the provision
of sufficient treatment.
Under the bill, payment for items and services included in the
essential benefits package should be made in accordance with generally
accepted standards of medical and other appropriate clinical or
professional practice. In addition under the bill, a qualified health
benefits plan may not impose any restriction (other than cost-sharing)
unrelated to clinical appropriateness on the coverage of the health
items and services included in the essential benefits package.
Consistent with medical, clinical, and professional practice,
appropriateness should be determined based on the unique needs of the
individual with brain injury and treatment should be of sufficient
scope, duration, and intensity.
Principle 2: An individual with brain injury should have access to
the full treatment continuum to manage the disease. This continuum
includes (1) early, acute treatment to stabilize the condition and (2)
acute and specialized post-acute brain injury treatment and
rehabilitation to minimize and/or prevent medical complication, recover
function and cope with remaining physical or mental disabilities, and
achieve long-term outcomes that maintain an optimal level of health,
function, and independence following brain injury. These post-acute
services include inpatient, outpatient, day treatment, and home health
programs. I believe that for individuals with disabilities such as
brain injury, rehabilitation and habilitation is equivalent to the
provision of antibiotics to a person with an infection--both are
essential medical interventions.
I am pleased to report that under the bill, the essential benefit
package includes, among other things, hospitalization, outpatient
hospital

[[Page H12897]]

and outpatient clinic services, professional services of physicians and
other health professionals, prescription drugs, mental health and
substance use disorder services (including behavioral health
treatments), rehabilitative and habilitative services, and durable
medical equipment, prosthetics, orthotics, and relates supplies. The
term ``rehabilitative and habilitative services'' includes items and
services used to restore functional capacity, minimize limitations on
physical and cognitive functions, and maintain or prevent deterioration
of functioning as a result of an illness, injury, disorder, or other
health condition. Such services also include training of individuals
with mental and physical disabilities to enhance functional
development.
Principle 3: Individuals with brain injury should receive treatment
in the most appropriate treatment setting by accredited programs--
including acute care hospitals, inpatient rehabilitation facilities,
residential rehabilitation facilities, day treatment programs,
outpatient clinics and home health agencies. The treatment and
treatment setting should be determined in accordance with the choice
and aspirations of the patient and family in concert with an
interdisciplinary team of qualified and specialized clinicians.
I am pleased to report that under the bill payment for items and
services included in the essential benefits package should be made in
accordance with generally accepted standards of medical or other
appropriate clinical or professional practice. The bill also requires
adequacy of provider networks in order to ensure enrollee access to
covered benefits, treatments, and services under a qualified health
benefits plan. Rehabilitative and habilitative services should be
available from a full continuum of accredited programs and treatment
settings at a level of intensity that is consistent with the needs of
the patient.
Principle 4: The bill should prevent private insurance systems from
delaying or denying treatment as a means of transferring the burden of
brain injury care to taxpayers at federal, state and local levels;
ensure that both public and private health insurance systems meet the
health  care needs of people with brain injury; and avoid using
Medicaid and Medicare as the first option for the coverage of people
with brain injury.

I am pleased to report that the bill includes numerous requirements
reforming the health insurance marketplace that should prevent private
insurance systems from delaying or denying treatment for individuals
with brain injury. These reforms include (1) prohibiting pre-existing
condition exclusions, (2) requiring guaranteed issue and renewal, (3)
requiring nondiscrimination in health benefits or benefit structure,
(4) requiring adequacy of provider networks, (5) limiting cost-sharing,
and (6) prohibiting the imposition of annual or lifetime limits on
coverage. I believe that these provisions will help prevent private
insurance from delaying or denying treatment to persons with brain
injury.
Finally, the bill includes provisions regarding modernized payment
initiatives and delivery system reform under which the Secretary may
use innovative payment mechanisms and policies to determine payment for
items and services under the public health insurance option, including
bundling of services. Separate provisions are included in the bill
regarding post-acute care bundling under Medicare. BIAA, in a recent
submission to the chairs of the Education & Labor, Ways & Means, and
Energy & Commerce Committees, commented that post-acute payment systems
must facilitate, not impede, improvements in functional status of
individuals with brain injury and their ability to return to their
homes and communities. BIAA supports a deliberative planning process
and rigorous pilot testing. According to BIAA's comments, the
deliberative process should determine whether post-acute care bundling
should exempt diagnoses such as brain injury, that are of low
predictability and highly complicated; establish certain minimum
requirements for any bundling proposal such as ``any willing provider''
in the bundled payment system; and test innovative payment methods that
make payments directly to non-hospital-based treatment centers,
including residential rehabilitation facilities specializing in the
treatment of brain injury.
I believe that the deliberative process should address each of these
issues. I also believe that the adoption of alternative innovative
payment mechanisms and policies must be guided by the goals included in
the bill--improving health outcomes, reducing health disparities,
providing efficient and affordable care, addressing geographic
variation in the provision of health services, preventing or managing
chronic illness, and promoting care that is integrated, patient-
centered, quality, and efficient.
I remain wary of mechanisms that bundle post-acute care to acute care
hospitals for patients with complex and highly unpredictable diagnosis
and health outcomes, like brain injury and other catastrophic
conditions. Such payment systems should not impede, rather than
facilitate, improvements in functional status and should not result in
premature return to homes and undue levels of preventable disability
without adequate facilitation of progression through necessary step
down levels of treatment.
Mr. LUETKEMEYER. Mr. Speaker, I have criticized many of the
provisions of this bill and rightfully so.
However, one bi-partisan area that strikes the appropriate balance in
providing lower-cost options to consumers without destroying a healthy
and functioning industry in this country that is included in both the
underlying bill, which I strongly oppose, and the Republican
substitute, which I intend to support, are the sections relating to the
creation of a market for biosimilar products. These provisions were one
of the few areas in the bill adopted on an overwhelming bipartisan vote
for the Eshoo-Inslee-Barton (EIB) amendment in the Energy and Commerce
Committee.
Creating a pathway for new products that doesn't destroy the ability
or the incentives for innovator companies to develop breakthrough
technologies and, at the same time, providing a safe and effective way
to bring competition to benefit patients is a laudable achievement. I
wish we could remove this provision from this fatally flawed piece of
legislation and consider it separately because it would pass with the
kind of overwhelming bi-partisan support that Americans across the
country wish to see.
However, these provisions are only the first step in a long path to
the marketing of these new products. New research and clinical testing
will have to occur, and the FDA will write rules that will ensure this
research is done safely and effectively. One of the reasons I have long
supported the U.S. biotechnology industry is that it is a homegrown
success story that has been an engine of job creation in this country.
Unfortunately, many of the largest companies that would seek to enter
the biosimilar market have made their money by outsourcing their
research to foreign countries like India. With this week's devastating
news that unemployment has reached 10.2%, it is critical that we
preserve jobs in the United States. While the innovators have created
jobs here, these generic companies have shipped them overseas, so they
can turn around and sell cheap knockoffs of innovative American
products.
As this new market launches in the U.S., we need to ensure that we
foster innovative products in this country for the creation of jobs and
research that will go into proving whether these products are
interchangeable with the innovators products. I have my doubts that
these companies can create such interchangeable products, but I am
certain that the research and testing of whether or not they can should
occur in this country and not somewhere across the globe. Testing and
research on these interchangeable biosimilars should be occurring in
this country to ensure that it is done properly and safely and to
benefit our economy.
Mr. EDWARDS of Texas. Mr. Speaker, after listening to thousands of my
constituents and carefully reviewing the legislation, I have made a
decision to vote ``no'' on the House health care reform bill.
Given the huge federal deficits facing our nation, I believe there is
too much new spending in this bill.
I am especially disappointed that the bill does not have a fiscal
trigger in it to cut spending if actual costs of new programs turn out
to be higher than projected.
While the Congressional Budget Office predicts this bill is paid for
over 10 years, there is no mechanism in the bill to force spending cuts
if those complicated projections turn out to be wrong.
I also have concerns about a government-run ``public option''
insurance company and question whether this bill goes far enough in
actually reducing health care costs for working families and
businesses.
Throughout this debate I have heard two extremes. Some on the far
left would like to see the federal government run a socialized health
care system. Some on the far right would get the government completely
out of health care, which would mean the elimination of Medicare and
Medicaid. I think both extremes are wrong.
I believe most people in our district recognize that health care
reform is needed to hold down costs and to make health care more
affordable and dependable, but they want any reform bill to be fiscally
responsible. I agree.
Mr. SHUSTER. Mr. Speaker, after weeks of closed-door meetings,
Speaker Nancy Pelosi has brought her healthcare reform to the floor for
a vote today on Saturday while the attention of the majority of
Americans is diverted. The Pelosi plan clocks in at over 1,900 pages,
which is 648 pages longer than Hillary-care and it costs over a
trillion dollars, or about $2 million per word.
The sheer size and scope of the Pelosi plan is enormous. As we enter
a time of 10.2 percent unemployment, the American people will

[[Page H12898]]

not accept a government takeover of healthcare that will kill even more
jobs, hurt small businesses, increase the deficit now and drown future
generations in stifling debt.
While the sheer size and scope of the Democrats' takeover of
healthcare prevents me from pointing out every egregious part of the
proposal, I would like to point out four areas that should give all
Americans pause.
Taxes: The Pelosi plan would impose $730 billion in new taxes on
businesses that can't afford to pay for their employees' health
coverage. According to President Obama's own economic advisor,
Christina Romer, these new taxes would put 5.5 million workers at
serious risk of losing their jobs. Close to 32,500 small businesses in
Pennsylvania would be at risk from this new healthcare surcharge.
Deficit Spending: The Pelosi plan contains $1.055 trillion in new
federal spending over the next ten years. All of this spending will be
used to take healthcare decisions out of the doctor's office and
centralize them in Washington, DC, requiring the creation of over 100
new federal panels, commissions and unelected civil servants who will
be charged with making decisions on your care.
Senior's Coverage: Earlier this year, President Obama pledged that
``the government is not going to make you change plans under health
reform.'' Today, he and Nancy Pelosi are proposing $170 billion in cuts
to Medicare Advantage. These cuts would force close to 38,000 enrollees
in the 9th district out of Medicare Advantage and into regular
Medicare.
Personal Freedom: The Pelosi plan will bring the nationalization of
one-sixth of our economy and the elimination of choice for a majority
of Americans to extend coverage to a few.
Republicans have an alternative focused on simple principles that
will lower the cost of quality healthcare for all Americans. Our plan
would let families and businesses buy health insurance across state
lines and pool together and buy health insurance at lower prices. We
would give states the tools to create their own innovative reforms that
lower health care costs. Finally our plan would end excessive and
unnecessary tests doctors perform that contribute to higher health care
costs to protect against junk lawsuits.
Real health care reform should foster a system where competition and
patient choice drive quality care and success. I believe we can
accomplish this and fix what is broken in our health care system
without forcing another trillion-dollar government takeover on
taxpayers. I urge all of the members of this House to vote no on this
reckless reform package. Vote no on a government takeover of
healthcare.
Mr. PUTNAM. Mr. Speaker, America is at a crossroads and we, as
Members of Congress have the duty and responsibility to ensure our
great country remains vibrant and competitive in the 21st Century. For
that reason, I cannot figure out why the Democratic leadership and the
administration want to rush to pass this monstrosity of a bill, with
its $1 trillion price tag and $730 billion in taxes. I can confidently
say that passing this health care reform bill will unwind private
health care in America and at the same time do very little to bring
down its cost.
I rise today to speak in strong opposition to the legislation before
us, H.R. 3962. This measure is indeed historic--an historic expansion
of the role of government in the lives of every American. Your choice
of physician . . . your choice of medical facility . . . your choice of
the kind of care and treatment you receive . . . these are some of the
most personal decisions you can ever make. The prospect of placing
those decisions into the hands of a new federal bureaucracy that would
combine the efficiencies of FEMA with the compassion of the Department
of Motor Vehicles ought to alarm every American.
So we are gathered here, to vote on legislation that is nearly twice
the length of the original bill, H.R. 3200, that was introduced this
summer. Mr. Speaker, I doubt that there are many people in this great
hall who can honestly tell you they are fully conversant with every
provision in this bill. But after doing our best to read, study and
understand the nearly two-thousand pages of H.R. 3962 we know certain
things this bill will do. For example, we know it will cost taxpayers
more than a trillion dollars. We know it will impose $730 billion in
new taxes on small businesses and individuals. We know it will cost
five-and-a-half million Americans their jobs. We know it will create
over 100 new bureaus, commissions, and programs. And we know it will
burden our states with tens of billions of dollars in new unfunded
federal mandates. In Florida alone, the additional costs associated
with the Medicaid mandates will be in the billions of dollars.
Mr. Speaker, we are told by the President and by the majority party
in Congress that we need all this in order to make health care more
affordable for the American people. How are we making health care more
affordable if we are driving the American people into bankruptcy by
taking historic steps toward a federal takeover of the entire health
care system?
The Democrat Majority seeks to pay for their health care reform bill
in part through 8 percent payroll penalty taxes on employers who cannot
afford to provide insurance coverage, and through a 5.4 percent surtax
on individuals making $500,000 a year or more. These provisions are
estimated to bring in more than $595 billion.
You don't have to be an economist to know that these new taxes will
have a direct and adverse affect on small businesses across America. An
overwhelming majority of small businesses--approximately 75 percent of
them--pay their business taxes through the owner at the individual
level. Essentially, one in every three small businesses would be
subject to the new surtax and just in the State of Florida as many as
57,000 small businesses would be affected. These provisions are
effectively a tax on jobs that will stifle job creation and depress
wages. In light of the latest unemployment numbers of 10.2 percent for
the U.S. and 11 percent for Florida, this is hardly the time to raise
costs on small businesses and employers.
If the taxes on America's small businesses were not enough, this bill
also imposes a 2.5 percent tax on medical devices. At a time when our
country spends about 17 percent of its GDP on health care, and we are
tasked with developing policies to bring down the overall cost of care,
it is irrational that we should tax an industry that is such an
integral part of health care. This tax, on everything from syringes to
artificial hips, will undoubtedly be passed along to the consumer.
Mr. Speaker, America has the best health care system in the world.
Why should we destroy the economic backbone of America to create a
government-run health care plan that the majority of Americans oppose?
It does not have to be this way.
We can take significant steps to address health care--steps guided by
principles based on the freedom of choice, transparency and openness,
and a competitive free market.
We can lower health care premiums for American families and small
businesses, addressing Americans' number-one priority for health care
reform.
We can establish a universal access program to guarantee access to
affordable health care for people with pre-existing conditions. The
Republican alternative plan creates Universal Access Programs that
expand and reform high-risk pools and reinsurance programs to guarantee
that all Americans, regardless of pre-existing conditions or past
illnesses, have access to affordable care.
We can curb the cost of defensive medicine in this country by putting
an end to ``junk lawsuits.'' The fear of lawsuits drives doctors to
order expensive tests and procedures for patients, and not necessarily
because they think they are in the best interest of the patients. Some
doctors have even had to close their doors because they cannot afford
the malpractice insurance premiums. It is evident that meaningful
medical malpractice reform should be a component of any health care
reform proposal. The Republican plan would help save $54 billion in the
health care sector by including measures that have been successfully
demonstrated in California and Texas.
Just as we all want to reduce the cost of care, we should seek
innovative ways to provide coverage without breaking the bank. We can
do this by empowering small businesses with the opportunity to pool
together and negotiate lower health care premiums--just as corporations
and labor unions do--through association health plans. Another common
sense reform would allow Americans to shop for coverage from coast to
coast across state lines.
We can promote prevention and wellness by giving employers greater
flexibility to financially reward employees who adopt healthier
lifestyles. Incidentally, about 75 percent of medical spending goes
toward the treatment of chronic diseases. Research shows that the
number of individuals suffering from chronic diseases like diabetes and
heart disease could be reduced through proper wellness, prevention, and
disease management programs. The Republican alternative would allow for
employers to offer flexible coverage options to reward and encourage
healthy behaviors in an effort to reduce overall spending on costly
chronic diseases.
We can do all of these things and more, Mr. Speaker. And we can do
these things with legislation that the Congressional Budget Office says
will lower premiums by up to 10 percent and reduce the deficit by $68
billion over the next ten years, without imposing tax increases on
families and small businesses.
This alternative will give Americans access to health care, it will
free up our medical system to become more innovative and efficient, and
it is what Americans expect from their country.
Mr. Speaker, this alternative is what this Congress should be sending
to the President's desk--not the mammoth, unwise, and extraordinary
expansion of government embodied in H.R. 3962.

[[Page H12899]]

I urge my colleagues to vote ``no'' on this bill.
Ms. JENKINS. Mr. Speaker, I have criticized many of the provisions of
this bill and rightfully so. However, I do believe the sections
relating to the creation of a market for biosimilar products is one
area of the bill that strikes the appropriate balance in providing
lower cost options to consumers without destroying a healthy and
functioning industry in this country. These provisions were one of the
few areas in the bill adopted on an overwhelming bipartisan vote for
the Eshoo-Inslee-Barton (EIB) amendment in the Energy and Commerce
Committee.
Creating a pathway for new products that doesn't destroy the ability
or the incentives for innovator companies to develop breakthrough
technologies and at the same time providing a safe and effective way to
bring competition to benefit patients is a laudable achievement. I wish
we could remove this provision from this fatally flawed piece of
legislation and consider it separately because it would pass with the
kind of overwhelming bipartisan support that Americans across the
country wish to see.
However, these provisions are only the first step in a long path to
the marketing of these new products. New research and clinical testing
will have to occur and the FDA will write rules that will ensure this
research is done safely and effectively. One of the reasons I have long
supported the U.S. biotechnology industry is that it is a homegrown
success story that has been an engine of job creation in this country.
Unfortunately, many of the largest companies that would seek to enter
the biosimilar market have made their money by outsourcing their
research to foreign countries like India. While the innovator's have
created jobs here, these generic companies have shipped them overseas,
so they can turn around and sell cheap knockoffs of innovative American
products.
As this new market launches in the U.S., we need to ensure that we
foster innovative products in this country for the creation of jobs and
research that will go into proving whether these products are
interchangeable with the innovators' products. I have my doubts that
these companies can create such interchangeable products, but I am
certain that the research and testing of whether or not they can should
occur in this country and not somewhere across the globe. Testing and
research on these interchangeable biosimilars should be occurring in
this country to ensure that it is done properly and safely and to
benefit our economy.
Mr. CONAWAY. Mr. Speaker, I have criticized many of the provisions of
H.R. 3962, the Affordable Health Care for America Act, and with good
reason. However, I believe that the creation of a market for biosimilar
products is one area of the bill that strikes the appropriate balance
in providing lower cost options to consumers without destroying a
healthy and functioning industry in this country. These provisions were
adopted on an overwhelming bipartisan vote for the Eshoo-Inslee-Barton
(EIB) amendment in the Energy and Commerce Committee.
Creating a pathway for new products that does not destroy the ability
or the incentives for innovator companies to develop breakthrough
technology and at the same time provide a safe and effective way to
bring competition to benefit patients is a creditable achievement.
Ideally, this provision would be removed from this fatally flawed piece
of legislation and considered separately, as it would pass with
overwhelming bipartisan support.
These provisions are the first step on the long path to the marketing
of these new products. New research and clinical testing will have to
occur, and the FDA must write rules that will ensure that research is
done safely and effectively. I have long supported the U.S.
biotechnology industry as it has been a strong engine of job creation
in this country. Unfortunately, many larger companies that seek to
enter the biosimilar market have outsourced research to foreign
countries. With this week's devastating news that unemployment has
reached 10.2 percent, it is critical that we preserve jobs in the
United States.
As this new market launches in the United States, we must foster
innovative products at home to create jobs, and conduct research that
will prove whether products are interchangeable with innovators'
products. It is unlikely that these companies can create such
interchangeable products; however research and testing will prove if it
can be conducted within our borders without being outsourced.
Mr. EHLERS. Mr. Speaker, on November 14, 2009, Northrop Grumman will
lay the keel of the first ship of the new Gerald R. Ford class of
nuclear-powered aircraft carriers, the U.S.S. Gerald R. Ford (CVN-78),
in Newport News, Virginia. Susan Ford Bales, the daughter of President
Ford, is the ship's sponsor and will serve as the keel authenticator
for the ceremony.
President Ford was a good friend of mine, and I am honored to hold
his former seat in the U.S. House of Representatives. In 2006, I
supported an amendment to the 2007 national defense authorization bill,
offered by then Senator John Warner, which expressed the sense of
Congress that the CVN-78 should be named after President Gerald R.
Ford. On January 16, 2007, the U.S. Navy followed Congress's
instruction and announced that CVN-78 would be so named. Consequently,
CVN-78 and other carriers built to the same design all will be referred
to as ``Ford class carriers.''
The Gerald R. Ford class carrier design is the successor to the
Nimitz class design, and it incorporates several improvements, such as
allowing more sorties per day and requiring fewer sailors for its
operations and maintenance. Expected to enter into service in 2015, the
U.S.S. Gerald Ford, and its Ford class successors, will ensure that the
U.S. Navy, and policymakers, will continue to have the assets they need
to adequately defend our nation and protect our allies and interests
around the globe.
President Ford served his country honorably and faithfully for more
than 60 years, first as a Navy officer during World War II, then as a
Congressman, Vice President and finally as President and former
President. I believe it is fitting that we name this next class of
aircraft carriers after President Ford, and I look forward to
monitoring the future success of the U.S.S. Ford.
Mr. HONDA. Mr. Speaker, in our lives as public servants, Members of
Congress are rarely presented with opportunities to support the passage
of truly historic legislation. Today is such a day, and this health
care vote such an opportunity. Over the past ten months that I have
participated in the creation of this health reform bill, I have been
thinking about the words of Hubert Humphrey: ``It was once said that
the moral test of government is how that government treats those who
are in the dawn of life, the children; those who are in the twilight of
life, the elderly; and those who are in the shadows of life, the sick,
the needy and the handicapped.''
Today I rise in strong support of H.R. 3962, the Affordable Health
Care for America Act. For 70 years Americans have been waiting for this
moment. I would like to particularly thank Speaker Pelosi for her deft
leadership and management of a complex policy debate, Majority Leader
Hoyer, Majority Whip Clyburn, the Chairs of the Committees on Energy
and Commerce, Education and Labor, and Ways and Means, along with my
fellow progressive and colleagues in the Congressional Asian Pacific
American Caucus, Congressional Black Caucus, and Congressional Hispanic
Caucus (collectively known as the TriCaucus) for their public and
private commitments to preserve the public option. Finally, I commend
staff of all the committees for their hard work and commitment to this
issue.
Against an organized, scorched earth campaign of misinformation and
fear mongering, we are emerging with a strong bill, and an even
stronger sense of unity and purpose in our fight to bring access,
affordability, and high quality health care to every person in America.
If the best of our reforms prevail, insurance companies will no longer
be able to subject people to complex, confusing policy details,
lifetime and annual limits, or denials based on pre-existing
conditions. American taxpayers will save over $100 billion in the first
decade and will experience significant improvements in our health care
system.
Although I have strenuously supported a stronger public option, I
recognize that the balance of improvements made to the health care
system as a whole through the reforms in this bill is substantial. When
some thought the public option was dead, I and my other colleagues
rallied to bring it back into the discussion and succeeded in keeping
the public option in the final bill. The public option is a cornerstone
of the effort to bend the cost curve in health care and must be
preserved.
In my district alone, H.R. 2692 will improve employer based coverage
for 500,000 residents, allow 16,700 small businesses to obtain
affordable health care coverage and provide coverage for 28,000
uninsured residents. Finally, in a time of increasing pressure on local
governments, it will reduce the cost of uncompensated care for
hospitals and health care providers by $205 million. It will protect
the seniors in my district from the doughnut hole and improve the
quality of their Medicare coverage.
As Chairman of the Congressional Asian Pacific American Caucus, I am
particularly encouraged by the inclusion of legislative language
addressing racial and ethnic health disparities. As members of the
TriCaucus, we have long been advocating on the issue of health
disparities and I am proud of the impact we have had in making changes
that will directly help the poorest and most disadvantaged communities.
across this nation. As a long-time supporter of Native Americans in
their struggle to survive and thrive after hundreds of years of
oppression and genocide, I am particularly pleased by the inclusion of
the Indian Comprehensive Health Insurance Act in

[[Page H12900]]

health care reform. Native American communities worked for over a
decade to come together and write policy that would help their
communities begin to address the terrible and tragic health disparities
they experience and the inclusion of ICHIA is a step in the right
direction by the Federal Government to rectify some of the imbalances
and abuses that they have caused in Native communities.
Despite the many extraordinary improvements to many aspects of our
healthcare system, including an unprecedented expansion of access to
Medicaid for many poor families, I am dismayed that we were not able to
lift the 5 year bar on legal immigrant participation in Medicaid. Legal
immigrants are tax paying citizens in waiting who work hard and
contribute. It is only fair that we afford them equal access to the
benefits of Medicaid. I will continue to advocate on this issue in the
future and I know that I am joined in my concern by many of my
colleagues.
Americans live in the wealthiest, most powerful nation in the world
and spend $2 trillion a year on health care every year--more than the
national budget of China--and yet we don't have the best health care in
the world. Thousands suffer and many die because of a lack of access to
health care. Passing this bill and preserving its structure is a
critical investment in the health of future generations.
Mr. CALVERT. Mr. Speaker, I rise today in objection to the Pelosi
Health Care Bill which creates over $1 trillion in new government
spending. It is funded with the ``Hope'' that our children will figure
out how to pay the bill tomorrow and with a ``Change'' in the Medicare
program that cuts $500 billion from the over 45 million beneficiaries
currently covered.
Provisions within the Pelosi Health Reform Bill will raise premiums
and lower access to care for America's seniors. Although Democrats try
to present these changes to Medicare as improvements and savings, the
White House's own actuaries have stated that these changes will
increase Medicare spending at a greater rate than if we had done
nothing at all. With the Centers for Medicare and Medicaid Services
reporting earlier this year that the Medicare trust fund will be
exhausted by 2017, I do not believe this Congress should take any
action that hastens the jeopardy already faced by America's seniors.
The Pelosi Health Care Bill cuts $170 billion from the Medicare
Advantage Program, which covers almost 50 percent of the Medicare
beneficiaries in the 44th Congressional District of California--36,124
senior citizens who rely on this highly successful program for their
health care needs. The cuts undermine a program that currently gives
seniors the choice to enroll in a private option and that provides the
same benefits as traditional Medicare, prescription drug and other
additional health benefits, usually with lower copayments.
The proposed changes also will result in reduced benefits for
Medicare Advantage beneficiaries or result in higher premiums and
copayments for fixed income seniors. But let me be clear--not for an
improvement in service, but for the same or reduced level of service.
For the workforce paying into the Medicare program, higher taxes are
ahead.
In addition to the increased tax burden working Americans will face
to keep Medicare afloat, this bill levies a 2.5 percent tax on the
incomes of hardworking working Americans who cannot afford insurance.
This breaks a fundamental promise of President Obama's campaign that he
would not raise taxes on the middle class.
And even as the national unemployment climbs above 10 percent
nationwide--over 20 percent in some parts of my district--Speaker
Pelosi seeks to place an 8 percent tax on small businesses who cannot
afford to provide government mandated ``acceptable insurance'' to their
employees. In this economic climate, Congress should be working to
enact real reform across the United States that creates jobs and
stimulates the economy, not enacting a government expansion and tax
regime that will put the jobs of at least 5.5 million largely low wage
earners, minorities and young people at risk.
Finally, while Americans struggle to pay their bills and put food on
the table, Speaker Pelosi wants even more of their tax dollars to be
spent to provide federal health benefits to the 12 million illegal
immigrants currently in the United States. As I understand the bill
before us today, a person would only need to ``declare'' that they are
a citizen, provide a name and Social Security number and they would be
eligible to receive health insurance benefits. There is no requirement
for the verification of identification documentation. It is absolutely
unacceptable that this bill would not, at a minimum, require even one
verified identification document in order to receive taxpayer funded
health care benefits. The bill should include clear processes and
require documentation to confirm that an individual applying for health
care benefits is a citizen or legal resident of the United States like
the E-Verify program I created in 1996 for employers to verify the
legal status of new employees.
The crafting of the bill before us today spent American liberties to
purchase House Democrat votes in order to secure a political victory.
The resulting legislation has put freedom and American ingenuity under
the knife. For the sake of American jobs, American families and future
generations, we must kill this bill and resume our work to create jobs,
rein in government spending, increase healthcare freedom and choice and
getting the U.S. government's financial house back in order.
However, I look forward to voting in favor of the Stupak-Pitts
Amendment, which maintains the current federal government policy of
preventing federal funding for abortion and for benefits packages that
include abortion. This amendment ensures that federal taxpayers will
not be coerced into funding elective abortions and is supported by U.S.
Conference of Catholic Bishops, Democrats for Life, National Right to
Life, Americans United for Life, Family Research Council, Concerned
Women for America and many other pro-life groups. I look forward to
continuing to work to ensure taxpayer funds are not used to fund
abortions and to provide the broadest possible conscience protections
for physicians, health professionals, hospitals, insurers, and all
those in the business of caring for the health of Americans.
Mr. DICKS. Mr. Speaker, we have reached a pivotal moment in the House
of Representatives today as we are about to approve the most
significant expansion of access to health care in America in at least a
generation. And the bill we are about to approve also represents the
most substantial improvement of the quality of health care in our
country that has been passed in the entire time I have been in
Congress. I am proud to support this long-overdue and aptly-named
legislation, the Affordable Health Care for America Act.
I am particularly pleased that we have come to an agreement within
this bill on a provision that I believe will lead to a dramatic
improvement in the way we pay for health care for America's seniors
under Medicare. Under the current Medicare payment system, providers
are reimbursed on a ``fee-for-service'' system that encourages more
procedures and office visits. One of the most encouraging aspects of
H.R. 3962 is language that will help shift Medicare to a system that is
more efficient and that encourages better coordination of health care
for seniors.
Medicare's complex reimbursement formula has long punished doctors
for providing more cost effective, quality health care. It is truly
unfair under our current system that Medicare spends $7,363 per
enrollee in a city in my district--Tacoma, Washington--while it spends
twice that amount, $14,946, in the small Texas town of McAllen. These
differences are largely due to discretionary decisions by physicians
that are influenced by the local availability of hospital beds, imaging
centers and other resources--and a payment system that rewards growth
and more intense use of medical facilities and testing. But this focus
on utilization is not only inherently more costly, it tends to ignore
the health care outcomes, which should really be the goal of any system
of care. And it exacerbates the problem we are already facing with
Medicare: out-of-control growth rates. At current trajectory, Medicare
will be $660 billion in the red by 2023, highlighting the urgent need
to find ways to trim this growth rate. If we could reduce the annual
growth in per capita Medicare spending from the national average--3.5
percent--to 2.4 percent, the rate in San Francisco, Medicare could save
$1.42 trillion over that period and turn the deficit into a healthy
surplus.
So in order to help move us toward this goal and produce a more
equitable system of reimbursement, I was pleased to work with a number
of concerned Members here in Congress on language in this bill that
will enlist the resources of the independent, non-profit Institute of
Medicine to examine the existing Medicare geographic payment inequities
for both physician and hospital payments and to address the inequities
that are clearly contained in our current system. We are also investing
$4 billion per year in 2012 and 2013 to make payment rate adjustments
so that no geographic area will be disadvantaged during 2012 and 2013.
I am also pleased that a related provision of this bill calls for an
additional study by the Institute of Medicine to conceptualize a system
of Medicare payments based on quality outcomes versus the current
system of ``fee-for-service.'' This ``High-Value Study'' will be
completed by April 15, 2011 and the Institute's recommendations will be
submitted to the Secretary of Health and Human Services, who will then
have 240 days to submit a final implementation plan to Congress. This
plan will take effect unless Congress passes a resolution of
disapproval by the end of May 2012.
These are very important reforms that I believe will help ensure the
solvency of Medicare and promote a more equitable system of health care
for seniors that stresses results over process. They are among the many
aspects of this overall health care reform package that deserve our
support, and I am proud

[[Page H12901]]

to be speaking today to recognize these provisions and to urge all my
colleagues to pass the Affordable Health Care for America Act.
Mr. WALZ. Mr. Speaker, over the past three years, I've discussed
health care reform with thousands of my constituents. I've heard from
doctors and nurses, health care policy experts and small business
owners. Most importantly, I've heard from middle-class Minnesotans who
are fed up with the status quo.
Take Kristy, who is a Rochester mother and breast cancer survivor.
Access to affordable health insurance is a life or death matter for her
and millions of other Americans.
Last year, Kristy's health insurance premium increased 17 percent.
Hard-working Americans every year see premiums rise faster than their
take-home pay. This is a financial disaster in progress. If ignored,
this will result in an explosion in the number of uninsured
individuals, reaching far into the ranks of the gainfully employed and
middle class.
Kristy's employer laid-off workers this year, in part because of
rapidly rising health care costs. Small businesses across America are
shedding good workers to cover sky-rocketing health care expenses,
stifling entrepreneurship and innovation.
And then, recently, Kristy lost her job. She worries about whether
she'll be able to get health insurance given her pre-existing medical
condition, once her temporary COBRA coverage expires.
Last year, more than 700 of our neighbors in southern Minnesota went
bankrupt because of medical bills. It is unconscionable for anyone to
go broke solely because they get sick. Now, Kristy wonders if she's
next.
Kristy's story has become all too common in America today.
It doesn't have to be this way.
I rise today in strong support of H.R. 3962, the Affordable Health
Care for America Act, because of people like Kristy. This bill, which
includes important fixes from Democrats and Republicans, will tear down
the status quo, rein in costs and bring stability and peace of mind to
regular people like Kristy.
The House health care bill has four important pillars of reform:
The first pillar stops run-away costs and rewards quality care. A
patient-centered initiative spearheaded by Mayo Clinic is at the heart
of rewarding quality. The current fee-for-service payment model in
Medicare perversely encourages health care providers to perform
unnecessary procedures and tests. This is backwards. Hospitals and
doctors should instead be rewarded for innovation, results, and quality
care. The Mayo-backed solution in this bill asks experts at the
independent Institute of Medicine to come up with and help implement
new pay-for-results policy in Medicare. This will help deliver better
care for our seniors.
The second pillar reforms the insurance industry to benefit ordinary
folks. It provides overdue transparency and accountability by ending
health insurance companies' blanket exemption from anti-trust laws.
Firms will no longer be shielded from liability for price-fixing or
monopolizing. We've seen what happened on Wall Street when corporations
got too big to fail and their books too confusing to understand.
It goes further to protect consumers by making it illegal to deny
coverage for pre-existing conditions like Kristy's or charging more
based on gender, occupation, or health status. It also caps annual out-
of-pocket expenses and prohibits unfair limits on benefits to ensure no
American goes bankrupt because of illness. And, it allows individuals
up to the age of 27 to stay on their parents' insurance plan.
The third pillar promotes competition and choice for people who don't
have insurance today or lose it in the future. Under the bill,
Americans will be required to obtain health insurance, just like
drivers are mandated by state law to purchase auto insurance.
People who don't have health insurance today or lose it in the future
can participate in the Health Insurance Exchange where they can compare
and purchase insurance products that best meets their needs. An
analysis by MIT Economist Jonathan Gruber found that premiums for folks
in the Exchange will be lower than they would be if those same people
were buying individual insurance in today's market.
Privately-owned insurance companies, member-owned cooperatives, and a
government-backed public option will compete for business in the
Exchange. Low-income workers will get financial credits to help them
afford to buy insurance.
Another solution brought up at my town hall meetings and championed
by Minnesota's Republican Governor Tim Pawlenty is fostering
competition and lower costs through interstate insurance sales. The
House health care bill allows states to work together to do just that.
Finally, the fourth pillar will improve seniors' access to quality,
affordable health care and protect the doctor-patient relationship. It
addresses one of seniors' top concerns by immediately beginning to fill
in the Medicare Part D donut hole which will make prescription drugs
more affordable.
I joined the President and Republicans in demanding that health care
reform be fiscally responsible. The bill before us now is paid for and
does not add to the national debt, according to the nonpartisan
Congressional Budget Office.
To the defenders of the status quo who are opposing health insurance
reform, I have one question for you: How does your plan help people
like Kristy?
I encourage my colleagues to stop playing political games and come
together across party lines to solve the problem. Vote yes on H.R.
3962, the Affordable Health Care for America Act.
Mr. MANZULLO. Mr. Speaker, America's health care system is in need of
reform. The families in the congressional district I represent have
seen their health premiums consume more and more of their salary.
Employers are faced with the difficult decision regarding whether or
not they can continue to afford to offer their employees the health
coverage they know they need. Many more wish they could offer their
employees coverage but the orders just aren't there, not in this
economy. Doctors and other health providers have seen their
reimbursements decline while their practice costs have risen and their
liability insurance premiums have skyrocketed due to those who abuse
our lawsuit system. Some doctors have reached the conclusion that they
can no longer accept Medicare or Medicaid patients.
I have spent my entire tenure in Congress working to reform our
health care system to help these families, employers, and health
providers. I have worked to pass association health plans so that small
businesses can join together with other small businesses from across
the country to grow their purchasing power on behalf their employees. I
have also supported allowing Americans to obtain health insurance
through other larger purchasing pools such as their church
denomination, alumni association or other memberships. The Republican
Congress twice passed association health plans only to come up short as
a result of Democrat opposition in the Senate.
I have worked to pass health care options that meet the unique needs
of families, such as medical savings accounts, health savings accounts,
and flexible spending arrangements. These important initiatives allow
families to save for future health needs and have been an important
tool for small businesses. However, I have also had to defend these
successful plans from assault by those who seek sources of revenue to
fund tried-and-failed big government programs.
I have worked to pass medical liability reform to reduce the high
premiums that are driving doctors and other health providers from
practice. Doctors in the district I represent face medical liability
premiums three to four times as high as their colleagues just north of
the border in Wisconsin as a result of Wisconsin's sensible cap on the
third-layer non-economic, punitive awards. The Republican Congress
twice passed medical liability reform only to have the reform die in
the Senate as a result of Democrat opposition.
I have worked to revise the flawed payment formula for doctors who
treat Medicare patients to ensure that our seniors continue to have
timely access to the most talented medical professionals in our
community. I have worked to make sure that none of our health providers
are targeted unfairly by government policies or agencies.
And I have spent over 75 percent of my time trying to improve the
economic climate for the manufacturers and other small businesses back
home so that they can not only remain competitive world-wide, but also
be able to offer competitive health care benefits for their employees.
Today, I support a Republican plan that continues to pursue these
important reforms. Rather than punish small businesses with onerous
mandates and tax penalties for not offering health coverage, the
Republican plan will provide tools for small businesses to pool
together, just as larger corporations or labor unions do, to offer
health care to their employees at lower prices.
The Republican plan would save $54 billion by helping to restore
common sense to the legal system and curb defensive medicine by
enacting medical liability reforms modeled after the successful state
laws of California and Texas. This will dramatically reduce health
costs for doctors and patients and will reduce the need for expensive
additional tests or procedures that do nothing to improve health status
but simply are ordered because of the threats of lawsuits.
The Republican plan will lower health insurance premiums for all
Americans. The non-partisan Congressional Budget Office estimated that
premiums would be reduced by 10 percent for employees who receive their
coverage through their small business employer; 8 percent for those who
do not have access to employer-provided coverage; and 3 percent for
employees who receive their coverage through a larger business.
Families will see

[[Page H12902]]

their premiums $5,000 lower than the cheapest government run health
insurance plan offered by the Democrats.

The Republican plan provides options for those with pre-existing
conditions or those otherwise unable to afford health insurance through
state high risk pool options designed to meet the unique regional needs
of local citizens. The Republican plan provides options for young
adults to remain on their parents' health plans.
The Republican plan promotes innovation in the areas of coverage,
technology, and wellness, and prevents government bureaucrats from
coming between a doctor and patient. It preserves existing law
preventing federal funding from paying for elective abortions. It
doesn't raise taxes; it doesn't cut Medicare benefits; it doesn't force
anyone into a new government-run health program; and rather than
increasing the debt burden on our children and grandchildren, the CBO
estimates that the Republican plan will save $68 billion over the next
ten years.
Unfortunately, the bill offered by House Speaker Nancy Pelosi (D-CA)
takes a very different approach. The Pelosi bill is a $1.3 trillion
dollar federal government takeover of the entire health care sector. It
increases taxes by $766 billion, taken from badly needed capital for
operations and loans for small businesses and is estimated to kill 5.5
million jobs. It penalizes employers for not offering and employees for
not purchasing the health coverage that a new all-powerful Health
Choices Commissioner deems acceptable. It increases the cost of health
care for patients and other health consumers through a new 2.5 percent
tax on medical equipment, such as wheel chairs. The Pelosi plan cuts
$500 billion from Medicare, which will hurt 18,425 seniors from the
Congressional district I represent. District hospitals will see their
Medicare payments cut by $244.7 million and local skilled nursing
facilities will lose $113.4 million.
Despite claiming the goal of decreasing health costs, the Democrat
bill creates 111 new bureaucracies, commissions, agencies, or offices,
necessitating the hiring of thousands of new bureaucrats. These new
czars and commissars will micromanage all aspects of Americans' health,
including the following from page 1514: ``The Secretary shall establish
by regulation standards for determining and disclosing the nutrient
content for standard menu items that come in different flavors,
varieties, or combinations, but which are listed as a single menu item,
such as soft drinks, ice cream, pizza, doughnuts, or children's
combination meals, through means determined by the Secretary, including
ranges, averages, or other methods.''
This Pelosi bill irresponsibly shifts significant costs to the states
by hiking their Medicaid expenses. Most states already face significant
existing Medicaid shortfalls as demonstrated by the Medicaid bailout
for states contained in the Democrat stimulus bill.
The creation of a new government health insurance exchange through
which all insurance must be approved and through which all individual
insurance must be sold will jeopardize the insurance choices currently
enjoyed by over 85 percent of Americans. The creation of a government
run health insurance plan coupled with a heavy-fisted regulatory scheme
tipped significantly in its favor will further erode the Americans
choice of coverage and eventually result in most Americans being forced
into a full-blown government run insurance scheme. Further troubling is
the inclusion of comparative effectiveness research panels that are
utilized in European single-payer systems to ration health care based
on cost factors.
And despite the CBO's estimate on the significant savings that could
be achieved, the Democrat bill not only contains no medical liability
reform, but it actually incentivizes states to repeal their existing
medical liability laws in exchange for money.
In sum, the Pelosi bill will kill jobs, cut Medicare, pile debt on
our children, increase health care costs, ration care, and raise taxes.
As a result of these and hundreds of other disturbing provisions, I
cannot in good conscience vote for the Pelosi government takeover of
health care.
Ms. KAPTUR. Mr. speaker the Affordable Health Care for America Act
will strengthen America and offer greater security to our workers,
families, seniors and businesses. It will enhance our nation's health
care system, placing American healthcare consumers where they belong:
at the heart of it. H.R. 3962 will improve quality, choice and
competition, while cutting down fraud, waste and abuse, and lowering
costs over the long term. It will strengthen Medicare, eliminate the
Part D ``donut hole,'' improve access for lower income citizens so that
Medicare is affordable for ALL seniors, and create new consumer
protections for Medicare Advantage Plans. Discrimination for pre-
existing conditions, dropped coverage, and yearly or lifetime caps will
no longer be tolerated. Co-pays and other cost-sharing for preventative
services will be eliminated and annual caps on what an individual or a
family pays out-of-pocket will be established.
Since 1987, the cost of the average family health insurance policy
has risen from 7 percent of median family income to 17 percent. Family
premiums are projected to increase an average of $1,800 each year and
in 2007, 60 percent of bankruptcies were reported to be related to
medical costs. With this bill, no American family will go bankrupt
because they get sick.
Sixty percent of our nation's entire uninsured population are small
business owners and their employees and families. This equals at least
28 to million uninsured Americans. Small business premiums have risen
129 percent since 2000. In 2008, 38 percent of small companies offered
health coverage, compared with 41 percent in 2007 and 61 percent in
1993.
For too long, the health of our nation has dwindled while the pockets
of the insurance giants have thickened. Our seniors have compromised
prescription drugs for necessary groceries, while the pharmaceutical
industry has made record profits. Hard working families have watched
their savings plummet and their homes foreclosed after unexpected
illnesses. Woman with breast cancer, men with heart disease and
children with leukemia or childhood diabetes have been flat-out denied
health insurance coverage for pre-existing conditions or reaching
insurance policy caps.
Under the House Plan, the Ninth Congressional District of Ohio will
benefit immensely and in very specific ways:
386,000 residents in the region I represent will see improved
employer-based coverage.
167,000 households would be eligible for credits to help pay for
coverage.
38,000 uninsured citizens just in our region would be eligible for
insurance under a reformed system.
14,500 small businesses will be allowed to obtain affordable health
care coverage and 12,400 among them will receive tax credits to help
reduce the costs of health insurance.
102,000 beneficiaries will benefit from an improved Medicare program.
7,600 seniors will benefit from closing the prescription drug donut
hole, starting with $500 of cost forgiveness is 2010.
1,700 families will be protected from bankruptcy due to unaffordable
health care costs.
$120 million in savings will be seen by hospitals and health care
providers as a result of reductions in uncompensated care.
The uninsured will receive immediate relieve through a temporary
insurance program. Individuals receiving COBRA will be allowed to keep
their coverage until a more customer friendly, one-stop marketplace for
health insurance, known as the Exchange, is created. The Exchange will
offer affordability credits and tax credits for individuals and
businesses that need them. Health plans will be required to allow young
people until their 27th birthday to remain on their parents' health
insurance policy. Moreover, insurance companies will be subject to
public review and disclosure of insurance excessive rate increases.
Much needed investments will be made right away in training programs
designed to increase the number of primary care doctors, nurses, and
public health professionals. Not-for-Profit purchasing collaboratives,
such as the FrontPath Health Coalition from Northwest Ohio, will be
strengthened to achieve careful plan management and cost-savings, and
encouraged as a central provision of Title I. Community Health Centers
will see an increase in funding to allow for a doubling of patients
over the next 5 years. A $10 billion fund will be created to finance a
temporary reinsurance program to help offset the costs of expensive
health claims for employers that provide health benefits for retirees
age 55-64.
The well being of individuals and our nation will benefit from these
reforms. From an economic standpoint, healthcare costs have stifled the
vitality of American businesses and their ability to compete in the
global marketplace. The 129 percent increase since 2000 in small
business premiums alone have smothered their potential and destroyed
their ability to cover employees, resulting in an astounding 60 percent
of our nation's entire uninsured population.
Affordable health insurance reform is necessary to cut the costs of
doing business, reduce the share of government expenditures spent on
health care, help our companies to be more competitive in the world
market, unleash the entrepreneurial talents of the American people, and
give peace of mind to the middle class and our seniors and others that
everything they have worked for will not be taken away if they get
sick.
As someone who grew up in a small business family, I watched our
father forced to sell our small family grocery when he became ill. He
needed health insurance for our family and took a job at a local auto
assembly plant to obtain it for his wife and children. I promised
myself when I was elected to Congress that passing legislation to cover
small business would be one of my top priorities. Finally, it has
become possible to vote on a bill that will do this for millions of our
fellow citizens.

[[Page H12903]]

With the mounting economic strain on American families and the rising
costs of health insurance to workers, businesses and federal budget,
the status quo has proven itself unsustainable, fiscally irresponsible
and morally unacceptable. The time has come for this historical change.
I stand in support of its promise to the American people.
Mr. KUCINICH. Mr. Speaker, we have been led to believe that we must
make our health care choices only within the current structure of a
predatory, for-profit insurance system which makes money not providing
health care. We cannot fault the insurance companies for being what
they are. But we can fault legislation in which the government
incentivizes the perpetuation, indeed the strengthening, of the for-
profit health insurance industry, the very source of the problem. When
health insurance companies deny care or raise premiums, co-pays and
deductibles they are simply trying to make a profit. That is our
system.
Clearly, the insurance companies are the problem, not the solution.
They are driving up the cost of health care. Because their massive
bureaucracy avoids paying bills so effectively, they force hospitals
and doctors to hire their own bureaucracy to fight the insurance
companies to avoid getting stuck with an unfair share of the bills. The
result is that since 1970, the number of physicians has increased by
less than 200% while the number of administrators has increased by
3000%. It is no wonder that 31 cents of every health care dollar goes
to administrative costs, not toward providing care. Even those with
insurance are at risk. The single biggest cause of bankruptcies in the
U.S. is health insurance policies that do not cover you when you get
sick.
But instead of working toward the elimination of for-profit
insurance, H.R. 3962 would put the government in the role of
accelerating the privatization of health care. In H.R. 3962, the
government is requiring at least 21 million Americans to buy private
health insurance from the very industry that causes costs to be so
high, which will result in at least $70 billion in new annual revenue,
much of which is coming from taxpayers. This inevitably will lead to
even more cost, more subsidies, and higher profits for insurance
companies--a bailout under a blue cross.
By incurring only a new requirement to cover pre-existing conditions,
a weakened public option, and a few other important but limited
concessions, the health insurance companies are getting quite a deal.
The Center for American Progress' blog, Think Progress, states ``since
the President signaled that he is backing away from the public option,
health insurance stocks have been on the rise.'' Similarly, healthcare
stocks rallied when Senator Max Baucus introduced a bill without a
public option. Bloomberg reports that Curtis Lane, a prominent health
industry investor, predicted a few weeks ago that ``money will start
flowing in again'' to health insurance stocks after passage of the
legislation. Investors.com last month reported that pharmacy benefit
managers share prices are hitting all-time highs, with the only
industry worry that the Administration would reverse its decision not
to negotiate Medicare Part D drug prices, leaving in place a Bush
Administration policy.
During the debate, when the interests of insurance companies would
have been effectively challenged, that challenge was turned back. The
``robust public option'' which would have offered a modicum of
competition to a monopolistic industry was whittled down from an
initial potential enrollment of 129 million Americans to 6 million. An
amendment which would have protected the rights of states to pursue
single-payer health care was stripped from the bill at the request of
the Administration. Looking ahead, we cringe at the prospect of even
greater favors for insurance companies.
Recent rises in unemployment indicate a widening separation between
the finance economy and the real economy. The finance economy considers
the health of Wall Street, rising corporate profits, and banks'
hoarding of cash, much of it from taxpayers, as sign of an economic
recovery. However in the real economy--in which most Americans live--
the recession is not over. Rising unemployment, business failures,
bankruptcies and foreclosures are still hammering Main Street.
This health care bill continues the redistribution of wealth to Wall
Street at the expense of America's manufacturing and service economies
which suffer from costs other countries do not have to bear, especially
the cost of health care. America continues to stand out among all
industrialized nations for its privatized health care system. As a
result, we are less competitive in steel, automotive, aerospace and
shipping while other countries subsidize their exports in these areas
through socializing the cost of health care.
Notwithstanding the fate of H.R. 3962, America will someday come to
recognize the broad social and economic benefits of a not-for-profit,
single-payer health care system, which is good for the American people
and good for America's businesses, with of course the notable
exceptions being insurance and pharmaceuticals.
Mr. AL GREEN of Texas. Mr. Speaker, I rise in support of H.R. 3962,
the Affordable Healthcare for America Act. I would like to thank the
Democratic Leadership and the Chairmen of the committees of
jurisdiction for their unwavering commitment to this important cause.
Today, we are faced with a historic opportunity to accomplish
meaningful change in the lives of millions of Americans. I am in
support of this bill because I believe in improving the quality of
care, the accessibility of care, and the affordability of care. The
status quo is unsustainable and the cost of inaction is simply too
high.
If we pass this legislation, we will reduce the federal deficit by an
estimated $129 billion over the next ten years. If we fail to do so, we
will ensure that our country continues to spend $79,274 a second on
healthcare. We will continue to dedicate 17.6 percent of our gross
domestic product, or $2.5 trillion a year towards healthcare
expenditures.
To pass this legislation would mean that an estimated 36 million
Americans would gain access to health insurance; failing to do so,
would mean that the 45.7 million Americans who cannot afford, or cannot
gain access to healthcare, would remain without coverage. Among the
45.7 million uninsured, 1.4 million are children in my home state of
Texas--this is simply unacceptable.
Finally, passing this legislation would mean an end to the
discriminatory practices of the health insurance industry that have
devastated so many Americans. No longer will people fear having a pre-
existing condition will prevent them from receiving health insurance
coverage. No longer will families fear the uncertainty of a
catastrophic health event, or fear being driven into bankruptcy in
trying to pay for the cost of care. No longer will people have to fear
losing their health coverage simply for getting sick. In passing this
legislation, we put an end to the days when 14,000 Americans lose their
coverage every day.
The time has come when we, in Congress, are faced with a decision to
either change the course of this country, to shift its direction
towards accessible and affordable healthcare, or continue down an
unsustainable path, one wrought with uncertainty. With so many American
families struggling to support themselves, I am proud to support this
legislation.
Mr. MARKEY. Mr. Speaker, thank you Speaker Pelosi, Chairman Waxman,
Chairman Emeritus Dingell, Chairman Rangel and Chairman Miller for your
leadership in bringing us to this historic day.
For almost a century, we have been laying the groundwork for
comprehensive health care reform in our country--ever since Theodore
Roosevelt's Progressive Party included health insurance coverage in its
platform for the 1912 elections.
Since then, there has been some progress--Medicare for seniors,
Medicaid for the poor, CHIP for children,--as well as successful
efforts in some states, including the landmark health reform law
enacted in my home state of Massachusetts three years ago. But we have
continued to come up short. And now the 46 million Americans without
health care are paying the price.
Our health care system has been ailing for decades, and now it's in
intensive care. The consequences of this broken health care system are
severe--the number one cause of personal bankruptcies today is medical
bills--Americans going broke when they get sick. And 80 percent of
these medical bankruptcies strike Americans who actually have
insurance. It is unconscionable that so many Americans have to fight
their insurance companies while they fight for their very lives. Their
insurance policies fail to cover all of the astronomical costs
associated with their treatment. They are insured, but not covered.
I recently received a letter from a constituent that illustrates one
of the reasons why we need health care reform now. Peter returned home
from the hospital to find a bill informing him that his insurance
company denied coverage for the anesthesia used during his operation.
The insurance company deemed the anesthesia ``medically unnecessary''
and billed him $10,000.
He had open heart surgery, Mr. Chairman. So he asked me, did the
insurance company expect him to ``take a swig of whiskey and bite a
bullet'' while the surgeon cut open his chest? Unbelievable, Mr.
Chairman, but true. Like too many Americans, he was insured, but not
covered. We desperately need health care reform because there are too
many stories like Pete's all across the country.
My Republican colleagues want to put a Band-Aid on our badly broken
system, but what it really needs is CPR--Coverage, Prevention and
Research. That's exactly what our health bill delivers for the American
people.
We expand COVERAGE to ensure that all Americans have access to
affordable care.
We invest in PREVENTION to transform our system from a ``sick care''
system into a true health care system.

[[Page H12904]]

We support RESEARCH, building on the $10.4 billion down payment in
the recovery and reinvestment act for NIH. In this bill, we will invest
in comparative effectiveness research to help improve the quality of
care and reduce costs.
The Republicans' plan is really quite simple: You're On Your Own. The
Republican plan tells Americans--``If you get sick and don't have
insurance, you're on your own.'' The Republican plan tells Americans if
you are denied coverage because of a pre-existing condition ``You're on
your own.'' Republican Leaders in Washington seem to be suffering from
a pre-existing condition of their own--a heart of stone. If you kicked
their heart, you'd break your toe! And under the Republican plan, they
could be denied coverage.
The Republicans say the Democratic Plan will put the government
between you and your doctor, but the doctors who make up the American
Medical Association support the Democratic bill, not the Republican
Plan. They say it will hurt small businesses but the Main Street
Alliance, representing thousands of small businesses around the
country, support the Democratic bill, not the Republican Plan. The
Republicans claim the Democratic bill will hurt seniors, but the AARP
has endorsed the Democratic bill, not the Republican Plan.
There are reasons why the AARP supports the Democratic bill. The
Democratic bill will close the Medicare part D donut hole, the
Republican bill does not. We provide support for low-income seniors,
they do not. We will extend the solvency of Medicare, they do not.
You know, GOP used to stand for Grand Old Party. Now it stands for
Grandstand, Oppose, and Pretend. They grandstand with phony claims
about non-existent death panels. They oppose any real reform. And with
this Substitute they pretend to offer a solution while really doing
nothing. GOP--Grandstand, Oppose, and Pretend.
Make no mistake about it; the Republican substitute is not real
reform. It does nothing to curb skyrocketing health care costs. It does
nothing to provide real insurance coverage to millions who are now
uninsured. It does nothing to stop the unfair practices of insurance
companies.
Mr. Speaker, there are too many Americans living in fear of a
terrorist attack, but not the kind that comes from a gunshot, bomb or
box cutter. It's the kind that may strike during a phone call from the
doctor's office or during a check-up when the doctor delivers
devastating news: ``You have cancer''; ``Your memory loss is early
onset Alzheimer's''; ``The numbness is Parkinson's''; ``The Lou
Gehrig's Disease that claimed your grandfather will strike you one
day.''
We can fight against the terror of disease by reforming our health
care system with better coordination, focusing on prevention, and
ensuring that all Americans have access to quality, affordable care.
And that's exactly what our bill will do.
I am pleased that this historic bill includes provisions that I
authored, including:
A Medicare program to provide coordinated care to severely ill
patients by a team of doctors and other health care professionals right
in the beneficiaries' own homes, allowing these frail Americans to
remain independent as long as possible.
A provision to allow patients with rare diseases, like cystic
fibrosis, to participate in clinical trial research to find a cure for
their devastating disease without losing eligibility for the Social
Security benefits they depend on.
A safeguard to ensure that insurance companies don't game the new
health care exchange by cherry-picking only healthy individuals.
Today, we are here to write a new chapter in our century-long effort
to provide every American with the health care coverage they need and
deserve.
Today we can vote for a bill that uses the American values of choice,
innovation, and competition to address some of our nation's greatest
challenges--skyrocketing health care costs, millions without health
insurance, and millions more who are under-insured and struggling to
pay their medical bills.
Today we can pass legislation that gives all Americans access to
quality, affordable health care. I urge my colleagues to vote ``aye''
on this bill.
Ms. HERSETH SANDLIN. Mr. Speaker, I believe it's critical that we
control rising health care costs, increase quality and value within our
health care system, and that we improve access to health care and
affordable health care insurance coverage.
H.R. 3962, the Affordable Health Care for America Act, represents one
of the most important votes of the year, on an issue that has been a
priority for me since I first was given the honor of representing South
Dakotans in Congress. I have long believed that the strength of our
communities in South Dakota depends on the health of our people and
that, unfortunately, quality, affordable care remains out of reach for
far too many South Dakotans.
I am convinced this Congress and the President will achieve
fundamental reform because our country must fix what's broken in our
health care system. The status quo is unsustainable. There is simply
too much at stake for South Dakota's families and businesses, who have
either seen their premiums rise sharply year after year, or who still
have no access to an affordable plan.
Done right, health care reform will both ensure that more people have
access to quality health care, and, just as critically, make the
common-sense reforms that are necessary to fix an unsustainable system
that threatens our fiscal future. These twin goals of addressing
access, quality and costs on the one hand, and solidifying our fiscal
future on the other are not mutually exclusive. In fact, they are
complementary.
Unfortunately, the House bill misses this critical opportunity. While
it does include many good provisions, it is not the right answer for
South Dakota, it could threaten existing access to health care in our
state, and it does not include nearly enough cost-containment and
deficit reduction measures.
I am concerned by the projected impact of the bill's Medicaid
provisions on South Dakota's state budget, and the reductions in
payments for long-term care under Medicare. I have recently discussed
the state's budgetary situation with Governor Rounds, along with a
number of community leaders, business people and others across South
Dakota, and we must take this situation very seriously. The growth in
the state Medicaid program due to the recession will produce a
projected 25 to 30 million dollar deficit in the state Medicaid program
in 2010, and, after the expiration of the Recovery Act enhancement in
the FMAP rate, a 50 to 60 million dollar deficit in FY2011.
Early analysis suggests that the House bill Medicaid provisions would
impose at least $87.6 million more in new Medicaid costs on the state
than the Senate Finance Committee bill. Given that budgetary impact, we
have to consider the likelihood that dramatic service cuts would be the
end result in South Dakota if the House bill were implemented, and that
is a source of serious concern for me. It should be for every South
Dakotan.
I have discussed the long-term care provisions of the House bill with
a number of long-term care providers in South Dakota and have serious
concerns about how the House bill would affect the future of care in
our state for our seniors. While the original House legislation again
has been improved in this respect by the addition of some incentive
payments under Medicaid, overall, I am concerned that the cuts under
Medicare to long-term care are unsustainable, and put undue financial
pressure on this essential part of the health care infrastructure of
South Dakota. Nursing homes will not derive the same benefit from
universal coverage that hospitals will, so this is another issue that
needs to be addressed as the process continues.
Another of my top priorities is the Indian Health Care Improvement
Act reauthorization that has been incorporated into the broader bill.
Together with the nine sovereign Native Tribes I represent, I have
worked hard to advance the Indian Health Care reauthorization in the
House of Representatives. I share the concerns of the Great Plains
Tribal Chairman's Association (GPTCA) regarding aspects of the current
version of that legislation. The GPTCA is comprised by the elected
leaders of the sovereign Indian Tribes and Nations of the Great Plains,
including South Dakota. I have consulted closely with the Tribes I
represent. For years, the Tribes and the GPTCA have supported the
Indian Health reauthorization and have been disappointed at the great
length of time it has taken to bring the legislation to this point in
the House. The GPTCA has reviewed the current version of the Indian
Health reauthorization contained in the broader health reform bill and
has serious concerns about certain provisions in the bill, principally
the fact that urban Indian non-profit organizations are, in various
sections outside of Title V of the reauthorization, treated on a par
with federally-recognized tribes.
The federal government has a unique relationship with the 562
federally-recognized American Indian and Alaska Native tribes. This
government-to-government relationship is established by our founders in
the U.S. Constitution, recognized through, hundreds of treaties, and
reaffirmed through executive orders, judicial decisions, and
congressional action. Fundamentally, this relationship establishes the
responsibilities to be carried out by one sovereign to the other. That
is why these requests by nine sovereign Sioux tribes located in South
Dakota are essential. I will continue to provide my full support to
GPTCA's requests to improve the reauthorization in conference with the
Senate, and to properly fund Indian health services.
Turning again to the broader House health care reform bill,
underlying my concerns relating to Medicaid and long-term care and
other issues is a fundamental concern about the effect of broader House
health care reform bill

[[Page H12905]]

on the nation's long-term deficit, and more specifically, my view that
it doesn't do enough to start bringing down the deficit and health care
costs in the long term. As President Obama noted earlier this year:
``If we do nothing to slow these skyrocketing costs, we will eventually
be spending more on Medicare and Medicaid than every other government
program combined. Put simply, our health care problem is our deficit
problem. Nothing else even comes close.'' He's right. Skyrocketing
long-term costs will bankrupt the Medicare trust fund by 2017--and
that's just part of the problem we need to fix.
But when it comes to the net change in the federal budgetary
commitment to health care, the House bill is seven times greater in
budgetary commitment of dollars than the Senate Finance Committee bill,
while falling far short of the long-term cost containment in the Senate
bill. In my view, any bill with such a significant increase should have
a similar commitment to cost containment. Otherwise, we'll find
ourselves in the same situation we find ourselves in with Medicare--an
essential program for South Dakotans that is going broke because we
can't make the tough choices now and are putting those choices off
until we face an immediate crisis. That's not reform--that's a recipe
for fiscal disaster.
Now, the House bill does include a number of good provisions on which
the vast majority of South Dakotans I have talked to agree. For
instance, I strongly support provisions in this bill to require
insurance companies to cover people with preexisting conditions, and to
end the insurance companies' ability to cancel coverage when someone
becomes sick. These practices must end. I was surprised and dismayed to
see that the House Republican proposal that we also will vote on
refuses to end the unconscionable practice of denying coverage for
preexisting conditions. The Congress will ultimately agree on a bill
that ends this practice. In addition, I support establishing health
insurance exchanges to provide a transparent and competitive
marketplace for individuals and businesses to buy more affordable
health care plans.
Unfortunately, in my view the House bill has not come far enough from
where it started, and the bill does not yet represent the right formula
for South Dakota. Nonetheless, I am very optimistic that, with the
House and Senate working together with the President, we will achieve a
good bill for South Dakota during this Congress, because the time has
come for fundamental reform.
Again--I believe the Congress has a responsibility to pass health
care reform legislation that is deficit neutral, that ensures access,
fairness and affordability of coverage for South Dakotans, and that
takes a responsible approach to long-term costs with a focus on
achieving higher quality health care outcomes. This bill meets some of
these goals but not all, and I can't support it. I remain steadfastly
committed to improving this legislation and I am optimistic that
through the legislative process we will achieve what South Dakotans
deserve, which is a fiscally responsible and sustainable reform of the
health care system that will dramatically improve coverage and quality
for all.
Mr. JORDAN of Ohio. Mr. Speaker, many of my colleagues from across
the aisle have called this an historic day.
I wish it was an historic day!
I wish this was the day that the majority in Congress sat up and
listened to the American people . . . not just the tens of thousands
that stood at the steps of our Capitol to speak out in defense of
protecting their health care . . . but the millions from around the
country who called our offices, wrote letters to their newspapers,
spoke at town hall meetings . . . or marched on Washington.
If they did, they would hear their deep and abiding concern for what
will happen to their health care if this bill passes.
What will happen to the relationship between them and their family
and their doctor when the heavy hand of government gets involved in
medical decisions?
What will happen to seniors, and everyone taking care of their
elderly parents or in-laws, when the overpromise of ``free health
care'' meets the economic reality of ``rationed care'' when the federal
government runs short on money?
What happens to Medicare Advantage customers whose services will be
cut?
What happens to those using Health Savings Accounts whose health
freedoms will be infringed upon?
What happens to the small business owner who desperately wants to
hire back some employees or expand his business to provide more
economic opportunities in his community? What happens when these
individuals, upon whose success our nation will rise from this
recession, have to pay the hundreds of billions in new taxes to pay for
the massive government expansion in this bill?
Mr. Speaker, how bad does it have to get? How bad does it have to get
before this Congress starts acting in a way that will help families,
create jobs, and leave a better America for our children and
grandchildren?
How bad does unemployment have to get? Earlier this week, it was
announced that our nation has reached an unemployment rate of 10.2
percent, which is the highest unemployment rate in almost 30 years. Yet
studies suggest that the taxes, mandates, and federal expansion in this
bill will cost our nation another 5.5 million jobs in the private
sector.
How bad does the deficit have to get? This year's deficit of over 1
trillion dollars was the highest in history. Yet this multi-trillion-
dollar expenditure to take over the nation's health care system will
explode the deficit, despite the fuzzy math that we've heard from the
other side of the aisle.
The debt . . . it has reached a nearly insurmountable level of 12
trillion dollars. How bad does it have to get? Even without the massive
uncontrolled expenditures involved with this health care bill, the
national debt is projected to surpass the size of our economy in the
next few years. Since when has the answer to an exploding national debt
been an explosive expansion of federal government spending in areas
that have always been a part of the private sector economy?
The one positive thing I can say about this bill is the pro-life
victory we won with the amendment offered by my fellow pro-life
colleagues, led by Mr. Stupak and Mr. Pitts. I was proud to support
that amendment because it honored the fundamental truths that life is
sacred, life should be protected, and taxpayer money should never be
used to take the life of an unborn child.
But Mr. Speaker, the bottom line is this: H.R. 3962 is the wrong
answer to what ails America's health care system.
It is too expensive. It raises taxes. It expands the reach of the
federal government into the personal health care decisions that should
be left between patients and their doctors. It is a job killer. It will
cause millions of Americans to lose their coverage, while expanding
coverage to millions of illegal aliens.
Despite the newly-enacted pro-life protections that I fought so hard
to enact both in this bill and every relevant piece of legislation
before this House, it is a bad bill.
Let me close here. We are blessed to live in the greatest country in
history. Our country is great, in part, because of something called the
American Dream. We're a country where people, through their own hard
work, can pull themselves up and reach for their goals and dreams.
Mr. Speaker, the American Dream happens because generations of
parents have worked hard and sacrificed so their children can have life
a little better than they did. When their children become parents, they
sacrifice for their children, and the dream lives on.
This bill is just another example in the recent years of our country
of borrowing for now and sending the bill to the next generation.
If we want the American Dream to live on, we must reject this bill
and return to the American principles that made our nation that shining
city on a hill.
Ms. Roybal-Allard. Mr. Speaker, I rise in support of H.R. 3962, the
Affordable Health Care for America Act, a bill that is undoubtedly the
most important single piece of legislation being considered by this
111th Congress, and possibly by any Congress in the last decade.
I commend Chairman Waxman from the Energy and Commerce Committee,
Chairman Miller from the Education and Labor Committee, and Chairman
Rangel from the Ways and Means Committee, and all of their dedicated
staff who have invested so much time and energy into crafting a bill
that addresses the complex and vast failures of our current health care
system.
This has been without a doubt the most transparent and inclusive
legislative effort that I have seen in my seventeen years in Congress,
and I commend Speaker Pelosi for her tenacious leadership in bringing
this bill to the floor.
The Affordable Health Care for America Act is not a perfect bill.
With an issue that impacts so many stakeholders, and involves so many
competing interests, it is doubtful any single legislative effort could
ever satisfy everyone and address all the problems.
But the fact of the matter is that we cannot afford to do nothing.
Study after study has shown that under our current system things will
get worse unless we act now. If we are not successful in passing this
health reform bill, Americans face a 50-50 chance of losing their
insurance in the next 10 years, the average family will have their
already prohibitive health costs increase an average of $1,800 each
year, and the rising price of medications may become unaffordable even
for those with insurance.
H.R. 3962 will help end this cycle of skyrocketing health care costs
and represents a milestone in our nation's history by finally framing
healthcare as a universal right for all Americans. With the passage of
this bill we will improve the quality and affordability of health
services, prioritize prevention and the reduction of health
disparities, and take the

[[Page H12906]]

necessary albeit difficult steps to rein in the escalating costs of
health care in this country.
I will vote for H.R. 3962 for many reasons. The most important is
that it will provide access to affordable health care to the millions
of uninsured individuals in this country. In my 34th Congressional
District of California, where the average annual household income is
less than $36,000, and where forty per cent of my constituents are
currently uninsured, this bill will provide access to health care for
240,000 more people.
The bill also helps families in our country who have health
insurance, but are struggling with high premiums and uncovered health
care costs. Last year 1,120 families in my district were forced to file
health care-related bankruptcies. H.R. 3962 will protect individuals
like them from catastrophic out of pocket costs through an annual
allowable personal expense cap.
This bill will protect our seniors from the Medicare Part D donut
hole by reducing 5 percent of the cost for brand name drugs and
gradually eliminating the donut hole altogether. This will be extremely
beneficial for the 4,100 seniors in my district who each year hit the
Medicare Part D donut hole requiring them to pay the full cost of
medications they can't afford.
H.R. 3962 will help make small businesses more competitive in
providing health insurance to their employees by providing tax credits
up to 50 percent of the cost of the insurance. In my district
approximately 15,000 small businesses would qualify for these credits.
As chair of the Congressional Hispanic Caucus Health Task Force, I
commend the Affordable Health Care for America Act for its efforts to
reduce health disparities and improve minority access to culturally and
linguistically competent health care. The bill expands Community Health
Centers which have been a cornerstone of primary care services in
communities of color, and incorporates critical health disparities
language guided by the Health Equity and Accountability Act of 2009. In
addition, the Manager's Amendment strengthens the focus of eliminating
health disparities by codifying the Office of Minority Health and
establishing Minority Health Offices across all Department of Health
and Human Services agencies.
As co-chair of the Congressional Study Group on Public Health, I am
particularly pleased that the Affordable Health Care for America Act
finally prioritizes prevention and public health in this country. The
bill ensures full coverage of evidence based preventive health
services, and establishes a Public Health Investment Fund that will
support core public health infrastructure, help finance the delivery of
community-based prevention and wellness services, and provide grants to
train the next generation of Public Health workforce professionals.
Mr. Speaker, I fully believe that the Affordable Health Care for
America Act is a bill that will transform our healthcare system and
will play a determining role in the collective health and fiscal
viability of our region, our state, and our nation.
I urge my colleagues to join me in voting yes for this bill today, to
ensure that our families and communities will have the promise of a
healthier tomorrow.
Mr. VAN HOLLEN. Mr. Speaker, we are taking a historic and very
important step today to lower health care costs for American families
and small businesses, and fix a broken health care system.
In considering the Affordable Health Care for America Act, this has
been one of the most open and transparent debates in Congress. There
have been countless hours of hearings and mark-ups and more than 3,000
public health care events around the country.
The Affordable Health Care for America Act contains significant
protections that will provide health care consumers greater stability,
lower costs, and improved quality--while all at the same time paying
down the deficit. According to independent analysis conducted by the
non-partisan Congressional Budget Office, the bill reduces the deficit
by $109 billion over the first 10 years. And it will continue to reduce
the deficit over the second 10 years.
This legislation will help the middle class by providing stable,
affordable health insurance that people can count on. It will rein in
health care costs for families, businesses and the government. It will
ensure that if you lose your job, you won't lose your access to health
care. No one should have to worry about whether they can see a doctor
when they're sick because they don't have health insurance.
I have heard from countless constituents who have been victims of
discrimination by insurance companies, like the family who recently
shared their experience with me about their inability to obtain health
insurance coverage. The father started his own company and applied for
health insurance for his family, but three out of the four family
members could not be fully covered due to pre-existing conditions. It
turns out that he was rejected for coverage because he had two chest
colds in the last 6 years and scar tissue in his lungs. For his
daughter, the insurance company would only issue a policy that
precludes coverage for any injury to any part of her back at any time
in the future because of a previous injury of her back. And the same
company refused to cover any injury to his son's knee at any time in
the future from any cause due to a previous injury. It is
unconscionable that the insurance company's policies precluded everyone
in his family from being fully covered.
There are a number of provisions that would help this family, my
constituents, and millions of Americans. Among them, the bill would end
the practice of discriminating against those with pre-existing
conditions, such as diabetes, cancer, a heart condition, or previous
injuries. It would prohibit insurance companies from dropping health
care coverage because you became sick. The bill eliminates co-pays for
preventive and wellness care, and it places annual caps on what
Americans pay out-of-pocket for health care services. And there would
be no yearly or lifetime cost caps on what insurance companies cover.
A critical piece of this legislation is the creation of a new Health
Insurance Exchange that will allow individuals and small business to
comparison shop for affordable and quality health insurance coverage.
The Exchange will help reduce the growth in health care spending
by encouraging competition on price, quality, and transparency among a
number of private health insurance companies and a public health
insurance option. The public option will add choice to the health
insurance market and participation is completely voluntary. That is why
Consumers Union and Consumer Reports endorsed this bill. With this
health care reform bill, Americans will have the freedom to keep their
doctor or select another one. The choice is theirs. It preserves and
strengthens the doctor-patient relationship. That's why the doctors of
America under the umbrella of the American Medical Association have
endorsed this bill.

The legislation takes steps to preserve and strengthen Medicare for
today's seniors and future generations of retirees. For over 40 years,
Medicare has been a stable, reliable program for senior citizens and
people with disabilities. It provides health care coverage to
approximately 45 million Americans. This bill will ensure that seniors
can see their doctor of choice or find a doctor by improving Medicare
reimbursement to doctors. It lowers drug costs for seniors by closing
the Medicare Part D ``doughnut hole'' and allowing the government to
negotiate with pharmaceutical companies for lower drug prices. And it
takes steps to reduce waste, fraud, abuse, and inefficiency in the
Medicare program. For all these reasons, AARP has endorsed this bill.
Thousands of small businesses in America will benefit from this bill
because it will provide them greater affordability. Small businesses
will gain access to the new Health Insurance Exchange that will allow
them to obtain rates normally enjoyed by larger employers, lower
administrative costs, greater transparency, and greater choice of plans
for their employees. They will benefit from increased competition for
better prices as well as tax credits for those who choose to provide
health insurance for their employees.
I am pleased that this bill contains several provisions I helped
author. The first, the Assessment of Medicare Cost-Intensive Diseases
and Conditions, directs the Department of Health and Human Services to
conduct an assessment of the diseases and conditions that are the most
cost-intensive for the Medicare program. Part of our effort to reform
the health care system is to develop cures and treatments for those
conditions and diseases that have a high cost, and this will go a long
way in that endeavor.
The second, which I worked on with Representative Kathy Dahlkemper
and others, requires health insurance plans to allow young people
through age 26 to remain on their parents' insurance policy, at the
parent's choice. Young adults between the ages of 19 and 29 are one of
the largest segments of the American population without health
insurance, comprising 29 percent of the total number of uninsured
Americans.
I am also pleased that we were able to include a provision that ends
the special advantages for health insurance companies. For far too
long, the health insurance industry has been exempt from the antitrust
laws that govern most other businesses. They have abused that benefit.
I believe it is long past time to repeal this exemption. By ending this
antitrust exemption, we are increasing competition and preventing
unfair business practices that allow health insurers to drive up the
cost of health care.
Lastly, I worked with Representatives Himes, Bean, and others to
include in the bill a provision that would allow the creation of state
health insurance compacts. This would permit states to enter into
agreements to allow for the sale of health insurance across state
lines. The creation of state health insurance compacts is another
element of the health reform

[[Page H12907]]

bill that will allow consumers to shop for insurance across state
lines, promote choice and competition, and ensure strong consumer
protections.
On the question of whether any of the insurance plans offered in the
Health Insurance Exchange could cover an abortion, I support the
provisions in the Rule that created a mechanism for ensuring that no
public subsidies would go to pay for abortions. The non-partisan
Congressional Research Service analyzed that provision and found that
it prevented taxpayer dollars from going to pay for any coverage of
abortions. The amendment offered by Representative Stupak goes much
further. It would effectively prevent Americans from using their own
money to purchase an insurance plan in the Health Insurance Exchange
that includes coverage of abortions. That would be a dramatic break
with the current practice where most insurance plans provide for such
coverage for individuals who choose such plans. Because the Stupak
amendment would effectively prohibit individuals from using their own
money to purchase such plans in the Exchange, I oppose it.
Mr. Speaker, today we stand at a historic crossroads. We can choose
the road that dead-ends in the status quo--where the health insurance
industry continues to call the shots and ration our health care--or we
can pass this legislation and take the path that leads to a future
where every American has access to affordable, quality health care.
Now I understand why the health industry is opposed. But our job is
not to protect the profits of the insurance companies. Let's not
protect special interests and the status quo. Let's move America
forward. Let's vote yes for America.
Ms. CORRINE BROWN of Florida. Mr. Speaker, like the majority of
Americans, I am well aware of the desperate need in our country for
comprehensive health care reform. In fact, the immediate need for
reform became crystal clear to me when, over the August district
period, I went to a hospital in Jacksonville to visit a friend. This
friend, who had worked in the Duval County school system for over 25
years, had lost his job, was without health insurance, was struggling
to support himself, and had no idea how he was going to be able to pay
the hospital bill. For the many, many Americans who find themselves in
similar situations: for the woman who cannot get insurance coverage
because she is diabetic and has a pre-existing condition, to the one in
nine children in America without health care, to the millions of middle
class American citizens who skip necessary treatments because they
cannot afford it, it is for them that the Affordable Healthcare for
America Act, which will ensure that all Americans are covered and have
access to affordable care, is necessary.
Unfortunately, the bill passed the House without any Republican
support. Although many pieces of legislation this session have advanced
in a bipartisan manner, particularly in my committees of
specialization, Veterans Affairs and Transportation, health care has
not been an issue of biparty agreement. In 2003, the Republican Party
pushed through a horrible Medicare Prescription drug law that was voted
along party lines, in which the Republicans included a ``donut hole''
provision, in which there is a wide gap in coverage that forces the co-
payer to pay for much of their own prescription drug costs.
Fortunately, the bill on the Floor today will begin to close this
loophole. Similarly, today's bill in the House as well as the Senate
health care bill, are advancing without any Republican support. Social
Security was created in 1935 by Franklin D. Roosevelt as part of the
New Deal, Medicare, in 1965, and Medicaid, in 1965, through Title XIX
of the Social Security Act. All of these programs were created by
Democrats without the votes of the majority of Republicans.
One aspect of health care reform of utmost importance to me is
maintaining proper funding for Disproportionate Share Hospitals (DSH),
like Shands Jacksonville (and Gainesville), who provide healthcare to
uninsured and/or individuals with limited incomes. Disproportionate
Share Hospitals are invaluable, as they are the one true safety net for
the working poor nationwide. I fought hard to keep DSH funding in the
Budget Reconciliation negotiations during the Clinton years, and have
been working throughout the entire process to ensure that their funding
was not stripped in the health care bill before us today.
Another extremely important issue addressed in this bill is that it
prevents insurance companies from denying people coverage based on pre-
existing medical conditions. Indisputably, denying a health insurance
plan to someone merely because they're likely to need a particular form
of medical care runs contrary to the underlying reason for providing
medical insurance and medical care in the first place. So the bill
before the House today opens doors to quality medical care to those who
were shut out of the system for much too long, and also makes
prevention a key piece of this legislation's goal, since it puts a
renewed emphasis on preventive care, expands access to screenings and
other treatments, and even promotes wellness in the workplace.
Indeed, for nearly a century leaders from all over the political
spectrum, beginning with President Theodore Roosevelt, have called and
fought for health care and health insurance reform. Finally today, the
House of Representatives, the People's House, is about to deliver on
the promise of making affordable, quality health care available for all
Americans,
The Affordable Health Care for America Act is founded on key
principles of American success: opportunity, choice, competition, and
innovation. Among the many positive things this bill does, a few items
that stand out is that it will provide coverage to nearly all our
nation's citizens, while at the same time reducing the deficit by $32
billion over the first 10 years. It will also require the Secretary of
Health and Human Services to negotiate drug prices for Medicare
beneficiaries; begin to close the prescription drug ``donut hole''
immediately; create a new, voluntary insurance program to make long-
term care more affordable; and repeal the anti-trust exemption for
health insurance companies.
For Floridians in particular, where more than one in five residents
do not have health insurance, and for my constituents in Florida's
third congressional district and minority communities nationwide, the
need for health care reform is obvious. For the African American
community and Hispanics, groups who make up nearly half of the
estimated 50 million Americans who lack insurance, this is imperative.
In addition, health care costs have become outright unsustainable, and
experts predict that in the near future, one-fifth of our nation's GDP
will go towards health care spending.
The benefits for my district, Florida's third, are numerous. In fact,
the Affordable Health Care Act will: Improve employer-based coverage
for 300,000 residents; provide credits to help pay for coverage for up
to 192,000 households; improve Medicare for 93,000 beneficiaries,
including closing the prescription drug donut hole for 6,600 seniors;
allow 20,100 small businesses to obtain affordable health care coverage
and provide tax credits to help reduce health insurance costs for up to
18,400 small businesses; provide coverage for 138,000 uninsured
residents; protect up to 1,400 families from bankruptcy due to
unaffordable health care costs; reduce the cost of uncompensated care
for hospitals and health care providers by $145 million. For too long,
health care has been a privilege, not a right in America. And for years
our nation's leaders have fought to bring the promise of quality,
affordable health care to every American.
Today is a groundbreaking moment in this historic effort. Indeed, we
are now closer than ever to guaranteeing every American access to
quality, affordable health insurance and giving middle-class families
and businesses relief from crushing costs, while simultaneously
reducing our nation's deficit.
Ms. McCOLLUM. Mr. Speaker, today we are making history. Today the
U.S. House of Representatives is making health care in the United
States of America more affordable and more accessible for millions of
our citizens. This legislation may not be perfect, but it is very good.
It will make our country stronger, our economy more productive, and
every American family healthier.
Our goal is to achieve universal coverage so that every Minnesotan
and every American has the ability to access quality, affordable health
care. The Affordable Health Care for America Act (H.R. 3962) comes
closer than ever before to realizing that goal by extending health
insurance coverage to 96 percent of Americans.
This bill will have immediate and lasting benefits for millions of
Americans. It will give families the confidence and security that comes
with knowing they will be able to access quality, affordable health
care when they or a family member is sick. And it places affordable
health care coverage within reach for millions of American families who
are asking for our help.
As I have often said, I believe that health care should be a right
for all Americans. Critics of making health care a right often say we
already have universal health care since people can go to the emergency
room and access care if they really need it. This flawed logic is the
best example of why I believe health care in America is broken and must
be fixed.
Our health care system is broken when we live in the wealthiest, most
powerful country in the world, but health care is a privilege available
to only those with enough money to afford insurance and for those of us
fortunate enough to have a job that provides health insurance.
Our health care system is broken when 60 million people in this
country have no health insurance coverage or are under-insured--more
than 85 percent of whom are from working families.
Our health care system is broken when families are forced to postpone
or skip necessary

[[Page H12908]]

care because premiums have increased more than 90 percent in the last
nine years for Minnesota families.
Our health care system is broken when our country spends $2.4
trillion a year for health care--almost twice as much per person as any
other country--but we rank 37th in the world in health care outcomes.
Our health care system is broken when you can be denied coverage for
being sick, for having a baby, or for suffering from domestic violence.
Our health care system is broken when 45,000 people die in the United
States each year because they lack health insurance and cannot access
needed care.
We can and must do better. Today we have an opportunity to save these
lives and make affordable health care insurance a reality for every
American.
My constituents and all citizens across this country need to know
what is in this bill to help American families and workers. This
legislation will make quality health care more affordable and more
accessible for every patient. It will protect families from falling
into bankruptcy due to unaffordable costs by limiting out-of-pocket
costs, lifting lifetime limits on coverage, and lowering premiums.
First and foremost, if you love your doctor and like your current
insurance, you are free to keep what you have. This legislation does
not require you to make any changes. Yet, the ranks of the insured are
shrinking more every year and the numbers of satisfied citizens are
falling. Millions of Americans have too little insurance, too few
choices, and no options left. For those Americans--for most Americans--
this legislation is a lifeline to the security they have longed for and
long-deserved.
This bill will give every American the peace of mind that insurance
companies can no longer deny coverage for pre-existing conditions, or
cancel your coverage when you are sick and need it the most.
It includes a competitive public insurance option to guarantee that
Americans will have an affordable choice among insurance providers and
keep private insurers honest.
It improves health care for patients and their families by making
investments to increase the number of providers, improve access to
primary care, and support a patient-centered approach that focuses on
quality and emphasizes prevention.
For our seniors, this legislation will strengthen Medicare by
eliminating the waste, fraud and abuse that diverts health care dollars
away from care and into the pockets of crooked companies. It will
immediately begin closing the ``donut hole'' in the Medicare
prescription drug benefit to make prescriptions more affordable. And it
will ensure the financial stability and solvency of Medicare for 45
million seniors.
For our children, it will help expand coverage and ensure that the
youngest Americans receive quality coverage that includes essential
benefits such as vision and oral services. And it will extend coverage
for young people by allowing them to remain on their parent's insurance
until their 27th birthday.

The Affordable Health Care for America Act does all these things
while meeting President Obama's call for new costs to be covered. In
fact, the bill goes much farther by reducing the deficit by $109
billion over the next 10 years.
This comprehensive health care legislation is ambitious by necessity.
I have confidence every one of these reforms will be implemented
successfully because of what my state of Minnesota has accomplished.
Through a combination of smart investments and an enduring commitment
to care for all of our friends and neighbors, my state proved a high-
quality, low-cost health care system is possible. Minnesota is
consistently ranked among the highest in the nation for quality of care
and rates of insured citizens--almost 92 percent. And Minnesota attains
these high standards with some of the lowest costs in the country.
Unfortunately, our state is forced to work with fewer resources than
most other states because of the Medicare geographic payment disparity.
Medicare's outdated and unfair reimbursement system pays Minnesota
doctors and hospitals at some of the country's lowest rates, despite
the fact they produce some of the country's best patient outcomes. The
current system rewards the amount of services provided rather than the
quality of care patients receive.
Patients, providers, health plans, hospitals, and unions have all
told me that ending this disparity and reversing this flawed incentive
structure is the most important issue for Minnesota in the national
debate on health care reform. While Minnesota's health care system is
excellent today, the broken Medicare payment system threatens to
undermine it in years to come.
This health care reform legislation is our last best chance to fix
this problem, achieve fairness for Minnesotans, and make evidence-
based, quality care the standard wherever you live in the United
States. That is why I worked to unite 40 of my House colleagues who
represent 17 different states in a new Quality Care Coalition. Together
with my coalition co-chairs Representatives Bruce Braley, Ron Kind and
Jay Inslee, we created the political will we have always needed but
never had to address this problem. After more than 20 coalition
meetings over the course of 6 months and a series of intensive
negotiations with House Leadership, our coalition secured an agreement
to end the unfair treatment of high quality, low-cost states such as
Minnesota. And by securing fairness for our states, we will be helping
to deliver better quality for all patients in every state.
This agreement places America on a path to reward high quality,
evidence based, cost-effective health care by making fundamental
improvements in the delivery system. H.R. 3962 directs the highly-
regarded Institute of Medicine to develop recommendations on how to
modernize the Medicare payment system so it rewards value and quality.
This will transform the Medicare payment system to ensure better care
for patients and reduce health care costs over the long-term, and will
help secure a better future for our patients, families, and seniors.
While the legislation we vote on today would make unprecedented
reforms, I will continue working to improve the bill before it returns
to the House for a final vote. To be truly comprehensive, health care
reform legislation must reach all Americans, including the 15 million
citizens employed in the nonprofit sector. Achieving parity between
small nonprofit and for-profit employers in this legislation is one
item of unfinished business. I am also concerned with the burden this
bill places on the medical device industry to generate revenue and
potentially negative impact such a tax would have on patients, workers,
and small businesses. I look forward to working with House Leadership
and the conference committee to help address these issues and
strengthen this legislation.
Still, H.R. 3962 remains a historic achievement. This legislation
addresses the needs of Minnesota's families and families across this
country. It modernizes Medicare and covers the uninsured. It invests in
prevention instead of paying for disease. For these reasons and many
more, the Affordable Health Care for America Act has the support of
over 300 state and national organizations. These supporters include the
American Nurses Association, American Medical Association, SEIU, AFL-
CIO, and AARP. Organizations representing millions of Americans back
this legislation because they know our health care system is broken and
change cannot wait another year.
Still, there are critics of health care reform that are fighting
desperately to maintain the status quo. It is disappointing to see
Republicans choose health care profiteers and insurance companies over
reforms that Americans need and want. My Republican colleagues have
offered politics and posturing but no real solutions. They have no
serious alternative to H.R. 3962 to control costs, expand access and
improve quality. They have made killing health reform and killing
America's chance at achieving health reform their only goal. The
American people deserve better.
I would like to thank Speaker Pelosi, Majority Leader Hoyer, Majority
Whip Clyburn and Caucus Chair Larson for their extraordinary leadership
to bring affordable, quality health care to all Americans. Thanks are
owed to the three committee chairmen--Chairman Waxman, Chairman Rangel,
and Chairman Miller--who held dozens of hearings throughout the year
and crafted a historic bill. I would also like to thank Chairman
Dingell for his dedicated service in introducing health care
legislation for over 50 years to bring health care coverage for all
Americans.
I would especially like to thank Speaker Pelosi for her attention to
the concerns of the Quality Care Coalition and all of the diverse
interests of the Caucus. Vice Chairman Becerra also has my gratitude
for the vital role he played in negotiating this agreement to move
health care reform toward high quality, cost-effective care.
Today is a historic step toward making health care reform a reality,
but it is not the end. I urge the Senate to stay focused and committed
so an equally strong bill meets H.R. 3962 in conference committee. I am
committed to sending a health care bill to the President's desk that
will bring meaningful reform for American families, seniors and
businesses. With passage of this legislation, health care will no
longer be a privilege for those who can afford it.
I urge my colleagues to support H.R. 3962 and guarantee that
affordable, quality health care will be accessible for every Minnesota
family.
Mr. McCAUL. Mr. Speaker, in the 72 hours we were allowed, Republicans
weeded through thousands of pages of bureaucratic provisions, mandates,
programs and spending. Despite its monstrous size, this health care
takeover has come down to a few clear, evident points: it raises taxes,
raises premiums, increases health care costs, and dumps trillions of
dollars of debt on our children and

[[Page H12909]]

grandchildren. Small businesses and families will bear the weight of
this bill for generations.
We all agree that health care reform is urgently needed, but this
bill destroys the American health care system as opposed to improving
it. Instead of incentivizing the private market to offer more
affordable health care coverage options, it punishes small businesses
and their employees. It threatens jail time for individuals who do not
purchase insurance and could soon lead to the rationing of care,
depriving Americans of life-saving treatments that are not deemed
``cost-effective.'' Even doctors, the most experienced in this health
care debate, oppose this proposal and have shared concerns of the many
clinics and hospitals that will be forced to reduce or deny services.
The over 2,000 page spending plan imposes nearly $800 billion in new
taxes on individuals, families and small businesses. It places mandates
on both individuals and employers which, according to the President's
Economic Advisor, will result in the loss of up to 5.5 million jobs.
These mandates will also discourage the hiring of low-wage and minority
workers. In the face of both a recession and a 10.2% unemployment rate,
Speaker Pelosi's unprecedented tax-and-spend approach will come at the
expense of American citizens.
Moreover, while the majority of Americans are happy with their health
care coverage, an estimated 114 million Americans will lose their
insurance under Speaker Pelosi's plan and be dumped into the
government-run option. The plan also cuts more than $170 billion from
Medicare Advantage plans, jeopardizing millions of seniors' existing
coverage. The bill puts the government in the middle of Americans'
personal health care decisions, as opposed to reform based on improving
the quality and affordability of health care.
While Democrats have continually touted the benefits of a public
option, they themselves voted against an amendment to require
enrollment for Members of Congress. This speaks volumes to the true
quality of a government plan, as what I view as adequate coverage for
the American public would also be adequate for my family. Furthermore,
the bill also abolishes the private health insurance market, forcing
all individuals to purchase coverage through a government-controlled
Exchange and eliminating choices from the health care system. While
this bill takes care of Members of Congress, it eliminates the freedom
of choice for the American public.
Republicans have introduced numerous bills to provide improvements in
the cost and delivery of health care, but we have been denied a seat at
the table. Behind closed doors, the Democrats crafted a monstrosity of
a bill to take over one sixth of the economy, and then limited floor
debate to four or five hours on one of the most sweeping pieces of
legislation we have ever seen.
The Republican alternative provides a common-sense approach to the
main problems in our health care system. It would lower premiums,
decrease health care costs, reign in federal spending, and allow for
more options, choice, and innovation in the health care system.
The non-partisan Congressional Budget Office has estimated that
average premiums under the Republican alternative would be almost
$5,000 less than under the Democratic plan in 2016. It would provide
incentive grants for states to further lower premiums, and allow
businesses to innovate ways to promote health and wellness and curb
health care spending. The alternative would also expand high risk
pools, prohibit insurance companies from denying individuals with pre-
existing conditions, and ensure inter-state purchasing of health
insurance. These reforms would drive down the costs of health care to
make it more affordable for Americans while also protecting the choice
and numerous options that citizens need.
I have spoken to many health care professionals in my District as
well as held town halls with my constituents, and both have expressed
not only their opposition, but their fear, of this government takeover
of health care. We are not listening to Americans, and we are missing
the opportunity to use insight from the experts in the field to enact
meaningful reform. This bill is not what Americans have asked for.
Mr. PLATTS. Mr. Speaker, I rise today in opposition to Speaker Nancy
Pelosi's health care bill (H.R. 3962). I plan to vote against this
legislation for numerous substantive reasons, including my concerns
about its trillion dollar plus cost to taxpayers, its mandates on
individuals and employers, its deep cuts to Medicare, and the strong
likelihood that H.R. 3962's provisions will cost millions of Americans
their jobs. H.R. 3962 is a health care bill that fails to abide by the
physician's guiding principle: ``First, do no harm.''
H.R. 3962 consists of approximately 2,000 pages and costs more than
$1 trillion over ten years. If adopted, this legislation will destroy
millions of jobs by raising taxes on small businesses and other
employers. H.R. 3962 also imposes new taxes on certain employer-
provided health benefits and on medical devices such as wheelchairs and
walkers. In total, H.R. 3962 includes more than $700 billion in new
taxes.
Unbelievably, in the name of health care reform, H.R. 3962 cuts
Medicare benefits by more than $400 billion and raises Medicare
premiums, making access to comprehensive health care more difficult for
our Nation's senior citizens. Additionally, over time, H.R. 3962 will
move countless Americans involuntarily from private health insurance to
government-run health care.
I have long maintained that there is no ``silver bullet'' for health
care reform. We should aim to build upon the current health care system
in a variety of ways, making health insurance more affordable and more
accessible. In other words, Congress should fix what is broken in our
nation's health care system and be certain not to break what is not.
Congress should adopt insurance reforms to end the practice of
denying coverage due to pre-existing conditions and ensure the
portability of one's health insurance. Additionally, Congress should
allow small businesses to band together to negotiate insurance coverage
for their employees, just as large corporations and labor unions are
already allowed to do. Congress should also allow individuals to
purchase health insurance across state lines from a competitive,
nation-wide market and should enact responsible medical malpractice
reform to lower health care costs. I plan to join with my fellow
Republicans in voting for an alternative legislative proposal that
includes such reforms.
The full Senate has yet to act on a health care bill of its own.
Hopefully, when it does so, the Senate will adhere to the principle of:
``First, do no harm.''
Ms. LINDA T. SANCHEZ of California. Mr. Speaker, I rise on behalf of
the nearly 50 million Americans who don't have health insurance.
On behalf of parents who have to choose between taking their sick
child to the doctor and paying the electric bill on time.
On behalf of adult children who are slowly losing their parents to
Alzheimer's, and yet can't afford the quality care their parents need.
In a Nation as prosperous as ours, it is a shame and a tragedy that
so many families suffer, watching their loved ones die, when timely
tests or early care could have prevented it.
American families have waited too long for the freedom and security
that universal healthcare can provide.
I strongly support H.R. 3962, the Affordable Health Care for America
Act because this legislation tells families yes.
Yes, they can afford high quality health care.
Yes, they can get health insurance even if they have a pre-existing
condition.
Yes, they can expect to be treated fairly by insurance companies,
regardless of their gender or age. Yes, they can keep their health
insurance, even if they get sick.
And yes, we can pass health reform that protects and strengthens our
economy by encouraging development and use of health information
technology, generic drugs, and advanced medical devices.
It's well past time for Congress to make sure that an unforeseen
illness or accident doesn't mean economic ruin for American families.
To stop the abuses of health insurance companies, who play games
instead of paying for health care. To ensure that Americans have the
freedom to change jobs or to become entrepreneurs, instead of being
locked into a job they hate because it is the only way they can afford
healthcare.
I worked to make sure this bill bars insurance companies from
charging women more just because they are women.
I worked to make sure that this bill creates Collaborative Care
Networks, to ensure that doctors, hospitals, and other health care
providers work together to provide working families, lower income
Americans, and those with chronic conditions the high quality
coordinated care they need to stay healthy and out of emergency rooms.
I worked to make sure this bill includes, among the choices it offers
consumers, a public option that will focus on health care, not profits.
I'm proud of my work on this bill, because it means American families
and businesses will have the peace of mind that comes with knowing they
can access affordable, quality care when they need it.
It means that my son Joaquin can grow up in a country that is a
little fairer, a little more humane, and a little more secure than the
one I grew up in.
I urge my colleagues on both sides of the aisle to vote for children
and families by supporting this bill.
Mr. KANJORSKI. Mr. Speaker, I rise today in support of H.R. 3962, the
Affordable Health Care for America Act.

[[Page H12910]]

The House has taken an important first step today to improve the
affordability and accessibility of health care. While today's health
care legislation is not perfect, action to address this important issue
is absolutely necessary. If we do nothing to reform health care, health
care costs are expected to double over the next ten years, just as they
have over the last ten years.
Insured Americans pay on average $500 per year just to administer
health insurance, more than double the administrative costs paid in any
other country which has a government-run health care system. The
McKinsey Global Institute estimates that $91 billion a year is wasted
on excessive insurance administrative costs.
Because about 60 percent of all Americans under the age of 65 receive
insurance through their employers, much of this waste is burdening
American companies. American companies competing in the global economy
cannot afford this economic disadvantage. The bill we voted on today
attempts to reduce the costs of insurance to employers and employees by
providing greater competition among insurers. According to a study by
the Massachusetts Institute of Technology, a family of four would save
$1,260 in annual health insurance premiums once this bill is enacted.
It is estimated that 96 percent of all Americans will have access to
affordable health insurance under this bill. While I believe that
caring for our fellow citizens is a moral imperative, it also makes
economic sense to have as many people covered by insurance as possible.
Families USA estimates that every insured American family pays over
$1000 per year in premiums just to cover the medical expenses of the
uninsured, who obtain urgently needed health care through inefficient
means such as visits to hospital emergency rooms. As we face the threat
of pandemics such as the current swine flu, it is in the best interest
of all of our health to make sure that sick people are treated quickly
and affordably so that infectious diseases are not spread.
While there are many detailed provisions in this complex legislation,
it is important to note what the bill does not do. The only effect it
will have on senior citizens who rely on Medicare is it will reduce
their out-of-pocket costs for prescription drugs, as noted by AARP in
its recent endorsement of the bill. The bill does not use tax dollars
to pay for abortions. It does not require our smallest businesses to
pay for insurance coverage for their employees. It will not result in
the federal government controlling the delivery of health care; in
fact, the non-partisan Congressional Budget Office (CBO) estimates that
only six million Americans will choose to enroll in the government-
sponsored insurance plan, the so-called ``public option.'' It does not
add to the federal deficit. CBO estimates that the bill will reduce the
deficit by $109 billion over the first ten years.
Finally, I want to praise the House leadership for including in this
bill a provision which will help to fund the education of the next
generation of doctors, some of whom I hope will be educated by our
region's own medical college.
We all share the goal of keeping American citizens healthy in the
most humane and efficient means possible. I believe this bill is a
reasonable first step toward reaching this goal.
In closing, I appreciate the opportunity to share my thoughts about
this important legislation.
Mr. TIAHRT. Mr. Speaker, I rise in strong opposition to H.R. 3962. I
cannot and will not support this government takeover of our health care
system that will restrict choice, ration care, increase the cost of
health care, greatly increase government spending, and lead to the
destruction of the world's best medical care.
Americans are fed up with Washington's out of control spending, with
more and more power over their daily lives being put in the hands of
nameless, unaccountable bureaucrats, and with the systematic shift of
the United States Government from a government OF the people to a
government FOR the people. The growing discontent began with the
bloated stimulus bill that did nothing but grow a bigger Washington and
create more bureaucratic jobs. It increased with the government
takeover of General Motors, the cap and tax bill, the placement of
power in the hands of unconfirmed and unconstitutional czars, and the
grossly inflated spending bills passed for fiscal year 2010. With the
Democrat attempt to takeover health care, the discontent has now come
to a full boil.
This spring, summer and fall the American people have spoken loudly
and clearly about what they do and do not want in health care reform.
The Democrats ignored these sentiments and introduced H.R. 3200 and the
two Senate bills. This led to the most lively, spirited town halls in
my 15 years in Congress, followed by an unprecedented number of phone
calls, emails and letters sent to my office by concerned Kansans.
The American people told us what they do and do not want: they do not
want a government takeover of health care, the American people do not
want higher taxes, the American people do very much want to keep their
health insurance and increase their choices and access for those who do
not have insurance.
What was the Democrat response to their constituents? A new, bigger
bill that again ignores the input of the American people and is even
worse than H.R. 3200.
The new bill is a government takeover of health care. H.R. 3962 is
double the original H.R. 3200 at 1990 pages long and loaded with new
mandates. The word ``shall'' appears 3,425 times--in other words--this
is the government telling you to do something. The bill creates 118 new
bureaucracies. The Congressional Budget Office (CBO) calculated the
cost of the bill at $1.2 trillion but this does not include 28
instances of hidden costs indicated by the ominous words indicating
that certain programs be appropriated ``such sums as may be
necessary.'' The bill raises taxes, on individuals and job creators,
including a $461 billion surtax on small businesses according to the
U.S. Chamber of Congress. The Pelosi bill will result in 5.5 million
job losses at a time when unemployment is already over 10 percent. And
to top all of that off--this bill completely rewrites 16th of our
nation's economy.
H.R. 3962 cuts benefits to seniors, does not ensure that Americans
can keep their health insurance, limits choice, covers even more
illegal immigrants than H.R. 3200 (2.5 million more according to CRS),
and allows for taxpayer funded abortions.
If H.R. 3962 is enacted into law, even the Democrats acknowledge that
health care costs will increase. As PJ O'Rourke said, ``If you think
health care is expensive now, wait until you see what it costs when
it's free.''
My biggest concern with the Democrat proposals is the intended
rationing of health care. The Obama administration has already begun to
set the framework for rationed care with comparative effectiveness
research. This is a very dangerous road to travel down.
In addition to all the other concerns I am also opposed to the Baucus
and Pelosi attempt to destroy Health Savings Accounts (HSAs). HSAs are
what we should be promoting as a way to expand choice, give patients
more control over their medical spending, and reduce health care costs.
I want health care reform and am saddened that this process has
become so political that we won't see the much needed modernization
that will ensure Americans have access to the best health care for
decades to come. I am saddened that states like my home state of Kansas
are forced to take drastic action to try to protect their citizens from
being affected by Washington's takeover of health care.
Republicans have offered better solutions and principles that should
be included in any health care reform. Those principles should: let
Americans who like their health coverage keep it, give all Americans
the freedom to choose the health plan that best meets their needs;
ensure that medical decisions are made by patients and their doctors,
not government bureaucrats; and improve Americans' lives through
effective prevention, wellness, and disease management programs, while
developing new treatments and cures for life-threatening diseases.
The Republican 219 page bill is a plan that will lower cost and
improve health care access. This bill includes: tax incentives;
Association Healthcare Options to let Americans group together for
greater purchasing power; limitations on defensive medicine and
implementing comprehensive medical liability reform; tackling waste,
fraud and abuse (a $10 Billion annual cost to taxpayers generated from
Medicare alone); and incentives for savings and increased use of
personal Health Savings Accounts (HSAs). In addition, the Republican
plan will ensure that Americans are not prevented from health coverage
due to pre-existing conditions and are not subject to lifetime caps on
treatment. Unlike the Pelosi and Obama plans, the Republican plan
protects Medicare for seniors. Finally, the Republican plan protects
taxpayers from funding abortions or health insurance for illegal
immigrants. The Congressional Budget Office has confirmed that the
Republican bill will lower premiums for the American people by up to 10
percent. Under our plan, premiums for families and small businesses
would be nearly $5,000 per year lower.
I strongly encourage my colleagues to vote for the Republican
substitute that will provide real solutions that will meet the needs of
the American people. Our constituents have spoken loudly and clearly
and it is our duty as their representatives to listen to them, not
ignore them and use the sacred Speaker's gavel to impose personal
political goals upon them.
Mr. FILNER. Mr. Speaker, many Members of the House of Representatives
have spoken at length on the ways that the Affordable Health Care for
America Act will improve health care for all of our constituents. I
wanted to draw attention to another significant benefit of this
legislation: the creation of new high-paying jobs in this country. Let
me repeat that

[[Page H12911]]

for some of my friends on the other side of the aisle, this bill will
create high-paying, high-quality jobs in healthcare delivery,
technology and research in the United States.
First, this bill will create enormous demand for healthcare workers,
especially in the area of primary care. Insuring the millions of
Americans in this country who currently have no insurance will allow
them to see primary care providers and receive the wellness and
preventive care they have been denied for too long. This influx of new
patients will need doctors, nurses and technicians for their care,
while reducing overall healthcare costs because they will not need much
more expensive hospitalizations. I support channeling resources that
for too long have been used to treat people once they become sick into
jobs and services that will prevent people from getting sick in the
first place.
Second, this bill will continue the efforts we began in the stimulus
package to deploy new health information technologies that better
manage both the quality of care people receive and the cost at which
they receive it. New health care exchanges and new demands on the
health system to provide high-quality and cost-effective health care
will create new opportunities and markets for our brightest technology
minds. They will be incentivized to create and develop products that
will be a win/win for Americans: high quality health care at an
affordable price.
Third, this bill will create high quality research opportunities in
this country. The Energy and Commerce Committee enacted a framework for
allowing biosimilar competition in this country. This new class of
medicines will help lower costs and bring competition to one area that
is key to the future of our healthcare system. Biotechnology is on the
cutting edge of efforts to reducing costly invasive procedures and
allowing our constituents to live healthier and more productive lives.
The creation of this new class of medicines comes with requirements for
new clinical research and testing, especially in the area of whether a
new biosimilar can be interchangeable with an innovator's product. This
research will create high quality and high paying jobs and it is
imperative that we keep this research and these jobs in this country.
We cannot allow these research opportunities to leave this country, and
I intend to work with the Secretary of HHS and the Commissioner of the
FDA to ensure they stay in the United States.
Mr. Speaker, I do not look at this bill as one of cost or drain on
the economy of our country like so many of its opponents on the other
side of the aisle. I see this bill as an exciting opportunity to create
the kind of jobs we so desperately need in this country while at the
same time improving the lives of ALL Americans. This bill will improve
health care, create jobs and grow our economy.
Mr. COSTELLO. Mr. Speaker, today is a historic day in the House of
Representatives, and will be one of a handful of votes that can be
deemed the most important of our careers. We are considering today how
to improve the provision of health care in America. Spiraling costs,
insurance limitations and a lack of insurance coverage continue to
impact families, our economy, and ultimately our way of life. It is for
this reason that after careful consideration, I will vote in favor of
H.R. 3962.
As the health care debate has developed this year, I have held
meetings with individuals, families, health care providers, business
owners and other groups. What everyone can agree on is that our health
care system is broken and needs attention. At the simplest level, we
need to put an emphasis on preventive medicine. As the old saying goes,
an ounce of prevention is worth a pound of cure. We treat too many
people in emergency rooms instead of doctors' offices, and often when
they are sickest and care is the most expensive. H.R. 3962 moves us
toward preventive care in a variety of ways, but chiefly through
providing health insurance to 36 million more Americans. Having
insurance will allow them to see a doctor on a regular basis and detect
health problems earlier.
Most importantly today, passing H.R. 3962 keeps the process of health
care reform moving forward. Today is a very important step, but there
is still a long way to go. As we all know, the Senate is working on its
version of health care reform legislation, and that bill is likely to
be very different from this one, but I am confident we can craft a
final product that incorporates these goals and makes our health care
system better.
Mr. Speaker, I am glad that we slowed our process down and took some
additional time before bringing it the floor. This is not a perfect
bill, but I think it will make a positive difference for the entire
country. Over 300 organizations have endorsed it, including AARP, the
American Heart Association and the American Medical Association. I urge
my colleagues to vote for H.R. 3962, and keep us moving toward a
healthier America.
Ms. LINDA T. SANCHEZ of California. Mr. Speaker, I strongly support
H.R. 3962, the Affordable Health Care for America Act, which delivers
on a promise Americans have been waiting for since the New Deal, a
promise that families can get the health care they need, when they need
it, without facing economic ruin.
I have previously spoken about the ways that this bill will help
ensure access to affordable, high quality health care for American
families. But another significant benefit of this legislation which has
not received much attention is its promotion of high-paying research,
high tech, and manufacturing jobs.
Contrary to the claims that this is a ``job killing bill,'' in fact,
this bill will create thousands of jobs here in the United States.
First, this bill will increase demand for healthcare workers,
including doctors, nurses, nurse practitioners, physician assistants,
home health workers, and more. More affordable insurance means more
families getting the primary and chronic care they need instead of
waiting until they need an emergency room. And it means more middle
class American jobs that can't be exported.
Second, this bill will continue the investments begun in the American
Recovery and Reinvestment Act, also known as the stimulus bill, to
expand the use of health information technology.
Health IT will help better manage the quality and cost of care
patients receive by eliminating duplicative tests and ensuring that
patients don't receive the wrong medicine or the wrong dose. And
investment in health IT creates jobs--jobs in hardware production,
software design, and computer training. When we invest in quality
health care for all Americans, we are investing in jobs.
Finally, this bill will promote more of what America already does so
well: medical research. By allowing more Americans access to health
insurance, this bill will increase the demand for advanced medical
technologies that are manufactured right here in America.
And by creating a process for the Food and Drug Administration to
approve so-called ``biosimilar'' drugs, this bill will encourage
competition in the cutting edge field of biologic drugs.
This new class of medicines will help cure and treat more Americans
at lower costs. And the promise of protection for intellectual property
and an FDA structure to approve bio-similars will result in increased
investment in this industry, which already provides thousands of well-
paying jobs in California and across the country.
I hope to work with the Secretary of Health and Human Services, the
Commissioner of the FDA, and like-minded colleagues in Congress to
ensure that these important research and manufacturing jobs stay right
here in the United States.
In sum, this bill preserves and promotes the strength of the American
health care system: innovation. And it fixes the shortcomings: spending
too much while caring for too few.
If we fail to pass this bill, we fail American families, and we fail
the American economy. As a champion of both, I strongly support this
bill.
Mr. ALEXANDER. Mr. Speaker, after months of meeting with constituents
and business leaders, as well as hosting town halls and roundtable
discussions, I can say that American public has clearly stated their
opposition to this government takeover of health care.
H.R. 3962, the Affordable Health Care for America Act, states in
section one that this legislation ``builds on what works in today's
health care system, while repairing what's broken.'' I agree that
improvements need to be made to drive down medical costs, but placing
individuals under one bureaucrat-run umbrella does not build on what
works or make any repairs. The bill includes the government-run public
option, cuts Medicare and Medicare Advantage programs, and raises taxes
on middle class families. In addition, the bill does not protect the
interests of small businesses nor does it adequately address defensive
medicine. And, in the midst of states struggling with fiscal
constraints, it will burden them with more unfunded mandates from the
federal government.
In the President's address to Congress on Sept. 9, President Obama
said, ``Nothing in our plan requires you to change what you have.'' A
study by the Lewin Group shows that two out of every three people would
lose their current coverage, including up to 114 million people who
receive health benefits through their employer or other current
coverage if a government-run plan ``competes'' with private companies.
I don't see the choice in this.
Medicare cuts total $162 billion. As a result, Medicare Advantage
plans will drop out of the program, limiting seniors' choices and
causing many to lose their current health care coverage. Medicare
Advantage has been successful in providing seniors with choice,
selection and value. This is especially true for residents of rural
America, where seniors have previously not had sufficient private
alternatives. Currently, over 600,000 seniors are Medicare
beneficiaries in Louisiana, while over 10,694 seniors in the 5th
District are enrolled in the Medicare Advantage program.

[[Page H12912]]

The bill includes taxes on individuals who do not purchase
government-forced health insurance. It also imposes new taxes on
businesses who cannot afford to fund government-forced health coverage
for their workers, therefore violating the bill's new employer mandate
and triggering an additional 8 percent payroll tax.
The bill also prohibits the reimbursement of over-the-counter
pharmaceuticals from Health Savings Accounts (HSAs), Medical Savings
Accounts, Flexible Spending Arrangements (FSAs), and Health
Reimbursement Arrangements (HRAs), increases the penalties for non-
qualified HSA withdrawals from 10 percent to 20 percent, and places a
cap on FSA contributions. Because at least 8 million individuals hold
insurance policies eligible for HSAs, and millions more participate in
FSAs, all these individuals would not be able to keep the coverage they
have without facing tax increases.
The grand total amount of tax increases included in this legislation
equals approximately $729.5 billion over ten years. Imposing these new
tax increases in the middle of a recession--with unemployment numbers
we haven't seen since 1983--will only harm the economy and kill jobs.
This bill intends to ensure that generic biologic companies will have
to do some research and clinical trials before the FDA will approve
them for use in the United States. This dramatically increases patient
safety as generics come to market. Likewise, keeping research and
trials in the country means more jobs at home. I hope this is included
in discussions as the health care debate continues in the coming
months.
The CBO has also said that this bill will increase seniors' Medicare
prescription drug premiums by 20 percent over the next decade. While
the cost of living continues to rise during these tough economic times,
I know that many cannot afford this increase. Medicare finances are
rapidly deteriorating and we should be working on real solutions that
ensure the long-term financial stability of Medicare.
Choice is not option in this government takeover of our health care
system. I am genuinely concerned for the well-being and options that
the people of this great nation have. I do not believe H.R. 3962 best
represents what the American people are asking for.
I agree that improvements need to be made to our system currently in
place. However, a solution should be built upon the principle that when
individuals--not the government, insurance companies, or employers--are
given control and ownership, we will achieve full access to coverage
and see the entire system move in a more positive, patient-centered
direction. America needs economic relief in the form of tax breaks for
working families and small businesses, and fiscal discipline in
Washington. Instead, our federal government keeps pushing policies that
will impose harmful taxes and increase our national debt, saddling
Americans who are already hurting with even more financial burdens. We
must work to find real solutions that will help create jobs and lower
health care costs.
Everyone can agree that affordability, accessibility, portability,
and quality should be the outcome of any overhaul of the health care
delivery system. More specifically, it should be guaranteed that
medical decisions are kept in the hands of patients and their doctors;
the cost of insurance is lowered, and in turn the number of Americans
who have insurance is increased. The American people deserve a plan
that allows them to keep their health care coverage if they like it,
and have the freedom to choose the plan that best meets their needs. As
I have said before, and as I will say again, I will not support any
type of health reform plan that raises taxes, rations health care,
eliminates employer-sponsored health benefits for working families, or
allows government bureaucrats to make decisions that should be made by
families and their doctors.
Mr. VISCLOSKY. Mr. Speaker, I am proud to support the Affordable
Health Care for America Act, a bill that will significantly improve our
healthcare system.
For too long, our healthcare system has allowed millions of Americans
to go uninsured, tolerated egregious and abusive business practices by
big insurance and pharmaceutical companies, and ignored skyrocketing
costs. It has diminished our nation's collective health and drained our
economy. The Affordable Health Care for America Act represents a
significant effort to address the iniquities of our current healthcare
system.
Specifically, the Affordable Health Care for America Act strengthens
the healthcare market for all Americans. For those with insurance, the
measure would establish benefits to be included in all health insurance
options, including preventative care, mental health services, and
dental and vision services for children. Additionally, the measure
would establish annual and lifetime out-of-pocket spending caps to
ensure that no family faces bankruptcy due to medical expenses. And the
Affordable Health Care for America Act would eliminate the decades-long
exemption of health insurance companies from federal anti-trust laws,
enabling the regulation of abusive business practices.
For those without insurance, the Affordable Health Care for America
Act would establish a public health insurance option to compete with--
not replace--private insurance plans. The public health insurance
option would aim to provide more Americans with healthcare coverage and
would be financed through its premiums. The measure would allow the
Secretary of Health and Human Services to negotiate physician and
hospital rates for the public option and would prohibit insurance
companies from denying coverage based on a pre-existing condition.
Importantly, the measure would repeal the prohibition on negotiating
with pharmaceutical companies and would require the Secretary of Health
and Human Services to negotiate the prices of prescription medications
for Medicare beneficiaries. It is my sincere hope that these
negotiations will ameliorate the high out-of-pocket costs for
prescription medications faced by our seniors. Additionally, the
Affordable Health Care for America Act would provide savings to the
Medicare programs by improving payment accuracy to Medicare Advantage.
The Affordable Health Care for America Act would reduce the costs to
small businesses, America's economic engine, by establishing a Health
Insurance Exchange where these businesses will benefit from large group
rates and a greater choice of insurance options for their employees.
Further, the measure would provide tax credits to eligible small
businesses for assistance with the costs of providing health insurance
to their employees.
Finally, the Affordable Health Care for America Act is not only fully
paid for, but according to the non-partisan Congressional Budget Office
it would reduce the deficit by $104 billion over the next ten years and
would continue to reduce the deficit in the following decade.
Through these provisions and others I believe that the Affordable
Health Care for America Act will accomplish my goals for healthcare
reform, namely to give more security and stability to those who have
health insurance, to provide affordable, quality options to those who
do not have health insurance, and to lower the cost of healthcare for
families, businesses, and society.
Although this bill may not be perfect, it will improve our
healthcare system. It is the result of a lengthy, transparent process
that has helped the bill evolve and improve at each step of the way. I
will continue to closely monitor the legislation's progress.
Voting for comprehensive healthcare reform at long last was a
gratifying experience. I believe that a generation from now people will
ask the question, what took us so long?
Mr. REYES. Mr. Speaker, this is a momentous occasion for the American
people, particularly for the hundreds of thousands of El Pasoans who
have unjustly struggled without health insurance in the world's
wealthiest nation. The Affordable Health Care for America Act, as
passed by the House, will dramatically improve the quality of life for
so many families in our community, who will finally have access to
quality affordable health coverage.
I am particularly pleased this legislation incorporates a provision
that I, along with Majority Leader Steny Hoyer, and others worked to
include that will support the development of our medical school. The
measure will allocate $100 million each year through fiscal year 2015
to the Department of Health and Human Services to help develop medical
schools in federally-designated health professional shortage areas for
construction, equipment, curriculum and faculty development. This is an
exciting opportunity for our community.
The House passage of the Affordable Health Care for America Act is
one of the most significant legislative victories for the people of El
Paso. Our community has one of the highest concentrations of America's
uninsured population, with over 230,000 residents without health
coverage, one in three people. Texas has the highest rate of children
and adults without health insurance in the entire nation. The status
quo is unacceptable, and we can no longer afford to pass this growing
problem to future generations.
While our community is spending a greater share of property taxes to
pay for individuals without health coverage, insurance companies have
continued to engage in practices that protect their bottom lines. For
too long, insurers have been the gatekeepers to our health care system,
with the power to dictate who receives health coverage and who does
not. Americans with pre-existing conditions and serious illnesses are
too often denied coverage or are dropped from their existing insurance
plans for developing a serious illness or reaching their cap on
coverage, and are denied access to the medical care they need.
When people lack access to quality affordable preventative care, they
end up in our

[[Page H12913]]

emergency rooms for ailments that could have been treated by a family
doctor or seek treatment for conditions that should have been diagnosed
earlier. When these patients fail to pay their medical bills from
publically-financed hospitals such as University Medical Center, local
property taxes are used to cover these expenses. Since 1998, El Paso
property tax payers have spent over $400 million to pay for treatment
and services for those patients who could not afford to pay their
medical bills.
The Affordable Health Care for America Act will dramatically reduce
the number of people without insurance in El Paso. First, it prohibits
insurance companies from denying coverage due to ``pre-existing
conditions.'' It requires that every American obtain health coverage,
and provides ``affordability credits'' to individuals and families with
incomes up to 400 percent of the federal poverty level (currently
$43,430 for individuals and $88,200 for a family of four).
The legislation also requires that most employers provide coverage.
It includes exemptions for small businesses with payrolls of less than
$500,000 and offers generous tax credits for those small businesses
that elect to provide coverage for their employees. The bill creates an
``insurance exchange,'' that will offer affordable health insurance
plans for individuals without employer-provided or government-provided
insurance (such as Medicaid and Medicare). This exchange will include a
public option to encourage competition with private insurers to keep
prices low for consumers.
This bill also brings much needed relief and peace of mind for those
who do have insurance coverage, as all Americans will no longer have to
worry about the possibility of financial ruin due to a serious illness.
It caps annual out-of-pocket expenses at $10,000 for families and
$5,000 for individuals, and prohibits insurance companies from imposing
lifetime limits on an individual's coverage.
Our local community leaders have expressed their support for health
insurance reform, and both the city and the county have passed
unanimous resolutions in support of reform. The Affordable Health Care
for America Act is endorsed by over 300 national organizations and
associations, including the AARP, the American Medical Association, the
American Cancer Society, the American Heart Association, and many other
medical professional organizations.
The passage of this landmark legislation by the House of
Representatives is an historic achievement and reflects the commitment
and determined leadership of President Obama and the Democratic
Congress to follow through on a key promise to help middle class
families, who have endured years of rising medical costs. I commend my
colleagues for their determination to pass this truly historic
legislation that will lower health care costs for all Americans, and
strengthen our country's financial future.
Ms. LINDA T. SANCHEZ of California. Mr. Speaker, I rise today to
oppose language in the Republican substitute that threatens the well-
being of patients in hospitals across the country.
The goal of the underlying legislation is to provide affordable,
quality healthcare to every American. According to The Institute of
Medicine, nearly 100,000 people die every year because of medical
errors in America's hospitals. I cannot understand how reducing the
accountability of our healthcare practitioners would lower that number
or improve the quality of healthcare in this country.
The facts are clear. Those states that restrict damage awards and
limit access to courts for patients injured by negligent doctors have
seen limited or no reduction in healthcare costs. Instead, many have
seen an increase in the cost of malpractice insurance. In fact, for
every malpractice damage award, 3 to 7 people die due to medical
errors.
While we all share a goal that doctors practice medicine with
confidence and avoid needless tests, we should not limit access to
justice where reckless action permanently alters the lives of patients
and their families. Make no mistake, that's what the Republican
substitute would do.
If we want to lower healthcare costs, let us instead cut down on
medical error by encouraging adoption of best practices, standardizing
safety procedures that are proven to reduce infection, and lowering
malpractice premiums by creating more competition in the insurance
industry. I listened to the Americans who visited Washington this week.
Many spoke about a fear of monopolies and in favor of increased
competition. I agree. Let's make the insurance companies comply with
antitrust laws and operate on the same competitive playing field as
other American businesses.
One of the great guarantees the founders provided in our Constitution
was the ability to address grievances in a court of law. Our courts
remain a great equalizer that allows every American the opportunity to
seek justice when wronged. Limiting this guarantee goes against that
spirit and leaves grieving and injured families without access to
justice. I ask my colleagues to join me in opposing this substitute.
Ms. CORRINE BROWN of Florida. Mr. Speaker, tonight, I'm thinking
about my grandmother, and all the grandmothers out there--back in
November of 2003 when the Republicans passed their Medicare
Prescription Drug bill, they put a provision in there known as the
donut hole. And that's why I voted against that bill because I knew
that my Grandma needed her prescriptions yet couldn't afford them
because of this gap in coverage. And they made it illegal for the
Secretary of HHS to negotiate the prices of drugs, even though we in
Congress allow the VA and DOD to negotiate drug prices.
Yet this bill closes that prescription drug loophole. It makes it
impossible for insurance companies to deny people health care because
of a pre-existing condition, and it allows the Secretary of HHS to
negotiate drug prices, which WILL help to bring down cost.
Secondly, one of the most family friendly provisions in this bill:
families can keep their children on their health care insurance policy
until age 27! This will be a great assistance to young adults studying
in graduate school, or those just starting out in their career and
barely making enough to get by.
To whom God has given much, much is expected. I strongly urge my
colleagues to vote in favor of this bill to reform health care in our
country and make sure access to health care is a right for every
American, not a privilege.
Mr. ETHERIDGE. Mr. Speaker, I rise today in support of H.R. 3962, the
Affordable Health Care for America Act. This bill is essential to
improving North Carolina's economy and will lower health care costs for
millions of Americans. I am committed to enacting comprehensive health
care reform that contains costs, protects patient choice, and assures
quality, affordable care for all Americans. As the only North Carolina
Member on the House Ways and Means Committee, a Member of the Budget
Committee, and a supporter of fiscal responsibility, I am pleased that
this legislation is fully paid for and according to the Congressional
Budget Office will reduce the deficit both in the short and long term.
Working families and small businesses are facing crushing health care
costs that threaten their lives and livelihoods. Health care costs will
reach $2.5 trillion in 2009, more than we are expected to spend on the
wars in Iraq and Afghanistan this decade. Families already have
experienced health care costs doubling in the past 10 years. Without
reform, health care costs will skyrocket in the next decade.
Independent analysis has predicted that family premiums will be $1,000
to $9,000 lower in 2016 under this legislation compared to what they
would be without reform.
H.R. 3962 will improve health care for seniors in Medicare by
reducing costs and extending Medicare's solvency. This bill brings an
end to the prescription drug ``donut hole'' which has unfairly burdened
the pocketbooks of seniors, decreasing out-of-pocket costs by $500
immediately, cutting copayments in half in the short term, and fully
closing it over the next 10 years. H.R. 3962 also provides better and
more timely payments to doctors who accept Medicare and attacks waste,
fraud and abuse in Medicare ensuring more money goes to benefits and
improving senior health and quality of life.
Too many people have their choices limited by insurance companies and
financial decisions, rather than by patients and doctors. H.R. 3962
will expand individual choice and prevent insurers from denying
benefits that doctors recommend. This bill will place caps on out-of-
pocket health expenses, and remove the ability of insurance companies
to place annual or lifetime limits on coverage. Choice will be
reinforced with one-stop comparison insurance shopping through a health
insurance exchange.
During this economic downturn, H.R. 3962 will help small businesses
address the crushing costs of health care. In particular, this
legislation will curb skyrocketing health care costs and provides
greater access to health care for small businesses. Companies that
offer their employees health insurance coverage will get a tax credit
for two years to help them transition to, or continue, providing health
benefits to their employees--paying up to 50 percent of their costs.
Mr. Speaker, as this bill moves to the Senate and then to conference,
I am hopeful that we can make sure that H.R. 3962 does not
unintentionally burden small businesses who employ seasonal workers.
While tax incentives in the bill are designed to help small employers
cover health care expenses, there are no allowances for seasonal
workers common to the agricultural industry. Workers who are only
employed for a short time by an employer should be able to get health
insurance, but there must be provisions to ensure that this is
affordable and not burdensome to their temporary employer. As we work
through the process of passing a final bill to be sent to the
President, I hope leadership will work with me to resolve this issue.

[[Page H12914]]

H.R. 3962 is fiscally responsible and will improve the health and
health care of people across my district, North Carolina, and the
country. I am pleased to be able to vote in favor of this historic
legislation.
Ms. FOXX. Mr. Speaker, small business owners and employees need more
choices of health insurance plans, not fewer. This bill will drive out
the private health insurance market and permit the government to
determine if the health insurance options a small business offers are
``acceptable.''
The bill places a new tax-compliance paperwork burden on all small
business owners.
This bill will kill jobs. It does nothing to lower the cost or
increase choice in the marketplace for America's small business. It
will harm small business owners with costly employer mandates and
punitive payroll taxes.
The Joint Committee on Taxation and the NFIB agree that more than
one-third of the $460.5 billion raised by this bill's surtax will come
from small business income.
Small business owners have shared their concerns about H.R. 3962 with
me. One small business owner in Statesville N.C. summed it up:
``If this bill is passed the way it is written, my business will be
unable to afford to comply with the legislation. My business has
drastically cut expenses, delayed capital investments and decreased our
work force to stay competitive. If H.R. 3962 is passed by Congress it
will force us to close down our business and end the paychecks for the
56 employees who depend on our company to feed their families.''
Mr. LUJAN. Mr. Speaker, as I came to the floor tonight I was reminded
of a constituent, Aunt Adrian, who we lost to cancer this last year and
who couldn't afford insurance, she spent her last few months worrying
about bills, rather than getter better. This story didn't have to end
this way.
We reached this point today because people have had enough.
People who have been ignored and shunned, because they are sick;
People who have lost their homes and all they have because a health
insurance company slammed a door on them and denied them coverage they
thought they had.
People who deserve to be treated fairly and with dignity.
We are here today not to frighten and scare the American people with
things that are untrue
But to act, to make a difference, to have the courage and will to put
the people first.
And I now know that we do have the courage and the will to get this
done, Aunt Adrian and the American people deserve no less.
Ms. RICHARDSON. Mr. Speaker, I rise today in strong support of H.R.
3962, the Affordable Health Care for America Act of 2009, because this
bill is good for seniors, good for women, good for small businesses,
and good for all Americans.
I would like to thank Speaker Pelosi, House Majority Leader Hoyer,
Congressman Dingell, Congressman Rangel, and Congressman Waxman for
their skill and leadership in bringing this historic bill to the floor.
I would also like to thank my colleagues who have worked so hard to
bring about a workable solution to one of the most critical challenges
in the history of our nation.
President Theodore Roosevelt proposed national health insurance in
1908 because he could not stand by and watch American families go
bankrupt when their children fell ill. Forty years later in 1948,
President Truman proposed it again. Under the leadership of Lyndon B.
Johnson and a Democratic Congress, Medicare was enacted in 1965 which
provided health care for senior citizens. Thirty years later, Congress
passed the State Children' Health Insurance Plan which expanded
affordable coverage to millions of poor children.
Today, this seventh day of November in the year 2009, we write
another great chapter in the remarkable history of this country. Today,
we extend to tens of millions of our fellow citizens the security that
comes from knowing that they will have health care that is there when
they need it and won't bankrupt their families. Today, we keep faith
with those who came before us and those who will come after us. Today,
we will pass the Affordable Health Care for Americans Act of 2009 and
change America for the better.
The health care system we have now is not working for middle and
working class families, not working for businesses trying to compete in
a global economy, not working for taxpayers or for the uninsured. There
are 54 million Americans who are uninsured who need us to reform this
broken system. 1 in 5 Californians are uninsured or underinsured. These
numbers are staggering and if we do nothing, they will only grow worse.
Mr. Speaker, House Republicans have offered a bill that they claim
solves the broken health care system, but the reality is quite
different from what their rhetoric makes it out to be. The fact is the
Republican substitute leaves affordable health insurance out of reach
for millions of Americans. It will allow discrimination based on
gender, age, and preexisting conditions to prevail in the insurance
industry. It will do nothing to protect consumers. It is not the
answer.
Mr. Speaker, the Affordable Health Care for Americans Act is a better
bill. It is the answer to the broken health care system. This bill
provides American families with stability and peace of mind. Never
again will they have to choose between their health and their
livelihood. This bill provides American families with higher quality
health care. It leaves important health decisions up to patients and
doctors, not to insurance companies. This bill provides American
families with greater choice. It creates a high-quality, robust, public
health insurance option for families to choose from. Finally, this bill
lowers costs for American families. It eliminates co-pays and
deductibles for preventive care while putting an annual cap on out-of-
pocket expenses for American families.
Mr. Speaker, this bill is the answer to the problems faced by real
American families today. The Republican bill is fantasy. It is not
grounded in reality. Now, we need to stop playing politics and focus on
actually improving people's lives. H.R. 3962 will reform the health
care system so that it provides quality, affordable coverage that
cannot be taken away. This bill eliminates discrimination based on
gender and pre-existing condition. It eliminates the prescription drug
donut hole for seniors. It ends the era of no and begins the era of yes
for millions of Americans seeking coverage.
As FDR once said, the test of our progress is not whether we add more
to the abundance of those who have much, it is whether we provide
enough for those who have little. It is time for us to move forward. It
is time for us to take this great nation in a new direction. It is time
for us to look out for all Americans in their time of sickness and
need. The hour is late, and the need is great. I urge my colleagues to
vote ``aye'' on H.R. 3962.
Mr. SHULER. Mr. Speaker, as you know I am opposed to the bill we are
considering today for many reasons that I have articulated previously.
I am pleased, however, that the bill strikes the appropriate balance on
the issue of follow on biologics. This bipartisan compromise language
will provide lower cost options to consumers and my constituents
without destroying a healthy and functioning bio-tech industry in this
country. The Barton-Eshoo biosimilar amendment in the Energy and
Commerce Committee was one of the few issues that was addressed on a
truly bi-partisan basis and ought to serve as model on how things
should get done in Congress.
I believe it is critical that the creation of a pathway for new
products does not destroy the ability or the incentives of innovator
companies to develop breakthrough technologies. We have a moral
obligation to provide a safe and effective pathway of bringing
competition that will benefit patients. I wish we could consider this
as a stand-alone bill because it would pass with the kind of
overwhelming bi-partisan support that Americans across the country wish
to see.
However, these provisions are only the first step in a long path to
the marketing of these new products. New research and clinical testing
will have to occur and the FDA will write rules that will ensure this
research is done safely and effectively. One of the reasons I have long
supported the U.S. biotechnology industry is that it is a homegrown
success story that has been an engine of job creation in this country
and in my home state of North Carolina. Unfortunately, many of the
largest companies that would seek to enter the biosimilar market have
made their money by outsourcing their research to foreign countries
that don't have the same safety and efficacy standards that we have in
the United States. With this week's devastating news that unemployment
has reached 10.2 percent it is critical that we preserve jobs in
America. While the innovators have created jobs here, these generic
companies have shipped them overseas, so they can turn around and sell
cheap knockoffs of innovative American products.
As this new market launches in the U.S., we need to ensure that we
foster innovative products in this country for the creation of jobs and
research that will go into proving whether these products are
interchangeable with the innovator's products. I don't know whether
these companies can create such interchangeable products, but I am
certain that the research and testing of whether or not they should
occur in this country and not somewhere across the globe. Testing and
research on these interchangeable biosimilars should be required to
occur in this country to ensure that it is done properly and safely.
Mr. BOOZMAN. Mr. Speaker, the Pelosi Health Care Bill is a bad bill
disguised as health care reform. I have heard my constituents and the
American people and they say they don't want this government takeover.
They want the right to make their own health care choices. I agree that
we need health care reform because the costs are too high. There

[[Page H12915]]

is nothing more frustrating as a medical professional then when my
patients can't afford the prescriptions I write for them. The Majority
plan will put Washington between me and my patients and this is
unacceptable.
We all deserve access to quality and affordable health care.
Unfortunately, a public option doesn't guarantee that we will
accomplish this. This government takeover will increase taxes, take
away health care choices Americans deserve to make and create more
bureaucratic red tape. We don't want reforms that come with higher
costs while the quality and access to health care suffers.
The cost is a staggering $1.2 trillion and to think that won't impact
our national deficit and state budgets is unrealistic. The increased
price for greatly expanding Medicaid will be an unfunded mandate to
Arkansas taxpayers that at the bare minimum will cost $205 million and
could be as high as $596 million. This is an unfunded mandate that we
cannot force Arkansans to pay. Health reform should not end up costing
hardworking Americans. Our citizens deserve better
Mr. ISSA. Mr. Speaker, today I will vote in strong opposition to H.R.
3962, the ``Affordable Health Care for America Act.''
This government takeover of health care is filled with tax increases,
job killing mandates, Medicare cuts, bureaucrat additions, and
entitlement expansions. This bill will lead to higher health care
premiums and a growth in long-term health care costs.
Despite this bill's many faults, I support the bill's language
establishing a market for biosimilars which balances the desire to
provide cheaper biologics with the need to continue incentivizing
investment in research and development. The bipartisan language
approved by the House Energy and Commerce Committee earlier this year
would create an FDA approval process that allows for the continued
development of biosimilar products.
This language appropriately protects intellectual property rights by
encouraging the creation of new technologies and helps protect patients
from possibly dangerous, insufficiently tested biosimilars. Because
biologics are more complex and susceptible to change during
formulation, it is of the utmost importance that we only support a
process that provides for a safe biosimilar market.
It is critical at this time of 10.2 percent nationwide unemployment
that the federal government allow job creating industries, like
biotechnology, to continue to invest and create jobs. It is unfortunate
that the Majority wrapped up a good biosimilar bill in a bad health
care bill, but I hope that we have the opportunity to support the
Eshoo-Inslee-Barton biosimilar provisions in a separate legislative
vote.
Mr. McCARTHY of California. Mr. Speaker, I rise today to express my
strong opposition to H.R. 3962. Specifically, I am very concerned about
how the House Democratic Leadership's government takeover of health
care legislation will affect the biotech industry, which has been a
source of innovation and job creation in California.
Californians know very well how the burden of heavy taxes and
regulations can harm small businesses and innovation, as our state
economy continues to lag and continues to have an unemployment rate
much higher than the national average. On top of state taxes and
regulatory burdens, H.R. 3962 would only add on to the devastating
burdens facing our biotech industry, through its $20 billion excise tax
on medical devices and by establishing a pathway for follow-on
biologics that could harm innovation and American jobs.
As one of the biotech leaders in our country, California boasts more
than 2,000 biomedical companies and has created more than 271,000 jobs.
The proposed excise tax, whose purpose seems to be solely to raise
revenue, is a job killer and would stifle innovation. It will
ultimately result in making it more difficult for millions of Americans
to have access to life-saving medical devices that they need for their
health and well-being.
Further, H.R. 3962 would establish a new pathway for follow-on
biologics that could slow advances to new life-saving therapies, and
ultimately reduce the number of American jobs. The bill does not
expressly require clinical trials for follow-on biologics to be
completed in the United States, which could allow for these studies to
be conducted overseas. Over the past decades, many innovator biologics
have demonstrated to be safe, reliable and life-changing--the product
of strong clinical trials and research done by dedicated researchers
here in America. As unemployment has now crossed 10 percent nationally,
and is over 12 percent in California, I hope that we could continue to
foster the creation of jobs and research in America.
These are some of the many concerns I have with H.R. 3962, which is
why I instead support the Republican health care alternative. The
alternative excludes the unnecessary and burdensome excise tax in H.R.
3962, and also includes a responsible pathway for follow-on biologics
by including provisions from the Pathways for Biosimilars Act, which I
am a proud cosponsor of. By passing the Republican alternative, we can
ensure that the American biotech industry can continue to lead the
world in innovative therapies and that the necessary research and
clinical testing in the field can continue to be done domestically so
we can continue to create good-paying American jobs.
Californians, and all Americans, need Washington to pass strong
common-sense health care solutions. But we need solutions that strike a
balance in reducing health care costs, strengthening health care
access, and allowing health innovators, like our biotech industry, to
continue to research and improve therapies for patients. That is why I
support the Republican health care alternative--it addresses the needs
of patients and ensures that we keep good-paying jobs in America.
Mr. BONNER. Mr. Speaker, I rise today to state my objection--in the
strongest way I know how--to Speaker Pelosi's health care bill.
This bill represents everything I have fought against during my years
in public service . . . it raises taxes by hundreds of billions of
dollars, it hides deficit spending with dubious accounting gimmicks,
and it will vastly expand the federal government's scope and size in
every aspect of our daily lives and take even greater control over one
sixth of our nation's economy.
Among other things, this bill piles crushing mandates on small
businesses, it wrings hundreds of billions of Medicare dollars out of
our doctors, hospitals, and other providers. It decimates the popular
Medicare Advantage program, which millions of seniors depend on.
Moreover, it will be the mother of all unfunded mandates on state
budgets which--like my home state of Alabama--are already stretched
thin because unlike the federal government, most states actually
balance their budgets.
Mr. Speaker, over the past several months I have heard from thousands
of Alabamans who have called, written, and e-mailed my office. In
August, my staff and I held 19 town meetings throughout Alabama's First
District where more than 5,000 people came out to voice their
opposition to this massive takeover of our health care system.
My friends and colleagues, the vast majority of the people I work
for--and have heard from--are unambiguous--they do not want this bill.
In fact, most Alabamians--and, I believe, most Americans--want to
preserve what's best about our health care while lowering costs and
improving access. That's why I will not only be opposing H.R. 3962, but
I am proud to support the Republican substitute. My Republican
colleagues and I believe this bill would lower costs in both the short
term and the long term, honoring our pledge for fiscal responsibility
while broadening access to quality heath care through lower costs and
more competition.
Mr. Speaker, I only have one vote but I will cast that vote against
this legislation that The Wall Street Journal correctly dubbed, ``the
worst bill ever,'' and I humbly urge my colleagues to do the same.
Ms. HIRONO. Mr. Speaker, the U.S. Congress has been grappling with
how to provide all our citizens with access to affordable, quality
health care since the time of President Harry Truman. H.R. 3962
represents a critical milestone in the effort to reform our health care
system.
For those who have it, health insurance is not something you can take
for granted. Every day 14,000 Americans lose their health insurance
coverage. A recent U.S. Treasury Department report noted that
approximately half of all Americans under the age of 65 will lose their
health insurance coverage at some point over the next ten years.
Thousands are denied coverage because of pre-existing conditions like
asthma, pregnancy, arthritis, or diabetes. Millions more have no health
insurance at all, including 54,000 people who live in Hawaii's Second
Congressional District.
In his health care speech before Congress and the nation, President
Obama appealed to the best part of us--to act unselfishly, and to put
ourselves in the shoes of others. He asked us to imagine what it must
be like for those who don't have insurance--to live in a State of
helplessness should illness strike you or the ones you love.
H.R. 3962 is a bill that will provide for comprehensive health care
reform that will protect consumers, hold insurance companies
accountable, rein in health care costs, reduce the deficit, and cover
36 million uninsured Americans. In supporting this bill, I want to
highlight three key points. First, for Hawaii the bill includes the
Hirono Amendment that provides an exemption for Hawaii's Prepaid Health
Care Act of 1974, which is our nation's first and only employer mandate
law of its kind. Second, the bill will provide health insurance
coverage for an unprecedented number of Americans while still reducing
our deficit. And third, the bill strengthens and improves the Medicare
program for our seniors.

[[Page H12916]]

First, there is a mistaken perception that everything and everyone in
Hawaii is exempted under H.R. 3962. That is not so. The Hirono
Amendment only exempts Hawaii's Prepaid Health Care Act (PHCA) and
those who come under it (certain full-time employees and their
employers). PHCA does not apply to part-time employees, seniors on
Medicare, those without health insurance, government employees, or
those covered by collective bargaining agreements.
Therefore, H.R. 3962 would apply to them. I know it is easier to talk
in terms of the State of Hawaii being exempt from the bill, but that is
wrong. The distinction between PHCA being exempt and the whole State
being exempt is a critical distinction to make.
PHCA requires employers to contribute at least 50 percent of the
premium cost for single health care coverage, and the employee must
contribute the balance, provided the employee's share does not exceed
1.5 percent of his or her wages. Because of rising health care costs,
Hawaii employers on average cover 94 percent of the premium cost
because of the second part of Hawaii's law limiting employees' share.
Hawaii employers may cover the full cost of the health insurance
premium and many do cover 100 percent of the cost of single coverage.
H.R. 3962 would require employers to cover 72.5 percent of premium
costs for single health care coverage.
Hawaii consistently ranks among the highest nationally in terms of
insurance coverage and lowest in regard to the number of uninsured.
This is largely due to PHCA. Private and public health insurance cover
an estimated 92 percent of our population of 1.3 million people. Of
those with private insurance, 93 percent are covered through
employment-based plans.
Lawrence Boyd, an economist at the University of Hawaii, estimates
that per capita health expenditures in Hawaii are seven percent lower
than the national average. Dr. Boyd believes that wider health
insurance coverage and support for preventive health care lead to this
outcome. The Hirono Amendment will provide maximum flexibility for
Hawaii once a federal health care reform bill becomes law. Hawaii will
be able to decide for itself to retain PHCA or come completely under
the new federal law.
Second, H.R. 3962 will ensure that 96 percent of Americans will have
health insurance coverage. The non-partisan Congressional Budget Office
(CBO) estimates that the cost of enacting H.R. 3962 will be $894
billion, consistent with the $900 billion limit established by
President Obama. The bill is fully paid for. About half of the cost of
H.R. 3962 is paid for by targeting waste, fraud, and inefficiency in
the federal Medicaid and Medicare programs. The other roughly half of
the cost of the bill is paid for through a surcharge on the wealthiest
Americans--those with incomes above $1 million for couples and $500,000
for singles; therefore, 99.7 percent of Americans will not be touched
by this surtax.
While H.R. 3962 will be paid for, CBO also estimates that the bill
reduces the deficit by over $100 billion in the first 10 years, and
continues to reduce the deficit in subsequent years. Leading economists
from educational institutions across our nation have concurred with
CBO's findings and support the idea that health care reform promotes
our country's economic health.
Finally, I want to address the importance of health care reform to
seniors. Some of the most damaging misinformation that has circulated
over the past several months on health care reform is the use of scare
tactics targeted at seniors. The cynical irony is that the
misinformation targeting seniors is largely perpetuated by the same
people who fought the establishment of Medicare and wanted to privatize
Social Security.
The truth is that H.R. 3962 will lower prescription drug costs for
people in the doughnut hole; give the Secretary of Health and Human
Services the authority to negotiate lower drug prices on behalf of
Medicare beneficiaries; and extend the solvency of the Medicare Trust
fund by five years.
Closing the doughnut hole is an especially critical issue for Hawaii,
as we have the nation's largest percentage--36 percent compared with 26
percent--of Medicare beneficiaries who fall into this gap of
prescription drug coverage. In its first year, H.R. 3962 will reduce
the doughnut hole by $500 per beneficiary, provide a 50 percent
discount on brand-name prescription drugs, and phase out the doughnut
hole by 2019.
It is remarkable that in just the past two days, over 300 groups
representing Americans from all walks of life--doctors, farmers,
seniors, consumers, cancer and diabetes patients--have rejected the
unsustainable status quo and have endorsed H.R. 3962. In its
endorsement of the bill, Consumers Union--publisher of the independent,
non-partisan Consumer Reports--called the health care status quo a
``consumer crisis with its crippling costs, its unreliability, and lack
of access,'' and strongly endorsed the House of Representatives health
care bill because it will create ``a more secure, affordable health
care system.'' Other groups endorsing the House bill include the:
American Medical Association, American Nurses Association, AARP, AFL-
CIO, AFSCME, Americans for Democratic Action, American Cancer Society,
American Diabetes Association, Asian & Pacific Islander American Health
Forum, Association of Asian Pacific Community Health Organizations,
National Association of Community Health Centers, National Education
Association, Campaign for Tobacco-Free Kids, and from my district,
Lana`i Community Health Center.
Now is the time to end insurance discrimination based on pre-existing
conditions or gender. Now is the time to begin to close the Medicare
doughnut hole for America's seniors. Now is the time to bring change to
a broken system.
I urge my colleagues to vote in support of H.R. 3962.
Aloha and mahalo.
Mr. THORNBERRY. Mr Speaker, most of us agree that improvements are
needed in our health care system, especially in the way we pay for
health care. Health insurance costs have been increasing faster than
many people can pay, and too many of us do not have health insurance.
At the same time, many aspects of our health care system are the best
in the world. We need to work step-by-step to make needed improvements
while we protect those parts that are improving the quality and length
of our lives.
The bill before us, H.R. 3962, takes a very different course. It cuts
over $400 billion from Medicare and Medicaid, increases various taxes,
and fines individuals and businesses that do not sign up for the
government-approved insurance, all to pay for massive new programs,
including a government-run health insurance plan.
I believe that this bill will not only fail to stem the growing cost
of health insurance; it will make health insurance significantly more
expensive for the 85 percent of Americans who are currently insured.
And it will severely affect those on Medicare and Medicaid. It will
also present the largest, most intrusive growth of government into our
lives in many years.
The alternative bill is a better approach. It focuses on lowering
health insurance costs, and CBO agrees that it will do so by up to 10
percent. At the same time, it makes it easier for those with pre-
existing conditions to obtain coverage. CBO judges that the alternative
would reduce the federal deficit by $68 billion over the next ten
years.
Unfortunately, other ideas have never been allowed to be considered.
This bill has been railroaded through this House from the beginning.
That is not the way to deal with an issue as important as health care.
H.R. 3962 must be stopped so common sense health insurance reform can
begin.
Mr. TIAHRT. Mr. Speaker, I rise today to express my opposition to
both the rule and to the massive government takeover of health care
that is before us today. There are a large number of issues that I
could raise, but right now I would like to focus on one of the most
blatant examples of disregard for the will of the American people found
within this bill. The bill includes abortions paid for by federal
dollars.
For more than 30 years, the United States federal government has not
been in the business of providing funding for abortion. Since 1976 the
Hyde amendment has struck a delicate, but respectful balance between
those who support abortion and those who do not. While it does not make
abortion illegal, it protects those who oppose abortion from being
forced to support it with their taxpayer dollars. This is a fair
compromise that should be included in the H.R. 3962.
Public opinion is clear on this issue. A number of polls have been
conducted in the last couple of months confirming that Americans do not
support federal funding of abortion. A Rasmussen Reports poll from
September found that only 13 percent of Americans support abortion
coverage by government-backed health insurance. A Public Option
Strategies poll from September found that only 8 percent of Americans
would be more likely to support a health care bill if it included
federal funding for abortions. A whopping two-thirds of Americans
oppose using federal dollars to pay for abortions, according to the
September International Communications Research poll. This is like
every other aspect of this health care bill--the American people do not
want it, but Democrat leadership is attempting to ram it down our
throats anyway.
This is why I support the Stupak-Pitts amendment. Their amendment
would extend the same restrictions found in the Hyde amendment to cover
this bill as well. It does not outlaw or prohibit abortion, or restrict
those who wish to have an abortion from seeking one. But it does
prevent federal dollars from being used to pay for those abortions.
I am pleased that we will be allowed to debate the Stupak-Pitts
amendment, even without assurance that should it pass, the House would
retain the language in conference, and

[[Page H12917]]

I hope that my colleagues vote in favor of the amendment. The
Republican bill clearly states that abortions will not be paid for with
taxpayer dollars. I urge my colleagues to vote for the Republican bill
and against H.R. 3962.
Mr. ENGEL. Mr. Speaker, I rise in strong support of the Affordable
Health Care for All Americans Act. In my 21 year career, this is by far
one of the most important votes I will take. I have spent the past ten
months meeting with the people of Bronx, Rockland and Westchester
Counties and have had heartbreaking stories shared with me about the
inadequacies of healthcare.
On this historic day, our Congress honors our country, honors our
citizens, and honors our moral imperative to provide all Americans with
comprehensive, affordable access to quality health care.
This is the reason so many of us get up day after day after day. It
is the reason why so many of us sought public office, and it is the
reason why our constituents sent us to Congress--to right the wrongs of
our broken healthcare system and steer our country back in the right
direction.
Never again will families worry late into the night over whether
their pre-existing medical conditions will prevent their loved ones
from getting access to health care coverage they so desperately need.
Never again will insurance companies be allowed to drop coverage for
those who have paid their premiums diligently, only to lose it when
they get sick and need it most.
Never again will families have to worry that if they lose their jobs,
they will also lose their healthcare coverage.
The underlying bill provides comprehensive reform to our nation's
healthcare system and puts our nation back on the road to fiscal
responsibility by reducing the deficit by $30 billion in the first 10
years.
Regardless of who you are, or where you live, this bill provides
significant benefits to all citizens.
If you have health insurance, you can keep your doctor and your
health plan. You like it, you keep it. It's that simple.
But for those that don't have health insurance, we will change that
today. Of the 46 million Americans that are uninsured, 85 percent of
them are in working families. Millions of Americans desperately want to
purchase health insurance and can't. They've been priced out of the
system. They have been priced out of a basic desire to keep them and
their families healthy. 53 percent of Americans postpone care or
medication because of cost. 60 percent of bankruptcies were related to
medical debt. It's unfair, unsustainable and un-American to allow this
failed health care system to continue.
Insurance companies have a chokehold on the market and we are
breaking through that today. If you don't have health insurance, or
lose your health insurance, the new health insurance exchange will
provide a one stop comparison shopping market place for you of private
insurance options or a new public health insurance option.
While in my heart of hearts I believe a single payer system would be
the best reform of our nation's health care, I have worked tirelessly
over the last year to enact a strong public option. The public option
included in the bill will undoubtedly inject competition into the
market for better prices and coverage of quality health insurance.
No longer will women be considered second class citizens when it
comes to healthcare coverage. H.R. 3962 supports women's health care by
ending the designation of pregnancy, domestic violence and caesarean
sections as pre-existing conditions, and eliminating out-of-pocket
expenses for preventive services including mammograms, well baby and
well-child care visits. It also prohibits plans from charging women
more for health coverage than men, and guarantees coverage for
maternity care.
H.R. 3962 invests in Medicare. Our seniors will see improved
benefits, free preventive care, better primary care and lower drug
costs. The donut hole, in which seniors pay monthly premiums for drug
coverage without a drug benefit, will finally be closed. I have been
fighting for this since the day we enacted the Medicare Prescription
drug benefit.
Young adults will have more access to affordable healthcare than ever
before. Our bill allows adults to stay on their parents' healthcare
plans until their 27th birthday. This measure alone will cover one out
of three uninsured young adults.
Additionally, small business owners will be granted access to
affordable large group rates in the new insurance exchange and tax
credits to help businesses insure employees across the 17th district
and our nation. I met with the Rockland Small Business Association this
summer and fought to make health insurance reform workable for small
businesses. 98.8 percent of small business owners will pay no surcharge
and 86 percent of America's businesses are exempt from the shared
responsibility requirement to provide insurance. In fact, businesses
with payrolls of $500,000 or below are completely exempt from
provisions in H.R. 3962.
Throughout this year, and in my role as the Senior New Yorker on the
Energy & Commerce health subcommittee, I have worked hand and hand with
Chairmen Waxman, Rangel, Miller, Majority Leader Hoyer and Speaker
Pelosi to improve the underlying bill for New York State and people
nationwide.
Here are just a few of the provisions I was successful in inserting
in the underlying bill.
I am proud to have reformed the Medicaid program to serve people with
HIV. Under current Medicaid rules, low-income people with HIV must wait
until they are disabled by AIDS before they can get covered by
Medicaid. In the House bill, states could cover all people with HIV
infection under state disability income and resource levels until
January 1, 2013, when the new health insurance exchange is operational,
at an enhanced federal match.
I worked to protect the ability of eight states, including NY to
preserve Adult Day Health care programs in Medicaid. These community-
based long term care programs provide comprehensive health care
services in day settings.
Beneficiaries are given nursing, case management, clinical
management, medical, diagnostic, social, rehabilitative, recreational
and personal care services on a routine, daily basis.
Since my time in the New York State Assembly when I was the Chair of
the Assembly Committee on Alcohol and Drug Abuse, I have been
championing for mental health and substance abuse services. I worked to
strengthen our capacity to serve people affected by these disorders
through Federally Qualified Behavioral Health Centers. My provision
will establish national standards of care for persons with serious
mental illness and addiction disorders. Furthermore, new reporting and
accountability standards for mental health care will better integrate
its providers and services within the larger healthcare system.
Many people have a family member, or are friends with someone who has
autism. I worked with Rep. Doyle, the Co-Chairman of the Congressional
Caucus on Autism on several provisions dear to me. We ensured that
discrimination in benefits against persons with autism are prohibited
by including behavioral health treatments as part of the essential
benefits package in the House health reform bill.
There is currently a shortage of appropriately-trained personnel who
can assess, diagnose, treat and support patients with Autism Spectrum
Disorders (ASD). These professionals require the most up-to-date
practices to best care for those with autism and their families. And so
we included a provision for the training for professionals working with
children and adults with autism.
I advocated to improve the healthcare for maternity and newborn care
in the Medicaid program. H.R. 3962 will extend important child health
quality improvement provisions to traditional-eligible childbearing
women and newborns and other covered adults younger than age 65. As a
result of my provision, the Secretary of Health & Human Services will
collect data and make recommendations on improving care for these key
populations.
Finally, I was tireless in my advocacy for the Disproportionate Share
Hospital (DSH) program, which assists with the cost of caring for
uninsured and underinsured people at hospitals. These payments ensure
that hospitals are not in financial distress from serving low-income
people.
We stand here as proud Americans determined and ready to transform a
broken health care system into a model of care worldwide. The cost of
inaction is too great. Today, we answer the call of history, and vote
for health insurance reform for America. Our nation's future depends on
it.
Mr. SCOTT of Virginia. Mr. Speaker, all afternoon we have heard about
the ``freedom'' to be uninsured. Seniors in my district do not want us
to repeal government run Medicare so that they can enjoy a ``freedom''
to be uninsured, and those without insurance now do not view themselves
as enjoying some ``freedom''; they want insurance.
The Republican substitute responds to the comprehensive Affordable
Health Care for America act with a bill that fails to reduce cost,
fails to cover uninsured Americans, and it may study--but it does not
help--those with pre-existing conditions. It does, however, attack
innocent victims of medical malpractice.
One recent study showed that medical malpractice represents less than
one-third of one percent of all health care costs. And yet the
Republican substitute seeks to blame our broken health care insurance
system on innocent victims of medical malpractice. For those victims,
the bill limits the ability to hire a lawyer, complicates the lawsuit,
shifts the costs of medical malpractice from the doctor to the victims'
own private insurance, and in some cases causes the injured victims to
lose the right to sue before they even know they've been injured. I'd
like to share some specific examples of the egregious provisions
included in the Republican substitute.

[[Page H12918]]

Under the Republican substitute, a young child whose life is forever
devastated by medical malpractice can lose all right to sue on his or
her eighth birthday--long before he or she reaches legal age to make
his or her own decision.
Under the Republican substitute, when two or more wrongdoers act
together, and one of them is able to flee or put their assets out of
reach, the innocent victim is left short, while the other wrongdoer is
shielded from full responsibility. They call this the ``fair share
rule.''
Under the Republican substitute, it is more difficult for a medical
malpractice victim to get a lawyer's help to fight against the
insurance companies, because the bill permits a court to reduce the fee
paid to the victim's lawyer--after the case has been fought and won.
This provision penalizes victims with winning cases. One would think
the purpose of this provision is to save the insurance carrier money
and thereby reduce malpractice premiums; however, insurance carriers
are not responsible for the victim's lawyer's fee. Insurance carriers
are responsible for the defendant's lawyer's fee, so permitting the
court to reduce fees paid to defendant's lawyers would actually save
money and reduce premiums. The substitute does not allow that. This
makes no sense. Under current practice, the victim's lawyers already
don't get paid if the victim loses. Now they might not get paid even if
the victim wins.
Under the Republican substitute, if the victim has health insurance
that helps pay for the victim's care while the victim is waiting for
the wrongdoer to be held accountable, the wrongdoer can escape legal
accountability for that part of the cost entirely. The wrongdoer gets
to shift the cost onto the victim's own health insurance. That's the
Republican approach to health insurance reform--saddling the victim's
insurer with the cost of someone else's negligence, while letting the
wrongdoer off the hook.
Under the Republican substitute, the only time punitive damages would
ever be available is when the wrongdoer has maliciously injured the
victim that is, when the wrongdoer has committed a violent felony. And
even then--even in cases of the most heinous violence imaginable--the
Republican substitute caps punitive damages.
The Republican substitute is empty of any meaningful health insurance
reform, and it is utterly callous to malpractice victims. None of these
unfair provisions were passed during previous attempts when the
Republicans controlled the House, the Senate and the White House, and
they should not be passed now. The substitute should be defeated.
In contrast, the majority's Affordable Health Care for America Act
reduces the number of uninsured, increases accessibility of health
care, controls skyrocketing costs, and addresses the denial of coverage
based on pre-existing conditions. This legislation will put us on a new
path where health care will be affordable to all and not just a luxury
for some, and I am proud to support this historic health insurance
reform legislation.
Ms. NORTON. Mr. Speaker, I support the Affordable Health Care for
America Act both because of the extraordinary step forward it brings
the nation and my district, the District of Columbia. First, I took
steps to assure that the Affordable Health Care for America Act we
expect to pass tonight would treat the District equally with the 50
states (although it does not do so for the territories). Consequently,
the bill will provide coverage for 14,000 uninsured D.C. residents and
affordable credits to help up to 134,000 D.C. families pay for
coverage; will improve employer-based coverage for 363,000 District
residents; will improve Medicare for 75,000 D.C. seniors, including
closing the prescription drug donut hole for 3,300 seniors, as well as
providing free preventative care and wellness check-ups for all
seniors; will allow 22,200 D.C. small businesses to obtain affordable
health care coverage; and will save about 400 District families from
bankruptcy resulting from unaffordable health costs. The bill also will
reduce the cost of uncompensated care by $126 million for the
District's besieged hospitals and health care providers.
I am proud of the remarkable advances made by our bill, even though
it does not meet all that I pressed to achieve. The Congress, of
course, is not known for perfect bills, but the extraordinary diversity
of our Democratic Caucus--from right to left--has assured that this
bill represents a cross-section of the American public--urban,
suburban, and rural. The incredible diversity of the Democratic Caucus,
representing Republican, right-leaning, moderate, and progressive
areas, meant that we could go to the floor only with a bill that
sensitively put all of America together into one convincing bill. That
is why we have produced a bill that satisfies deficit hawks, more wary
of increasing deficits than of most other issues as well as single-
payer advocates, who believe that only Medicare for all can
sufficiently reduce costs while providing adequate health care to the
middle class and the uninsured. Thus, there can be no doubt that the
Affordable Health Care for America Act is a balanced bill.
The bill's greatest achievements are that it will reduce the deficit
over the next 10 years and into the future while covering 96 percent of
the American people; will end discrimination by insurers who dropped or
refused to renew or sell coverage because of health status; and will
ensure that coverage is affordable by providing subsidies for people in
employer-based health care or through the insurance exchange of private
insurers as well as a consumer option to drive down the cost of health
care while operating on a level playing field with other insurers.
I particularly support this bill because it will take off the burden
that the District of Columbia heroically took on, beginning with the
Williams administration, to offer health care to the uninsured, without
any assistance from the federal government, rather than subject them,
as well as the District, to costly emergency room care, the most
expensive available. The District's Health Care Alliance, which
provides insurance to more than 50,000 residents lacking health
insurance, who do not qualify for Medicaid or Medicare, is collapsing
under the weight of increasing requests from individuals without
insurance. The city had to cut its Health Alliance budget this year to
46,000 individuals, although a year ago 48,000 individuals had
registered and 55,000 were expected to register in the 2010 fiscal
year.
At my ``Fact Check Town Hall Meeting on Health Care Reform,'' which
observers said was notable for its civility and the diversity of
residents attending, it was apparent that District residents strongly
support the approach taken by today's bill. By September, my office had
received 2,000 contacts on health care reform, almost all supporting
the reform efforts underway in the House, with only nine residents
expressing opposition to any reform. Also, 276 District residents had
written in opposition to parts of the proposed bill, and 220 of them
opposed the public plan. Most who opposed the public plan, appeared to
believe that such a plan would affect their employer-based plans, which
this bill ensures cannot happen.
I believe that this bill is strong and compelling enough to offer
stiff resilience to those who have been unwilling to take on the
special interests and who may now believe their best hope is in the
other body. Tonight, this bill provides the best hope for the health
care of our nation's longsuffering people.
Mr. PAULSEN. Mr. Speaker, like many of my colleagues on both sides of
the aisle, I believe the status quo of our nation's health care is
unacceptable. We need real reform in this country that will lower costs
and keep health care decisions in the hands of patients and their
doctors.
This bill would establish a new government run bureaucracy and a
public-plan that will drastically expand the role of government into
personal health care, at a massive cost of more than $1 trillion. And
it's important to note, that like nearly every other entitlement
program, the costs from this bill will only skyrocket.
The bill raises taxes on small businesses, individuals and medical
devices like pacemakers and stents. Indeed, this bill would impose
$729.5 billion in higher taxes. $135 billion in taxes will be levied on
business. $20 billion in taxes will be levied on medical device
manufacturers. Using President Obama's economic measuring stick, as
many as 5.5 million jobs could be lost from the taxes in this bill.
We all heard over and over again that, ``those of you who like your
health care plan can keep it.'' What is not mentioned is that every
plan will need to meet government requirements for a government seal of
approval. This plan cuts $500 billion in Medicare benefits to seniors,
including over $170 billion in cuts to Medicare Advantage--a plan that
is used by more than 19,000 seniors in my district. These seniors will
no longer get the same care and coverage that they need.
Mr. Speaker, in the bill before us there is no provision in this bill
to allow small businesses to pool together, no protection for those who
want keep the coverage they have, and no medical liability reform.
The health care plan I support lowers health care premiums for all
Americans, guarantees affordable coverage for patients with preexisting
conditions, protects seniors, Medicare benefits, includes no tax
increases, enacts real medical liability reform, empowers the doctor-
patient relationship, and reduces the budget deficit.
I also want to point out that I offered five amendments to the
healthcare bill, but none were made in order. The first amendment would
have removed the onerous medical device tax from the bill and replaced
it with unobligated stimulus funding. It makes no sense to me that this
bill taxes innovation and our job creators and takes away funding for
life saving technology.

[[Page H12919]]

I had another amendment that would have required a study of the
harmful effects the innovation tax would have on the medical technology
industry. Americans should know the implications of the negative
effects on life saving technologies in this nearly 2,000 page bill.
Yet another amendment I offered would have removed the seasonal and
temporary workers from the employer mandate. This amendment would have
helped to lessen the heavy burden this legislation imposes on small
businesses.
In addition, I offered an amendment that would have improved and
expanded health savings accounts. This would have helped make health
care more affordable for the millions of people covered by high
deductible health plans.
Finally, I offered an amendment to clarify that nothing in this bill
would have infringed on the healthcare that was promised to our
nation's veterans. Unfortunately, this health care bill makes massive
changes and our nation's veterans are owed the assurance that they will
have adequate care.
Mr. Speaker, I would like to close by saying that I oppose this bill
because it puts the government in between the decisions of a patient
and their doctor. This is simply unacceptable. Patients should have the
right to make their own choices regarding the medical care they need
without government interference. Whether it is taking care of your
children, parents or grandparents, there is no issue that is more
personal to a family than health care. No special interest group,
Member of Congress or federal bureaucrat should stand between a patient
and their doctor.
Americans continue to lose jobs and faith in their American
government each day. This bill is not only the wrong direction for our
economy but also the wrong direction for America.
Mr. BISHOP of Georgia. Madam Speaker, after months of studying the
various proposals, listening to feedback from my constituents on both
sides of the issue in town hall meetings, informal discussions,
letters, e-mails and faxes, and after prayerful reflection, I concluded
that I must support the health care reform legislation. I believe it
would improve the lives of my constituents by ensuring that they have
access to quality, affordable health care. H.R. 3962, while not
perfect, makes substantial progress in this regard.
During my town hall meetings on health insurance reform last August,
I said that we have a moral obligation to ensure that all Americans
receive the health care they need to live healthy and productive lives.
I have long been concerned about the poor health indicators among my
constituents, and this evening I cast a vote that I believe will have a
significant impact on improving the lives of Southwest Georgians now
and into the future.
Georgia ranks third in obesity rates for children age 10-17; sixth in
the number of tuberculosis cases; seventh in number of low birthweight
babies; ninth in diabetes rates for adults; tenth in the number of
uninsured; eleventh in hypertension rates; eleventh in the number of
new cancer cases; and fourteenth in obesity rates for adults. These
numbers are unacceptable.
H.R. 3962, when signed into law, will immediately bring about reforms
that will benefit the citizens of Georgia's Second Congressional
District and all Americans. The bill will immediately begin to close
the donut hole in the Medicare part D prescription drug coverage for
seniors. It will outlaw denial of coverage for people with pre-existing
conditions, limit premium discrimination based on gender and age, and
prevent insurance companies from dropping coverage when people develop
serious illnesses and need it the most.
In addition, the bill increases funding for community health centers
and other primary care providers, doubling the number of patients seen
over five years. It will extend coverage for young people to stay on
their parents' insurance plans up to their 27th birthday. It will
extend COBRA health insurance coverage for displaced workers.
Furthermore, it will hinder price-gouging by requiring that insurance
companies disclose rate increases.
By 2013, when the mandate for coverage and the Exchange are in place,
additional provisions will take effect including no more co-pays for
routine checkups and preventive care, yearly caps on individuals' out-
of-pocket expenses and no lifetime caps on what insurance companies
will cover.
In addition to the benefits for Southwest Georgia, the bill will
reduce the federal budget deficit by $104 billion over the next decade.
It will allow states to form compacts that will enable consumers to buy
policies from insurers across state lines.
With regards to small businesses, the health care legislation will
provide tax credits to nearly 14,000 small businesses in the Second
Congressional District who offer their employees coverage and exempts
86 percent of small businesses (those with payrolls of less than
$500,000) from having to provide coverage, and continues the business
deduction for those who do.
Finally, the House health care bill prohibits the use of federal
funds for abortions. It also requires verification of citizenship or
lawful presence for undocumented immigrants to receive coverage.
I look forward to further improvements as the bill is considered by
the Senate and the Conference Committee, where differences between the
House and Senate bills will be resolved. But this evening's vote is a
significant step towards affordable, quality health care for all.
Mr. KENNEDY. Today is truly a historic day for all Americans, and as
an elected official of this great democracy, it is an extremely proud
day for me. It is an occasion to celebrate and thank all those who
fought to protect our nation's democratic process. It is also an
occasion to recognize and remember all those Americans who have
suffered waiting for this day to arrive. We have worked together to
achieve this goal of quality, affordable health care for all Americans.
To all these people, I express my sincere gratitude, and I rejoice with
you today that a new chapter in our history has begun.
The Affordable Health Care for America Act creates basic protections
for all Americans seeking access to healthcare. No longer will insurers
be able to drop you from your insurance when you get sick, nor can they
deny you coverage for a pre-existing condition. A public option will
offer a choice for consumers and provide real competition to keep
private insurers honest. Affordability credits will help individuals
and small businesses to purchase health insurance. Additionally, these
reforms are fully paid for and will actually lower the deficit over the
next 10 years.
I am proud that the final version of this legislation includes
numerous provisions I have long advocated for and worked with my
colleagues to achieve. While the initial draft of the Affordable Health
Care for America Act gradually closed the donut hole for Medicare
prescription drug coverage over 15 years, I am pleased to have worked
with the Speaker to successfully reduce the timeline in which this
critical reform will take place. The donut hole will now begin to close
immediately and will close completely by 2019, providing much needed
assistance and relief to seniors starting next year.
Likewise, I am also pleased that the Affordable Health Care for
America Act eliminates lifetime caps, provisions of many health
insurance plans that limit the total dollars in benefits that the
insurance plan will pay out over the lifetime of an enrollee in the
plan. I authored a letter, signed by 23 of my colleagues, urging this
lifesaving provision to become effective immediately. I am pleased that
the elimination of lifetime caps on insurance has been made effective
in 2010, so that none of the 25,000 individuals who reach their
lifetime caps each year will die waiting for the provisions to take
place.
A key aspect of this legislation that is of particular importance to
me is the extension of the mental health parity protections established
into law last year by my legislation, the Paul Wellstone and Pete
Domenici Mental Health Parity and Addiction Equity Act. Not only are
these protections extended to all plans in the Health Insurance
Exchange, but mental health and substance use benefits are a part of
the essential benefits package created by this legislation. For 67
percent of adults and 80 percent of children needing mental health care
that do not receive it, this victory cannot be understated. I commend
my colleagues and my fellow citizens for their leadership in
recognizing that the health of the mind truly cannot be separated from
the health of the body. Today marks a new day and a giant leap forward
towards our transition from a ``sick care'' system to one which is
preventive, collaborative, and patient-centered.
Along these lines, I have also worked closely with my colleagues to
ensure that mental health and substance use screening tools, such as
Screening, Brief Intervention and Referral to Treatment (SBIRT), were
included in this legislation. Severe mental illnesses are estimated to
cost the U.S. hundreds of billions annually in lost wages. Screening
for mental health and substance use has proven to be a significant cost
saver for our health care system. The Affordable Health Care for
America Act establishes a program to provide grants to support these
critical services.
I will continue to work with my colleagues to ensure that our health
care professionals have the tools that are needed to recognize mental
health and substance use in their patients. This means ensuring that
mental health and substance use education be required of all health
care professionals and integrated into the medical curricula,
continuing medical education, and licensing examinations. It also
includes addressing the drastic shortages of child and adolescent
mental health professionals by providing loan forgiveness and making
grants to professional schools to develop, expand, and improve training
programs for professionals who serve children and adolescents. Language
to this effect is included in

[[Page H12920]]

some of the Senate healthcare reform legislation, and I will work with
my colleagues to ensure that these critical provisions are retained.
Again, I commend my colleagues, the leadership, and my fellow
Americans for their steadfast effort, diligence, and tremendous
stewardship towards realizing the dream of quality, affordable health
care for all Americans.
Mr. SMITH of New Jersey. Mr. Speaker, like most Americans, I believe
we urgently need health care reform to provide every American access to
high-quality medical care.
During the long and painful illnesses of both my parents, I had to
fight with their health management organization to get them the care
they deserved. Their HMO put my family through months of frustration
and anguish. I know I'm not alone--tens of millions of Americans have
gone through this as well. It's not right, and it's time to change
that. Americans need more protection, power, and say in their health
care programs, and they need us to reform the system to make it more
affordable for everyone.
Regrettably, H.R. 3962, the bill before the House tonight, not only
falls short, but it will make most people's health care worse, and it
will certainly disempower all of us. For this reason I strongly oppose
the bill--H.R. 3962.
After carefully studying H.R. 3962, I am concerned that the bill is
actually a step backwards--many patients will have less, not more,
access to and say over their health care if H.R. 3692 is enacted. I
firmly believe we can and must reform our health care system and
provide better solutions for those currently uninsured or underinsured.
But we must do so without jeopardizing the quality of health care for
these currently insured people and families, many of whom will see
their own health care access and quality seriously eroded under the
bill.
H.R. 3962 will:
Limit patient access by establishing federal bureaucracies with new
authority to determine what medical treatments and services will be
covered at, what costs patients will pay--Americans will be so
disadvantaged that this bill makes those who don't purchase
``acceptable'' coverage (as defined by the federal government) subject
to criminal fines and imprisonment up to 5 years.
Cause most Americans to lose access to their current health insurance
coverage and force them into a nationally uniform public plan. It will
do this by subsidizing a government-run ``public plan'' that will
ultimately drive private health plans out of business. Most Americans
don't want to lose their current insurance, and they trust the public
plan even less than they trust private insurance, which at least has to
compete for customers, and permits them to choose their doctors. This
would hit my constituents especially hard--according to the Urban
Institute, approximately 90% of the people in my district currently
have health coverage;
Slash payments to health-care providers, threatening the continued
existence of many hospitals, home health and skilled nursing facilities
serving New Jersey residents.
Madam Speaker, throughout my career in Congress, I have been a
steadfast supporter of Medicare for our senior citizens and the
disabled. I have voted several times to preserve and protect Medicare
even when I stood alone in my own party rejecting a proposal to cut
$270 billion from Medicare in 1995.
That is why I find it absolutely unacceptable that H.R. 3962 cuts
Medicare by a whopping $500 billion. Proponents argue that some funding
will be returned through other avenues. But even if that were true,
Medicare will still be drastically cut by a net of $219.4 billion, in
their ``best case scenario.''
The bill also guts Medicare Advantage plans, which offer additional
coverage to over 11 million seniors--15,983 in my district alone--who
choose Medicare Advantage plans as the coverage that best meets their
needs.
I will not vote for massive cuts in Medicare. These cuts will wreak
havoc on our nation's health care system and everyone it serves,
particularly the seniors and disabled. We need reform legislation that
respects all human life, the most vulnerable among us which includes
the frail and the disabled of all ages.
Finally, this bill will hinder economic recovery and job creation
during a major recession. Just yesterday the nation's unemployment rate
rose above 10 percent for the first time since 1983, and if you include
those who have stopped looking for jobs and those who can only find
part-time work, the rate is 17.5 percent. The bill does additional harm
by:
Raising taxes on individuals and small businesses by $729.5 billion;
Failing to reform our costly and unfair system of medical liability
lawsuits, which inflates health care costs by billions of dollars each
year, exceeding 10% of all health care expenditures;
Mandating a $34 billion expansion of state Medicaid payments--in
order to cover this massive increase, financially strapped states like
New Jersey will have to cut other services; and
Costing the taxpayer, according to the Congressional Budget Office
(CBO), $1.3 trillion over ten years and using budget gimmicks and tax
increases to cover that cost.
I must mention two other serious problems with the bill:
It does not adequately protect the freedom of conscience of health
care providers opposed to abortion, and sets up mechanisms that ration
care by creating government ``waiting lists'' if there are insufficient
funds to pay expenses; and
It does not require patients to verify their identity, which,
according to the CBO, means that millions undocumented immigrants will
receive free health care, unfairly subsidized by taxpaying citizens.
It is truly unfortunate that the Democratic leadership did not work
to put forth a health care reform bill that addressed these concerns.
We need a proposal that advances solutions rather than creates new
problems. Let me be clear, I take a back seat to no one when it comes
to working to ensure that the federal government accepts its role and
is doing its part in helping people and providing a health care safety
net for those in desperate need of health care support. I am proud of
my record, voting to defeat cuts to and expand existing federal health
care programs, while working to protect patient rights and the delivery
of quality medical care. These efforts include:
Medicare/Medicaid/SCHIP. I support providing our senior citizens a
high level of benefits under the Medicare program. On one occasion, I
voted against a $270 billion reduction in Medicare spending. One reason
I cannot support the current health care legislation is because it
makes over $500 billion in cuts to Medicare. To expand health insurance
to more uninsured low-income children, I voted in 1997 for legislation
creating the State Children's Health Insurance Program (SCHIP) and
voted last year to expand the program. SCHIP and Medicaid together
cover more than 30 million low-income children, as well as 16 million
adults, 6 million seniors, and 10 million persons with disabilities.
That is why I have been so adamant about protecting those programs.
Community Health Centers. Federally designated community health
centers are another effective means to get affordable health care to
underserved communities. The health centers program includes community,
migrant, homeless, and public housing health centers and provides
primary and preventive care to more than 18 million individuals at over
3,700 sites located in every state and U.S. territory. I have been a
consistent supporter of increased funding for the community health
centers program. A significant factor in the success of community
health centers is that they are managed at the community level with a
concern for serving their clients in their local neighborhoods.

Veterans Health Care. As former Chairman of the House Committee on
Veterans' Affairs, I fought successfully (and sometimes nearly alone)
to provide increased medical services and funding for veterans health
care programs. I wrote several laws to boost and expand veterans health
care, including the Department of Veterans Affairs Health Care Programs
Enhancement Act (PL 107-135), which expanded and enhanced veterans'
healthcare services and reduced out-of-pocket costs for low income
veterans by 80 percent and continues to help disabled veterans obtain
the tools they need to live fuller lives. I also wrote the law, the
Veterans Health Programs Improvement Act of 2004 (PL 108-422), that
created 5 poly-trauma centers within the VA, and an additional 17
networked sites, that specialize in treating complex multi-trauma
injuries--including severe brain injury--associated with combat
injuries from Iraq and Afghanistan.
Health Care Caucuses. Working with my colleagues across the aisle, I
have cofounded and currently co-chair important bipartisan health care
working groups, i.e. caucuses, which aim to educate Members of Congress
and increase federal resources and research on treatments and cures for
specific diseases, some which effect New Jersey residents
disproportionately. For instance, I serve as co-chairman of the
bipartisan Congressional Alzheimer's Task Force; the Coalition for
Autism Research and Education; the Spina Bifida Caucus; and the Lyme
Disease Caucus. Each caucus has served as an effective forum to advance
legislation that helps families combating health care challenges;
Patients Rights. As far back as 2001, I cosponsored and voted for the
Patient Protection Act which contained critical patient protections to
help put doctors and patients back in control of their health care
decisions, rather than bureaucrats at managed care companies.
Unfortunately, while separate bills passed the House and the Senate,
they were never signed into law.
Insurance Reform. I voted for the Health Insurance Portability and
Accountability Act of

[[Page H12921]]

1996 (HIPPA), which provided insurability protections for individuals
moving between insurance plans in the individual or group markets and
reduced or eliminated preexisting medical condition exclusion periods
for such individuals. I have also been a strong advocate for allowing
small businesses, associations, and non-profit organizations to band
together to purchase health insurance. In acquiring health insurance,
small businesses do not enjoy the benefits of economies of scale of
large businesses, which allows those large businesses to spread
administrative costs over a large base and provide significant leverage
in negotiating lower premiums. Over 50 percent of the nation's
uninsured are employed in a small business or are a dependent of such a
worker.
Medical Malpractice Reform. The House of Representatives has voted to
pass medical liability reform legislation with my support eight times
in the past 15 years. These bills--which sought to place a cap on non-
economic damages, limit punitive damages, and restrict attorneys'
fees--were modeled after a California law that many credited for
relatively low malpractice premiums in the state.
While we have had some significant successes in these critical areas
expanding--frequently after much toil--it is indisputable that more
comprehensive changes are needed, including major reforms of the
private health insurance market.

The goal of responsible health care reform should be to provide
credible health insurance coverage for everyone, strengthening the
health care safety net so that no one is left out, and incentivizing
quality and innovation, as well as healthy behaviors and prevention.
This means that the current private health insurance market will have
to be reformed to put patients first, and to eliminate denials for pre-
existing conditions and lifetime caps and promoting portability between
jobs and geographic areas, including across state lines. The tax code
should be modernized to promote affordability and individual control,
provide assistance to low-income and middle-class families. Medicare
requires reform to be more efficient and responsive, with sustainable
payment rates.
Of course responsible health care reform will respect basic
principles of justice: it will put patients and their doctors in charge
of medical decisions, not insurance companies or government
bureaucrats. It will also ensure that the lives and health of all
persons are respected regardless of stage of development, age or
disability.
The Republican alternative amendment does these things. It focuses on
lowering health care premiums for families and small businesses,
increasing access to affordable, high-quality care, and promoting
healthier lifestyles--without increasing taxes or adding to the
crushing debt Washington has placed on our children and grandchildren
and without cutting Medicare. It also establishes a real conscience
protection for health care providers and it requires verification of
citizenship and identity.
I oppose H.R. 3962 because in many ways it jeopardizes coverage for
those who already have it, especially seniors and the disabled. At the
same time it exercises far too much top-down government control,
forcing everyone toward a government plan, controlling exactly what
sort of care will be offered. For this reason I support the Republican
alternative amendment. It moves significantly in the right direction
while applying the wisdom of Hippocrates' first principle of medicine:
doing no harm.

Amendment Offered by Mr. Stupak

Mr. STUPAK. Mr. Speaker, I have an amendment at the desk.
The SPEAKER pro tempore. The Clerk will designate the amendment.
The text of the amendment is as follows:

Part C amendment printed in House Report 111-330 offered by
Mr. Stupak:
Page 97, strike line 13 and all that follows through page
98, line 7.
Page 110, strike lines 1 through 7.
Page 114, line 21, strike ``consistent with subsection (e)
of such section''.
Page 118, line 21, strike ``(including subsection (e))''.
Page 154, after line 18, insert the following new section
(and conform the table of contents of division A
accordingly):

SEC. 265. LIMITATION ON ABORTION FUNDING.

(a) In General.--No funds authorized or appropriated by
this Act (or an amendment made by this Act) may be used to
pay for any abortion or to cover any part of the costs of any
health plan that includes coverage of abortion, except in the
case where a woman suffers from a physical disorder, physical
injury, or physical illness that would, as certified by a
physician, place the woman in danger of death unless an
abortion is performed, including a life-endangering physical
condition caused by or arising from the pregnancy itself, or
unless the pregnancy is the result of an act of rape or
incest.
(b) Option To Purchase Separate Supplemental Coverage or
Plan.--Nothing in this section shall be construed as
prohibiting any nonfederal entity (including an individual or
a State or local government) from purchasing separate
supplemental coverage for abortions for which funding is
prohibited under this section, or a plan that includes such
abortions, so long as--
(1) such coverage or plan is paid for entirely using only
funds not authorized or appropriated by this Act; and
(2) such coverage or plan is not purchased using--
(A) individual premium payments required for a Exchange-
participating health benefits plan towards which an
affordability credit is applied; or
(B) other nonfederal funds required to receive a federal
payment, including a State's or locality's contribution of
Medicaid matching funds.
(c) Option To Offer Separate Supplemental Coverage or
Plan.--Notwithstanding section 303(b), nothing in this
section shall restrict any nonfederal QHBP offering entity
from offering separate supplemental coverage for abortions
for which funding is prohibited under this section, or a plan
that includes such abortions, so long as--
(1) premiums for such separate supplemental coverage or
plan are paid for entirely with funds not authorized or
appropriated by this Act;
(2) administrative costs and all services offered through
such supplemental coverage or plan are paid for using only
premiums collected for such coverage or plan; and
(3) any nonfederal QHBP offering entity that offers an
Exchange-participating health benefits plan that includes
coverage for abortions for which funding is prohibited under
this section also offers an Exchange-participating health
benefits plan that is identical in every respect except that
it does not cover abortions for which funding is prohibited
under this section.
Page 171, strike line 5 and all that follows through page
172, line 8.
Page 182, line 22, strike ``willingness or''.
Page 246, strike lines 11 through 14.

The SPEAKER pro tempore. Pursuant to House Resolution 903, the
gentleman from Michigan (Mr. Stupak) and a Member opposed each will
control 10 minutes.
The Chair recognizes the gentleman from Michigan.
Mr. STUPAK. Mr. Speaker, I ask unanimous consent that 5 of the 10
minutes granted to our side be controlled by the gentleman from
Pennsylvania (Mr. Pitts).
The SPEAKER pro tempore. Is there objection to the request of the
gentleman from Michigan?
There was no objection.
Mr. STUPAK. Mr. Speaker, our amendment does one very simple thing: It
applies the Hyde amendment, which bars Federal funding for abortion
except in the case of rape, incest, or life of the mother to the health
care reform bill. The Hyde amendment has been law in Federal funding of
abortion since 1977 and applies to all other federally funded health
care programs, including SCHIP, Medicare, Medicaid, Indian Health
Services, veterans health, military health care programs, and the
Federal Employees Health Benefits Program.
More specifically, our amendment applies the Hyde amendment to the
public health insurance option and private policies purchased using
affordability credits. I am not writing a new Federal abortion policy.
The Hyde amendment already prohibits Federal funding of abortion and
the use of Federal dollars to pay for health care policies that cover
abortion. This policy currently applies to the 8 million Americans,
including Members of Congress, covered under the Federal Employees
Health Benefits Program, and should apply in this bill.
The amendment has no impact on those individuals with private
insurance who do not receive affordability credits and in no way
prohibits any individual from purchasing a supplemental abortion
coverage policy. Health insurance companies can still offer policies in
the exchange that cover abortion; they just can't sell those policies
to individuals receiving affordability credits.
I wish to thank Speaker Pelosi for her commitment to trying to reach
an agreement between all sides late last night. Unfortunately, at the
last minute the deal fell apart. The Speaker then took the only
appropriate action remaining, which was to allow a vote on the floor.
So we are asking Members to maintain current law and vote ``no'' on
public funding for abortion. Let me also reassure my colleagues, both
Democrats and Republicans, I did not buck my party. I did not buck my
party leadership to trade a vote for this amendment. I did it based on
principle.
This bill, with the Capps language, is the most direct assault on the
Hyde

[[Page H12922]]

language we have had since 1997. So I ask my colleagues, Democrats and
Republicans alike, let us stand together on the principle of no public
funding for abortion, no public funding for insurance policies that pay
for abortion. Stand with us, protect our role, and let's keep current
law.
I reserve the balance of my time.
Ms. DeGETTE. Mr. Speaker, I rise to claim the time in opposition to
the Stupak-Pitts amendment.
The SPEAKER pro tempore. The gentlewoman from Colorado is recognized
for 10 minutes.
Ms. DeGETTE. I yield myself 3 minutes, Mr. Speaker.
Mr. Speaker, to say that this amendment is a wolf in sheep's clothing
would be the understatement of a lifetime. The proponents say it simply
extends the Hyde amendment, just a clarification of current law.
Nothing could be further from the truth.
If enacted, this amendment will be the greatest restriction of a
woman's right to choose to pass in our careers.

{time}  1945

Here is why: The Hyde amendment states that no Federal funds shall be
used for abortions. This has been contained in our annual
appropriations bills for many years.
In the Energy and Commerce Committee, the pro-choice and some pro-
life Democrats came together and compromised and we said no Federal
funds in this bill will be used for abortions, the Capps amendment.
This bill does not spend one Federal dollar on abortions.
This Stupak-Pitts amendment goes much further. It says that as part
of their basic coverage, the public option cannot offer abortions to
anyone, even those purchasing the policies with 100 percent private
money. The amendment further says that anyone who purchases insurance
in the exchange and who receives premium assistance cannot get
insurance coverage for a legal medical procedure even with the portion
of their premium that is their own private money.
Well, the proponents say women can just purchase supplemental
insurance for abortions. This very notion is offensive to women. No one
thinks that women will have an unplanned pregnancy or a planned
pregnancy that goes terribly wrong. Would we expect to have people buy
supplemental insurance for cancer treatment just in case maybe they
might get sick? Like it or not, this is a legal medical procedure, and
we should respect those who need to make this very personal decision.
Once again, the base bill contains language that preserves the Hyde
amendment. Let's keep our eyes on the goal here, providing safe medical
treatment for 36 million Americans. Let's not sacrifice reproductive
rights today in pursuance of that noble goal.
I reserve the balance of my time.
Mr. PITTS. Mr. Speaker, I yield myself 1\1/4\ minutes.
I rise in support of this bipartisan amendment.
Polls have repeatedly shown that the public does not support Federal
funding of abortion, yet that is exactly what is in this bill. Current
law actually prevents any Federal health care plan from paying for
abortion. It also prevents taxpayer subsidies from flowing to benefit
packages that include abortion. However, the Capps amendment included
in this legislation would have the opposite effect.
Under this bill, funds will flow from premium payments and
affordability credits into the U.S. Treasury account, and that account
will then reimburse for abortion services. Every dollar in the public
option is a Federal dollar. Let me be clear, if the government plan
covers abortion, that amounts to Federal funding for abortion. It's
that simple. Our amendment would maintain the principles of the Hyde
amendment, something that the large majority of Americans support.
I urge my colleagues to stand with the majority of the American
people, to oppose establishing a Federal Government program that will
directly fund abortion on demand, to keep the government out of the
business of promoting abortion as health care, and support this
amendment.
I reserve the balance of my time.
Ms. DeGETTE. I yield 1 minute to the distinguished gentlelady from
Connecticut (Ms. DeLauro).
Ms. DeLAURO. This amendment undermines the thoughtfully crafted and
balanced language in the bill that already prohibits Federal funds from
being used to pay for abortion. It attempts an unprecedented overreach
of women's basic rights and freedoms in this country.
Abortion is a matter of conscience on both sides of the debate, and
it goes to the very heart of our belief as citizens and as legislators.
This amendment takes away that same freedom of conscience from
America's women. It prohibits them from access to an abortion even if
they pay for it with their own money. It invades women's personal
decisions, discriminates against working women, and, put simply,
violates the law of the land.
Access to quality, affordable health care coverage is a question of
life or death for millions of Americans. We should not be injecting
this divisive and polarizing issue into our debate.
The best vote for life we could make today would be to pass the
critical reforms American families have asked for and desperately need.
I urge my colleagues to oppose this amendment.

Announcement by the Speaker Pro Tempore

The SPEAKER pro tempore. The Chair would remind Members to please
heed the gavel.
Mr. STUPAK. Mr. Speaker, I yield 45 seconds to Mrs. Dahlkemper from
Pennsylvania to speak on the bill. She has been a stalwart on this
issue, and I appreciate her support on this issue.
Mrs. DAHLKEMPER. Mr. Speaker, I want to thank Congressman Stupak.
I rise today to ask my colleagues to support the Stupak-Ellsworth-
Pitts-Kaptur-Dahlkemper-Lipinski-Smith amendment which will keep in
place current Federal law on abortion funding in H.R. 3962, the
Affordable Health Care for America Act.
Mr. Speaker, our amendment does not change current law regarding
abortion. It does not outlaw abortion. It does not prohibit women from
making a choice to which they are entitled under the law. What this
amendment does do is make the House's health care reform legislation
consistent with all other Federal health care programs, including
Medicaid, Medicare, SCHIP, and veterans care. It prohibits Federal
funding for abortions consistent with legislation that has been in
place since the 1970s.
Ms. DeGETTE. I am now delighted to yield 1 minute to the gentlelady
from California (Mrs. Capps).
Mrs. CAPPS. Mr. Speaker, I rise in strong opposition to this
amendment.
Contrary to what its sponsors and their supporters say, the
underlying bill does prohibit Federal funding for abortion. It is
written clearly and plainly on page 246, line 11, ``prohibition of use
of public funds for abortion coverage.'' But apparently that isn't good
enough for people whose goal really is to strip women of their right to
choose altogether despite purporting to just want to maintain the
status quo. So instead we have this amendment which restricts a woman's
right to access a legal medical procedure in this country.
It is ironic, actually, because most of the people who support the
amendment claim to oppose government interference in health care, yet
this amendment is government interference and a decision that should be
made between a woman and her physician.
If this amendment passes, it will be the only language in the entire
legislation that actually restricts coverage of a legal medical
procedure. Not one other legal medical procedure is singled out in this
legislation for rationing.
I urge my colleagues to vote ``no'' on this devastating amendment.
Mr. PITTS. Mr. Speaker, I yield 30 seconds to the gentleman from
Indiana, Chairman Mike Pence.
Mr. PENCE. Mr. Speaker, I rise in support of this amendment, though
it will not change my opposition to the Pelosi health care bill. I am
grateful this amendment has been brought to the floor, and I wish to
commend Mr. Pitts and Mr. Stupak for their principled leadership.
Ending an innocent human life is morally wrong, but it's also morally
wrong to take the taxpayer dollars of millions of Americans and use
them to provide for a procedure that they find morally offensive. In
the Congress of the United States, we have a responsibility to respect
the moral beliefs of the majority of the American people.

[[Page H12923]]

I urge my colleagues to prevent Federal dollars from funding
abortions. Take a stand for life, support the Stupak-Pitts amendment,
and vote ``no'' on Pelosi health care.
Ms. DeGETTE. I yield 1 minute to the distinguished gentlelady from
New York (Mrs. Lowey).
Mrs. LOWEY. I rise in strong opposition to this amendment. This is a
disappointing distraction from the bill before us.
Under current law, no taxpayer funds can be used to cover abortion.
While I believe abortion should be legal and safe, I have worked for
years with colleagues on both sides of this issue to also make this
procedure rare. If we want to reduce abortions, we should provide women
health coverage for reproductive care, contraceptives to prevent
unintended pregnancies, and prenatal care to ensure healthy
pregnancies.
This amendment threatens the rights and health of women to seek a
legal procedure covered by the premiums they will pay out from their
own pockets. The underlying bill would uphold current law which states
that no Federal funds can support abortion. Therefore, I urge my
colleagues to oppose this unnecessary and reprehensible amendment.
Mr. STUPAK. Mr. Speaker, may I inquire as to how much time we have
remaining?
The SPEAKER pro tempore. The gentleman from Michigan has 2\1/4\
minutes remaining. The gentlewoman from Colorado has 4\1/2\ minutes
remaining. The gentleman from Pennsylvania has 3\1/2\ minutes
remaining.
Mr. STUPAK. Mr. Speaker, I continue to reserve.
Ms. DeGETTE. Mr. Speaker, I reserve.
Mr. PITTS. Mr. Speaker, at this time, I yield 30 seconds to the
gentlelady from Washington, Vice Chairwoman Cathy McMorris Rodgers.
Mrs. McMORRIS RODGERS. Mr. Speaker, many have stood before me from
both sides of the aisle to ensure that Federal taxpayer dollars do not
fund abortion, whether it's Medicaid, whether it's the Federal
Government's own health program. Today, I stand to ensure that this
policy is included in the health care bill that is being rammed through
this Congress.
If we are talking about health care reform for women and children,
then protection for children should start at the moment their life
begins. Two-thirds of women recently polled representing all parties,
races, and marital statuses object to government funding of abortion.
I urge my colleagues to support this amendment.
Mr. STUPAK. Mr. Speaker, I yield 1 minute to Mr. Ellsworth from
Indiana, who has been a champion on this issue and has worked hard to
get this amendment to where we are here today.
Mr. ELLSWORTH. Thank you, Mr. Stupak.
Mr. Speaker, I rise today to urge the passage of this vital
amendment.
Since this debate started, my goal has been to ensure Federal
taxpayer dollars are not used to pay for abortions and to provide
Americans with pro-life options on this exchange. I have been proud to
work with Mr. Stupak and all my colleagues and the Catholic Bishops to
make the goal a reality.
Getting to this point has not been very easy, but today we're on the
brink of passing health care reform that honors and respects life at
every stage, including the unborn. If this amendment passes today, I
will support this bill.
It is time to fix what's broken in our health care system and begin
to fulfill the promises we've made to Americans that we represent.
That's why I urge Members on both sides of the aisle to vote for this
amendment.
Ms. DeGETTE. Mr. Speaker, I am delighted to yield 1 minute to the
gentlelady from California (Ms. Lee).
Ms. LEE of California. Mr. Speaker, this amendment inserts the
Federal Government further directly into the medical decisions that a
woman makes with her doctor.
As a person of faith who was raised in the Catholic Church, I have
the deepest respect for Mr. Stupak and Mr. Pitts. I know personally the
moral dilemmas women face in making personal decisions about abortion,
but I'll tell you one thing, I remember the days of back alley
abortions, and this amendment takes us one step back to those dark
days.
This amendment goes way beyond the Hyde amendment that denies Federal
funds for abortion and attempts to dictate to women how to spend their
own money. It is simply outrageous. It is outrageous.
It further places the religious views, mind you, of some into our
public policy. Again, we're a democracy; we're not a theocracy. The
separation of church and State requires us as legislators to never
cross this line and it allows personal religious views to be personal.
We should not, as Members of Congress, compromise this separation. And
low-income women especially will be hurt by this amendment. Reject it.
Mr. PITTS. Mr. Speaker, at this time, I yield 30 seconds to the
ranking member of the Budget Committee, the gentleman from Wisconsin,
Paul Ryan.
Mr. RYAN of Wisconsin. Mr. Speaker, this is perhaps the worst bill I
have seen come to the floor in my 11 years of serving in Congress, and
what would make this bill worse is if we break with the long-standing
law of preventing abortions from being funded with taxpayer dollars.
For those of us who support the protection of and the sanctity of
life, the only vote, the right vote, the vote to keep a clean
conscience is a ``yes'' vote for the Stupak amendment.
Ms. DeGETTE. Mr. Speaker, I am now pleased to yield 1 minute to the
distinguished gentleman from New York (Mr. Nadler).
Mr. NADLER of New York. Mr. Speaker, I rise in opposition to the
Stupak amendment.
Despite significant efforts made by the underlying bill to level the
playing field for women and to end discrimination against them in the
health insurance market, this amendment adds a new discriminatory
measure against women. Under this proposal, if a woman is of low or
moderate income and receives tax credits to help her to afford the
premiums for a health insurance plan she purchases on the exchange, she
cannot choose a plan that covers abortion services. And if she chooses
the public option, she cannot receive abortion coverage at all, even if
she receives no help of any kind and pays for the plan entirely by
herself.
The provision inserted in the underlying bill by our colleague,
Representative Capps, extends the Hyde amendment in current law by
ensuring that no Federal dollars can be used to fund abortions. That
should be sufficient.
This is a bill to extend health care to all Americans. It should not
be used as a political football to try to change existing laws
regarding abortion coverage.
Mr. Speaker, I reiterate my opposition to this discriminatory
amendment and ask my colleagues to vote ``no.''
Mr. Speaker, I rise in opposition to the Stupak amendment.
Despite significant efforts made by the underlying bill to level the
playing field for women and end discrimination against them in the
health insurance market, this amendment adds a new discriminatory
measure against women. Under the Stupak proposal, if a woman is of low-
or moderate income and receives tax credits to help her afford the
premiums for a health plan she purchases through the Exchange, she
cannot choose a plan that covers abortion services. And if a woman
chooses the public option, she cannot receive abortion coverage--even
if she receives no help of any kind and pays for the plan entirely by
herself.
The Stupak amendment says to women--if you think you might have an
unintended pregnancy, you should purchase separate insurance. Put
another way, this amendment requires women to plan that they will
encounter an unplanned pregnancy. This defies logic and is absurd.
The compromise provision inserted in the underlying bill by our
colleague, Representative Capps, extends the Hyde Amendment in current
law by ensuring that no federal dollars can be used to fund abortions.
That should be sufficient.
This is a bill to extend health care to all Americans. It should not
be used as a political football to change existing law regarding
abortion coverage.
Mr. Speaker, I reiterate my opposition to this discriminatory
amendment and ask my colleagues to vote ``no.''

{time}  2000

Mr. STUPAK. Mr. Speaker, I continue to reserve the balance of my
time.
Ms. DeGETTE. Mr. Speaker, I continue to reserve the balance of my
time.

[[Page H12924]]

Mr. PITTS. Mr. Speaker, I yield 30 seconds to the gentlewoman from
Minnesota, Michele Bachmann.
Mrs. BACHMANN. Mr. Speaker, it all begins with life and with
protecting the most vulnerable among us, the unborn. Life is the
watershed issue of our generation. How can one claim to call the
destruction of innocent human life ``health care''?
Orwellian statements aside, it is the duty of government to preserve
and protect human life. If we do nothing else tonight, let's choose
life.
Ms. DeGETTE. I inquire of the Speaker as to the time remaining.
The SPEAKER pro tempore. The gentlewoman has 2\1/2\ minutes. The
gentleman from Michigan has 1\1/4\ minutes remaining. The gentleman
from Pennsylvania has 2 minutes remaining.
Ms. DeGETTE. Mr. Speaker, I yield 30 seconds to the distinguished
gentleman from Illinois (Mr. Quigley).
Mr. QUIGLEY. Mr. Speaker, the health care bill we are considering
today makes a strong statement that everyone in this country deserves
access to health care.
For over 8 months, this body has strived to overcome the health care
inequalities in our country, but this amendment disrupts that sense of
equality. This amendment says that only women who can afford insurance
deserve access to reproductive health care. This amendment says that
women who need a little help paying for health care have to surrender
their right to privacy.
This amendment will serve only to hurt low-income women, and it will
restrict their ability to access reproductive health care even with
their own money. It is wrong and we should oppose it.
Mr. PITTS. Mr. Speaker, I yield 30 seconds to the gentleman from
Nebraska, Jeff Fortenberry.
Mr. FORTENBERRY. Mr. Speaker, the vast majority of Americans oppose--
do not want--their government funding abortion.
I want to thank Mr. Stupak and Mr. Pitts for this amendment to
prohibit Federal funding for abortion in the guise of health care
reform. Women deserve better.
Last week, we heard a lot of talk about compromise. Well, Mr.
Speaker, neither a child in an early phase of life nor an elderly
person clinging to each breath in the waning days of this life should
ever be subject to a compromise. I hope that, if House has learned
anything from this debate, it is this: that we must first do no harm.
It is not ours to decide who lives or who dies.
Ms. DeGETTE. Mr. Speaker, I am now delighted to yield 30 seconds to
the distinguished Chair of the Rules Committee and the co-Chair of the
Congressional Pro-Choice Caucus, the gentlewoman from New York (Ms.
Slaughter).
Ms. SLAUGHTER. I thank the gentlewoman for yielding.
Mr. Speaker, for over 30 years, we lived in this House in peaceful
co-existence with the pros and cons getting together on the fact that
the Hyde amendment said that no Federal money can be spent--the
strongest conscience clause in the world--which is now being
strengthened, by the way, in this bill. We on our side simply have the
law.
I am very concerned about this bill because, in my own case and in
the cases of many of my colleagues, it means 30 or 40 years of our life
is being canceled out with this amendment. After the things that we
have fought for, we are driving now, I am afraid, young women and poor
women who cannot afford to buy their own insurance policies out of
their pockets back to the back alley. I dread to see that day.
Mr. PITTS. Mr. Speaker, we are prepared to close on our side.
Ms. DeGETTE. Mr. Speaker, I yield for a unanimous consent request to
the gentlewoman from Wisconsin (Ms. Baldwin).
(Ms. BALDWIN asked and was given permission to revise and extend her
remarks.)
Ms. BALDWIN. Mr. Speaker, I rise in opposition to this amendment.
A journalist asked me a few years ago if I could point to one thing
that has contributed the most to the empowerment of women in our
society. In answer to that query, I might have pointed to the 19th
Amendment to the Constitution giving women the right to vote, or Title
VII of the Civil Rights Act of 1964, or laws mandating equal pay for
equal work. But instead, I responded to that journalist that it is the
array of legal choices a woman now has that make it possible for her to
plan her family--to decide whether to have children, and to decide when
to have children. We refer to this array of choices as ``reproductive
freedom.''
In the days before women were able to legally access contraception
and abortion services, women often had to drop out of school, few could
pursue careers in the professions, and too many women in desperate
circumstances lost their lives from so-called back-alley abortions.
In 1970 women made up a third of the workforce. Today for the first
time in history, women make up half of the U.S. workforce. In 1970, ten
women served in the House of Representatives. Today there are 76. In
1970, the percentage of female medical students was 9.6 percent. This
year, women are 48 percent of our Nation's medical students. In 1970,
the percentage of women in law school was 8 percent. Today, 46.7
percent of law students are female.
These are just some of the changes in the role of women in American
society that have occurred over the years during which women have
secured the right to a full range of family planning options.
The Stupak/Pitts amendment is an erosion of a woman's reproductive
freedom. Access to abortion services in the United States is already
severely limited. State laws mandating waiting periods, the lack of
insurance coverage of abortion and the scarcity of clinics providing
abortion services mean that the right to a safe and legal abortion for
many women is already pretty hollow. If this amendment is adopted, a
woman's right to choose will be further limited.
I urge my colleagues to oppose this amendment.
Ms. DeGETTE. Mr. Speaker, I yield for a unanimous consent request to
the distinguished gentlewoman from New York (Mrs. Maloney).
(Mrs. MALONEY asked and was given permission to revise and extend her
remarks.)
Mrs. MALONEY. Mr. Speaker, I rise in strong opposition to this
amendment.
Mr. Speaker, it is outrageous that even the historic bill to extend
health coverage to 96 percent of Americans includes an abortion fight
because of the anti-abortion movement.
The Stupak amendment is a huge step backwards for American women.
Mr. Speaker, I rise in strong opposition to the Stupak/Pitts
amendment which plainly discriminates against women, puts women's
health at risk, and marks an unprecedented restriction on people who
pay for their own health insurance.
The commonsense Capps Compromise which was agreed to during debate in
the Energy and Commerce Committee ensures that taxpayers will not be
paying for abortion and reflects the status quo and current law.
It prohibits federal funds from being used for abortion but still
allows women to use their own money to buy the coverage they need.
Despite this effort to address concerns raised by pro-life Members,
Representatives Stupak and Pitts decided to further restrict women's
access to care by offering their shortsighted, dangerous, and
discriminatory amendment to H.R. 3962.
The Stupak/Pitts amendment would make abortion coverage virtually
inaccessible for most women in the new exchange.
It does so by:
(1) Banning abortion coverage in the exchange for women who receive
subsidies, except by separate rider that they could only purchase with
their own, private funds.
(2) Making it highly unlikely that women buying insurance in the
exchange with their own money could obtain abortion coverage.
It is an outrage that at time when we are making historic changes--
expanding American's access to health care--a group of legislators are
bonding together to deprive women of the very health care they both
need and deserve.
Ms. DeGETTE. Mr. Speaker, I yield for a unanimous consent request to
the distinguished gentlewoman from Maryland (Ms. Edwards).
(Ms. EDWARDS of Maryland asked and was given permission to revise and
extend her remarks.)
Ms. EDWARDS of Maryland. Mr. Speaker, I rise in opposition to this
amendment.
Ms. DeGETTE. Mr. Speaker, I yield 1 minute to the distinguished
gentlewoman from Illinois (Ms. Schakowsky).
Ms. SCHAKOWSKY. No matter how many times it is said, our health
reform bill does not allow one Federal dollar for abortions.
This Stupak-Pitts amendment goes way beyond current law. It says a

[[Page H12925]]

woman cannot purchase, using her own dollars, coverage that includes
abortion services. Even middle class women who are using exclusively
their own money will be prohibited from purchasing a plan including
abortion coverage, and this is in every single public or private
insurance plan in the new health care exchange. Her only option is to
buy a separate insurance policy that covers an abortion, a ridiculous
and unworkable approach since no woman plans an unplanned pregnancy.
This amendment is a radical departure from current law, and it will
result in millions of women losing the coverage they already have. Our
bill is about lowering health care costs for millions of women and
their families. It is not about further marginalizing women by forcing
them to pay more for their care.
This amendment is a disservice and an insult to millions of women
throughout the country. I urge a ``no'' vote on this amendment.
The SPEAKER pro tempore. The Chair will remind the gentlewoman from
Colorado that she has the right to close.
The gentleman from Michigan has 1\1/4\ minutes remaining. The
gentleman from Pennsylvania has 1\1/2\ minutes remaining. The
gentlewoman from Colorado has 30 seconds remaining.
Mr. STUPAK. Mr. Speaker, I yield 15 seconds to the gentleman from
Illinois (Mr. Lipinski) to state how current laws are maintained with
the Stupak amendment.
Mr. LIPINSKI. Mr. Speaker, I thank my colleagues, especially Mr.
Stupak, for their perseverance as we work together on this amendment.
Every year for over three decades, including this past July, we have
approved the Hyde amendment.
I ask my colleagues again tonight: do the same thing, and approve the
Hyde amendment in this bill.
Ms. DeGETTE. Mr. Speaker, I reserve the balance of my time.
Mr. PITTS. Mr. Speaker, I yield to the gentleman from Texas (Mr.
Gohmert) for a unanimous consent request.
(Mr. GOHMERT asked and was given permission to revise and extend his
remarks.)
Mr. GOHMERT. Mr. Speaker, I rise in support of the wonderful work in
the Stupak-Pitts amendment, addressing things like the money on page
110 for abortions.
Mr. PITTS. Mr. Speaker, I yield the balance of the time to the Chair
of the Pro-Life Caucus in support of this bipartisan amendment, the
gentleman from New Jersey, Chris Smith.
Mr. SMITH of New Jersey. This week, another Planned Parenthood clinic
director resigned after watching an ultrasound of an actual abortion in
progress.
Self-described as extremely pro-choice but now pro-life, Abby Johnson
said she watched an unborn child ``crumple'' before her very eyes as
the infant was vacuumed and dismembered by a suction device 20 to 30
times more powerful than a household vacuum cleaner.
Ms. Johnson said and told ABC News, ``I could see the baby try to
move away. I just thought, `What am I doing?' ``Never again.''
Mr. Speaker, abortion not only kills children; it harms women
physically and psychologically, and it risks significant harm to
subsequent children.
Recently, the Times of London reported, ``Women who have had
abortions have twice the level of psychological problems and three
times the level of depression as women who have given birth or never
been pregnant.'' The Times said ``senior obstetrians and psychiatrists
say new evidence has uncovered a clear link between abortion and mental
illness. . . .''
Numerous studies show that the risk of preterm birth to children born
to women who have had abortions increases. It skyrockets. One abortion
preterm births goes up by 35 percent, two abortions a staggering 93
percent. One of the the leading causes of mental and motor retardation
is prematurity.
We have and are going to have more disabling, because of abortion. If
we truly don't want to see more abortions and if we want to reduce
them, don't fund it.
The Guttmacher Institute has said, formerly the research arm of
Planned Parenthood, that prohibiting Federal funds for abortion reduces
abortion by 25 percent.
Millions of people are alive today because of the Hyde amendment,
because funding was not there to effectuate their demise. Vote for the
Stupak-Pitts amendment. It will save lives.
The SPEAKER pro tempore. The gentleman from Michigan has 1 minute
remaining.
Mr. STUPAK. Mr. Speaker, to close on our side, I yield 1 minute to
the gentlewoman from Ohio (Ms. Kaptur).
Ms. KAPTUR. I thank the gentleman.
With respect for all of my colleagues, I rise in support of the
Stupak amendment, which maintains existing Federal law, the Hyde
amendment, on the compelling issue of abortion.
For 34 years, citizens of conscience have weighed in on this
important moral and legal issue. Let me repeat: This amendment
reaffirms longstanding, existing law and nothing more. It represents
the broad consensus of the American people after 34 years of
consideration on this issue. This is what it says:
``No Federal funds 'authorized under this act may be used to pay for
any abortion or cover any part of the costs of any health plan that
includes coverage of abortion,' except in the cases of the life of the
mother, rape or incest.''
The amendment does no more, no less. It is similar to language that
applies in Federal law on Medicaid, Medicare, Veterans Affairs, the
CHIP program, and the Federal Health Employees Program, which is a
model for how this language should be applied. It has been tried,
tested and proven. The inclusion of this amendment clarifies the bill's
language on the potential fungibility of premium dollars.
I urge my colleagues to support the amendment and the bill.
Ms. DeGETTE. Mr. Speaker, I yield for a unanimous consent request to
the gentlewoman from California (Mrs. Davis).
(Mrs. DAVIS of California asked and was given permission to revise
and extend her remarks.)
Mrs. DAVIS of California. Mr. Speaker, I rise in opposition to this
amendment.
Ms. DeGETTE. Mr. Speaker, I yield for a unanimous consent request to
the gentlewoman from Texas (Ms. Jackson-Lee).
(Ms. JACKSON-LEE of Texas asked and was given permission to revise
and extend her remarks.)
Ms. JACKSON-LEE of Texas. Mr. Speaker, I rise in strong opposition to
this amendment.
This amendment critically threatens women throughout America, and is
unquestionably a ban on abortion coverage. H.R. 3962 already provided
for no federal dollars to be used for abortion--now this bill denies
women the reimbursement for insurance to provide them good health care.
This amendment acutely threatens the personal liberties of our
country's most vulnerable women. It negatively affects these women's
health, wellbeing, and financial security. This amendment will
disproportionally affect women of color. According to the Center for
Disease Control, ``the abortion ratio for black women (467 per 1,000
live births) was 2.9 times the ratio for white women (158 per 1,000),
and the ratio for women of the heterogeneous ``other'' race category
(319 per 1,000) was 2.0 times the ratio for white women. The abortion
rate for black women (28 per 1,000 women) was 3.1 times the rate for
white women (nine per 1,000), whereas the abortion rate for women of
other races (18 per 1,000 women) was 2.0 times the rate for white
women.'' We should not be so naive to believe that these statistics
represent anything less than the reality that minority women have less
financial and personal autonomy. Women who decide to abort a pregnancy
are not acting on whim or caprice. Rather, the decision to abort is a
painful decision process borne out of necessity. I do not support these
higher statistics among minority women, however their lives should not
be jeopardized because of botched abortions.
As a woman of faith myself, the issue of abortion is very dear to me.
I must begin by saying that I am not pro-abortion, I am pro-choice. The
early termination of a fetus is a terribly sad and unfortunate event,
and the decision to abort is a long and difficult one. Situations arise
in which a woman is forced to make the very tough decision about
something very private and personal. In situations like this I believe
strongly in a woman's right to choose. It is her body and any law
prohibiting woman from having total control over their bodies is in
violation of our constitutional rights.
I have always supported a woman's right to choose. The decision to
have a baby is something between a woman, her family, her faith

[[Page H12926]]

and her doctor. This is an instance where the federal government does
not need to be involved. It is my hope that society will continue to be
progressive in their decisions, and if a woman decides to terminate her
pregnancy, there are places that she can go to have the procedure done
safely.
The Supreme Court in 1973, in the landmark case of Roe v. Wade, ruled
that a woman's right to have an abortion is a constitutionally
protected right. Judge Blackmon wrote that ``a statute that
criminalizes abortion is violative of the Due Process Clause of the
Fourteenth Amendment and the abortion decision and its effectuation
must be left to the medical judgment of the pregnant woman's attending
physician.''
The Stupak-Pitts amendment effectively reverses a women's control
over her body. According to a 2002 study by the Guttmacher Institute,
90 percent of private policies currently cover abortion services. If
this amendment is adopted, it will instantly modify the insurance
coverage for the millions of women whose current insurance plans
include coverage for abortion care. These women entered into their
insurance contracts with the guarantee that potential abortions would
be covered. Yet, if this amendment is passed, every women covered under
the new health care system would have to purchase supplemental
insurance or pay out of pocket for abortions. It is estimated that one
third of Americans will have an abortion in their lifetime. If this
amendment is adopted, thousands of women will be unable to afford a
procedure for unpredictable and unwanted pregnancies. This would
essentially be a ban on abortions for these women.
This is an unacceptable violation of a woman's personal sovereignty.
I strongly oppose this amendment.
Ms. DeGETTE. Mr. Speaker, the gentleman from Pennsylvania said
exactly what the intention is here. The intention is not simply to
expand the Hyde amendment. The base bill does that. The base bill says
that no Federal funds will be used in this bill for abortion.
It is the intention of our opponents to effectively stop a legal
medical procedure from all plans that are in the exchange, even plans
that are paid for with private dollars. This is the first time it would
expand the Hyde exceptions to the private sector market. Mr. Speaker,
it would not only affect the poor. It would affect the middle class.
Vote ``no'' on this ill-conceived amendment.
Ms. CHU. Mr. Speaker, I rise today in strong opposition to this
amendment.
Ms. HIRONO. Mr. Speaker, I rise today in strong opposition to the
Stupak Amendment, an amendment that is anti-choice and anti-women.
Earlier this week, I spoke about the importance of health care reform
to women. If there was ever a group that has a lot at stake in reform,
it is women. Health insurance companies today essentially treat being a
woman as a pre-existing condition and charge them more for it. H.R.
3962 will put an end to the unjustifiable insurance practices of
gender-rating--treating pregnancy, domestic violence, and previous c-
section as pre-existing conditions--and not covering comprehensive
maternity care. The men of this country would rise up in protest if
they faced this kind of disparate treatment based on conditions
particular to their gender.
The Stupak Amendment would effectively deny low-income women abortion
coverage through insurance plans in the health insurance exchange. This
is not only discriminatory but dangerous to women's health. Women
without abortion coverage will be forced to postpone abortion care
while attempting to raise the necessary funds--a delay that can
exacerbate both the costs and the health risks of the procedure.
As a woman, I find it frankly insulting that the amendment would make
women purchase additional insurance coverage for a legal medical
procedure. We aren't asking individuals to purchase additional coverage
in case they get cancer or in case they get diabetes. We aren't
flagging out any other legal medical procedures to be treated in this
manner.
Women do not plan to have unintended pregnancies or pregnancies with
complications that create health risks. And yet unintended pregnancies
and complications do arise. This amendment says it's okay to tell
women, if you want to guard against these situations, go buy a rider.
This is a deeply insulting attitude. An abortion rider policy also
raises serious privacy concerns, as it fundamentally undermines the
spirit of existing privacy law.
The sponsors of the amendment have consistently failed to highlight
that the bill already contains a compromise that stipulates that state
laws regarding abortion procedures are not pre-empted. The bill already
states that no federal funds--neither tax nor cost sharing tax
credits--can be used to pay for abortion procedures.
Before taking this vote, I urge my colleagues who support this
amendment to think about the women in their lives, their mothers,
sisters, daughters, granddaughters. Would they put the lives of these
women at risk? Would they take away their fundamental rights of choice
and freedom? Would they want to limit their access to any legal medical
procedure? I ask these questions of my colleagues because in voting in
support of the Stupak Amendment, they are answering yes to all these
questions.
I urge my colleagues to join me in voting ``no'' on the amendment.
Ms. HARMAN. Mr. Speaker, It is going to be very difficult for me to
vote for a health care bill that contains the Stupak amendment on
abortion.
Far from codifying the Hyde language, which has been included in
House appropriations bills since 1976, the Stupak amendment would
essentially make it impossible for most women to use their own funds to
purchase insurance to pay for abortions. This is not chipping away at a
woman's right to choose, this is an outright assault on my
constitutional rights--and it is wrong.
I respect the right of any woman or man to oppose abortion. But, in
return, I expect those who are anti-choice to respect my views. My
views are that abortion should be safe and rare--but that a woman's
constitutional right to privacy as articulated in Roe v. Wade is
inviolable.
I am old enough to remember the days of back alley abortions. Some
women I know had them. I cannot bear the idea that the 111th Congress
would restore that horror.
The Stupak amendment is insulting and destructive. Its passage would
pair us with the government of Afghanistan in sending women's rights
back to the Stone Age. I intend to vote for this bill, but if it
contains the Stupak amendment when it emerges from Conference
Committee, my conscience demands that I reconsider my support.
Ms. McCOLLUM. Mr. Speaker, every member of this House has the right
to their own opinions and views on issues related to health care
reform--including women's reproductive health care issues. However, as
comprehensive healthcare legislation reaches the House floor for a
vote, Congress must not violate the first tenant of the entire reform
effort, which is to ensure that no one loses healthcare coverage they
currently have.
Today we have an amendment on the floor that bans legal reproductive
health care services for woman who pay for their own health insurance.
This amendment is wrong, it is dangerous, and it should be defeated.
The opportunity to meet the health care needs of all Americans is the
strength of the bill we are debating. I want every American to have
access to affordable, quality health care. This amendment and the work
of many special interest groups to use this amendment to undermine
health care reform is a transparent political game that puts millions
of Americans at risk. Single issue political games must not be used to
deny health care to millions of Americans.
I would like to submit for the Record a statement by a broad
coalition of Minnesota religious leaders who call health care reform a
matter of social justice that should not be undone by a single issue.
These religious leaders understand the complex personal decision making
that goes into health care choices, but they also know that Americans
without access to health care too often have no choice except to suffer
and too often endure conditions that result in severe illness or even
preventable death.
These religious leaders are an inspiration to me. They are helping to
frame the social, economic, moral and spiritual importance of passing
health care reform legislation in Congress.

November 7, 2009.
As more Americans lose jobs and insurance coverage, health
care reform bills are moving to final votes in Congress.
Instead of working toward the reform that is so desperately
needed, some groups, including the United States Conference
of Catholic Bishops, are working overtime to ensure that
women are denied the comprehensive health care they currently
have.
With all the hyperbole, we have lost sight of the original
goal of health reform: to expand access to health care,
improve quality, and reduce costs--not to litigate abortion
rights. As Congress works toward health care reform, they
must make women's health a priority and guarantee that
reproductive health care is covered.
Our faith traditions are abundantly clear about living in
community with others and being responsible for them. Our
traditions share the common core of serving those most in
need. We join with others in expressing the need for us to
return to the core of our faith traditions and realize that
providing access to safe and quality health care makes sense
morally, ethically, spiritually, and financially.
The president has repeatedly stated that no one should lose
the coverage she or he currently has under health care
reform. But, if dangerous amendments put forth by the vocal
minority in Washington aren't defeated, women will lose their
benefits, plain and simple.

[[Page H12927]]

It's simply untrue that abortion coverage will be mandated
under the proposed new health plan. Simply put, Federal money
would not pay for abortion care.
In fact, the House bill contains carefully crafted
compromise language that allows women to keep the benefits
they currently have while also ensuring that no federal
funding is used for abortions.
Rep. Lois Capps drafted this provision to address both pro-
life and pro-choice concerns around health care reform and
balance both sides of the issue. The Capps proposal maintains
the current policy of restricting federal funding for
abortions and ensures that women won't lose benefits they
currently have and will have access to insurance that covers
abortion if they want it. Further, it expressly prohibits the
use of federal funds to pay for abortion care.
This is an even-handed compromise supported by people on
both sides of the issue. While reasonable people disagree
over the issue of abortion, no woman wants her health to be
the object of political gamesmanship in this debate. That's
why the Capps proposal was created. It's a common sense
solution to help health care reform move forward with the
support of the mainstream on all sides of the issue.
As religious leaders, we support public policies that are
just and compassionate and prioritize the needs of those who
are poor and marginalized in our society. In this religiously
pluralistic nation, our health care system should be
inclusive and respectful of diverse religious beliefs and
decisions regarding childbearing. A health care system that
serves all persons with dignity and equality will include
comprehensive reproductive health services.
Health care reform is far too important a social justice
issue to be left to chance and overheated rhetoric. It's time
to move forward for the good of American women and families.

Members and Friends of the Minnesota Religious Coalition
for Reproductive Choice; Rev. Judith Allen Kim, Presbytery of
the Twin Cities Area; The Rev. Norma Burton, Linden Hills
United Church of Christ, Minneapolis; Kelli Clement,
Candidate for Ministry, UUA; Rev. Doug Donley, University
Baptist Church, Minneapolis; Rev. Dr. Rob Eller-Isaacs, and
Rev. Dr. Janne Eller-Isaacs, Co-Ministers, Unity Church
Unitarian, St. Paul; Rev. Dr. Kendyl Gibbons, Sr. Minister,
First Unitarian Society of Minneapolis; Rev. Walter Lockhart
IV, Walker Community United Methodist Church, Minneapolis;
Rev. Meg Riley, Unitarian Universalist Association; Rev. T.
Michael Rock, Robbinsdale United Church of Christ; Kiely Todd
Roska, United Church of Christ in New Brighton; Rev. Dr.
Christine M. Smith, Cherokee Park United Church, St. Paul;
Rev. Victoria Safford, White Bear Unitarian Universalist
Church, Mahtomedi; Rabbi Jared Saks, Temple Israel,
Minneapolis; Barbara Schmiechen, Linden Hills United Church
of Christ, Minneapolis; and Rev. Daniel R. Schmiechen, Linden
Hills United Church of Christ, Minneapolis.

Mr. MORAN of Kansas. Mr. Speaker, I rise in support of the Stupak-
Pitts Amendment to H.R. 3962, Speaker Pelosi's health care reform bill.
This amendment would maintain the current policy of preventing federal
funding for abortion and for health benefits packages that include
abortion. I feel a special obligation to protect innocent, young life.
I recently sponsored H. Con. Res. 169, legislation urging members of
Congress to eliminate taxpayer-funded abortions from any proposed
health care reform package. Directing taxpayer dollars to fund
abortions is a clear violation of many Americans' deeply held beliefs
and Americans should not be forced to compromise their core moral
beliefs as a means to health care reform. Additionally, on September
28, 2009, I urged Speaker Pelosi and Democratic leadership, along with
182 of my House colleagues, to allow members of the House to vote their
consciences with regard to abortion and health care reform by allowing
consideration of an amendment to prohibit government funding of
abortion.
Ms. BORDALLO. Mr. Speaker, I rise today in support of the Stupak-
Ellsworth-Pitts-Smith-Kaptur-Dahlkemper Amendment to H.R. 3962 the
``Affordable Health Care for America Act.'' This amendment, supported
by the United States Conference of Catholic Bishops, is important
because it ensures that current federal law on abortion funding will
apply to the public health care option created by H.R. 3962.
This amendment codifies the Hyde Amendment in H.R. 3962. It will
prevent public funds from being used to pay for or subsidize elective
abortions, either through the public option or heath care affordability
tax credits, except in the case of rape, incest, physical injury or
physical illness to the women. The Hyde Amendment is already in place
in current federal health programs like Medicaid and Medicare and this
amendment will make sure that H.R. 3962 is governed in a consistent
manner.
I have received numerous letters from my constituents expressing both
support for health care reform, but also grave concerns that federal
funds would be used to pay for elective abortion under the new law. I
am very supportive of the overall goals of H.R. 3962 and particularly
its provisions that address the health disparity issues in the
territories. The addition of the Stupak-Ellsworth-Pitts-Smith-Kaptur-
Dahlkemper amendment will further strengthen this legislation and
ensure that no one will need to choose between their conscientious
objections to abortion and their desire to work toward more affordable
quality health care in America.
I commend Congressman Stupak for his leadership on this important
issue and urge my colleagues to support this amendment.
Mr. FARR. Mr. Speaker, I rise to express my strong opposition to the
Stupak-Pitts amendment.
The health care bill before the House tonight retains existing law on
the ban on federal dollars being used for abortion services in federal
programs. This health care bill does what it promised to do: not to
expand abortion services. But the Stupak amendment wants to rewrite
current law. This amendment ignores the constitutionally protected
right for women to choose their reproductive health care. It makes
women, and only women, have to purchase an additional policy with their
own money to cover women's reproductive health care.
That we are considering outlawing a medical procedure--one chosen by
patients and their doctors--in existing law. This amendment makes it
impossible for women to purchase health care insurance to cover a
health care procedure that can only be needed at a time of crisis. It
would require women to plan for an unplanned pregnancy. That is plain
wrong.
When will we stop treating women like second class citizens? When
will we admit that they have the right to determine their health care
like anyone else? Why are we boxing them in with this amendment that
restricts and restrains their ability to act in a manner they deem
appropriate for their well-being? Shame on us for being so
disrespectful of their humanity and for attempting to disenfranchise
them this way.
If we want health care for all Americans then women should be
entitled to all health care, not just some aspects of it.
The SPEAKER pro tempore. The question is on the amendment offered by
the gentleman from Michigan (Mr. Stupak).
The question was taken; and the Speaker pro tempore announced that
the noes appeared to have it.
Mr. STUPAK. Mr. Speaker, on that I demand the yeas and nays.
The yeas and nays were ordered.
The SPEAKER pro tempore. Pursuant to section 2 of House Resolution
903, further proceedings on this question will be postponed.

Amendment Offered by Mr. Boehner

Mr. BOEHNER. Mr. Speaker, pursuant to the rule, I call up the
amendment in the nature of a substitute printed in the rule.
The SPEAKER pro tempore (Mr. Obey). The Clerk will designate the
amendment.
The text of the amendment is as follows:

Part D amendment in the nature of a substitute printed in
House Report 111-330 offered by Mr. Boehner:
Strike all after the enacting clause and insert the
following:

SECTION 1. SHORT TITLE; PURPOSE; TABLE OF CONTENTS.

(a) Short Title.--This Act may be cited as the ``Common
Sense Health Care Reform and Affordability Act''.
(b) Purpose.--The purpose of this Act is to take meaningful
steps to lower health care costs and increase access to
health insurance coverage (especially for individuals with
preexisting conditions) without--
(1) raising taxes;
(2) cutting Medicare benefits for seniors;
(3) adding to the national deficit;
(4) intervening in the doctor-patient relationship; or
(5) instituting a government takeover of health care.
(c) Table of Contents.--The table of contents of this Act
is as follows:

Sec. 1. Short title; purpose; table of contents.

DIVISION A--MAKING HEALTH CARE COVERAGE AFFORDABLE FOR EVERY AMERICAN

TITLE I--ENSURING COVERAGE FOR INDIVIDUALS WITH PREEXISTING CONDITIONS
AND MULTIPLE HEALTH CARE NEEDS

Sec. 101. Establish universal access programs to improve high risk
pools and reinsurance markets.
Sec. 102. Elimination of certain requirements for guaranteed
availability in individual market.
Sec. 103. No annual or lifetime spending caps.
Sec. 104. Preventing unjust cancellation of insurance coverage.

TITLE II--REDUCING HEALTH CARE PREMIUMS AND THE NUMBER OF UNINSURED
AMERICANS

Sec. 111. State innovation programs.
Sec. 112. Health plan finders.
Sec. 113. Administrative simplification.

[[Page H12928]]

DIVISION B--IMPROVING ACCESS TO HEALTH CARE

TITLE I--EXPANDING ACCESS AND LOWERING COSTS FOR SMALL BUSINESSES

Sec. 201. Rules governing association health plans.
Sec. 202. Clarification of treatment of single employer arrangements.
Sec. 203. Enforcement provisions relating to association health plans.
Sec. 204. Cooperation between Federal and State authorities.
Sec. 205. Effective date and transitional and other rules.

TITLE II--TARGETED EFFORTS TO EXPAND ACCESS

Sec. 211. Extending coverage of dependents.
Sec. 212. Allowing auto-enrollment for employer sponsored coverage.

TITLE III--EXPANDING CHOICES BY ALLOWING AMERICANS TO BUY HEALTH CARE
COVERAGE ACROSS STATE LINES

Sec. 221. Interstate purchasing of Health Insurance.

TITLE IV--IMPROVING HEALTH SAVINGS ACCOUNTS

Sec. 231. Saver's credit for contributions to health savings accounts.
Sec. 232. HSA funds for premiums for high deductible health plans.
Sec. 233. Requiring greater coordination between HDHP administrators
and HSA account administrators so that enrollees can
enroll in both at the same time.
Sec. 234. Special rule for certain medical expenses incurred before
establishment of account.

DIVISION C--ENACTING REAL MEDICAL LIABILITY REFORM

Sec. 301. Encouraging speedy resolution of claims.
Sec. 302. Compensating patient injury.
Sec. 303. Maximizing patient recovery.
Sec. 304. Additional health benefits.
Sec. 305. Punitive damages.
Sec. 306. Authorization of payment of future damages to claimants in
health care lawsuits.
Sec. 307. Definitions.
Sec. 308. Effect on other laws.
Sec. 309. State flexibility and protection of states' rights.
Sec. 310. Applicability; effective date.

DIVISION D--PROTECTING THE DOCTOR-PATIENT RELATIONSHIP

Sec. 401. Rule of construction.
Sec. 402. Repeal of Federal Coordinating Council for Comparative
Effectiveness Research.

DIVISION E--INCENTIVIZING WELLNESS AND QUALITY IMPROVEMENTS

Sec. 501. Incentives for prevention and wellness programs.

DIVISION F--PROTECTING TAXPAYERS

Sec. 601. Provide full funding to HHS OIG and HCFAC.
Sec. 602. Prohibiting taxpayer funded abortions and conscience
protections.
Sec. 603. Improved enforcement of the Medicare and Medicaid secondary
payer provisions.
Sec. 604. Strengthen Medicare provider enrollment standards and
safeguards.
Sec. 605. Tracking banned providers across State lines.

DIVISION G--PATHWAY FOR BIOSIMILAR BIOLOGICAL PRODUCTS

Sec. 701. Licensure pathway for biosimilar biological products.
Sec. 702. Fees relating to biosimilar biological products.
Sec. 703. Amendments to certain patent provisions.

DIVISION A--MAKING HEALTH CARE COVERAGE AFFORDABLE FOR EVERY AMERICAN

TITLE I--ENSURING COVERAGE FOR INDIVIDUALS WITH PREEXISTING CONDITIONS
AND MULTIPLE HEALTH CARE NEEDS

SEC. 101. ESTABLISH UNIVERSAL ACCESS PROGRAMS TO IMPROVE HIGH
RISK POOLS AND REINSURANCE MARKETS.

(a) State Requirement.--
(1) In general.--Not later than January 1, 2010, each State
shall--
(A) subject to paragraph (3), operate--
(i) a qualified State reinsurance program described in
subsection (b); or
(ii) qualifying State high risk pool described in
subsection (c)(1); and
(B) subject to paragraph (3), apply to the operation of
such a program from State funds an amount equivalent to the
portion of State funds derived from State premium assessments
(as defined by the Secretary) that are not otherwise used on
State health care programs.
(2) Relation to current qualified high risk pool program.--
(A) States not operating a qualified high risk pool.--In
the case of a State that is not operating a current section
2745 qualified high risk pool as of the date of the enactment
of this Act--
(i) the State may only meet the requirement of paragraph
(1) through the operation of a qualified State reinsurance
program described in subsection (b); and
(ii) the State's operation of such a reinsurance program
shall be treated, for purposes of section 2745 of the Public
Health Service Act, as the operation of a qualified high risk
pool described in such section.
(B) State operating a qualified high risk pool.--In the
case of a State that is operating a current section 2745
qualified high risk pool as of the date of the enactment of
this Act--
(i) as of January 1, 2010, such a pool shall not be treated
as a qualified high risk pool under section 2745 of the
Public Health Service Act unless the pool is a qualifying
State high risk pool described in subsection (c)(1); and
(ii) the State may use premium assessment funds described
in paragraph (1)(B) to transition from operation of such a
pool to operation of a qualified State reinsurance program
described in subsection (b).
(3) Application of funds.--If the program or pool operated
under paragraph (1)(A) is in strong fiscal health, as
determined in accordance with standards established by the
National Association of Insurance Commissioners and as
approved by the State Insurance Commissioner involved, the
requirement of paragraph (1)(B) shall be deemed to be met.
(b) Qualified State Reinsurance Program.--
(1) In general.--For purposes of this section, a
``qualified State reinsurance program'' means a program
operated by a State program that provides reinsurance for
health insurance coverage offered in the small group market
in accordance with the model for such a program established
(as of the date of the enactment of this Act).
(2) Form of program.--A qualified State reinsurance program
may provide reinsurance--
(A) on a prospective or retrospective basis; and
(B) on a basis that protects health insurance issuers
against the annual aggregate spending of their enrollees as
well as purchase protection against individual catastrophic
costs.
(3) Satisfaction of hipaa requirement.--A qualified State
reinsurance program shall be deemed, for purposes of section
2745 of the Public Health Service Act, to be a qualified
high-risk pool under such section.
(c) Qualifying State High Risk Pool.--
(1) In general.--A qualifying State high risk pool
described in this subsection means a current section 2745
qualified high risk pool that meets the following
requirements:
(A) The pool must provide at least two coverage options,
one of which must be a high deductible health plan coupled
with a health savings account.
(B) The pool must be funded with a stable funding source.
(C) The pool must eliminate any waiting lists so that all
eligible residents who are seeking coverage through the pool
should be allowed to receive coverage through the pool.
(D) The pool must allow for coverage of individuals who,
but for the 24-month disability waiting period under section
226(b) of the Social Security Act, would be eligible for
Medicare during the period of such waiting period.
(E) The pool must limit the pool premiums to no more than
150 percent of the average premium for applicable standard
risk rates in that State.
(F) The pool must conduct education and outreach
initiatives so that residents and brokers understand that the
pool is available to eligible residents.
(G) The pool must provide coverage for preventive services
and disease management for chronic diseases.
(2) Verification of citizenship or alien qualification.--
(A) In general.--Notwithstanding any other provision of
law, only citizens and nationals of the United States shall
be eligible to participate in a qualifying State high risk
pool that receives funds under section 2745 of the Public
Health Service Act or this section.
(B) Condition of participation.--As a condition of a State
receiving such funds, the Secretary shall require the State
to certify, to the satisfaction of the Secretary, that such
State requires all applicants for coverage in the qualifying
State high risk pool to provide satisfactory documentation of
citizenship or nationality in a manner consistent with
section 1903(x) of the Social Security Act.
(C) Records.--The Secretary shall keep sufficient records
such that a determination of citizenship or nationality only
has to be made once for any individual under this paragraph.
(3) Relation to section 2745.--As of January 1, 2010, a
pool shall not qualify as qualified high risk pool under
section 2745 of the Public Health Service Act unless the pool
is a qualifying State high risk pool described in paragraph
(1).
(d) Waivers.--In order to accommodate new and innovative
programs, the Secretary may waive such requirements of this
section for qualified State reinsurance programs and for
qualifying State high risk pools as the Secretary deems
appropriate.
(e) Funding.--In addition to any other amounts
appropriated, there is appropriated to carry out section 2745
of the Public Health Service Act (including through a program
or pool described in subsection (a)(1))--
(1) $15,000,000,000 for the period of fiscal years 2010
through 2019; and
(2) an additional $10,000,000,000 for the period of fiscal
years 2015 through 2019.
(f) Definitions.--In this section:

[[Page H12929]]

(1) Health insurance coverage; health insurance issuer.--
The terms ``health insurance coverage'' and ``health
insurance issuer'' have the meanings given such terms in
section 2791 of the Public Health Service Act.
(2) Current section 2745 qualified high risk pool.--The
term ``current section 2745 qualified high risk pool'' has
the meaning given the term ``qualified high risk pool'' under
section 2745(g) of the Public Health Service Act as in effect
as of the date of the enactment of this Act.
(3) Secretary.--The term ``Secretary'' means Secretary of
Health and Human Services.
(4) Standard risk rate.--The term ``standard risk rate''
means a rate that--
(A) is determined under the State high risk pool by
considering the premium rates charged by other health
insurance issuers offering health insurance coverage to
individuals in the insurance market served;
(B) is established using reasonable actuarial techniques;
and
(C) reflects anticipated claims experience and expenses for
the coverage involved.
(5) State.--The term ``State'' means any of the 50 States
or the District of Columbia.

SEC. 102. ELIMINATION OF CERTAIN REQUIREMENTS FOR GUARANTEED
AVAILABILITY IN INDIVIDUAL MARKET.

(a) In General.--Section 2741(b) of the Public Health
Service Act (42 U.S.C. 300gg-41(b)) is amended----
(1) in paragraph (1)--
(A) by striking ``(1)(A)'' and inserting ``(1)''; and
(B) by striking ``and (B)'' and all that follows up to the
semicolon at the end;
(2) by adding ``and'' at the end of paragraph (2);
(3) in paragraph (3)--
(A) by striking ``(1)(A)'' and inserting ``(1)''; and
(B) by striking the semicolon at the end and inserting a
period; and
(4) by striking paragraphs (4) and (5).
(b) Effective Date.--The amendments made by subsection (a)
shall take effect on the date of the enactment of this Act.

SEC. 103. NO ANNUAL OR LIFETIME SPENDING CAPS.

Notwithstanding any other provision of law, a health
insurance issuer (including an entity licensed to sell
insurance with respect to a State or group health plan) may
not apply an annual or lifetime aggregate spending cap on any
health insurance coverage or plan offered by such issuer.

SEC. 104. PREVENTING UNJUST CANCELLATION OF INSURANCE
COVERAGE.

(a) Clarification Regarding Application of Guaranteed
Renewability of Individual Health Insurance Coverage.--
Section 2742 of the Public Health Service Act (42 U.S.C.
300gg-42) is amended--
(1) in its heading, by inserting ``, continuation in force,
including prohibition of rescission,'' after ``guaranteed
renewability'';
(2) in subsection (a), by inserting ``, including without
rescission,'' after ``continue in force''; and
(3) in subsection (b)(2), by inserting before the period at
the end the following: ``, including intentional concealment
of material facts regarding a health condition related to the
condition for which coverage is being claimed''.
(b) Opportunity for Independent, External Third Party
Review in Certain Cases.--Subpart 1 of part B of title XXVII
of the Public Health Service Act is amended by adding at the
end the following new section:

``SEC. 2746. OPPORTUNITY FOR INDEPENDENT, EXTERNAL THIRD
PARTY REVIEW IN CERTAIN CASES.

``(a) Notice and Review Right.--If a health insurance
issuer determines to nonrenew or not continue in force,
including rescind, health insurance coverage for an
individual in the individual market on the basis described in
section 2742(b)(2) before such nonrenewal, discontinuation,
or rescission, may take effect the issuer shall provide the
individual with notice of such proposed nonrenewal,
discontinuation, or rescission and an opportunity for a
review of such determination by an independent, external
third party under procedures specified by the Secretary.
``(b) Independent Determination.--If the individual
requests such review by an independent, external third party
of a nonrenewal, discontinuation, or rescission of health
insurance coverage, the coverage shall remain in effect until
such third party determines that the coverage may be
nonrenewed, discontinued, or rescinded under section
2742(b)(2).''.
(c) Effective Date.--The amendments made by this section
shall apply after the date of the enactment of this Act with
respect to health insurance coverage issued before, on, or
after such date.

TITLE II--REDUCING HEALTH CARE PREMIUMS AND THE NUMBER OF UNINSURED
AMERICANS

SEC. 111. STATE INNOVATION PROGRAMS.

(a) Programs That Reduce the Cost of Health Insurance
Premiums.--
(1) Payments to states.--
(A) For premium reductions in the small group market.--If
the Secretary determines that a State has reduced the average
per capita premium for health insurance coverage in the small
group market in year 3, in year 6, or year 9 (as defined in
subsection (c)) below the premium baseline for such year (as
defined paragraph (2)), the Secretary shall pay the State an
amount equal to the product of--
(i) bonus premium percentage (as defined in paragraph (3))
for the State, market, and year; and
(ii) the maximum State premium payment amount (as defined
in paragraph (4)) for the State, market, and year
(B) For premium reductions in the individual market.--If
the Secretary determines that a State has reduced the average
per capita premium for health insurance coverage in the
individual market in year 3, in year 6, or in year 9 below
the premium baseline for such year, the Secretary shall pay
the State an amount equal to the product of--
(i) bonus premium percentage for the State, market, and
year; and
(ii) the maximum State premium payment amount for the
State, market, and year.
(2) Premium baseline.--For purposes of this subsection, the
term ``premium baseline'' means, for a market in a State--
(A) for year 1, the average per capita premiums for health
insurance coverage in such market in the State in such year;
or
(B) for a subsequent year, the baseline for the market in
the State for the previous year under this paragraph
increased by a percentage specified in accordance with a
formula established by the Secretary, in consultation with
the Congressional Budget Office and the Bureau of the Census,
that takes into account at least the following:
(i) Growth factor.--The inflation in the costs of inputs to
health care services in the year.
(ii) Historic premium growth rates.--Historic growth rates,
during the 10 years before year 1, of per capita premiums for
health insurance coverage.
(iii) Demographic considerations.--Historic average changes
in the demographics of the population covered that impact on
the rate of growth of per capita health care costs.
(3) Bonus premium percentage defined.--
(A) In general.--For purposes of this subsection, the term
``bonus premium percentage'' means, for the small group
market or individual market in a State for a year, such
percentage as determined in accordance with the following
table based on the State's premium performance level (as
defined in subparagraph (B)) for such market and year:

----------------------------------------------------------------------------------------------------------------
The bonus
premium        For year 3 if the premium        For year 6 if the premium        For year 9 if the premium
percentage for   performance level of the State   performance level of the State  performance level of the State
a State is--                 is--                             is--                            is--
----------------------------------------------------------------------------------------------------------------
100 percent   at least 8.5%                    at least 11%                     at least 13.5%
----------------------------------------------------------------------------------------------------------------
50 percent   at least 6.38%, but less than    at least 10.38%, but less than   at least 12.88%, but less than
8.5%                             11%                              13.5%
----------------------------------------------------------------------------------------------------------------
25 percent   at least 4.25%, but less than     at least 9.75%, but less than   at least 12.25%, but less than
6.38%                            10.38%                           12.88%
----------------------------------------------------------------------------------------------------------------
0 percent   less than 4.25%                  less than 9.75%                  less than 12.25%
----------------------------------------------------------------------------------------------------------------

(B) Premium performance level.--For purposes of this
subsection, the term ``premium performance level'' means, for
a State, market, and year, the percentage reduction in the
average per capita premiums for health insurance coverage for
the State, market, and year, as compared to the premium
baseline for such State, market, and year.
(4) Maximum state premium payment amount defined.--For
purposes of this subsection, the term ``maximum State premium
payment amount'' means, for a State for the small group
market or the individual market for a year, the product of--
(A) the proportion (as determined by the Secretary), of the
number of nonelderly individuals lawfully residing in all the
States who are enrolled in health insurance coverage in the
respective market in the year, who are residents of the
State; and
(B) the amount available for obligation from amounts
appropriated under subsection (d) for such market with
respect to performance in such year.
(5) Methodology for calculating average per capita
premiums.--

[[Page H12930]]

(A) Establishment.--The Secretary shall establish, by rule
and consistent with this subsection, a methodology for
computing the average per capita premiums for health
insurance coverage for the small group market and for the
individual market in each State for each year beginning with
year 1.
(B) Adjustments.--Under such methodology, the Secretary
shall provide for the following adjustments (in a manner
determined appropriate by the Secretary):
(i) Exclusion of illegal aliens.--An adjustment so as not
to take into account enrollees who are not lawfully present
in the United States and their premium costs.
(ii) Treating state premium subsidies as premium costs.--An
adjustment so as to increase per capita premiums to remove
the impact of premium subsidies made directly by a State to
reduce health insurance premiums.
(6) Conditions of payment.--As a condition of receiving a
payment under paragraph (1), a State must agree to submit
aggregate, non-individually identifiable data to the
Secretary, in a form and manner specified by the Secretary,
for use by the Secretary to determine the State's premium
baseline and premium performance level for purposes of this
subsection.
(b) Programs That Reduce the Number of Uninsured.--
(1) In general.--If the Secretary determines that a State
has reduced the percentage of uninsured nonelderly residents
in year 5, year 7, or year 9, below the uninsured baseline
(as defined in paragraph (2)) for the State for the year, the
Secretary shall pay the State an amount equal to the product
of--
(A) bonus uninsured percentage (as defined in paragraph
(3)) for the State and year; and
(B) the maximum uninsured payment amount (as defined in
paragraph (4)) for the State and year.
(2) Uninsured baseline.--
(A) In general.--For purposes of this subsection, and
subject to subparagraph (B), the term ``uninsured baseline''
means, for a State, the percentage of nonelderly residents in
the State who are uninsured in year 1.
(B) Adjustment.--The Secretary may, at the written request
of a State, adjust the uninsured baseline for States for a
year to take into account unanticipated and exceptional
changes, such as an unanticipated migration, of nonelderly
individuals into, or out of, States in a manner that does not
reflect substantially the proportion of uninsured nonelderly
residents in the States involved in year 1. Any such
adjustment shall only be done in a manner that does not
result in the average of the uninsured baselines for
nonelderly residents for all States being changed.
(3) Bonus uninsured percentage.--
(A) Bonus uninsured percentage.--For purposes of this
subsection, the term ``bonus uninsured percentage'' means,
for a State for a year, such percentage as determined in
accordance with the following table, based on the uninsured
performance level (as defined in subparagraph (B)) for such
State and year:

----------------------------------------------------------------------------------------------------------------
The bonus
uninsured      For year 5 if the uninsured      For year 7 if the uninsured      For year 9 if the uninsured
percentage for   performance level of the State   performance level of the State  performance level of the State
a State is--                 is--                             is--                            is--
----------------------------------------------------------------------------------------------------------------
100 percent   at least 10%                     at least 15%                     at least 20%
----------------------------------------------------------------------------------------------------------------
50 percent   at least 7.5% but less than 10%  at least 13.75% but less than    at least 18.75% but less than
15%                              20%
----------------------------------------------------------------------------------------------------------------
25 percent   at least 5% but less than 7.5%   at least 12.5% but less than     at least 17.5% but less than
13.75%                           18.75%
----------------------------------------------------------------------------------------------------------------
0 percent   less than 5%                     less than 12.5%                  less than 17.5%
----------------------------------------------------------------------------------------------------------------

(B) Uninsured performance level.--For purposes of this
subsection, the term ``uninsured performance level'' means,
for a State for a year, the reduction (expressed as a
percentage) in the percentage of uninsured nonelderly
residents in such State in the year as compared to the
uninsured baseline for such State for such year.
(4) Maximum state uninsured payment amount defined.--For
purposes of this subsection, the term ``maximum State
uninsured payment amount'' means, for a State for a year, the
product of--
(A) the proportion (as determined by the Secretary), of the
number of uninsured nonelderly individuals lawfully residing
in all the States in the year, who are residents of the
State; and
(B) the amount available for obligation under this
subsection from amounts appropriated under subsection (d)
with respect to performance in such year.
(5) Methodology for computing the percentage of uninsured
nonelderly residents in a state.--
(A) Establishment.--The Secretary shall establish, by rule
and consistent with this subsection, a methodology for
computing the percentage of nonelderly residents in a State
who are uninsured in each year beginning with year 1.
(B) Rules.--
(i) Treatment of uninsured.--Such methodology shall treat
as uninsured those residents who do not have health insurance
coverage or other creditable coverage (as defined in section
9801(c)(1) of the Internal Revenue Code of 1986), except that
such methodology shall rely upon data on the nonelderly and
uninsured populations within each State in such year provided
through population surveys conducted by federal agencies.
(ii) Limitation to nonelderly.--Such methodology shall
exclude individuals who are 65 years of age or older.
(iii) Exclusion of illegal aliens.--Such methodology shall
exclude individuals not lawfully present in the United
States.
(6) Conditions of payment.--As a condition of receiving a
payment under paragraph (1), a State must agree to submit
aggregate, non-individually identifiable data to the
Secretary, in a form and manner specified by the Secretary,
for use by the Secretary in determining the State's uninsured
baseline and uninsured performance level for purposes of this
subsection.
(c) Definitions.--For purposes of this section:
(1) Group health plan.--The term ``group health plan'' has
the meaning given such term in section 9832(a) of the
Internal Revenue Code of 1986.
(2) Health insurance coverage.--The term ``health insurance
coverage'' has the meaning given such term in section
9832(b)(1) of the Internal Revenue Code of 1986.
(3) Individual market.--Except as the Secretary may
otherwise provide in the case of group health plans that have
fewer than 2 participants as current employees on the first
day of a plan year, the term ``individual market'' means the
market for health insurance coverage offered to individuals
other than in connection with a group health plan.
(4) Secretary.--The term ``Secretary'' means the Secretary
of Health and Human Services.
(5) Small group market.--The term ``small group market''
means the market for health insurance coverage under which
individuals obtain health insurance coverage (directly or
through any arrangement) on behalf of themselves (and their
dependents) through a group health plan maintained by an
employer who employed on average at least 2 but not more than
50 employees on business days during a calendar year.
(6) State.--The term ``State'' means any of the 50 States
and the District of Columbia.
(7) Years.--The terms ``year 1'', ``year 2'', ``year 3'',
and similar subsequently numbered years mean 2010, 2011,
2012, and subsequent sequentially numbered years.
(d) Appropriations; Payments.--
(1) Payments for reductions in cost of health insurance
coverage.--
(A) Small group market.--
(i) In general.--From any funds in the Treasury not
otherwise appropriated, there is appropriated for payments
under subsection (a)(1)(A)--

(I) $18,000,000,000 with respect to performance in year 3;
(II) $5,000,000,000 with respect to performance in year 6;
and
(III) $2,000,000,000 with respect to performance in year 9.

(ii) Availability of appropriated funds.--Funds
appropriated under clause (i) shall remain available until
expended.
(B) Individual market.--
(i) In general.--Subject to clause (ii), from any funds in
the Treasury not otherwise appropriated, there is
appropriated for payments under subsection (a)(1)(B)--

(I) $7,000,000,000 with respect to performance in year 3;
(II) $2,000,000,000 with respect to performance in year 6;
and
(III) $1,000,000,000 with respect to performance in year 9.

(ii) Availability of appropriated funds.--Of the funds
appropriated under clause (i) that are not expended or
obligated by the end of the year following the year for which
the funds are appropriated--

(I) 75 percent shall remain available until expended for
payments under subsection (a)(1)(B); and
(II) 25 percent shall remain available until expended for
payments under subsection (a)(1)(A).

(2) Payments for reductions in the percentage of
uninsured.--
(A) In general.--From any funds in the Treasury not
otherwise appropriated, there is appropriated for payments
under subsection (b)(1)--

[[Page H12931]]

(i) $10,000,000,000 with respect to performance in year 5;
(ii) $3,000,000,000 with respect to performance in year 7;
and
(iii) $2,000,000,000 with respect to performance in year 9
(B) Availability of appropriated funds.--Funds appropriated
under subparagraph (A) shall remain available until expended.
(3) Payment timing.--Payments under this section shall be
made in a form and manner specified by the Secretary in the
year after the performance year involved.

SEC. 112. HEALTH PLAN FINDERS.

(a) State Plan Finders.--Not later than 12 months after the
date of the enactment of this Act, each State may contract
with a private entity to develop and operate a plan finder
website (referred to in this section as a ``State plan
finder'') which shall provide information to individuals in
such State on plans of health insurance coverage that are
available to individuals in such State (in this section
referred to as a ``health insurance plan''). Such State may
not operate a plan finder itself.
(b) Multi-State Plan Finders.--
(1) In general.--A private entity may operate a multi-State
finder that operates under this section in the States
involved in the same manner as a State plan finder would
operate in a single State.
(2) Sharing of information.--States shall regulate the
manner in which data is shared between plan finders to ensure
consistency and accuracy in the information about health
insurance plans contained in such finders.
(c) Requirements for Plan Finders.--Each plan finder shall
meet the following requirements:
(1) The plan finder shall ensure that each health insurance
plan in the plan finder meets the requirements for such plans
under subsection (d).
(2) The plan finder shall present complete information on
the costs and benefits of health insurance plans (including
information on monthly premium, copayments, and deductibles)
in a uniform manner that--
(A) uses the standard definitions developed under paragraph
(3); and
(B) is designed to allow consumers to easily compare such
plans.
(3) The plan finder shall be available on the internet and
accessible to all individuals in the State or, in the case of
a multi-State plan finder, in all States covered by the
multi-State plan finder.
(4) The plan finder shall allow consumers to search and
sort data on the health insurance plans in the plan finder on
criteria such as coverage of specific benefits (such as
coverage of disease management services or pediatric care
services), as well as data available on quality.
(5) The plan finder shall meet all relevant State laws and
regulations, including laws and regulations related to the
marketing of insurance products. In the case of a multi-State
plan finder, the finder shall meet such laws and regulations
for all of the States involved.
(6) The plan finder shall meet solvency, financial, and
privacy requirements established by the State or States in
which the plan finder operates or the Secretary for multi-
State finders.
(7) The plan finder and the employees of the plan finder
shall be appropriately licensed in the State or States in
which the plan finder operates, if such licensure is required
by such State or States.
(8) Notwithstanding subsection (f)(1), the plan finder
shall assist individuals who are eligible for the Medicaid
program under title XIX of the Social Security Act or State
Children's Health Insurance Program under title XXI of such
Act by including information on Medicaid options,
eligibility, and how to enroll.
(d) Requirements for Plans Participating in a Plan
Finder.--
(1) In general.--Each State shall ensure that health
insurance plans participating in the State plan finder or in
a multi-State plan finder meet the requirements of paragraph
(2) (relating to adequacy of insurance coverage, consumer
protection, and financial strength).
(2) Specific requirements.--In order to participate in a
plan finder, a health insurance plan must meet all of the
following requirements, as determined by each State in which
such plan operates:
(A) The health insurance plan shall be actuarially sound.
(B) The health insurance plan may not have a history of
abusive policy rescissions.
(C) The health insurance plan shall meet financial and
solvency requirements.
(D) The health insurance plan shall disclose--
(i) all financial arrangements involving the sale and
purchase of health insurance, such as the payment of fees and
commissions; and
(ii) such arrangements may not be abusive.
(E) The health insurance plan shall maintain electronic
health records that comply with the requirements of the
American Recovery and Reinvestment Act of 2009 (Public Law
111-5) related to electronic health records.
(F) The health insurance plan shall make available to plan
enrollees via the finder, whether by information provided to
the finder or by a website link directing the enrollee from
the finder to the health insurance plan website, data that
includes the price and cost to the individual of services
offered by a provider according to the terms and conditions
of the health plan. Data described in this paragraph is not
made public by the finder, only made available to the
individual once enrolled in the health plan.
(e) Prohibitions.--
(1) Direct enrollment.--The State plan finder may not
directly enroll individuals in health insurance plans.
(2) Conflicts of interest.--
(A) Companies.--A health insurance issuer offering a health
insurance plan through a plan finder may not--
(i) be the private entity developing and maintaining a plan
finder under subsections (a) and (b); or
(ii) have an ownership interest in such private entity or
in the plan finder.
(B) Individuals.--An individual employed by a health
insurance issuer offering a health insurance plan through a
plan finder may not serve as a director or officer for--
(i) the private entity developing and maintaining a plan
finder under subsections (a) and (b); or
(ii) the plan finder.
(f) Construction.--Nothing in this section shall be
construed to allow the Secretary authority to regulate
benefit packages or to prohibit health insurance brokers and
agents from--
(1) utilizing the plan finder for any purpose; or
(2) marketing or offering health insurance products.
(g) Plan Finder Defined.--For purposes of this section, the
term ``plan finder'' means a State plan finder under
subsection (a) or a multi-State plan finder under subsection
(b).
(h) State Defined.--In this section, the term ``State'' has
the meaning given such term for purposes of title XIX of the
Social Security Act.

SEC. 113. ADMINISTRATIVE SIMPLIFICATION.

(a) Operating Rules for Health Information Transactions.--
(1) Definition of operating rules.--Section 1171 of the
Social Security Act (42 U.S.C. 1320d) is amended by adding at
the end the following:
``(9) Operating rules.--The term `operating rules' means
the necessary business rules and guidelines for the
electronic exchange of information that are not defined by a
standard or its implementation specifications as adopted for
purposes of this part.''.
(2) Operating rules and compliance.--Section 1173 of the
Social Security Act (42 U.S.C. 1320d-2) is amended--
(A) in subsection (a)(2), by adding at the end the
following new subparagraph:
``(J) Electronic funds transfers.''; and
(B) by adding at the end the following new subsections:
``(g) Operating Rules.--
``(1) In general.--The Secretary shall adopt a single set
of operating rules for each transaction described in
subsection (a)(2) with the goal of creating as much
uniformity in the implementation of the electronic standards
as possible. Such operating rules shall be consensus-based
and reflect the necessary business rules affecting health
plans and health care providers and the manner in which they
operate pursuant to standards issued under Health Insurance
Portability and Accountability Act of 1996.
``(2) Operating rules development.--In adopting operating
rules under this subsection, the Secretary shall rely on
recommendations for operating rules developed by a qualified
nonprofit entity, as selected by the Secretary, that meets
the following requirements:
``(A) The entity focuses its mission on administrative
simplification.
``(B) The entity demonstrates an established multi-
stakeholder and consensus-based process for development of
operating rules, including representation by or participation
from health plans, health care providers, vendors, relevant
Federal agencies, and other standard development
organizations.
``(C) The entity has established a public set of guiding
principles that ensure the operating rules and process are
open and transparent.
``(D) The entity coordinates its activities with the HIT
Policy Committee and the HIT Standards Committee (as
established under title XXX of the Public Health Service Act)
and complements the efforts of the Office of the National
Healthcare Coordinator and its related health information
exchange goals.
``(E) The entity incorporates national standards, including
the transaction standards issued under Health Insurance
Portability and Accountability Act of 1996.
``(F) The entity supports nondiscrimination and conflict of
interest policies that demonstrate a commitment to open,
fair, and nondiscriminatory practices.
``(G) The entity allows for public review and updates of
the operating rules.
``(3) Review and recommendations.--The National Committee
on Vital and Health Statistics shall--
``(A) review the operating rules developed by a nonprofit
entity described under paragraph (2);
``(B) determine whether such rules represent a consensus
view of the health care industry and are consistent with and
do not alter current standards;
``(C) evaluate whether such rules are consistent with
electronic standards adopted for health information
technology; and

[[Page H12932]]

``(D) submit to the Secretary a recommendation as to
whether the Secretary should adopt such rules.
``(4) Implementation.--
``(A) In general.--The Secretary shall adopt operating
rules under this subsection, by regulation in accordance with
subparagraph (C), following consideration of the rules
developed by the non-profit entity described in paragraph (2)
and the recommendation submitted by the National Committee on
Vital and Health Statistics under paragraph (3)(D) and having
ensured consultation with providers.
``(B) Adoption requirements; effective dates.--
``(i) Eligibility for a health plan and health claim
status.--The set of operating rules for transactions for
eligibility for a health plan and health claim status shall
be adopted not later than July 1, 2011, in a manner ensuring
that such rules are effective not later than January 1, 2013,
and may allow for the use of a machine readable
identification card.
``(ii) Electronic funds transfers and health care payment
and remittance advice.--The set of operating rules for
electronic funds transfers and health care payment and
remittance advice shall be adopted not later than July 1,
2012, in a manner ensuring that such rules are effective not
later than January 1, 2014.
``(iii) Other completed transactions.--The set of operating
rules for the remainder of the completed transactions
described in subsection (a)(2), including health claims or
equivalent encounter information, enrollment and
disenrollment in a health plan, health plan premium payments,
and referral certification and authorization, shall be
adopted not later than July 1, 2014, in a manner ensuring
that such rules are effective not later than January 1, 2016.
``(C) Expedited rulemaking.--The Secretary shall promulgate
an interim final rule applying any standard or operating rule
recommended by the National Committee on Vital and Health
Statistics pursuant to paragraph (3). The Secretary shall
accept public comments on any interim final rule published
under this subparagraph for 60 days after the date of such
publication.
``(h) Compliance.--
``(1) Health plan certification.--
``(A) Eligibility for a health plan, health claim status,
electronic funds transfers, health care payment and
remittance advice.--Not later than December 31, 2013, a
health plan shall file a statement with the Secretary, in
such form as the Secretary may require, certifying that the
data and information systems for such plan are in compliance
with any applicable standards (as described under paragraph
(7) of section 1171) and operating rules (as described under
paragraph (9) of such section) for electronic funds
transfers, eligibility for a health plan, health claim
status, and health care payment and remittance advice,
respectively.
``(B) Other completed transactions.--Not later than
December 31, 2015, a health plan shall file a statement with
the Secretary, in such form as the Secretary may require,
certifying that the data and information systems for such
plan are in compliance with any applicable standards and
operating rules for the remainder of the completed
transactions described in subsection (a)(2), including health
claims or equivalent encounter information, enrollment and
disenrollment in a health plan, health plan premium payments,
and referral certification and authorization, respectively. A
health plan shall provide the same level of documentation to
certify compliance with such transactions as is required to
certify compliance with the transactions specified in
subparagraph (A).
``(2) Documentation of compliance.--A health plan shall
provide the Secretary, in such form as the Secretary may
require, with adequate documentation of compliance with the
standards and operating rules described under paragraph (1).
A health plan shall not be considered to have provided
adequate documentation and shall not be certified as being in
compliance with such standards, unless the health plan--
``(A) demonstrates to the Secretary that the plan conducts
the electronic transactions specified in paragraph (1) in a
manner that fully complies with the regulations of the
Secretary; and
``(B) provides documentation showing that the plan has
completed end-to-end testing for such transactions with their
partners, such as hospitals and physicians.
``(3) Service contracts.--A health plan shall be required
to comply with any applicable certification and compliance
requirements (and provide the Secretary with adequate
documentation of such compliance) under this subsection for
any entities that provide services pursuant to a contract
with such health plan.
``(4) Certification by outside entity.--The Secretary may
contract with an independent, outside entity to certify that
a health plan has complied with the requirements under this
subsection, provided that the certification standards
employed by such entities are in accordance with any
standards or rules issued by the Secretary.
``(5) Compliance with revised standards and rules.--A
health plan (including entities described under paragraph
(3)) shall comply with the certification and documentation
requirements under this subsection for any interim final rule
promulgated by the Secretary under subsection (i) that amends
any standard or operating rule described under paragraph (1)
of this subsection. A health plan shall comply with such
requirements not later than the effective date of the
applicable interim final rule.
``(6) Audits of health plans.--The Secretary shall conduct
periodic audits to ensure that health plans (including
entities described under paragraph (3)) are in compliance
with any standards and operating rules that are described
under paragraph (1).
``(i) Review and Amendment of Standards and Rules.--
``(1) Establishment.--Not later than January 1, 2014, the
Secretary shall establish a review committee (as described
under paragraph (4)).
``(2) Evaluations and reports.--
``(A) Hearings.--Not later than April 1, 2014, and not less
than biennially thereafter, the Secretary, acting through the
review committee, shall conduct hearings to evaluate and
review the existing standards and operating rules established
under this section.
``(B) Report.--Not later than July 1, 2014, and not less
than biennially thereafter, the review committee shall
provide recommendations for updating and improving such
standards and rules. The review committee shall recommend a
single set of operating rules per transaction standard and
maintain the goal of creating as much uniformity as possible
in the implementation of the electronic standards.
``(3) Interim final rulemaking.--
``(A) In general.--Any recommendations to amend existing
standards and operating rules that have been approved by the
review committee and reported to the Secretary under
paragraph (2)(B) shall be adopted by the Secretary through
promulgation of an interim final rule not later than 90 days
after receipt of the committee's report.
``(B) Public comment.--
``(i) Public comment period.--The Secretary shall accept
public comments on any interim final rule published under
this paragraph for 60 days after the date of such
publication.
``(ii) Effective date.--The effective date of any amendment
to existing standards or operating rules that is adopted
through an interim final rule published under this paragraph
shall be 25 months following the close of such public comment
period.
``(4) Review committee.--
``(A) Definition.--For the purposes of this subsection, the
term `review committee' means a committee within the
Department of Health and Human services that has been
designated by the Secretary to carry out this subsection,
including--
``(i) the National Committee on Vital and Health
Statistics; or
``(ii) any appropriate committee as determined by the
Secretary.
``(B) Coordination of hit standards.--In developing
recommendations under this subsection, the review committee
shall consider the standards approved by the Office of the
National Coordinator for Health Information Technology.
``(j) Penalties.--
``(1) Penalty fee.--
``(A) In general.--Not later than April 1, 2014, and
annually thereafter, the Secretary shall assess a penalty fee
(as determined under subparagraph (B)) against a health plan
that has failed to meet the requirements under subsection (h)
with respect to certification and documentation of compliance
with the standards (and their operating rules) as described
under paragraph (1) of such subsection.
``(B) Fee amount.--Subject to subparagraphs (C), (D), and
(E), the Secretary shall assess a penalty fee against a
health plan in the amount of $1 per covered life until
certification is complete. The penalty shall be assessed per
person covered by the plan for which its data systems for
major medical policies are not in compliance and shall be
imposed against the health plan for each day that the plan is
not in compliance with the requirements under subsection (h).
``(C) Additional penalty for misrepresentation.--A health
plan that knowingly provides inaccurate or incomplete
information in a statement of certification or documentation
of compliance under subsection (h) shall be subject to a
penalty fee that is double the amount that would otherwise be
imposed under this subsection.
``(D) Annual fee increase.--The amount of the penalty fee
imposed under this subsection shall be increased on an annual
basis by the annual percentage increase in total national
health care expenditures, as determined by the Secretary.
``(E) Penalty limit.--A penalty fee assessed against a
health plan under this subsection shall not exceed, on an
annual basis--
``(i) an amount equal to $20 per covered life under such
plan; or
``(ii) an amount equal to $40 per covered life under the
plan if such plan has knowingly provided inaccurate or
incomplete information (as described under subparagraph (C)).
``(F) Determination of covered individuals.--The Secretary
shall determine the number of covered lives under a health
plan based upon the most recent statements and filings that
have been submitted by such plan to the Securities and
Exchange Commission.

[[Page H12933]]

``(2) Notice and dispute procedure.--The Secretary shall
establish a procedure for assessment of penalty fees under
this subsection that provides a health plan with reasonable
notice and a dispute resolution procedure prior to provision
of a notice of assessment by the Secretary of the Treasury
(as described under paragraph (4)(B)).
``(3) Penalty fee report.--Not later than May 1, 2014, and
annually thereafter, the Secretary shall provide the
Secretary of the Treasury with a report identifying those
health plans that have been assessed a penalty fee under this
subsection.
``(4) Collection of penalty fee.--
``(A) In general.--The Secretary of the Treasury, acting
through the Financial Management Service, shall administer
the collection of penalty fees from health plans that have
been identified by the Secretary in the penalty fee report
provided under paragraph (3).
``(B) Notice.--Not later than August 1, 2014, and annually
thereafter, the Secretary of the Treasury shall provide
notice to each health plan that has been assessed a penalty
fee by the Secretary under this subsection. Such notice shall
include the amount of the penalty fee assessed by the
Secretary and the due date for payment of such fee to the
Secretary of the Treasury (as described in subparagraph (C)).
``(C) Payment due date.--Payment by a health plan for a
penalty fee assessed under this subsection shall be made to
the Secretary of the Treasury not later than November 1,
2014, and annually thereafter.
``(D) Unpaid penalty fees.--Any amount of a penalty fee
assessed against a health plan under this subsection for
which payment has not been made by the due date provided
under subparagraph (C) shall be--
``(i) increased by the interest accrued on such amount, as
determined pursuant to the underpayment rate established
under section 6601 of the Internal Revenue Code of 1986; and
``(ii) treated as a past-due, legally enforceable debt owed
to a Federal agency for purposes of section 6402(d) of the
Internal Revenue Code of 1986.
``(E) Administrative fees.--Any fee charged or allocated
for collection activities conducted by the Financial
Management Service will be passed on to a health plan on a
pro-rata basis and added to any penalty fee collected from
the plan.''.
(b) Promulgation of Rules.--
(1) Unique health plan identifier.--The Secretary shall
promulgate a final rule to establish a unique health plan
identifier (as described in section 1173(b) of the Social
Security Act (42 U.S.C. 1320d-2(b))) based on the input of
the National Committee of Vital and Health Statistics. The
Secretary may do so on an interim final basis and such rule
shall be effective not later than October 1, 2012.
(2) Electronic funds transfer.--The Secretary shall
promulgate a final rule to establish a standard for
electronic funds transfers (as described in section
1173(a)(2)(J) of the Social Security Act, as added by
subsection (a)(2)(A)). The Secretary may do so on an interim
final basis and shall adopt such standard not later than
January 1, 2012, in a manner ensuring that such standard is
effective not later than January 1, 2014.
(c) Expansion of Electronic Transactions in Medicare.--
Section 1862(a) of the Social Security Act (42 U.S.C.
1395y(a)) is amended--
(1) in paragraph (23), by striking the ``or'' at the end;
(2) in paragraph (24), by striking the period and inserting
``; or''; and
(3) by inserting after paragraph (24) the following new
paragraph:
``(25) not later than January 1, 2014, for which the
payment is other than by electronic funds transfer (EFT) or
an electronic remittance in a form as specified in ASC X12
835 Health Care Payment and Remittance Advice or subsequent
standard.''.
(d) Medicare and Medicaid Compliance Reports.--Not later
than July 1, 2013, the Secretary of Health and Human Services
shall submit a report to the Chairs and Ranking Members of
the Committee on Ways and Means and the Committee on Energy
and Commerce of the House of Representatives and the Chairs
and Ranking Members of the Committee on Health, Education,
Labor, and Pensions and the Committee on Finance of the
Senate on the extent to which the Medicare program and
providers that serve beneficiaries under that program, and
State Medicaid programs and providers that serve
beneficiaries under those programs, transact electronically
in accordance with transaction standards issued under the
Health Insurance Portability and Accountability Act of 1996,
part C of title XI of the Social Security Act, and
regulations promulgated under such Acts.

DIVISION B--IMPROVING ACCESS TO HEALTH CARE

TITLE I--EXPANDING ACCESS AND LOWERING COSTS FOR SMALL BUSINESSES

SEC. 201. RULES GOVERNING ASSOCIATION HEALTH PLANS.

(a) In General.--Subtitle B of title I of the Employee
Retirement Income Security Act of 1974 is amended by adding
after part 7 the following new part:

``PART 8--RULES GOVERNING ASSOCIATION HEALTH PLANS

``SEC. 801. ASSOCIATION HEALTH PLANS.

``(a) In General.--For purposes of this part, the term
`association health plan' means a group health plan whose
sponsor is (or is deemed under this part to be) described in
subsection (b).
``(b) Sponsorship.--The sponsor of a group health plan is
described in this subsection if such sponsor--
``(1) is organized and maintained in good faith, with a
constitution and bylaws specifically stating its purpose and
providing for periodic meetings on at least an annual basis,
as a bona fide trade association, a bona fide industry
association (including a rural electric cooperative
association or a rural telephone cooperative association), a
bona fide professional association, or a bona fide chamber of
commerce (or similar bona fide business association,
including a corporation or similar organization that operates
on a cooperative basis (within the meaning of section 1381 of
the Internal Revenue Code of 1986)), for substantial purposes
other than that of obtaining or providing medical care;
``(2) is established as a permanent entity which receives
the active support of its members and requires for membership
payment on a periodic basis of dues or payments necessary to
maintain eligibility for membership in the sponsor; and
``(3) does not condition membership, such dues or payments,
or coverage under the plan on the basis of health status-
related factors with respect to the employees of its members
(or affiliated members), or the dependents of such employees,
and does not condition such dues or payments on the basis of
group health plan participation.

Any sponsor consisting of an association of entities which
meet the requirements of paragraphs (1), (2), and (3) shall
be deemed to be a sponsor described in this subsection.

``SEC. 802. CERTIFICATION OF ASSOCIATION HEALTH PLANS.

``(a) In General.--The applicable authority shall prescribe
by regulation a procedure under which, subject to subsection
(b), the applicable authority shall certify association
health plans which apply for certification as meeting the
requirements of this part.
``(b) Standards.--Under the procedure prescribed pursuant
to subsection (a), in the case of an association health plan
that provides at least one benefit option which does not
consist of health insurance coverage, the applicable
authority shall certify such plan as meeting the requirements
of this part only if the applicable authority is satisfied
that the applicable requirements of this part are met (or,
upon the date on which the plan is to commence operations,
will be met) with respect to the plan.
``(c) Requirements Applicable to Certified Plans.--An
association health plan with respect to which certification
under this part is in effect shall meet the applicable
requirements of this part, effective on the date of
certification (or, if later, on the date on which the plan is
to commence operations).
``(d) Requirements for Continued Certification.--The
applicable authority may provide by regulation for continued
certification of association health plans under this part.
``(e) Class Certification for Fully Insured Plans.--The
applicable authority shall establish a class certification
procedure for association health plans under which all
benefits consist of health insurance coverage. Under such
procedure, the applicable authority shall provide for the
granting of certification under this part to the plans in
each class of such association health plans upon appropriate
filing under such procedure in connection with plans in such
class and payment of the prescribed fee under section 807(a).
``(f) Certification of Self-Insured Association Health
Plans.--An association health plan which offers one or more
benefit options which do not consist of health insurance
coverage may be certified under this part only if such plan
consists of any of the following:
``(1) a plan which offered such coverage on the date of the
enactment of the Small Business Health Fairness Act of 2009,
``(2) a plan under which the sponsor does not restrict
membership to one or more trades and businesses or industries
and whose eligible participating employers represent a broad
cross-section of trades and businesses or industries, or
``(3) a plan whose eligible participating employers
represent one or more trades or businesses, or one or more
industries, consisting of any of the following: agriculture;
equipment and automobile dealerships; barbering and
cosmetology; certified public accounting practices; child
care; construction; dance, theatrical and orchestra
productions; disinfecting and pest control; financial
services; fishing; food service establishments; hospitals;
labor organizations; logging; manufacturing (metals); mining;
medical and dental practices; medical laboratories;
professional consulting services; sanitary services;
transportation (local and freight); warehousing; wholesaling/
distributing; or any other trade or business or industry
which has been indicated as having average or above-average
risk or health claims experience by reason of State rate
filings, denials of coverage, proposed premium rate levels,
or other means demonstrated by such plan in accordance with
regulations.

``SEC. 803. REQUIREMENTS RELATING TO SPONSORS AND BOARDS OF
TRUSTEES.

``(a) Sponsor.--The requirements of this subsection are met
with respect to an association health plan if the sponsor has
met (or is deemed under this part to have met) the
requirements of section 801(b) for a continuous period of not
less than 3 years ending

[[Page H12934]]

with the date of the application for certification under this
part.
``(b) Board of Trustees.--The requirements of this
subsection are met with respect to an association health plan
if the following requirements are met:
``(1) Fiscal control.--The plan is operated, pursuant to a
trust agreement, by a board of trustees which has complete
fiscal control over the plan and which is responsible for all
operations of the plan.
``(2) Rules of operation and financial controls.--The board
of trustees has in effect rules of operation and financial
controls, based on a 3-year plan of operation, adequate to
carry out the terms of the plan and to meet all requirements
of this title applicable to the plan.
``(3) Rules governing relationship to participating
employers and to contractors.--
``(A) Board membership.--
``(i) In general.--Except as provided in clauses (ii) and
(iii), the members of the board of trustees are individuals
selected from individuals who are the owners, officers,
directors, or employees of the participating employers or who
are partners in the participating employers and actively
participate in the business.
``(ii) Limitation.--

``(I) General rule.--Except as provided in subclauses (II)
and (III), no such member is an owner, officer, director, or
employee of, or partner in, a contract administrator or other
service provider to the plan.
``(II) Limited exception for providers of services solely
on behalf of the sponsor.--Officers or employees of a sponsor
which is a service provider (other than a contract
administrator) to the plan may be members of the board if
they constitute not more than 25 percent of the membership of
the board and they do not provide services to the plan other
than on behalf of the sponsor.
``(III) Treatment of providers of medical care.--In the
case of a sponsor which is an association whose membership
consists primarily of providers of medical care, subclause
(I) shall not apply in the case of any service provider
described in subclause (I) who is a provider of medical care
under the plan.

``(iii) Certain plans excluded.--Clause (i) shall not apply
to an association health plan which is in existence on the
date of the enactment of the Small Business Health Fairness
Act of 2009.
``(B) Sole authority.--The board has sole authority under
the plan to approve applications for participation in the
plan and to contract with a service provider to administer
the day-to-day affairs of the plan.
``(c) Treatment of Franchise Networks.--In the case of a
group health plan which is established and maintained by a
franchiser for a franchise network consisting of its
franchisees--
``(1) the requirements of subsection (a) and section 801(a)
shall be deemed met if such requirements would otherwise be
met if the franchiser were deemed to be the sponsor referred
to in section 801(b), such network were deemed to be an
association described in section 801(b), and each franchisee
were deemed to be a member (of the association and the
sponsor) referred to in section 801(b); and
``(2) the requirements of section 804(a)(1) shall be deemed
met.

The Secretary may by regulation define for purposes of this
subsection the terms `franchiser', `franchise network', and
`franchisee'.

``SEC. 804. PARTICIPATION AND COVERAGE REQUIREMENTS.

``(a) Covered Employers and Individuals.--The requirements
of this subsection are met with respect to an association
health plan if, under the terms of the plan--
``(1) each participating employer must be--
``(A) a member of the sponsor,
``(B) the sponsor, or
``(C) an affiliated member of the sponsor with respect to
which the requirements of subsection (b) are met,

except that, in the case of a sponsor which is a professional
association or other individual-based association, if at
least one of the officers, directors, or employees of an
employer, or at least one of the individuals who are partners
in an employer and who actively participates in the business,
is a member or such an affiliated member of the sponsor,
participating employers may also include such employer; and
``(2) all individuals commencing coverage under the plan
after certification under this part must be--
``(A) active or retired owners (including self-employed
individuals), officers, directors, or employees of, or
partners in, participating employers; or
``(B) the beneficiaries of individuals described in
subparagraph (A).
``(b) Coverage of Previously Uninsured Employees.--In the
case of an association health plan in existence on the date
of the enactment of the Small Business Health Fairness Act of
2009, an affiliated member of the sponsor of the plan may be
offered coverage under the plan as a participating employer
only if--
``(1) the affiliated member was an affiliated member on the
date of certification under this part; or
``(2) during the 12-month period preceding the date of the
offering of such coverage, the affiliated member has not
maintained or contributed to a group health plan with respect
to any of its employees who would otherwise be eligible to
participate in such association health plan.
``(c) Individual Market Unaffected.--The requirements of
this subsection are met with respect to an association health
plan if, under the terms of the plan, no participating
employer may provide health insurance coverage in the
individual market for any employee not covered under the plan
which is similar to the coverage contemporaneously provided
to employees of the employer under the plan, if such
exclusion of the employee from coverage under the plan is
based on a health status-related factor with respect to the
employee and such employee would, but for such exclusion on
such basis, be eligible for coverage under the plan.
``(d) Prohibition of Discrimination Against Employers and
Employees Eligible To Participate.--The requirements of this
subsection are met with respect to an association health plan
if--
``(1) under the terms of the plan, all employers meeting
the preceding requirements of this section are eligible to
qualify as participating employers for all geographically
available coverage options, unless, in the case of any such
employer, participation or contribution requirements of the
type referred to in section 2711 of the Public Health Service
Act are not met;
``(2) upon request, any employer eligible to participate is
furnished information regarding all coverage options
available under the plan; and
``(3) the applicable requirements of sections 701, 702, and
703 are met with respect to the plan.

``SEC. 805. OTHER REQUIREMENTS RELATING TO PLAN DOCUMENTS,
CONTRIBUTION RATES, AND BENEFIT OPTIONS.

``(a) In General.--The requirements of this section are met
with respect to an association health plan if the following
requirements are met:
``(1) Contents of governing instruments.--The instruments
governing the plan include a written instrument, meeting the
requirements of an instrument required under section
402(a)(1), which--
``(A) provides that the board of trustees serves as the
named fiduciary required for plans under section 402(a)(1)
and serves in the capacity of a plan administrator (referred
to in section 3(16)(A));
``(B) provides that the sponsor of the plan is to serve as
plan sponsor (referred to in section 3(16)(B)); and
``(C) incorporates the requirements of section 806.
``(2) Contribution rates must be nondiscriminatory.--
``(A) The contribution rates for any participating small
employer do not vary on the basis of any health status-
related factor in relation to employees of such employer or
their beneficiaries and do not vary on the basis of the type
of business or industry in which such employer is engaged.
``(B) Nothing in this title or any other provision of law
shall be construed to preclude an association health plan, or
a health insurance issuer offering health insurance coverage
in connection with an association health plan, from--
``(i) setting contribution rates based on the claims
experience of the plan; or
``(ii) varying contribution rates for small employers in a
State to the extent that such rates could vary using the same
methodology employed in such State for regulating premium
rates in the small group market with respect to health
insurance coverage offered in connection with bona fide
associations (within the meaning of section 2791(d)(3) of the
Public Health Service Act),

subject to the requirements of section 702(b) relating to
contribution rates.
``(3) Floor for number of covered individuals with respect
to certain plans.--If any benefit option under the plan does
not consist of health insurance coverage, the plan has as of
the beginning of the plan year not fewer than 1,000
participants and beneficiaries.
``(4) Marketing requirements.--
``(A) In general.--If a benefit option which consists of
health insurance coverage is offered under the plan, State-
licensed insurance agents shall be used to distribute to
small employers coverage which does not consist of health
insurance coverage in a manner comparable to the manner in
which such agents are used to distribute health insurance
coverage.
``(B) State-licensed insurance agents.--For purposes of
subparagraph (A), the term `State-licensed insurance agents'
means one or more agents who are licensed in a State and are
subject to the laws of such State relating to licensure,
qualification, testing, examination, and continuing education
of persons authorized to offer, sell, or solicit health
insurance coverage in such State.
``(5) Regulatory requirements.--Such other requirements as
the applicable authority determines are necessary to carry
out the purposes of this part, which shall be prescribed by
the applicable authority by regulation.
``(b) Ability of Association Health Plans To Design Benefit
Options.--Subject to section 514(d), nothing in this part or
any provision of State law (as defined in section 514(c)(1))
shall be construed to preclude an association health plan, or
a health insurance issuer offering health insurance coverage
in connection with an association health plan, from
exercising its sole discretion in selecting the specific
items and services consisting of medical care to be included
as benefits under such plan or coverage, except (subject to
section 514) in the case of (1) any law to the extent that it
is not preempted under section 731(a)(1) with respect

[[Page H12935]]

to matters governed by section 711, 712, or 713, or (2) any
law of the State with which filing and approval of a policy
type offered by the plan was initially obtained to the extent
that such law prohibits an exclusion of a specific disease
from such coverage.

``SEC. 806. MAINTENANCE OF RESERVES AND PROVISIONS FOR
SOLVENCY FOR PLANS PROVIDING HEALTH BENEFITS IN
ADDITION TO HEALTH INSURANCE COVERAGE.

``(a) In General.--The requirements of this section are met
with respect to an association health plan if--
``(1) the benefits under the plan consist solely of health
insurance coverage; or
``(2) if the plan provides any additional benefit options
which do not consist of health insurance coverage, the plan--
``(A) establishes and maintains reserves with respect to
such additional benefit options, in amounts recommended by
the qualified actuary, consisting of--
``(i) a reserve sufficient for unearned contributions;
``(ii) a reserve sufficient for benefit liabilities which
have been incurred, which have not been satisfied, and for
which risk of loss has not yet been transferred, and for
expected administrative costs with respect to such benefit
liabilities;
``(iii) a reserve sufficient for any other obligations of
the plan; and
``(iv) a reserve sufficient for a margin of error and other
fluctuations, taking into account the specific circumstances
of the plan; and
``(B) establishes and maintains aggregate and specific
excess/stop loss insurance and solvency indemnification, with
respect to such additional benefit options for which risk of
loss has not yet been transferred, as follows:
``(i) The plan shall secure aggregate excess/stop loss
insurance for the plan with an attachment point which is not
greater than 125 percent of expected gross annual claims. The
applicable authority may by regulation provide for upward
adjustments in the amount of such percentage in specified
circumstances in which the plan specifically provides for and
maintains reserves in excess of the amounts required under
subparagraph (A).
``(ii) The plan shall secure specific excess/stop loss
insurance for the plan with an attachment point which is at
least equal to an amount recommended by the plan's qualified
actuary. The applicable authority may by regulation provide
for adjustments in the amount of such insurance in specified
circumstances in which the plan specifically provides for and
maintains reserves in excess of the amounts required under
subparagraph (A).
``(iii) The plan shall secure indemnification insurance for
any claims which the plan is unable to satisfy by reason of a
plan termination.

Any person issuing to a plan insurance described in clause
(i), (ii), or (iii) of subparagraph (B) shall notify the
Secretary of any failure of premium payment meriting
cancellation of the policy prior to undertaking such a
cancellation. Any regulations prescribed by the applicable
authority pursuant to clause (i) or (ii) of subparagraph (B)
may allow for such adjustments in the required levels of
excess/stop loss insurance as the qualified actuary may
recommend, taking into account the specific circumstances of
the plan.
``(b) Minimum Surplus in Addition to Claims Reserves.--In
the case of any association health plan described in
subsection (a)(2), the requirements of this subsection are
met if the plan establishes and maintains surplus in an
amount at least equal to--
``(1) $500,000, or
``(2) such greater amount (but not greater than $2,000,000)
as may be set forth in regulations prescribed by the
applicable authority, considering the level of aggregate and
specific excess/stop loss insurance provided with respect to
such plan and other factors related to solvency risk, such as
the plan's projected levels of participation or claims, the
nature of the plan's liabilities, and the types of assets
available to assure that such liabilities are met.
``(c) Additional Requirements.--In the case of any
association health plan described in subsection (a)(2), the
applicable authority may provide such additional requirements
relating to reserves, excess/stop loss insurance, and
indemnification insurance as the applicable authority
considers appropriate. Such requirements may be provided by
regulation with respect to any such plan or any class of such
plans.
``(d) Adjustments for Excess/Stop Loss Insurance.--The
applicable authority may provide for adjustments to the
levels of reserves otherwise required under subsections (a)
and (b) with respect to any plan or class of plans to take
into account excess/stop loss insurance provided with respect
to such plan or plans.
``(e) Alternative Means of Compliance.--The applicable
authority may permit an association health plan described in
subsection (a)(2) to substitute, for all or part of the
requirements of this section (except subsection
(a)(2)(B)(iii)), such security, guarantee, hold-harmless
arrangement, or other financial arrangement as the applicable
authority determines to be adequate to enable the plan to
fully meet all its financial obligations on a timely basis
and is otherwise no less protective of the interests of
participants and beneficiaries than the requirements for
which it is substituted. The applicable authority may take
into account, for purposes of this subsection, evidence
provided by the plan or sponsor which demonstrates an
assumption of liability with respect to the plan. Such
evidence may be in the form of a contract of indemnification,
lien, bonding, insurance, letter of credit, recourse under
applicable terms of the plan in the form of assessments of
participating employers, security, or other financial
arrangement.
``(f) Measures To Ensure Continued Payment of Benefits by
Certain Plans in Distress.--
``(1) Payments by certain plans to association health plan
fund.--
``(A) In general.--In the case of an association health
plan described in subsection (a)(2), the requirements of this
subsection are met if the plan makes payments into the
Association Health Plan Fund under this subparagraph when
they are due. Such payments shall consist of annual payments
in the amount of $5,000, and, in addition to such annual
payments, such supplemental payments as the Secretary may
determine to be necessary under paragraph (2). Payments under
this paragraph are payable to the Fund at the time determined
by the Secretary. Initial payments are due in advance of
certification under this part. Payments shall continue to
accrue until a plan's assets are distributed pursuant to a
termination procedure.
``(B) Penalties for failure to make payments.--If any
payment is not made by a plan when it is due, a late payment
charge of not more than 100 percent of the payment which was
not timely paid shall be payable by the plan to the Fund.
``(C) Continued duty of the secretary.--The Secretary shall
not cease to carry out the provisions of paragraph (2) on
account of the failure of a plan to pay any payment when due.
``(2) Payments by secretary to continue excess/stop loss
insurance coverage and indemnification insurance coverage for
certain plans.--In any case in which the applicable authority
determines that there is, or that there is reason to believe
that there will be: (A) a failure to take necessary
corrective actions under section 809(a) with respect to an
association health plan described in subsection (a)(2); or
(B) a termination of such a plan under section 809(b) or
810(b)(8) (and, if the applicable authority is not the
Secretary, certifies such determination to the Secretary),
the Secretary shall determine the amounts necessary to make
payments to an insurer (designated by the Secretary) to
maintain in force excess/stop loss insurance coverage or
indemnification insurance coverage for such plan, if the
Secretary determines that there is a reasonable expectation
that, without such payments, claims would not be satisfied by
reason of termination of such coverage. The Secretary shall,
to the extent provided in advance in appropriation Acts, pay
such amounts so determined to the insurer designated by the
Secretary.
``(3) Association health plan fund.--
``(A) In general.--There is established on the books of the
Treasury a fund to be known as the `Association Health Plan
Fund'. The Fund shall be available for making payments
pursuant to paragraph (2). The Fund shall be credited with
payments received pursuant to paragraph (1)(A), penalties
received pursuant to paragraph (1)(B); and earnings on
investments of amounts of the Fund under subparagraph (B).
``(B) Investment.--Whenever the Secretary determines that
the moneys of the fund are in excess of current needs, the
Secretary may request the investment of such amounts as the
Secretary determines advisable by the Secretary of the
Treasury in obligations issued or guaranteed by the United
States.
``(g) Excess/Stop Loss Insurance.--For purposes of this
section--
``(1) Aggregate excess/stop loss insurance.--The term
`aggregate excess/stop loss insurance' means, in connection
with an association health plan, a contract--
``(A) under which an insurer (meeting such minimum
standards as the applicable authority may prescribe by
regulation) provides for payment to the plan with respect to
aggregate claims under the plan in excess of an amount or
amounts specified in such contract;
``(B) which is guaranteed renewable; and
``(C) which allows for payment of premiums by any third
party on behalf of the insured plan.
``(2) Specific excess/stop loss insurance.--The term
`specific excess/stop loss insurance' means, in connection
with an association health plan, a contract--
``(A) under which an insurer (meeting such minimum
standards as the applicable authority may prescribe by
regulation) provides for payment to the plan with respect to
claims under the plan in connection with a covered individual
in excess of an amount or amounts specified in such contract
in connection with such covered individual;
``(B) which is guaranteed renewable; and
``(C) which allows for payment of premiums by any third
party on behalf of the insured plan.
``(h) Indemnification Insurance.--For purposes of this
section, the term `indemnification insurance' means, in
connection with an association health plan, a contract--
``(1) under which an insurer (meeting such minimum
standards as the applicable authority may prescribe by
regulation) provides for payment to the plan with respect to
claims under the plan which the plan is unable to satisfy by
reason of a termination

[[Page H12936]]

pursuant to section 809(b) (relating to mandatory
termination);
``(2) which is guaranteed renewable and noncancellable for
any reason (except as the applicable authority may prescribe
by regulation); and
``(3) which allows for payment of premiums by any third
party on behalf of the insured plan.
``(i) Reserves.--For purposes of this section, the term
`reserves' means, in connection with an association health
plan, plan assets which meet the fiduciary standards under
part 4 and such additional requirements regarding liquidity
as the applicable authority may prescribe by regulation.
``(j) Solvency Standards Working Group.--
``(1) In general.--Within 90 days after the date of the
enactment of the Small Business Health Fairness Act of 2009,
the applicable authority shall establish a Solvency Standards
Working Group. In prescribing the initial regulations under
this section, the applicable authority shall take into
account the recommendations of such Working Group.
``(2) Membership.--The Working Group shall consist of not
more than 15 members appointed by the applicable authority.
The applicable authority shall include among persons invited
to membership on the Working Group at least one of each of
the following:
``(A) a representative of the National Association of
Insurance Commissioners;
``(B) a representative of the American Academy of
Actuaries;
``(C) a representative of the State governments, or their
interests;
``(D) a representative of existing self-insured
arrangements, or their interests;
``(E) a representative of associations of the type referred
to in section 801(b)(1), or their interests; and
``(F) a representative of multiemployer plans that are
group health plans, or their interests.

``SEC. 807. REQUIREMENTS FOR APPLICATION AND RELATED
REQUIREMENTS.

``(a) Filing Fee.--Under the procedure prescribed pursuant
to section 802(a), an association health plan shall pay to
the applicable authority at the time of filing an application
for certification under this part a filing fee in the amount
of $5,000, which shall be available in the case of the
Secretary, to the extent provided in appropriation Acts, for
the sole purpose of administering the certification
procedures applicable with respect to association health
plans.
``(b) Information To Be Included in Application for
Certification.--An application for certification under this
part meets the requirements of this section only if it
includes, in a manner and form which shall be prescribed by
the applicable authority by regulation, at least the
following information:
``(1) Identifying information.--The names and addresses
of--
``(A) the sponsor; and
``(B) the members of the board of trustees of the plan.
``(2) States in which plan intends to do business.--The
States in which participants and beneficiaries under the plan
are to be located and the number of them expected to be
located in each such State.
``(3) Bonding requirements.--Evidence provided by the board
of trustees that the bonding requirements of section 412 will
be met as of the date of the application or (if later)
commencement of operations.
``(4) Plan documents.--A copy of the documents governing
the plan (including any bylaws and trust agreements), the
summary plan description, and other material describing the
benefits that will be provided to participants and
beneficiaries under the plan.
``(5) Agreements with service providers.--A copy of any
agreements between the plan and contract administrators and
other service providers.
``(6) Funding report.--In the case of association health
plans providing benefits options in addition to health
insurance coverage, a report setting forth information with
respect to such additional benefit options determined as of a
date within the 120-day period ending with the date of the
application, including the following:
``(A) Reserves.--A statement, certified by the board of
trustees of the plan, and a statement of actuarial opinion,
signed by a qualified actuary, that all applicable
requirements of section 806 are or will be met in accordance
with regulations which the applicable authority shall
prescribe.
``(B) Adequacy of contribution rates.--A statement of
actuarial opinion, signed by a qualified actuary, which sets
forth a description of the extent to which contribution rates
are adequate to provide for the payment of all obligations
and the maintenance of required reserves under the plan for
the 12-month period beginning with such date within such 120-
day period, taking into account the expected coverage and
experience of the plan. If the contribution rates are not
fully adequate, the statement of actuarial opinion shall
indicate the extent to which the rates are inadequate and the
changes needed to ensure adequacy.
``(C) Current and projected value of assets and
liabilities.--A statement of actuarial opinion signed by a
qualified actuary, which sets forth the current value of the
assets and liabilities accumulated under the plan and a
projection of the assets, liabilities, income, and expenses
of the plan for the 12-month period referred to in
subparagraph (B). The income statement shall identify
separately the plan's administrative expenses and claims.
``(D) Costs of coverage to be charged and other expenses.--
A statement of the costs of coverage to be charged, including
an itemization of amounts for administration, reserves, and
other expenses associated with the operation of the plan.
``(E) Other information.--Any other information as may be
determined by the applicable authority, by regulation, as
necessary to carry out the purposes of this part.
``(c) Filing Notice of Certification With States.--A
certification granted under this part to an association
health plan shall not be effective unless written notice of
such certification is filed with the applicable State
authority of each State in which at least 25 percent of the
participants and beneficiaries under the plan are located.
For purposes of this subsection, an individual shall be
considered to be located in the State in which a known
address of such individual is located or in which such
individual is employed.
``(d) Notice of Material Changes.--In the case of any
association health plan certified under this part,
descriptions of material changes in any information which was
required to be submitted with the application for the
certification under this part shall be filed in such form and
manner as shall be prescribed by the applicable authority by
regulation. The applicable authority may require by
regulation prior notice of material changes with respect to
specified matters which might serve as the basis for
suspension or revocation of the certification.
``(e) Reporting Requirements for Certain Association Health
Plans.--An association health plan certified under this part
which provides benefit options in addition to health
insurance coverage for such plan year shall meet the
requirements of section 103 by filing an annual report under
such section which shall include information described in
subsection (b)(6) with respect to the plan year and,
notwithstanding section 104(a)(1)(A), shall be filed with the
applicable authority not later than 90 days after the close
of the plan year (or on such later date as may be prescribed
by the applicable authority). The applicable authority may
require by regulation such interim reports as it considers
appropriate.
``(f) Engagement of Qualified Actuary.--The board of
trustees of each association health plan which provides
benefits options in addition to health insurance coverage and
which is applying for certification under this part or is
certified under this part shall engage, on behalf of all
participants and beneficiaries, a qualified actuary who shall
be responsible for the preparation of the materials
comprising information necessary to be submitted by a
qualified actuary under this part. The qualified actuary
shall utilize such assumptions and techniques as are
necessary to enable such actuary to form an opinion as to
whether the contents of the matters reported under this
part--
``(1) are in the aggregate reasonably related to the
experience of the plan and to reasonable expectations; and
``(2) represent such actuary's best estimate of anticipated
experience under the plan.

The opinion by the qualified actuary shall be made with
respect to, and shall be made a part of, the annual report.

``SEC. 808. NOTICE REQUIREMENTS FOR VOLUNTARY TERMINATION.

``Except as provided in section 809(b), an association
health plan which is or has been certified under this part
may terminate (upon or at any time after cessation of
accruals in benefit liabilities) only if the board of
trustees, not less than 60 days before the proposed
termination date--
``(1) provides to the participants and beneficiaries a
written notice of intent to terminate stating that such
termination is intended and the proposed termination date;
``(2) develops a plan for winding up the affairs of the
plan in connection with such termination in a manner which
will result in timely payment of all benefits for which the
plan is obligated; and
``(3) submits such plan in writing to the applicable
authority.

Actions required under this section shall be taken in such
form and manner as may be prescribed by the applicable
authority by regulation.

``SEC. 809. CORRECTIVE ACTIONS AND MANDATORY TERMINATION.

``(a) Actions To Avoid Depletion of Reserves.--An
association health plan which is certified under this part
and which provides benefits other than health insurance
coverage shall continue to meet the requirements of section
806, irrespective of whether such certification continues in
effect. The board of trustees of such plan shall determine
quarterly whether the requirements of section 806 are met. In
any case in which the board determines that there is reason
to believe that there is or will be a failure to meet such
requirements, or the applicable authority makes such a
determination and so notifies the board, the board shall
immediately notify the qualified actuary engaged by the plan,
and such actuary shall, not later than the end of the next
following month, make such recommendations to the board for
corrective action as the actuary determines necessary to
ensure compliance with section 806. Not later than 30 days
after receiving from the actuary recommendations for
corrective actions, the board shall notify the

[[Page H12937]]

applicable authority (in such form and manner as the
applicable authority may prescribe by regulation) of such
recommendations of the actuary for corrective action,
together with a description of the actions (if any) that the
board has taken or plans to take in response to such
recommendations. The board shall thereafter report to the
applicable authority, in such form and frequency as the
applicable authority may specify to the board, regarding
corrective action taken by the board until the requirements
of section 806 are met.
``(b) Mandatory Termination.--In any case in which--
``(1) the applicable authority has been notified under
subsection (a) (or by an issuer of excess/stop loss insurance
or indemnity insurance pursuant to section 806(a)) of a
failure of an association health plan which is or has been
certified under this part and is described in section
806(a)(2) to meet the requirements of section 806 and has not
been notified by the board of trustees of the plan that
corrective action has restored compliance with such
requirements; and
``(2) the applicable authority determines that there is a
reasonable expectation that the plan will continue to fail to
meet the requirements of section 806,

the board of trustees of the plan shall, at the direction of
the applicable authority, terminate the plan and, in the
course of the termination, take such actions as the
applicable authority may require, including satisfying any
claims referred to in section 806(a)(2)(B)(iii) and
recovering for the plan any liability under subsection
(a)(2)(B)(iii) or (e) of section 806, as necessary to ensure
that the affairs of the plan will be, to the maximum extent
possible, wound up in a manner which will result in timely
provision of all benefits for which the plan is obligated.

``SEC. 810. TRUSTEESHIP BY THE SECRETARY OF INSOLVENT
ASSOCIATION HEALTH PLANS PROVIDING HEALTH
BENEFITS IN ADDITION TO HEALTH INSURANCE
COVERAGE.

``(a) Appointment of Secretary as Trustee for Insolvent
Plans.--Whenever the Secretary determines that an association
health plan which is or has been certified under this part
and which is described in section 806(a)(2) will be unable to
provide benefits when due or is otherwise in a financially
hazardous condition, as shall be defined by the Secretary by
regulation, the Secretary shall, upon notice to the plan,
apply to the appropriate United States district court for
appointment of the Secretary as trustee to administer the
plan for the duration of the insolvency. The plan may appear
as a party and other interested persons may intervene in the
proceedings at the discretion of the court. The court shall
appoint such Secretary trustee if the court determines that
the trusteeship is necessary to protect the interests of the
participants and beneficiaries or providers of medical care
or to avoid any unreasonable deterioration of the financial
condition of the plan. The trusteeship of such Secretary
shall continue until the conditions described in the first
sentence of this subsection are remedied or the plan is
terminated.
``(b) Powers as Trustee.--The Secretary, upon appointment
as trustee under subsection (a), shall have the power--
``(1) to do any act authorized by the plan, this title, or
other applicable provisions of law to be done by the plan
administrator or any trustee of the plan;
``(2) to require the transfer of all (or any part) of the
assets and records of the plan to the Secretary as trustee;
``(3) to invest any assets of the plan which the Secretary
holds in accordance with the provisions of the plan,
regulations prescribed by the Secretary, and applicable
provisions of law;
``(4) to require the sponsor, the plan administrator, any
participating employer, and any employee organization
representing plan participants to furnish any information
with respect to the plan which the Secretary as trustee may
reasonably need in order to administer the plan;
``(5) to collect for the plan any amounts due the plan and
to recover reasonable expenses of the trusteeship;
``(6) to commence, prosecute, or defend on behalf of the
plan any suit or proceeding involving the plan;
``(7) to issue, publish, or file such notices, statements,
and reports as may be required by the Secretary by regulation
or required by any order of the court;
``(8) to terminate the plan (or provide for its termination
in accordance with section 809(b)) and liquidate the plan
assets, to restore the plan to the responsibility of the
sponsor, or to continue the trusteeship;
``(9) to provide for the enrollment of plan participants
and beneficiaries under appropriate coverage options; and
``(10) to do such other acts as may be necessary to comply
with this title or any order of the court and to protect the
interests of plan participants and beneficiaries and
providers of medical care.
``(c) Notice of Appointment.--As soon as practicable after
the Secretary's appointment as trustee, the Secretary shall
give notice of such appointment to--
``(1) the sponsor and plan administrator;
``(2) each participant;
``(3) each participating employer; and
``(4) if applicable, each employee organization which, for
purposes of collective bargaining, represents plan
participants.
``(d) Additional Duties.--Except to the extent inconsistent
with the provisions of this title, or as may be otherwise
ordered by the court, the Secretary, upon appointment as
trustee under this section, shall be subject to the same
duties as those of a trustee under section 704 of title 11,
United States Code, and shall have the duties of a fiduciary
for purposes of this title.
``(e) Other Proceedings.--An application by the Secretary
under this subsection may be filed notwithstanding the
pendency in the same or any other court of any bankruptcy,
mortgage foreclosure, or equity receivership proceeding, or
any proceeding to reorganize, conserve, or liquidate such
plan or its property, or any proceeding to enforce a lien
against property of the plan.
``(f) Jurisdiction of Court.--
``(1) In general.--Upon the filing of an application for
the appointment as trustee or the issuance of a decree under
this section, the court to which the application is made
shall have exclusive jurisdiction of the plan involved and
its property wherever located with the powers, to the extent
consistent with the purposes of this section, of a court of
the United States having jurisdiction over cases under
chapter 11 of title 11, United States Code. Pending an
adjudication under this section such court shall stay, and
upon appointment by it of the Secretary as trustee, such
court shall continue the stay of, any pending mortgage
foreclosure, equity receivership, or other proceeding to
reorganize, conserve, or liquidate the plan, the sponsor, or
property of such plan or sponsor, and any other suit against
any receiver, conservator, or trustee of the plan, the
sponsor, or property of the plan or sponsor. Pending such
adjudication and upon the appointment by it of the Secretary
as trustee, the court may stay any proceeding to enforce a
lien against property of the plan or the sponsor or any other
suit against the plan or the sponsor.
``(2) Venue.--An action under this section may be brought
in the judicial district where the sponsor or the plan
administrator resides or does business or where any asset of
the plan is situated. A district court in which such action
is brought may issue process with respect to such action in
any other judicial district.
``(g) Personnel.--In accordance with regulations which
shall be prescribed by the Secretary, the Secretary shall
appoint, retain, and compensate accountants, actuaries, and
other professional service personnel as may be necessary in
connection with the Secretary's service as trustee under this
section.

``SEC. 811. STATE ASSESSMENT AUTHORITY.

``(a) In General.--Notwithstanding section 514, a State may
impose by law a contribution tax on an association health
plan described in section 806(a)(2), if the plan commenced
operations in such State after the date of the enactment of
the Small Business Health Fairness Act of 2009.
``(b) Contribution Tax.--For purposes of this section, the
term `contribution tax' imposed by a State on an association
health plan means any tax imposed by such State if--
``(1) such tax is computed by applying a rate to the amount
of premiums or contributions, with respect to individuals
covered under the plan who are residents of such State, which
are received by the plan from participating employers located
in such State or from such individuals;
``(2) the rate of such tax does not exceed the rate of any
tax imposed by such State on premiums or contributions
received by insurers or health maintenance organizations for
health insurance coverage offered in such State in connection
with a group health plan;
``(3) such tax is otherwise nondiscriminatory; and
``(4) the amount of any such tax assessed on the plan is
reduced by the amount of any tax or assessment otherwise
imposed by the State on premiums, contributions, or both
received by insurers or health maintenance organizations for
health insurance coverage, aggregate excess/stop loss
insurance (as defined in section 806(g)(1)), specific excess/
stop loss insurance (as defined in section 806(g)(2)), other
insurance related to the provision of medical care under the
plan, or any combination thereof provided by such insurers or
health maintenance organizations in such State in connection
with such plan.

``SEC. 812. DEFINITIONS AND RULES OF CONSTRUCTION.

``(a) Definitions.--For purposes of this part--
``(1) Group health plan.--The term `group health plan' has
the meaning provided in section 733(a)(1) (after applying
subsection (b) of this section).
``(2) Medical care.--The term `medical care' has the
meaning provided in section 733(a)(2).
``(3) Health insurance coverage.--The term `health
insurance coverage' has the meaning provided in section
733(b)(1).
``(4) Health insurance issuer.--The term `health insurance
issuer' has the meaning provided in section 733(b)(2).
``(5) Applicable authority.--The term `applicable
authority' means the Secretary, except that, in connection
with any exercise of the Secretary's authority regarding
which the Secretary is required under section 506(d) to
consult with a State, such term means the Secretary, in
consultation with such State.
``(6) Health status-related factor.--The term `health
status-related factor' has the meaning provided in section
733(d)(2).
``(7) Individual market.--

[[Page H12938]]

``(A) In general.--The term `individual market' means the
market for health insurance coverage offered to individuals
other than in connection with a group health plan.
``(B) Treatment of very small groups.--
``(i) In general.--Subject to clause (ii), such term
includes coverage offered in connection with a group health
plan that has fewer than 2 participants as current employees
or participants described in section 732(d)(3) on the first
day of the plan year.
``(ii) State exception.--Clause (i) shall not apply in the
case of health insurance coverage offered in a State if such
State regulates the coverage described in such clause in the
same manner and to the same extent as coverage in the small
group market (as defined in section 2791(e)(5) of the Public
Health Service Act) is regulated by such State.
``(8) Participating employer.--The term `participating
employer' means, in connection with an association health
plan, any employer, if any individual who is an employee of
such employer, a partner in such employer, or a self-employed
individual who is such employer (or any dependent, as defined
under the terms of the plan, of such individual) is or was
covered under such plan in connection with the status of such
individual as such an employee, partner, or self-employed
individual in relation to the plan.
``(9) Applicable state authority.--The term `applicable
State authority' means, with respect to a health insurance
issuer in a State, the State insurance commissioner or
official or officials designated by the State to enforce the
requirements of title XXVII of the Public Health Service Act
for the State involved with respect to such issuer.
``(10) Qualified actuary.--The term `qualified actuary'
means an individual who is a member of the American Academy
of Actuaries.
``(11) Affiliated member.--The term `affiliated member'
means, in connection with a sponsor--
``(A) a person who is otherwise eligible to be a member of
the sponsor but who elects an affiliated status with the
sponsor,
``(B) in the case of a sponsor with members which consist
of associations, a person who is a member of any such
association and elects an affiliated status with the sponsor,
or
``(C) in the case of an association health plan in
existence on the date of the enactment of the Small Business
Health Fairness Act of 2009, a person eligible to be a member
of the sponsor or one of its member associations.
``(12) Large employer.--The term `large employer' means, in
connection with a group health plan with respect to a plan
year, an employer who employed an average of at least 51
employees on business days during the preceding calendar year
and who employs at least 2 employees on the first day of the
plan year.
``(13) Small employer.--The term `small employer' means, in
connection with a group health plan with respect to a plan
year, an employer who is not a large employer.
``(b) Rules of Construction.--
``(1) Employers and employees.--For purposes of determining
whether a plan, fund, or program is an employee welfare
benefit plan which is an association health plan, and for
purposes of applying this title in connection with such plan,
fund, or program so determined to be such an employee welfare
benefit plan--
``(A) in the case of a partnership, the term `employer' (as
defined in section 3(5)) includes the partnership in relation
to the partners, and the term `employee' (as defined in
section 3(6)) includes any partner in relation to the
partnership; and
``(B) in the case of a self-employed individual, the term
`employer' (as defined in section 3(5)) and the term
`employee' (as defined in section 3(6)) shall include such
individual.
``(2) Plans, funds, and programs treated as employee
welfare benefit plans.--In the case of any plan, fund, or
program which was established or is maintained for the
purpose of providing medical care (through the purchase of
insurance or otherwise) for employees (or their dependents)
covered thereunder and which demonstrates to the Secretary
that all requirements for certification under this part would
be met with respect to such plan, fund, or program if such
plan, fund, or program were a group health plan, such plan,
fund, or program shall be treated for purposes of this title
as an employee welfare benefit plan on and after the date of
such demonstration.''.
(b) Conforming Amendments to Preemption Rules.--
(1) Section 514(b)(6) of such Act (29 U.S.C. 1144(b)(6)) is
amended by adding at the end the following new subparagraph:
``(E) The preceding subparagraphs of this paragraph do not
apply with respect to any State law in the case of an
association health plan which is certified under part 8.''.
(2) Section 514 of such Act (29 U.S.C. 1144) is amended--
(A) in subsection (b)(4), by striking ``Subsection (a)''
and inserting ``Subsections (a) and (d)'';
(B) in subsection (b)(5), by striking ``subsection (a)'' in
subparagraph (A) and inserting ``subsection (a) of this
section and subsections (a)(2)(B) and (b) of section 805'',
and by striking ``subsection (a)'' in subparagraph (B) and
inserting ``subsection (a) of this section or subsection
(a)(2)(B) or (b) of section 805'';
(C) by redesignating subsections (d) and (e) as subsections
(e) and (f), respectively; and
(D) by inserting after subsection (c) the following new
subsection:
``(d)(1) Except as provided in subsection (b)(4), the
provisions of this title shall supersede any and all State
laws insofar as they may now or hereafter preclude, or have
the effect of precluding, a health insurance issuer from
offering health insurance coverage in connection with an
association health plan which is certified under part 8.
``(2) Except as provided in paragraphs (4) and (5) of
subsection (b) of this section--
``(A) In any case in which health insurance coverage of any
policy type is offered under an association health plan
certified under part 8 to a participating employer operating
in such State, the provisions of this title shall supersede
any and all laws of such State insofar as they may preclude a
health insurance issuer from offering health insurance
coverage of the same policy type to other employers operating
in the State which are eligible for coverage under such
association health plan, whether or not such other employers
are participating employers in such plan.
``(B) In any case in which health insurance coverage of any
policy type is offered in a State under an association health
plan certified under part 8 and the filing, with the
applicable State authority (as defined in section 812(a)(9)),
of the policy form in connection with such policy type is
approved by such State authority, the provisions of this
title shall supersede any and all laws of any other State in
which health insurance coverage of such type is offered,
insofar as they may preclude, upon the filing in the same
form and manner of such policy form with the applicable State
authority in such other State, the approval of the filing in
such other State.
``(3) Nothing in subsection (b)(6)(E) or the preceding
provisions of this subsection shall be construed, with
respect to health insurance issuers or health insurance
coverage, to supersede or impair the law of any State--
``(A) providing solvency standards or similar standards
regarding the adequacy of insurer capital, surplus, reserves,
or contributions, or
``(B) relating to prompt payment of claims.
``(4) For additional provisions relating to association
health plans, see subsections (a)(2)(B) and (b) of section
805.
``(5) For purposes of this subsection, the term
`association health plan' has the meaning provided in section
801(a), and the terms `health insurance coverage',
`participating employer', and `health insurance issuer' have
the meanings provided such terms in section 812,
respectively.''.
(3) Section 514(b)(6)(A) of such Act (29 U.S.C.
1144(b)(6)(A)) is amended--
(A) in clause (i)(II), by striking ``and'' at the end;
(B) in clause (ii), by inserting ``and which does not
provide medical care (within the meaning of section
733(a)(2)),'' after ``arrangement,'', and by striking
``title.'' and inserting ``title, and''; and
(C) by adding at the end the following new clause:
``(iii) subject to subparagraph (E), in the case of any
other employee welfare benefit plan which is a multiple
employer welfare arrangement and which provides medical care
(within the meaning of section 733(a)(2)), any law of any
State which regulates insurance may apply.''.
(4) Section 514(e) of such Act (as redesignated by
paragraph (2)(C)) is amended--
(A) by striking ``Nothing'' and inserting ``(1) Except as
provided in paragraph (2), nothing''; and
(B) by adding at the end the following new paragraph:
``(2) Nothing in any other provision of law enacted on or
after the date of the enactment of the Small Business Health
Fairness Act of 2009 shall be construed to alter, amend,
modify, invalidate, impair, or supersede any provision of
this title, except by specific cross-reference to the
affected section.''.
(c) Plan Sponsor.--Section 3(16)(B) of such Act (29 U.S.C.
102(16)(B)) is amended by adding at the end the following new
sentence: ``Such term also includes a person serving as the
sponsor of an association health plan under part 8.''.
(d) Disclosure of Solvency Protections Related to Self-
Insured and Fully Insured Options Under Association Health
Plans.--Section 102(b) of such Act (29 U.S.C. 102(b)) is
amended by adding at the end the following: ``An association
health plan shall include in its summary plan description, in
connection with each benefit option, a description of the
form of solvency or guarantee fund protection secured
pursuant to this Act or applicable State law, if any.''.
(e) Savings Clause.--Section 731(c) of such Act is amended
by inserting ``or part 8'' after ``this part''.
(f) Report to the Congress Regarding Certification of Self-
Insured Association Health Plans.--Not later than January 1,
2012, the Secretary of Labor shall report to the Committee on
Education and the Workforce of the House of Representatives
and the Committee on Health, Education, Labor, and Pensions
of the Senate the effect association health plans have had,
if any, on reducing the number of uninsured individuals.
(g) Clerical Amendment.--The table of contents in section 1
of the Employee Retirement Income Security Act of 1974 is
amended

[[Page H12939]]

by inserting after the item relating to section 734 the
following new items:

``Part 8--Rules Governing Association Health Plans

``801. Association health plans.
``802. Certification of association health plans.
``803. Requirements relating to sponsors and boards of trustees.
``804. Participation and coverage requirements.
``805. Other requirements relating to plan documents, contribution
rates, and benefit options.
``806. Maintenance of reserves and provisions for solvency for plans
providing health benefits in addition to health insurance
coverage.
``807. Requirements for application and related requirements.
``808. Notice requirements for voluntary termination.
``809. Corrective actions and mandatory termination.
``810. Trusteeship by the Secretary of insolvent association health
plans providing health benefits in addition to health
insurance coverage.
``811. State assessment authority.
``812. Definitions and rules of construction.''.

SEC. 202. CLARIFICATION OF TREATMENT OF SINGLE EMPLOYER
ARRANGEMENTS.

Section 3(40)(B) of the Employee Retirement Income Security
Act of 1974 (29 U.S.C. 1002(40)(B)) is amended--
(1) in clause (i), by inserting after ``control group,''
the following: ``except that, in any case in which the
benefit referred to in subparagraph (A) consists of medical
care (as defined in section 812(a)(2)), two or more trades or
businesses, whether or not incorporated, shall be deemed a
single employer for any plan year of such plan, or any fiscal
year of such other arrangement, if such trades or businesses
are within the same control group during such year or at any
time during the preceding 1-year period,'';
(2) in clause (iii), by striking ``(iii) the
determination'' and inserting the following:
``(iii)(I) in any case in which the benefit referred to in
subparagraph (A) consists of medical care (as defined in
section 812(a)(2)), the determination of whether a trade or
business is under `common control' with another trade or
business shall be determined under regulations of the
Secretary applying principles consistent and coextensive with
the principles applied in determining whether employees of
two or more trades or businesses are treated as employed by a
single employer under section 4001(b), except that, for
purposes of this paragraph, an interest of greater than 25
percent may not be required as the minimum interest necessary
for common control, or
``(II) in any other case, the determination'';
(3) by redesignating clauses (iv) and (v) as clauses (v)
and (vi), respectively; and
(4) by inserting after clause (iii) the following new
clause:
``(iv) in any case in which the benefit referred to in
subparagraph (A) consists of medical care (as defined in
section 812(a)(2)), in determining, after the application of
clause (i), whether benefits are provided to employees of two
or more employers, the arrangement shall be treated as having
only one participating employer if, after the application of
clause (i), the number of individuals who are employees and
former employees of any one participating employer and who
are covered under the arrangement is greater than 75 percent
of the aggregate number of all individuals who are employees
or former employees of participating employers and who are
covered under the arrangement,''.

SEC. 203. ENFORCEMENT PROVISIONS RELATING TO ASSOCIATION
HEALTH PLANS.

(a) Criminal Penalties for Certain Willful
Misrepresentations.--Section 501 of the Employee Retirement
Income Security Act of 1974 (29 U.S.C. 1131) is amended--
(1) by inserting ``(a)'' after ``Sec. 501.''; and
(2) by adding at the end the following new subsection:
``(b) Any person who willfully falsely represents, to any
employee, any employee's beneficiary, any employer, the
Secretary, or any State, a plan or other arrangement
established or maintained for the purpose of offering or
providing any benefit described in section 3(1) to employees
or their beneficiaries as--
``(1) being an association health plan which has been
certified under part 8;
``(2) having been established or maintained under or
pursuant to one or more collective bargaining agreements
which are reached pursuant to collective bargaining described
in section 8(d) of the National Labor Relations Act (29
U.S.C. 158(d)) or paragraph Fourth of section 2 of the
Railway Labor Act (45 U.S.C. 152, paragraph Fourth) or which
are reached pursuant to labor-management negotiations under
similar provisions of State public employee relations laws;
or
``(3) being a plan or arrangement described in section
3(40)(A)(i),

shall, upon conviction, be imprisoned not more than 5 years,
be fined under title 18, United States Code, or both.''.
(b) Cease Activities Orders.--Section 502 of such Act (29
U.S.C. 1132) is amended by adding at the end the following
new subsection:
``(n) Association Health Plan Cease and Desist Orders.--
``(1) In general.--Subject to paragraph (2), upon
application by the Secretary showing the operation,
promotion, or marketing of an association health plan (or
similar arrangement providing benefits consisting of medical
care (as defined in section 733(a)(2))) that--
``(A) is not certified under part 8, is subject under
section 514(b)(6) to the insurance laws of any State in which
the plan or arrangement offers or provides benefits, and is
not licensed, registered, or otherwise approved under the
insurance laws of such State; or
``(B) is an association health plan certified under part 8
and is not operating in accordance with the requirements
under part 8 for such certification,

a district court of the United States shall enter an order
requiring that the plan or arrangement cease activities.
``(2) Exception.--Paragraph (1) shall not apply in the case
of an association health plan or other arrangement if the
plan or arrangement shows that--
``(A) all benefits under it referred to in paragraph (1)
consist of health insurance coverage; and
``(B) with respect to each State in which the plan or
arrangement offers or provides benefits, the plan or
arrangement is operating in accordance with applicable State
laws that are not superseded under section 514.
``(3) Additional equitable relief.--The court may grant
such additional equitable relief, including any relief
available under this title, as it deems necessary to protect
the interests of the public and of persons having claims for
benefits against the plan.''.
(c) Responsibility for Claims Procedure.--Section 503 of
such Act (29 U.S.C. 1133) is amended by inserting ``(a) In
General.--'' before ``In accordance'', and by adding at the
end the following new subsection:
``(b) Association Health Plans.--The terms of each
association health plan which is or has been certified under
part 8 shall require the board of trustees or the named
fiduciary (as applicable) to ensure that the requirements of
this section are met in connection with claims filed under
the plan.''.

SEC. 204. COOPERATION BETWEEN FEDERAL AND STATE AUTHORITIES.

Section 506 of the Employee Retirement Income Security Act
of 1974 (29 U.S.C. 1136) is amended by adding at the end the
following new subsection:
``(d) Consultation With States With Respect to Association
Health Plans.--
``(1) Agreements with states.--The Secretary shall consult
with the State recognized under paragraph (2) with respect to
an association health plan regarding the exercise of--
``(A) the Secretary's authority under sections 502 and 504
to enforce the requirements for certification under part 8;
and
``(B) the Secretary's authority to certify association
health plans under part 8 in accordance with regulations of
the Secretary applicable to certification under part 8.
``(2) Recognition of primary domicile state.--In carrying
out paragraph (1), the Secretary shall ensure that only one
State will be recognized, with respect to any particular
association health plan, as the State with which consultation
is required. In carrying out this paragraph--
``(A) in the case of a plan which provides health insurance
coverage (as defined in section 812(a)(3)), such State shall
be the State with which filing and approval of a policy type
offered by the plan was initially obtained, and
``(B) in any other case, the Secretary shall take into
account the places of residence of the participants and
beneficiaries under the plan and the State in which the trust
is maintained.''.

SEC. 205. EFFECTIVE DATE AND TRANSITIONAL AND OTHER RULES.

(a) Effective Date.--The amendments made by this title
shall take effect 1 year after the date of the enactment of
this Act. The Secretary of Labor shall first issue all
regulations necessary to carry out the amendments made by
this title within 1 year after the date of the enactment of
this Act.
(b) Treatment of Certain Existing Health Benefits
Programs.--
(1) In general.--In any case in which, as of the date of
the enactment of this Act, an arrangement is maintained in a
State for the purpose of providing benefits consisting of
medical care for the employees and beneficiaries of its
participating employers, at least 200 participating employers
make contributions to such arrangement, such arrangement has
been in existence for at least 10 years, and such arrangement
is licensed under the laws of one or more States to provide
such benefits to its participating employers, upon the filing
with the applicable authority (as defined in section
812(a)(5) of the Employee Retirement Income Security Act of
1974 (as amended by this subtitle)) by the arrangement of an
application for certification of the arrangement under part 8
of subtitle B of title I of such Act--
(A) such arrangement shall be deemed to be a group health
plan for purposes of title I of such Act;
(B) the requirements of sections 801(a) and 803(a) of the
Employee Retirement Income Security Act of 1974 shall be
deemed met with respect to such arrangement;
(C) the requirements of section 803(b) of such Act shall be
deemed met, if the arrangement is operated by a board of
directors which--
(i) is elected by the participating employers, with each
employer having one vote; and

[[Page H12940]]

(ii) has complete fiscal control over the arrangement and
which is responsible for all operations of the arrangement;
(D) the requirements of section 804(a) of such Act shall be
deemed met with respect to such arrangement; and
(E) the arrangement may be certified by any applicable
authority with respect to its operations in any State only if
it operates in such State on the date of certification.

The provisions of this subsection shall cease to apply with
respect to any such arrangement at such time after the date
of the enactment of this Act as the applicable requirements
of this subsection are not met with respect to such
arrangement.
(2) Definitions.--For purposes of this subsection, the
terms ``group health plan'', ``medical care'', and
``participating employer'' shall have the meanings provided
in section 812 of the Employee Retirement Income Security Act
of 1974, except that the reference in paragraph (7) of such
section to an ``association health plan'' shall be deemed a
reference to an arrangement referred to in this subsection.

TITLE II--TARGETED EFFORTS TO EXPAND ACCESS

SEC. 211. EXTENDING COVERAGE OF DEPENDENTS.

(a) Employee Retirement Income Security Act of 1974.--
(1) In general.--Part 7 of subtitle B of title I of the
Employee Retirement Income Security Act of 1974 is amended by
inserting after section 2714 the following new section:

``SEC. 715. EXTENDING COVERAGE OF DEPENDENTS.

``(a) In General.--In the case of a group health plan, or
health insurance coverage offered in connection with a group
health plan, that treats as a beneficiary under the plan an
individual who is a dependent child of a participant or
beneficiary under the plan, the plan or coverage shall
continue to treat the individual as a dependent child without
regard to the individual's age through at least the end of
the plan year in which the individual turns an age specified
in the plan, but not less than 25 years of age.
``(b) Construction.--Nothing in this section shall be
construed as requiring a group health plan to provide
benefits for dependent children as beneficiaries under the
plan or to require a participant to elect coverage of
dependent children.''.
(2) Clerical amendment.--The table of contents of such Act
is amended by inserting after the item relating to section
714 the following new item:

``Sec. 715. Extending coverage of dependents through plan year that
includes 25th birthday.''.

(b) PHSA.--Title XXVII of the Public Health Service Act is
amended by inserting after section 2707 the following new
section:

``SEC. 2708. EXTENDING COVERAGE OF DEPENDENTS.

``(a) In General.--In the case of a group health plan, or
health insurance coverage offered in connection with a group
health plan, that treats as a beneficiary under the plan an
individual who is a dependent child of a participant or
beneficiary under the plan, the plan or coverage shall
continue to treat the individual as a dependent child without
regard to the individual's age through at least the end of
the plan year in which the individual turns an age specified
in the plan, but not less than 25 years of age.
``(b) Construction.--Nothing in this section shall be
construed as requiring a group health plan to provide
benefits for dependent children as beneficiaries under the
plan or to require a participant to elect coverage of
dependent children.''.
(c) IRC.--
(1) In general.--Subchapter B of chapter 100 of the
Internal Revenue Code of 1986 is amended by adding at the end
the following new section:

``SEC. 9814. EXTENDING COVERAGE OF DEPENDENTS.

``(a) In General.--In the case of a group health plan that
treats as a beneficiary under the plan an individual who is a
dependent child of a participant or beneficiary under the
plan, the plan shall continue to treat the individual as a
dependent child without regard to the individual's age
through at least the end of the plan year in which the
individual turns an age specified in the plan, but not less
than 25 years of age.
``(b) Construction.--Nothing in this section shall be
construed as requiring a group health plan to provide
coverage for dependent children as beneficiaries under the
plan or to require a participant to elect coverage of
dependent children.''.
(2) Clerical amendment.--The table of sections in such
subchapter is amended by adding at the end the following new
item:

``Sec. 9814. Extending coverage of dependents through plan year that
includes 25th birthday.''.

(d) Effective Date.--The amendments made by this section
shall apply to group health plans for plan years beginning
more than 3 months after the date of the enactment of this
Act and shall apply to individuals who are dependent children
under a group health plan, or health insurance coverage
offered in connection with such a plan, on or after such
date.

SEC. 212. ALLOWING AUTO-ENROLLMENT FOR EMPLOYER SPONSORED
COVERAGE.

(a) In General.--No State shall establish a law that
prevents an employer from instituting auto-enrollment for
coverage of a participant or beneficiary, including current
employees, under a group health plan, or health insurance
coverage offered in connection with such a plan, so long as
the participant or beneficiary has the option of declining
such coverage.
(b) Autoenrollment.--
(1) Notice required.--Employers with auto-enrollment under
a group health plan or health insurance coverage shall
provide annual notification, within a reasonable period
before the beginning of each plan year, to each employee
eligible to participate in the plan. The notice shall explain
the employee contribution to such plan and the employee's
right to decline coverage.
(2) Treatment of non-action.--After a reasonable period of
time after receipt of the notice, if an employee fails to
make an affirmative declaration declining coverage, then such
an employee may be enrolled in the group health plan or
health insurance coverage offered in connection with such a
plan.''
(c) Construction.--Nothing in this section shall be
construed to supersede State law which establishes,
implements, or continues in effect any standard or
requirement relating to employers in connection with payroll
or the sponsoring of employer sponsored health insurance
coverage except to the extent that such standard or
requirement prevents an employer from instituting the auto-
enrollment described in subsection (a).

TITLE III--EXPANDING CHOICES BY ALLOWING AMERICANS TO BUY HEALTH CARE
COVERAGE ACROSS STATE LINES

SEC. 221. INTERSTATE PURCHASING OF HEALTH INSURANCE.

(a) In General.--Title XXVII of the Public Health Service
Act (42 U.S.C. 300gg et seq.) is amended by adding at the end
the following new part:

``PART D--COOPERATIVE GOVERNING OF INDIVIDUAL HEALTH INSURANCE COVERAGE

``SEC. 2795. DEFINITIONS.

``In this part:
``(1) Primary state.--The term `primary State' means, with
respect to individual health insurance coverage offered by a
health insurance issuer, the State designated by the issuer
as the State whose covered laws shall govern the health
insurance issuer in the sale of such coverage under this
part. An issuer, with respect to a particular policy, may
only designate one such State as its primary State with
respect to all such coverage it offers. Such an issuer may
not change the designated primary State with respect to
individual health insurance coverage once the policy is
issued, except that such a change may be made upon renewal of
the policy. With respect to such designated State, the issuer
is deemed to be doing business in that State.
``(2) Secondary state.--The term `secondary State' means,
with respect to individual health insurance coverage offered
by a health insurance issuer, any State that is not the
primary State. In the case of a health insurance issuer that
is selling a policy in, or to a resident of, a secondary
State, the issuer is deemed to be doing business in that
secondary State.
``(3) Health insurance issuer.--The term `health insurance
issuer' has the meaning given such term in section
2791(b)(2), except that such an issuer must be licensed in
the primary State and be qualified to sell individual health
insurance coverage in that State.
``(4) Individual health insurance coverage.--The term
`individual health insurance coverage' means health insurance
coverage offered in the individual market, as defined in
section 2791(e)(1).
``(5) Applicable state authority.--The term `applicable
State authority' means, with respect to a health insurance
issuer in a State, the State insurance commissioner or
official or officials designated by the State to enforce the
requirements of this title for the State with respect to the
issuer.
``(6) Hazardous financial condition.--The term `hazardous
financial condition' means that, based on its present or
reasonably anticipated financial condition, a health
insurance issuer is unlikely to be able--
``(A) to meet obligations to policyholders with respect to
known claims and reasonably anticipated claims; or
``(B) to pay other obligations in the normal course of
business.
``(7) Covered laws.--
``(A) In general.--The term `covered laws' means the laws,
rules, regulations, agreements, and orders governing the
insurance business pertaining to--
``(i) individual health insurance coverage issued by a
health insurance issuer;
``(ii) the offer, sale, rating (including medical
underwriting), renewal, and issuance of individual health
insurance coverage to an individual;
``(iii) the provision to an individual in relation to
individual health insurance coverage of health care and
insurance related services;
``(iv) the provision to an individual in relation to
individual health insurance coverage of management,
operations, and investment activities of a health insurance
issuer; and
``(v) the provision to an individual in relation to
individual health insurance coverage of loss control and
claims administration for a health insurance issuer with
respect to liability for which the issuer provides insurance.
``(B) Exception.--Such term does not include any law, rule,
regulation, agreement,

[[Page H12941]]

or order governing the use of care or cost management
techniques, including any requirement related to provider
contracting, network access or adequacy, health care data
collection, or quality assurance.
``(8) State.--The term `State' means the 50 States and
includes the District of Columbia, Puerto Rico, the Virgin
Islands, Guam, American Samoa, and the Northern Mariana
Islands.
``(9) Unfair claims settlement practices.--The term `unfair
claims settlement practices' means only the following
practices:
``(A) Knowingly misrepresenting to claimants and insured
individuals relevant facts or policy provisions relating to
coverage at issue.
``(B) Failing to acknowledge with reasonable promptness
pertinent communications with respect to claims arising under
policies.
``(C) Failing to adopt and implement reasonable standards
for the prompt investigation and settlement of claims arising
under policies.
``(D) Failing to effectuate prompt, fair, and equitable
settlement of claims submitted in which liability has become
reasonably clear.
``(E) Refusing to pay claims without conducting a
reasonable investigation.
``(F) Failing to affirm or deny coverage of claims within a
reasonable period of time after having completed an
investigation related to those claims.
``(G) A pattern or practice of compelling insured
individuals or their beneficiaries to institute suits to
recover amounts due under its policies by offering
substantially less than the amounts ultimately recovered in
suits brought by them.
``(H) A pattern or practice of attempting to settle or
settling claims for less than the amount that a reasonable
person would believe the insured individual or his or her
beneficiary was entitled by reference to written or printed
advertising material accompanying or made part of an
application.
``(I) Attempting to settle or settling claims on the basis
of an application that was materially altered without notice
to, or knowledge or consent of, the insured.
``(J) Failing to provide forms necessary to present claims
within 15 calendar days of a requests with reasonable
explanations regarding their use.
``(K) Attempting to cancel a policy in less time than that
prescribed in the policy or by the law of the primary State.
``(10) Fraud and abuse.--The term `fraud and abuse' means
an act or omission committed by a person who, knowingly and
with intent to defraud, commits, or conceals any material
information concerning, one or more of the following:
``(A) Presenting, causing to be presented or preparing with
knowledge or belief that it will be presented to or by an
insurer, a reinsurer, broker or its agent, false information
as part of, in support of or concerning a fact material to
one or more of the following:
``(i) An application for the issuance or renewal of an
insurance policy or reinsurance contract.
``(ii) The rating of an insurance policy or reinsurance
contract.
``(iii) A claim for payment or benefit pursuant to an
insurance policy or reinsurance contract.
``(iv) Premiums paid on an insurance policy or reinsurance
contract.
``(v) Payments made in accordance with the terms of an
insurance policy or reinsurance contract.
``(vi) A document filed with the commissioner or the chief
insurance regulatory official of another jurisdiction.
``(vii) The financial condition of an insurer or reinsurer.
``(viii) The formation, acquisition, merger,
reconsolidation, dissolution or withdrawal from one or more
lines of insurance or reinsurance in all or part of a State
by an insurer or reinsurer.
``(ix) The issuance of written evidence of insurance.
``(x) The reinstatement of an insurance policy.
``(B) Solicitation or acceptance of new or renewal
insurance risks on behalf of an insurer reinsurer or other
person engaged in the business of insurance by a person who
knows or should know that the insurer or other person
responsible for the risk is insolvent at the time of the
transaction.
``(C) Transaction of the business of insurance in violation
of laws requiring a license, certificate of authority or
other legal authority for the transaction of the business of
insurance.
``(D) Attempt to commit, aiding or abetting in the
commission of, or conspiracy to commit the acts or omissions
specified in this paragraph.

``SEC. 2796. APPLICATION OF LAW.

``(a) In General.--The covered laws of the primary State
shall apply to individual health insurance coverage offered
by a health insurance issuer in the primary State and in any
secondary State, but only if the coverage and issuer comply
with the conditions of this section with respect to the
offering of coverage in any secondary State.
``(b) Exemptions From Covered Laws in a Secondary State.--
Except as provided in this section, a health insurance issuer
with respect to its offer, sale, rating (including medical
underwriting), renewal, and issuance of individual health
insurance coverage in any secondary State is exempt from any
covered laws of the secondary State (and any rules,
regulations, agreements, or orders sought or issued by such
State under or related to such covered laws) to the extent
that such laws would--
``(1) make unlawful, or regulate, directly or indirectly,
the operation of the health insurance issuer operating in the
secondary State, except that any secondary State may require
such an issuer--
``(A) to pay, on a nondiscriminatory basis, applicable
premium and other taxes (including high risk pool
assessments) which are levied on insurers and surplus lines
insurers, brokers, or policyholders under the laws of the
State;
``(B) to register with and designate the State insurance
commissioner as its agent solely for the purpose of receiving
service of legal documents or process;
``(C) to submit to an examination of its financial
condition by the State insurance commissioner in any State in
which the issuer is doing business to determine the issuer's
financial condition, if--
``(i) the State insurance commissioner of the primary State
has not done an examination within the period recommended by
the National Association of Insurance Commissioners; and
``(ii) any such examination is conducted in accordance with
the examiners' handbook of the National Association of
Insurance Commissioners and is coordinated to avoid
unjustified duplication and unjustified repetition;
``(D) to comply with a lawful order issued--
``(i) in a delinquency proceeding commenced by the State
insurance commissioner if there has been a finding of
financial impairment under subparagraph (C); or
``(ii) in a voluntary dissolution proceeding;
``(E) to comply with an injunction issued by a court of
competent jurisdiction, upon a petition by the State
insurance commissioner alleging that the issuer is in
hazardous financial condition;
``(F) to participate, on a nondiscriminatory basis, in any
insurance insolvency guaranty association or similar
association to which a health insurance issuer in the State
is required to belong;
``(G) to comply with any State law regarding fraud and
abuse (as defined in section 2795(10)), except that if the
State seeks an injunction regarding the conduct described in
this subparagraph, such injunction must be obtained from a
court of competent jurisdiction;
``(H) to comply with any State law regarding unfair claims
settlement practices (as defined in section 2795(9)); or
``(I) to comply with the applicable requirements for
independent review under section 2798 with respect to
coverage offered in the State;
``(2) require any individual health insurance coverage
issued by the issuer to be countersigned by an insurance
agent or broker residing in that Secondary State; or
``(3) otherwise discriminate against the issuer issuing
insurance in both the primary State and in any secondary
State.
``(c) Clear and Conspicuous Disclosure.--A health insurance
issuer shall provide the following notice, in 12-point bold
type, in any insurance coverage offered in a secondary State
under this part by such a health insurance issuer and at
renewal of the policy, with the 5 blank spaces therein being
appropriately filled with the name of the health insurance
issuer, the name of primary State, the name of the secondary
State, the name of the secondary State, and the name of the
secondary State, respectively, for the coverage concerned:

this policy is issued by _____ AND IS GOVERNED BY THE LAWS
AND REGULATIONS OF THE STATE OF _____, AND IT HAS MET ALL THE
LAWS OF THAT STATE AS DETERMINED BY THAT STATE'S DEPARTMENT
OF INSURANCE. THIS POLICY MAY BE LESS EXPENSIVE THAN OTHERS
BECAUSE IT IS NOT SUBJECT TO ALL OF THE INSURANCE LAWS AND
REGULATIONS OF THE STATE OF _____, INCLUDING COVERAGE OF SOME
SERVICES OR BENEFITS MANDATED BY THE LAW OF THE STATE OF
_____. ADDITIONALLY, THIS POLICY IS NOT SUBJECT TO ALL OF THE
CONSUMER PROTECTION LAWS OR RESTRICTIONS ON RATE CHANGES OF
THE STATE OF _____. AS WITH ALL INSURANCE PRODUCTS, BEFORE
PURCHASING THIS POLICY, YOU SHOULD CAREFULLY REVIEW THE
POLICY AND DETERMINE WHAT HEALTH CARE SERVICES THE POLICY
COVERS AND WHAT BENEFITS IT PROVIDES, INCLUDING ANY
EXCLUSIONS, LIMITATIONS, OR CONDITIONS FOR SUCH SERVICES OR
BENEFITS.''.
``(d) Prohibition on Certain Reclassifications and Premium
Increases.--
``(1) In general.--For purposes of this section, a health
insurance issuer that provides individual health insurance
coverage to an individual under this part in a primary or
secondary State may not upon renewal--
``(A) move or reclassify the individual insured under the
health insurance coverage from the class such individual is
in at the time of issue of the contract based on the health-
status related factors of the individual; or
``(B) increase the premiums assessed the individual for
such coverage based on a health status-related factor or
change of a health status-related factor or the past or
prospective claim experience of the insured individual.
``(2) Construction.--Nothing in paragraph (1) shall be
construed to prohibit a health insurance issuer--

[[Page H12942]]

``(A) from terminating or discontinuing coverage or a class
of coverage in accordance with subsections (b) and (c) of
section 2742;
``(B) from raising premium rates for all policy holders
within a class based on claims experience;
``(C) from changing premiums or offering discounted
premiums to individuals who engage in wellness activities at
intervals prescribed by the issuer, if such premium changes
or incentives--
``(i) are disclosed to the consumer in the insurance
contract;
``(ii) are based on specific wellness activities that are
not applicable to all individuals; and
``(iii) are not obtainable by all individuals to whom
coverage is offered;
``(D) from reinstating lapsed coverage; or
``(E) from retroactively adjusting the rates charged an
insured individual if the initial rates were set based on
material misrepresentation by the individual at the time of
issue.
``(e) Prior Offering of Policy in Primary State.--A health
insurance issuer may not offer for sale individual health
insurance coverage in a secondary State unless that coverage
is currently offered for sale in the primary State.
``(f) Licensing of Agents or Brokers for Health Insurance
Issuers.--Any State may require that a person acting, or
offering to act, as an agent or broker for a health insurance
issuer with respect to the offering of individual health
insurance coverage obtain a license from that State, with
commissions or other compensation subject to the provisions
of the laws of that State, except that a State may not impose
any qualification or requirement which discriminates against
a nonresident agent or broker.
``(g) Documents for Submission to State Insurance
Commissioner.--Each health insurance issuer issuing
individual health insurance coverage in both primary and
secondary States shall submit--
``(1) to the insurance commissioner of each State in which
it intends to offer such coverage, before it may offer
individual health insurance coverage in such State--
``(A) a copy of the plan of operation or feasibility study
or any similar statement of the policy being offered and its
coverage (which shall include the name of its primary State
and its principal place of business);
``(B) written notice of any change in its designation of
its primary State; and
``(C) written notice from the issuer of the issuer's
compliance with all the laws of the primary State; and
``(2) to the insurance commissioner of each secondary State
in which it offers individual health insurance coverage, a
copy of the issuer's quarterly financial statement submitted
to the primary State, which statement shall be certified by
an independent public accountant and contain a statement of
opinion on loss and loss adjustment expense reserves made
by--
``(A) a member of the American Academy of Actuaries; or
``(B) a qualified loss reserve specialist.
``(h) Power of Courts To Enjoin Conduct.--Nothing in this
section shall be construed to affect the authority of any
Federal or State court to enjoin--
``(1) the solicitation or sale of individual health
insurance coverage by a health insurance issuer to any person
or group who is not eligible for such insurance; or
``(2) the solicitation or sale of individual health
insurance coverage that violates the requirements of the law
of a secondary State which are described in subparagraphs (A)
through (H) of section 2796(b)(1).
``(i) Power of Secondary States To Take Administrative
Action.--Nothing in this section shall be construed to affect
the authority of any State to enjoin conduct in violation of
that State's laws described in section 2796(b)(1).
``(j) State Powers To Enforce State Laws.--
``(1) In general.--Subject to the provisions of subsection
(b)(1)(G) (relating to injunctions) and paragraph (2),
nothing in this section shall be construed to affect the
authority of any State to make use of any of its powers to
enforce the laws of such State with respect to which a health
insurance issuer is not exempt under subsection (b).
``(2) Courts of competent jurisdiction.--If a State seeks
an injunction regarding the conduct described in paragraphs
(1) and (2) of subsection (h), such injunction must be
obtained from a Federal or State court of competent
jurisdiction.
``(k) States' Authority To Sue.--Nothing in this section
shall affect the authority of any State to bring action in
any Federal or State court.
``(l) Generally Applicable Laws.--Nothing in this section
shall be construed to affect the applicability of State laws
generally applicable to persons or corporations.
``(m) Guaranteed Availability of Coverage to HIPAA Eligible
Individuals.--To the extent that a health insurance issuer is
offering coverage in a primary State that does not
accommodate residents of secondary States or does not provide
a working mechanism for residents of a secondary State, and
the issuer is offering coverage under this part in such
secondary State which has not adopted a qualified high risk
pool as its acceptable alternative mechanism (as defined in
section 2744(c)(2)), the issuer shall, with respect to any
individual health insurance coverage offered in a secondary
State under this part, comply with the guaranteed
availability requirements for eligible individuals in section
2741.

``SEC. 2797. PRIMARY STATE MUST MEET FEDERAL FLOOR BEFORE
ISSUER MAY SELL INTO SECONDARY STATES.

``A health insurance issuer may not offer, sell, or issue
individual health insurance coverage in a secondary State if
the State insurance commissioner does not use a risk-based
capital formula for the determination of capital and surplus
requirements for all health insurance issuers.

``SEC. 2798. INDEPENDENT EXTERNAL APPEALS PROCEDURES.

``(a) Right to External Appeal.--A health insurance issuer
may not offer, sell, or issue individual health insurance
coverage in a secondary State under the provisions of this
title unless--
``(1) both the secondary State and the primary State have
legislation or regulations in place establishing an
independent review process for individuals who are covered by
individual health insurance coverage, or
``(2) in any case in which the requirements of subparagraph
(A) are not met with respect to the either of such States,
the issuer provides an independent review mechanism
substantially identical (as determined by the applicable
State authority of such State) to that prescribed in the
`Health Carrier External Review Model Act' of the National
Association of Insurance Commissioners for all individuals
who purchase insurance coverage under the terms of this part,
except that, under such mechanism, the review is conducted by
an independent medical reviewer, or a panel of such
reviewers, with respect to whom the requirements of
subsection (b) are met.
``(b) Qualifications of Independent Medical Reviewers.--In
the case of any independent review mechanism referred to in
subsection (a)(2)--
``(1) In general.--In referring a denial of a claim to an
independent medical reviewer, or to any panel of such
reviewers, to conduct independent medical review, the issuer
shall ensure that--
``(A) each independent medical reviewer meets the
qualifications described in paragraphs (2) and (3);
``(B) with respect to each review, each reviewer meets the
requirements of paragraph (4) and the reviewer, or at least 1
reviewer on the panel, meets the requirements described in
paragraph (5); and
``(C) compensation provided by the issuer to each reviewer
is consistent with paragraph (6).
``(2) Licensure and expertise.--Each independent medical
reviewer shall be a physician (allopathic or osteopathic) or
health care professional who--
``(A) is appropriately credentialed or licensed in 1 or
more States to deliver health care services; and
``(B) typically treats the condition, makes the diagnosis,
or provides the type of treatment under review.
``(3) Independence.--
``(A) In general.--Subject to subparagraph (B), each
independent medical reviewer in a case shall--
``(i) not be a related party (as defined in paragraph (7));
``(ii) not have a material familial, financial, or
professional relationship with such a party; and
``(iii) not otherwise have a conflict of interest with such
a party (as determined under regulations).
``(B) Exception.--Nothing in subparagraph (A) shall be
construed to--
``(i) prohibit an individual, solely on the basis of
affiliation with the issuer, from serving as an independent
medical reviewer if--

``(I) a non-affiliated individual is not reasonably
available;
``(II) the affiliated individual is not involved in the
provision of items or services in the case under review;
``(III) the fact of such an affiliation is disclosed to the
issuer and the enrollee (or authorized representative) and
neither party objects; and
``(IV) the affiliated individual is not an employee of the
issuer and does not provide services exclusively or primarily
to or on behalf of the issuer;

``(ii) prohibit an individual who has staff privileges at
the institution where the treatment involved takes place from
serving as an independent medical reviewer merely on the
basis of such affiliation if the affiliation is disclosed to
the issuer and the enrollee (or authorized representative),
and neither party objects; or
``(iii) prohibit receipt of compensation by an independent
medical reviewer from an entity if the compensation is
provided consistent with paragraph (6).
``(4) Practicing health care professional in same field.--
``(A) In general.--In a case involving treatment, or the
provision of items or services--
``(i) by a physician, a reviewer shall be a practicing
physician (allopathic or osteopathic) of the same or similar
specialty, as a physician who, acting within the appropriate
scope of practice within the State in which the service is
provided or rendered, typically treats the condition, makes
the diagnosis, or provides the type of treatment under
review; or
``(ii) by a non-physician health care professional, the
reviewer, or at least 1 member of the review panel, shall be
a practicing non-physician health care professional of the
same or similar specialty as the non-physician health care
professional who, acting within the appropriate scope of
practice

[[Page H12943]]

within the State in which the service is provided or
rendered, typically treats the condition, makes the
diagnosis, or provides the type of treatment under review.
``(B) Practicing defined.--For purposes of this paragraph,
the term `practicing' means, with respect to an individual
who is a physician or other health care professional, that
the individual provides health care services to individual
patients on average at least 2 days per week.
``(5) Pediatric expertise.--In the case of an external
review relating to a child, a reviewer shall have expertise
under paragraph (2) in pediatrics.
``(6) Limitations on reviewer compensation.--Compensation
provided by the issuer to an independent medical reviewer in
connection with a review under this section shall--
``(A) not exceed a reasonable level; and
``(B) not be contingent on the decision rendered by the
reviewer.
``(7) Related party defined.--For purposes of this section,
the term `related party' means, with respect to a denial of a
claim under a coverage relating to an enrollee, any of the
following:
``(A) The issuer involved, or any fiduciary, officer,
director, or employee of the issuer.
``(B) The enrollee (or authorized representative).
``(C) The health care professional that provides the items
or services involved in the denial.
``(D) The institution at which the items or services (or
treatment) involved in the denial are provided.
``(E) The manufacturer of any drug or other item that is
included in the items or services involved in the denial.
``(F) Any other party determined under any regulations to
have a substantial interest in the denial involved.
``(8) Definitions.--For purposes of this subsection:
``(A) Enrollee.--The term `enrollee' means, with respect to
health insurance coverage offered by a health insurance
issuer, an individual enrolled with the issuer to receive
such coverage.
``(B) Health care professional.--The term `health care
professional' means an individual who is licensed,
accredited, or certified under State law to provide specified
health care services and who is operating within the scope of
such licensure, accreditation, or certification.

``SEC. 2799. ENFORCEMENT.

``(a) In General.--Subject to subsection (b), with respect
to specific individual health insurance coverage the primary
State for such coverage has sole jurisdiction to enforce the
primary State's covered laws in the primary State and any
secondary State.
``(b) Secondary State's Authority.--Nothing in subsection
(a) shall be construed to affect the authority of a secondary
State to enforce its laws as set forth in the exception
specified in section 2796(b)(1).
``(c) Court Interpretation.--In reviewing action initiated
by the applicable secondary State authority, the court of
competent jurisdiction shall apply the covered laws of the
primary State.
``(d) Notice of Compliance Failure.--In the case of
individual health insurance coverage offered in a secondary
State that fails to comply with the covered laws of the
primary State, the applicable State authority of the
secondary State may notify the applicable State authority of
the primary State.''.
(b) Effective Date.--The amendment made by subsection (a)
shall apply to individual health insurance coverage offered,
issued, or sold after the date that is one year after the
date of the enactment of this Act.
(c) GAO Ongoing Study and Reports.--
(1) Study.--The Comptroller General of the United States
shall conduct an ongoing study concerning the effect of the
amendment made by subsection (a) on--
(A) the number of uninsured and under-insured;
(B) the availability and cost of health insurance policies
for individuals with preexisting medical conditions;
(C) the availability and cost of health insurance policies
generally;
(D) the elimination or reduction of different types of
benefits under health insurance policies offered in different
States; and
(E) cases of fraud or abuse relating to health insurance
coverage offered under such amendment and the resolution of
such cases.
(2) Annual reports.--The Comptroller General shall submit
to Congress an annual report, after the end of each of the 5
years following the effective date of the amendment made by
subsection (a), on the ongoing study conducted under
paragraph (1).

TITLE IV--IMPROVING HEALTH SAVINGS ACCOUNTS

SEC. 231. SAVER'S CREDIT FOR CONTRIBUTIONS TO HEALTH SAVINGS
ACCOUNTS.

(a) Allowance of Credit.--Subsection (a) of section 25B of
the Internal Revenue Code of 1986 is amended by inserting
``aggregate qualified HSA contributions and'' after ``so much
of the''.
(b) Qualified HSA Contributions.--Subsection (d) of section
25B of such Code is amended by redesignating paragraph (2) as
paragraph (3) and by inserting after paragraph (1) the
following new paragraph:
``(2) Qualified hsa contributions.--The term `qualified HSA
contribution' means, with respect to any taxable year, a
contribution of the eligible individual to a health savings
account (as defined in section 223(d)(1)) for which a
deduction is allowable under section 223(a) for such taxable
year.''.
(c) Conforming Amendment.--The first sentence of section
25B(d)(3)(A) of such Code (as redesignated by subsection (b))
is amended to read as follows: ``The aggregate qualified
retirement savings contributions determined under paragraph
(1) and qualified HSA contributions determined under
paragraph (2) shall be reduced (but not below zero) by the
aggregate distributions received by the individual during the
testing period from any entity of a type to which
contributions under paragraph (1) or paragraph (2) (as the
case may be) may be made.''.
(d) Effective Date.--The amendments made by this section
shall apply to contributions made after December 31, 2009.

SEC. 232. HSA FUNDS FOR PREMIUMS FOR HIGH DEDUCTIBLE HEALTH
PLANS.

(a) In General.--Subparagraph (C) of section 223(d)(2) of
the Internal Revenue Code of 1986 is amended by striking
``or'' at the end of clause (iii), by striking the period at
the end of clause (iv) and inserting ``, or'', and by adding
at the end the following:
``(v) a high deductible health plan if--

``(I) such plan is not offered in connection with a group
health plan,
``(II) no portion of any premium (within the meaning of
applicable premium under section 4980B(f)(4)) for such plan
is excludable from gross income under section 106, and
``(III) the account beneficiary demonstrates, using
procedures deemed appropriate by the Secretary, that after
payment of the premium for such insurance the balance in the
health savings account is at least twice the minimum
deductible in effect under subsection (c)(2)(A)(i) which is
applicable to such plan.''.

(b) Effective Date.--The amendment made by subsection (a)
shall apply to premiums for a high deductible health plan for
periods beginning after December 31, 2009.

SEC. 233. REQUIRING GREATER COORDINATION BETWEEN HDHP
ADMINISTRATORS AND HSA ACCOUNT ADMINISTRATORS
SO THAT ENROLLEES CAN ENROLL IN BOTH AT THE
SAME TIME.

The Secretary of the Treasury, through the issuance of
regulations or other guidance, shall encourage administrators
of health plans and trustees of health savings accounts to
provide for simultaneous enrollment in high deductible health
plans and setup of health savings accounts.

SEC. 234. SPECIAL RULE FOR CERTAIN MEDICAL EXPENSES INCURRED
BEFORE ESTABLISHMENT OF ACCOUNT.

(a) In General.--Subsection (d) of section 223 of the
Internal Revenue Code of 1986 is amended by redesignating
paragraph (4) as paragraph (5) and by inserting after
paragraph (3) the following new paragraph:
``(4) Certain medical expenses incurred before
establishment of account treated as qualified.--
``(A) In general.--For purposes of paragraph (2), an
expense shall not fail to be treated as a qualified medical
expense solely because such expense was incurred before the
establishment of the health savings account if such expense
was incurred during the 60-day period beginning on the date
on which the high deductible health plan is first effective.
``(B) Special rules.--For purposes of subparagraph (A)--
``(i) an individual shall be treated as an eligible
individual for any portion of a month for which the
individual is described in subsection (c)(1), determined
without regard to whether the individual is covered under a
high deductible health plan on the 1st day of such month, and
``(ii) the effective date of the health savings account is
deemed to be the date on which the high deductible health
plan is first effective after the date of the enactment of
this paragraph.''.
(b) Effective Date.--The amendment made by this section
shall apply with respect to insurance purchased after the
date of the enactment of this Act in taxable years beginning
after such date.

DIVISION C--ENACTING REAL MEDICAL LIABILITY REFORM

SEC. 301. ENCOURAGING SPEEDY RESOLUTION OF CLAIMS.

The time for the commencement of a health care lawsuit
shall be 3 years after the date of manifestation of injury or
1 year after the claimant discovers, or through the use of
reasonable diligence should have discovered, the injury,
whichever occurs first. In no event shall the time for
commencement of a health care lawsuit exceed 3 years after
the date of manifestation of injury unless tolled for any of
the following--
(1) upon proof of fraud;
(2) intentional concealment; or
(3) the presence of a foreign body, which has no
therapeutic or diagnostic purpose or effect, in the person of
the injured person.

Actions by a minor shall be commenced within 3 years from the
date of the alleged manifestation of injury except that
actions by a minor under the full age of 6 years shall be
commenced within 3 years of manifestation of injury or prior
to the minor's 8th birthday, whichever provides a longer
period. Such time limitation shall be tolled for minors for
any period during which a parent or guardian and a health
care provider or health care organization have committed
fraud or collusion in the failure to bring an action on
behalf of the injured minor.

SEC. 302. COMPENSATING PATIENT INJURY.

(a) Unlimited Amount of Damages for Actual Economic Losses
in Health Care Lawsuits.--In any health care lawsuit, nothing

[[Page H12944]]

in this title shall limit a claimant's recovery of the full
amount of the available economic damages, notwithstanding the
limitation in subsection (b).
(b) Additional Noneconomic Damages.--In any health care
lawsuit, the amount of noneconomic damages, if available, may
be as much as $250,000, regardless of the number of parties
against whom the action is brought or the number of separate
claims or actions brought with respect to the same injury.
(c) No Discount of Award for Noneconomic Damages.--For
purposes of applying the limitation in subsection (b), future
noneconomic damages shall not be discounted to present value.
The jury shall not be informed about the maximum award for
noneconomic damages. An award for noneconomic damages in
excess of $250,000 shall be reduced either before the entry
of judgment, or by amendment of the judgment after entry of
judgment, and such reduction shall be made before accounting
for any other reduction in damages required by law. If
separate awards are rendered for past and future noneconomic
damages and the combined awards exceed $250,000, the future
noneconomic damages shall be reduced first.
(d) Fair Share Rule.--In any health care lawsuit, each
party shall be liable for that party's several share of any
damages only and not for the share of any other person. Each
party shall be liable only for the amount of damages
allocated to such party in direct proportion to such party's
percentage of responsibility. Whenever a judgment of
liability is rendered as to any party, a separate judgment
shall be rendered against each such party for the amount
allocated to such party. For purposes of this section, the
trier of fact shall determine the proportion of
responsibility of each party for the claimant's harm.

SEC. 303. MAXIMIZING PATIENT RECOVERY.

(a) Court Supervision of Share of Damages Actually Paid to
Claimants.--In any health care lawsuit, the court shall
supervise the arrangements for payment of damages to protect
against conflicts of interest that may have the effect of
reducing the amount of damages awarded that are actually paid
to claimants. In particular, in any health care lawsuit in
which the attorney for a party claims a financial stake in
the outcome by virtue of a contingent fee, the court shall
have the power to restrict the payment of a claimant's damage
recovery to such attorney, and to redirect such damages to
the claimant based upon the interests of justice and
principles of equity. In no event shall the total of all
contingent fees for representing all claimants in a health
care lawsuit exceed the following limits:
(1) 40 percent of the first $50,000 recovered by the
claimant(s).
(2) 33\1/3\ percent of the next $50,000 recovered by the
claimant(s).
(3) 25 percent of the next $500,000 recovered by the
claimant(s).
(4) 15 percent of any amount by which the recovery by the
claimant(s) is in excess of $600,000.
(b) Applicability.--The limitations in this section shall
apply whether the recovery is by judgment, settlement,
mediation, arbitration, or any other form of alternative
dispute resolution. In a health care lawsuit involving a
minor or incompetent person, a court retains the authority to
authorize or approve a fee that is less than the maximum
permitted under this section. The requirement for court
supervision in the first two sentences of subsection (a)
applies only in civil actions.

SEC. 304. ADDITIONAL HEALTH BENEFITS.

In any health care lawsuit involving injury or wrongful
death, any party may introduce evidence of collateral source
benefits. If a party elects to introduce such evidence, any
opposing party may introduce evidence of any amount paid or
contributed or reasonably likely to be paid or contributed in
the future by or on behalf of the opposing party to secure
the right to such collateral source benefits. No provider of
collateral source benefits shall recover any amount against
the claimant or receive any lien or credit against the
claimant's recovery or be equitably or legally subrogated to
the right of the claimant in a health care lawsuit involving
injury or wrongful death. This section shall apply to any
health care lawsuit that is settled as well as a health care
lawsuit that is resolved by a fact finder. This section shall
not apply to section 1862(b) (42 U.S.C. 1395y(b)) or section
1902(a)(25) (42 U.S.C. 1396a(a)(25)) of the Social Security
Act.

SEC. 305. PUNITIVE DAMAGES.

(a) In General.--Punitive damages may, if otherwise
permitted by applicable State or Federal law, be awarded
against any person in a health care lawsuit only if it is
proven by clear and convincing evidence that such person
acted with malicious intent to injure the claimant, or that
such person deliberately failed to avoid unnecessary injury
that such person knew the claimant was substantially certain
to suffer. In any health care lawsuit where no judgment for
compensatory damages is rendered against such person, no
punitive damages may be awarded with respect to the claim in
such lawsuit. No demand for punitive damages shall be
included in a health care lawsuit as initially filed. A court
may allow a claimant to file an amended pleading for punitive
damages only upon a motion by the claimant and after a
finding by the court, upon review of supporting and opposing
affidavits or after a hearing, after weighing the evidence,
that the claimant has established by a substantial
probability that the claimant will prevail on the claim for
punitive damages. At the request of any party in a health
care lawsuit, the trier of fact shall consider in a separate
proceeding--
(1) whether punitive damages are to be awarded and the
amount of such award; and
(2) the amount of punitive damages following a
determination of punitive liability.

If a separate proceeding is requested, evidence relevant only
to the claim for punitive damages, as determined by
applicable State law, shall be inadmissible in any proceeding
to determine whether compensatory damages are to be awarded.
(b) Determining Amount of Punitive Damages.--
(1) Factors considered.--In determining the amount of
punitive damages, if awarded, in a health care lawsuit, the
trier of fact shall consider only the following--
(A) the severity of the harm caused by the conduct of such
party;
(B) the duration of the conduct or any concealment of it by
such party;
(C) the profitability of the conduct to such party;
(D) the number of products sold or medical procedures
rendered for compensation, as the case may be, by such party,
of the kind causing the harm complained of by the claimant;
(E) any criminal penalties imposed on such party, as a
result of the conduct complained of by the claimant; and
(F) the amount of any civil fines assessed against such
party as a result of the conduct complained of by the
claimant.
(2) Maximum award.--The amount of punitive damages, if
awarded, in a health care lawsuit may be as much as $250,000
or as much as two times the amount of economic damages
awarded, whichever is greater. The jury shall not be informed
of this limitation.

SEC. 306. AUTHORIZATION OF PAYMENT OF FUTURE DAMAGES TO
CLAIMANTS IN HEALTH CARE LAWSUITS.

(a) In General.--In any health care lawsuit, if an award of
future damages, without reduction to present value, equaling
or exceeding $50,000 is made against a party with sufficient
insurance or other assets to fund a periodic payment of such
a judgment, the court shall, at the request of any party,
enter a judgment ordering that the future damages be paid by
periodic payments. In any health care lawsuit, the court may
be guided by the Uniform Periodic Payment of Judgments Act
promulgated by the National Conference of Commissioners on
Uniform State Laws.
(b) Applicability.--This section applies to all actions
which have not been first set for trial or retrial before the
effective date of this title.

SEC. 307. DEFINITIONS.

In this title:
(1) Alternative dispute resolution system; adr.--The term
``alternative dispute resolution system'' or ``ADR'' means a
system that provides for the resolution of health care
lawsuits in a manner other than through a civil action
brought in a State or Federal court.
(2) Claimant.--The term ``claimant'' means any person who
brings a health care lawsuit, including a person who asserts
or claims a right to legal or equitable contribution,
indemnity, or subrogation, arising out of a health care
liability claim or action, and any person on whose behalf
such a claim is asserted or such an action is brought,
whether deceased, incompetent, or a minor.
(3) Collateral source benefits.--The term ``collateral
source benefits'' means any amount paid or reasonably likely
to be paid in the future to or on behalf of the claimant, or
any service, product, or other benefit provided or reasonably
likely to be provided in the future to or on behalf of the
claimant, as a result of the injury or wrongful death,
pursuant to--
(A) any State or Federal health, sickness, income-
disability, accident, or workers' compensation law;
(B) any health, sickness, income-disability, or accident
insurance that provides health benefits or income-disability
coverage;
(C) any contract or agreement of any group, organization,
partnership, or corporation to provide, pay for, or reimburse
the cost of medical, hospital, dental, or income-disability
benefits; and
(D) any other publicly or privately funded program.
(4) Compensatory damages.--The term ``compensatory
damages'' means objectively verifiable monetary losses
incurred as a result of the provision of, use of, or payment
for (or failure to provide, use, or pay for) health care
services or medical products, such as past and future medical
expenses, loss of past and future earnings, cost of obtaining
domestic services, loss of employment, and loss of business
or employment opportunities, damages for physical and
emotional pain, suffering, inconvenience, physical
impairment, mental anguish, disfigurement, loss of enjoyment
of life, loss of society and companionship, loss of
consortium (other than loss of domestic service), hedonic
damages, injury to reputation, and all other nonpecuniary
losses of any kind or nature. The term ``compensatory
damages'' includes economic damages and noneconomic damages,
as such terms are defined in this section.
(5) Contingent fee.--The term ``contingent fee'' includes
all compensation to any person or persons which is payable
only if a recovery is effected on behalf of one or more
claimants.

[[Page H12945]]

(6) Economic damages.--The term ``economic damages'' means
objectively verifiable monetary losses incurred as a result
of the provision of, use of, or payment for (or failure to
provide, use, or pay for) health care services or medical
products, such as past and future medical expenses, loss of
past and future earnings, cost of obtaining domestic
services, loss of employment, and loss of business or
employment opportunities.
(7) Health care lawsuit.--The term ``health care lawsuit''
means any health care liability claim concerning the
provision of health care goods or services or any medical
product affecting interstate commerce, or any health care
liability action concerning the provision of health care
goods or services or any medical product affecting interstate
commerce, brought in a State or Federal court or pursuant to
an alternative dispute resolution system, against a health
care provider, a health care organization, or the
manufacturer, distributor, supplier, marketer, promoter, or
seller of a medical product, regardless of the theory of
liability on which the claim is based, or the number of
claimants, plaintiffs, defendants, or other parties, or the
number of claims or causes of action, in which the claimant
alleges a health care liability claim. Such term does not
include a claim or action which is based on criminal
liability; which seeks civil fines or penalties paid to
Federal, State, or local government; or which is grounded in
antitrust.
(8) Health care liability action.--The term ``health care
liability action'' means a civil action brought in a State or
Federal court or pursuant to an alternative dispute
resolution system, against a health care provider, a health
care organization, or the manufacturer, distributor,
supplier, marketer, promoter, or seller of a medical product,
regardless of the theory of liability on which the claim is
based, or the number of plaintiffs, defendants, or other
parties, or the number of causes of action, in which the
claimant alleges a health care liability claim.
(9) Health care liability claim.--The term ``health care
liability claim'' means a demand by any person, whether or
not pursuant to ADR, against a health care provider, health
care organization, or the manufacturer, distributor,
supplier, marketer, promoter, or seller of a medical product,
including, but not limited to, third-party claims, cross-
claims, counter-claims, or contribution claims, which are
based upon the provision of, use of, or payment for (or the
failure to provide, use, or pay for) health care services or
medical products, regardless of the theory of liability on
which the claim is based, or the number of plaintiffs,
defendants, or other parties, or the number of causes of
action.
(10) Health care organization.--The term ``health care
organization'' means any person or entity which is obligated
to provide or pay for health benefits under any health plan,
including any person or entity acting under a contract or
arrangement with a health care organization to provide or
administer any health benefit.
(11) Health care provider.--The term ``health care
provider'' means any person or entity required by State or
Federal laws or regulations to be licensed, registered, or
certified to provide health care services, and being either
so licensed, registered, or certified, or exempted from such
requirement by other statute or regulation.
(12) Health care goods or services.--The term ``health care
goods or services'' means any goods or services provided by a
health care organization, provider, or by any individual
working under the supervision of a health care provider, that
relates to the diagnosis, prevention, or treatment of any
human disease or impairment, or the assessment or care of the
health of human beings.
(13) Malicious intent to injure.--The term ``malicious
intent to injure'' means intentionally causing or attempting
to cause physical injury other than providing health care
goods or services.
(14) Medical product.--The term ``medical product'' means a
drug, device, or biological product intended for humans, and
the terms ``drug'', ``device'', and ``biological product''
have the meanings given such terms in sections 201(g)(1) and
201(h) of the Federal Food, Drug and Cosmetic Act (21 U.S.C.
321(g)(1) and (h)) and section 351(a) of the Public Health
Service Act (42 U.S.C. 262(a)), respectively, including any
component or raw material used therein, but excluding health
care services.
(15) Noneconomic damages.--The term ``noneconomic damages''
means damages for physical and emotional pain, suffering,
inconvenience, physical impairment, mental anguish,
disfigurement, loss of enjoyment of life, loss of society and
companionship, loss of consortium (other than loss of
domestic service), hedonic damages, injury to reputation, and
all other nonpecuniary losses of any kind or nature.
(16) Punitive damages.--The term ``punitive damages'' means
damages awarded, for the purpose of punishment or deterrence,
and not solely for compensatory purposes, against a health
care provider, health care organization, or a manufacturer,
distributor, or supplier of a medical product. Punitive
damages are neither economic nor noneconomic damages.
(17) Recovery.--The term ``recovery'' means the net sum
recovered after deducting any disbursements or costs incurred
in connection with prosecution or settlement of the claim,
including all costs paid or advanced by any person. Costs of
health care incurred by the plaintiff and the attorneys'
office overhead costs or charges for legal services are not
deductible disbursements or costs for such purpose.
(18) State.--The term ``State'' means each of the several
States, the District of Columbia, the Commonwealth of Puerto
Rico, the Virgin Islands, Guam, American Samoa, the Northern
Mariana Islands, the Trust Territory of the Pacific Islands,
and any other territory or possession of the United States,
or any political subdivision thereof.

SEC. 308. EFFECT ON OTHER LAWS.

(a) Vaccine Injury.--
(1) To the extent that title XXI of the Public Health
Service Act establishes a Federal rule of law applicable to a
civil action brought for a vaccine-related injury or death--
(A) this title does not affect the application of the rule
of law to such an action; and
(B) any rule of law prescribed by this title in conflict
with a rule of law of such title XXI shall not apply to such
action.
(2) If there is an aspect of a civil action brought for a
vaccine-related injury or death to which a Federal rule of
law under title XXI of the Public Health Service Act does not
apply, then this title or otherwise applicable law (as
determined under this title) will apply to such aspect of
such action.
(b) Other Federal Law.--Except as provided in this section,
nothing in this title shall be deemed to affect any defense
available to a defendant in a health care lawsuit or action
under any other provision of Federal law.

SEC. 309. STATE FLEXIBILITY AND PROTECTION OF STATES' RIGHTS.

(a) Health Care Lawsuits.--The provisions governing health
care lawsuits set forth in this title preempt, subject to
subsections (b) and (c), State law to the extent that State
law prevents the application of any provisions of law
established by or under this title. The provisions governing
health care lawsuits set forth in this title supersede
chapter 171 of title 28, United States Code, to the extent
that such chapter--
(1) provides for a greater amount of damages or contingent
fees, a longer period in which a health care lawsuit may be
commenced, or a reduced applicability or scope of periodic
payment of future damages, than provided in this title; or
(2) prohibits the introduction of evidence regarding
collateral source benefits, or mandates or permits
subrogation or a lien on collateral source benefits.
(b) Protection of States' Rights and Other Laws.--(1) Any
issue that is not governed by any provision of law
established by or under this title (including State standards
of negligence) shall be governed by otherwise applicable
State or Federal law.
(2) This title shall not preempt or supersede any State or
Federal law that imposes greater procedural or substantive
protections for health care providers and health care
organizations from liability, loss, or damages than those
provided by this title or create a cause of action.
(c) State Flexibility.--No provision of this title shall be
construed to preempt--
(1) any State law (whether effective before, on, or after
the date of the enactment of this Act) that specifies a
particular monetary amount of compensatory or punitive
damages (or the total amount of damages) that may be awarded
in a health care lawsuit, regardless of whether such monetary
amount is greater or lesser than is provided for under this
title, notwithstanding section 302(a); or
(2) any defense available to a party in a health care
lawsuit under any other provision of State or Federal law.

SEC. 310. APPLICABILITY; EFFECTIVE DATE.

This title shall apply to any health care lawsuit brought
in a Federal or State court, or subject to an alternative
dispute resolution system, that is initiated on or after the
date of the enactment of this Act, except that any health
care lawsuit arising from an injury occurring prior to the
date of the enactment of this Act shall be governed by the
applicable statute of limitations provisions in effect at the
time the injury occurred.

DIVISION D--PROTECTING THE DOCTOR-PATIENT RELATIONSHIP

SEC. 401. RULE OF CONSTRUCTION.

Nothing in this Act shall be construed to interfere with
the doctor-patient relationship or the practice of medicine.

SEC. 402. REPEAL OF FEDERAL COORDINATING COUNCIL FOR
COMPARATIVE EFFECTIVENESS RESEARCH.

Effective on the date of the enactment of this Act, section
804 of the American Recovery and Reinvestment Act of 2009 is
repealed.

DIVISION E--INCENTIVIZING WELLNESS AND QUALITY IMPROVEMENTS

SEC. 501. INCENTIVES FOR PREVENTION AND WELLNESS PROGRAMS.

(a) Employee Retirement Income Security Act of 1974
Limitation on Exception for Wellness Programs Under HIPAA
Discrimination Rules.--
(1) In general.--Section 702(b)(2) of the Employee
Retirement Income Security Act of 1974 (29 U.S.C. 1182(b)(2))
is amended by adding after and below subparagraph (B) the
following:

``In applying subparagraph (B), a group health plan (or a
health insurance issuer with respect to health insurance
coverage) may vary premiums and cost-sharing by up to 50
percent of the value of the benefits under the plan (or
coverage) based on participation in a standards-based
wellness program.''.

[[Page H12946]]

(2) Effective date.--The amendment made by paragraph (1)
shall apply to plan years beginning more than 1 year after
the date of the enactment of this Act.
(b) Conforming Amendments to PHSA.--
(1) Group market rules.--
(A) In general.--Section 2702(b)(2) of the Public Health
Service Act (42 U.S.C. 300gg-1(b)(2)) is amended by adding
after and below subparagraph (B) the following:

``In applying subparagraph (B), a group health plan (or a
health insurance issuer with respect to health insurance
coverage) may vary premiums and cost-sharing by up to 50
percent of the value of the benefits under the plan (or
coverage) based on participation in a standards-based
wellness program.''.
(B) Effective date.--The amendment made by subparagraph (A)
shall apply to plan years beginning more than 1 year after
the date of the enactment of this Act.
(2) Individual market rules relating to guaranteed
availability.--
(A) In general.--Section 2741(f) of the Public Health
Service Act (42 U.S.C. 300gg-1(b)(2)) is amended by adding
after and below paragraph (1) the following:

``In applying paragraph (2), a health insurance issuer may
vary premiums and cost-sharing under health insurance
coverage by up to 50 percent of the value of the benefits
under the coverage based on participation in a standards-
based wellness program.''.
(B) Effective date.--The amendment made by paragraph (1)
shall apply to health insurance coverage offered or renewed
on and after the date that is 1 year after the date of the
enactment of this Act.
(c) Conforming Amendments to IRC.--
(1) In general.--Section 9802(b)(2) of the Internal Revenue
Code of 1986 is amended by adding after and below
subparagraph (B) the following:

``In applying subparagraph (B), a group health plan (or a
health insurance issuer with respect to health insurance
coverage) may vary premiums and cost-sharing by up to 50
percent of the value of the benefits under the plan (or
coverage) based on participation in a standards-based
wellness program.''.
(2) Effective date.--The amendment made by paragraph (1)
shall apply to plan years beginning more than 1 year after
the date of the enactment of this Act.

DIVISION F--PROTECTING TAXPAYERS

SEC. 601. PROVIDE FULL FUNDING TO HHS OIG AND HCFAC.

(a) HCFAC Funding.-- Section 1817(k)(3)(A) of the Social
Security Act (42 U.S.C. 1395i(k)(3)(A)) is amended--
(1) in clause (i)--
(A) in subclause (IV), by striking ``2009, and 2010'' and
inserting ``and 2009''; and
(B) by amending subclause (V) to read as follows:

``(V) for each fiscal year after fiscal year 2009,
$300,000,000.''; and

(2) in clause (ii)--
(A) in subclause (IX), by striking ``2009, and 2010'' and
inserting ``and 2009''; and
(B) in subclause (X), by striking ``2010'' and inserting
``2009'' and by inserting before the period at the end the
following: ``, plus the amount by which the amount made
available under clause (i)(V) for fiscal year 2010 exceeds
the amount made available under clause (i)(IV) for 2009''.
(b) OIG Funding.--There are authorized to be appropriated
for each of fiscal years 2010 through 2019 $100,000,000 for
the Office of the Inspector General of the Department of
Health and Human Services for fraud prevention activities
under the Medicare and Medicaid programs.

SEC. 602. PROHIBITING TAXPAYER FUNDED ABORTIONS AND
CONSCIENCE PROTECTIONS.

Title 1 of the United States Code is amended by adding at
the end the following new chapter:

``CHAPTER 4--PROHIBITING TAXPAYER FUNDED ABORTIONS AND CONSCIENCE
PROTECTIONS

``SEC. 301. PROHIBITION ON FUNDING FOR ABORTIONS.

``No funds authorized or appropriated by federal law, and
none of the funds in any trust fund to which funds are
authorized or appropriated by federal law, shall be expended
for any abortion.

``SEC. 302. PROHIBITION ON FUNDING FOR HEALTH BENEFITS PLANS
THAT COVER ABORTION.

``None of the funds authorized or appropriated by federal
law, and none of the funds in any trust fund to which funds
are authorized or appropriated by federal law, shall be
expended for a health benefits plan that includes coverage of
abortion.

``SEC. 303. TREATMENT OF ABORTIONS RELATED TO RAPE, INCEST,
OR PRESERVING THE LIFE OF THE MOTHER.

``The limitations established in sections 301 and 302 shall
not apply to an abortion--
``(1) if the pregnancy is the result of an act of rape or
incest; or
``(2) in the case where a woman suffers from a physical
disorder, physical injury, or physical illness that would, as
certified by a physician, place the woman in danger of death
unless an abortion is performed, including a life-endangering
physical condition caused by or arising from the pregnancy
itself.

``SEC. 304. CONSTRUCTION RELATING TO SUPPLEMENTAL COVERAGE.

``Nothing in this chapter shall be construed as prohibiting
any individual, entity, or State or locality from purchasing
separate supplemental abortion plan or coverage that includes
abortion so long as such plan or coverage is paid for
entirely using only funds not authorized or appropriated by
federal law and such plan or coverage shall not be purchased
using matching funds required for a federally subsidized
program, including a State's or locality's contribution of
Medicaid matching funds.

``SEC. 305. CONSTRUCTION RELATING TO THE USE OF NON-FEDERAL
FUNDS FOR HEALTH COVERAGE.

``Nothing in this chapter shall be construed as restricting
the ability of any managed care provider or other
organization from offering abortion coverage or the ability
of a State to contract separately with such a provider or
organization for such coverage with funds not authorized or
appropriated by federal law and such plan or coverage shall
not be purchased using matching funds required for a
federally subsidized program, including a State's or
locality's contribution of Medicaid matching funds.

``SEC. 306. NO GOVERNMENT DISCRIMINATION AGAINST CERTAIN
HEALTH CARE ENTITIES.

``(a) In General.--No funds authorized or appropriated by
federal law may be made available to a Federal agency or
program, or to a State or local government, if such agency,
program, or government subjects any institutional or
individual health care entity to discrimination on the basis
that the health care entity does not provide, pay for,
provide coverage of, or refer for abortions.
``(b) Health Care Entity Defined.--For purposes of this
section, the term `health care entity' includes an individual
physician or other health care professional, a hospital, a
provider-sponsored organization, a health maintenance
organization, a health insurance plan, or any other kind of
health care facility, organization, or plan.''.

SEC. 603. IMPROVED ENFORCEMENT OF THE MEDICARE AND MEDICAID
SECONDARY PAYER PROVISIONS.

(a) Medicare.--
(1) In general.--The Secretary, in coordination with the
Inspector General of the Department of Health and Human
Services, shall provide through the Coordination of Benefits
Contractor for the identification of instances where the
Medicare program should be, but is not, acting as a secondary
payer to an individual's private health benefits coverage
under section 1862(b) of the Social Security Act (42 U.S.C.
1395y(b)).
(2) Updating procedures.--The Secretary shall update
procedures for identifying and resolving credit balance
situations which occur under the Medicare program when
payment under such title and from other health benefit plans
exceed the providers' charges or the allowed amount.
(3) Report on improved enforcement.--Not later than 1 year
after the date of the enactment of this Act, the Secretary
shall submit a report to Congress on progress made in
improved enforcement of the Medicare secondary payer
provisions, including recoupment of credit balances.
(b) Medicaid.--Section 1903 of the Social Security Act (42
U.S.C. 1396b) is amended by adding at the end the following
new subsection:
``(aa) Enforcement of Payer of Last Resort Provisions.--
``(1) Submission of state plan amendment.--Each State shall
submit, not later than 1 year after the date of the enactment
of this subsection, a State plan amendment that details how
the State will become fully compliant with the requirements
of section 1902(a)(25).
``(2) Bonus for compliance.--If a State submits a timely
State plan amendment under paragraph (1) that the Secretary
determines provides for full compliance of the State with the
requirements of section 1902(a)(25), the Secretary shall
provide for an additional payment to the State of $1,000,000.
If a State certifies, to the Secretary's satisfaction, that
it is already fully compliant with such requirements, such
amount shall be increased to $2,000,000.
``(3) Reduction for noncompliance.--If a State does not
submit such an amendment, the Secretary shall reduce the
Federal medical assistance percentage otherwise applicable
under this title by 1 percentage point until the State
submits such an amendment.
``(4) Ongoing reduction.--If at any time the Secretary
determines that a State is not in compliance with section
1902(a)(25), regardless of the status of the State's
submission of a State plan amendment under this subsection or
previous determinations of compliance such requirements, the
Secretary shall reduce the Federal medical assistance
percentage otherwise applicable under this title for the
State by 1 percentage point during the period of non-
compliance as determined by the Secretary.''.

SEC. 604. STRENGTHEN MEDICARE PROVIDER ENROLLMENT STANDARDS
AND SAFEGUARDS.

(a) Protecting Against the Fraudulent Use of Medicare
Provider Numbers.--Subject to subsection (c)(2)--
(1) Screening new providers.--As a condition of a provider
of services or a supplier, including durable medical
equipment suppliers and home health agencies, applying for
the first time for a provider number under the Medicare
program and before granting billing privileges under such
title, the Secretary shall screen the provider or supplier
for a criminal background or other financial or operational
irregularities

[[Page H12947]]

through fingerprinting, licensure checks, site-visits, other
database checks.
(2) Application fees.--The Secretary shall impose an
application charge on such a provider or supplier in order to
cover the Secretary's costs in performing the screening
required under paragraph (1) and that is revenue neutral to
the Federal government.
(3) Provisional approval.--During an initial, provisional
period (specified by the Secretary) In which such a provider
or supplier has been issued such a number, the Secretary
shall provide enhanced oversight of the activities of such
provider or supplier under the Medicare program, such as
through prepayment review and payment limitations.
(4) Penalties for false statements.--In the case of a
provider or supplier that makes a false statement in an
application for such a number, the Secretary may exclude the
provider or supplier from participation under the Medicare
program, or may impose a civil money penalty (in the amount
described in section 1128A(a)(4) of the Social Security Act),
in the same manner as the Secretary may impose such an
exclusion or penalty under sections 1128 and 1128A,
respectively, of such Act in the case of knowing presentation
of a false claim described in section 1128A(a)(1)(A) of such
Act.
(5) Disclosure requirements.--With respect to approval of
such an application, the Secretary--
(A) shall require applicants to disclose previous
affiliation with enrolled entities that have uncollected debt
related to the Medicare or Medicaid programs;
(B) may deny approval if the Secretary determines that
these affiliations pose undue risk to the Medicare or
Medicaid program, subject to an appeals process for the
applicant as determined by the Secretary; and
(C) may implement enhanced safeguards (such as surety
bonds).
(b) Moratoria.--The Secretary may impose moratoria on
approval of provider and supplier numbers under the Medicare
program for new providers of services and suppliers as
determined necessary to prevent or combat fraud a period of
delay for any one applicant cannot exceed 30 days unless
cause is shown by the Secretary.
(c) Funding.--
(1) In general.--There are authorized to be appropriated to
carry out this section such sums as may be necessary.
(2) Condition.--The provisions of paragraphs (1) and (2) of
subsection (a) shall not apply unless and until funds are
appropriated to carry out such provisions.

SEC. 605. TRACKING BANNED PROVIDERS ACROSS STATE LINES.

(a) Greater Coordination.--The Secretary of Health and
Human Services shall provide for increased coordination
between the Administrator of the Centers for Medicare &
Medicaid Services (in this section referred to as ``CMS'')
and its regional offices to ensure that providers of services
and suppliers that have operated in one State and are
excluded from participation in the Medicare program are
unable to begin operation and participation in the Medicare
program in another State.
(b) Improved Information Systems.--
(1) In general.--The Secretary shall improve information
systems to allow greater integration between databases under
the Medicare program so that--
(A) medicare administrative contractors, fiscal
intermediaries, and carriers have immediate access to
information identifying providers and suppliers excluded from
participation in the Medicare and Medicaid program and other
Federal health care programs; and
(B) such information can be shared across Federal health
care programs and agencies, including between the Departments
of Health and Human Services, the Social Security
Administration, the Department of Veterans Affairs, the
Department of Defense, the Department of Justice, and the
Office of Personnel Management.
(c) Medicare/Medicaid ``One PI'' Database.--The Secretary
shall implement a database that includes claims and payment
data for all components of the Medicare program and the
Medicaid program.
(d) Authorizing Expanded Data Matching.--Notwithstanding
any provision of the Computer Matching and Privacy Protection
Act of 1988 to the contrary--
(1) the Secretary and the Inspector General in the
Department of Health and Human Services may perform data
matching of data from the Medicare program with data from the
Medicaid program; and
(2) the Commissioner of Social Security and the Secretary
may perform data matching of data of the Social Security
Administration with data from the Medicare and Medicaid
programs.
(e) Consolidation of Data Bases.--The Secretary shall
consolidate and expand into a centralized data base for
individuals and entities that have been excluded from Federal
health care programs the Healthcare Integrity and Protection
Data Bank, the National Practitioner Data Bank, the List of
Excluded Individuals/Entities, and a national patient abuse/
neglect registry.
(f) Comprehensive Provider Database.--
(1) Establishment.--The Secretary shall establish a
comprehensive database that includes information on providers
of services, suppliers, and related entities participating in
the Medicare program, the Medicaid program, or both. Such
database shall include, information on ownership and business
relationships, history of adverse actions, results of site
visits or other monitoring by any program.
(2) Use.--Prior to issuing a provider or supplier number
for an entity under the Medicare program, the Secretary shall
obtain information on the entity from such database to assure
the entity qualifies for the issuance of such a number.
(g) Comprehensive Sanctions Database.--The Secretary shall
establish a comprehensive sanctions database on sanctions
imposed on providers of services, suppliers, and related
entities. Such database shall be overseen by the Inspector
General of the Department of Health and Human Services and
shall be linked to related databases maintained by State
licensure boards and by Federal or State law enforcement
agencies.
(h) Access to Claims and Payment Databases.--The Secretary
shall ensure that the Inspector General of the Department of
Health and Human Services and Federal law enforcement
agencies have direct access to all claims and payment
databases of the Secretary under the Medicare or Medicaid
programs.
(i) Civil Money Penalties for Submission of Erroneous
Information.--In the case of a provider of services,
supplier, or other entity that submits erroneous information
that serves as a basis for payment of any entity under the
Medicare or Medicaid program, the Secretary may impose a
civil money penalty of not to exceed $50,000 for each such
erroneous submission. A civil money penalty under this
subsection shall be imposed and collected in the same manner
as a civil money penalty under subsection (a) of section
1128A of the Social Security Act is imposed and collected
under that section.

DIVISION G--PATHWAY FOR BIOSIMILAR BIOLOGICAL PRODUCTS

SEC. 701. LICENSURE PATHWAY FOR BIOSIMILAR BIOLOGICAL
PRODUCTS.

(a) Licensure of Biological Products as Biosimilar or
Interchangeable.--Section 351 of the Public Health Service
Act (42 U.S.C. 262) is amended--
(1) in subsection (a)(1)(A), by inserting ``under this
subsection or subsection (k)'' after ``biologics license'';
and
(2) by adding at the end the following:
``(k) Licensure of Biological Products as Biosimilar or
Interchangeable.--
``(1) In general.--Any person may submit an application for
licensure of a biological product under this subsection.
``(2) Content.--
``(A) In general.--
``(i) Required information.--An application submitted under
this subsection shall include information demonstrating
that--

``(I) the biological product is biosimilar to a reference
product based upon data derived from--

``(aa) analytical studies that demonstrate that the
biological product is highly similar to the reference product
notwithstanding minor differences in clinically inactive
components;
``(bb) animal studies (including the assessment of
toxicity); and
``(cc) a clinical study or studies (including the
assessment of immunogenicity and pharmacokinetics or
pharmacodynamics) that are sufficient to demonstrate safety,
purity, and potency in 1 or more appropriate conditions of
use for which the reference product is licensed and intended
to be used and for which licensure is sought for the
biological product;

``(II) the biological product and reference product utilize
the same mechanism or mechanisms of action for the condition
or conditions of use prescribed, recommended, or suggested in
the proposed labeling, but only to the extent the mechanism
or mechanisms of action are known for the reference product;
``(III) the condition or conditions of use prescribed,
recommended, or suggested in the labeling proposed for the
biological product have been previously approved for the
reference product;
``(IV) the route of administration, the dosage form, and
the strength of the biological product are the same as those
of the reference product; and
``(V) the facility in which the biological product is
manufactured, processed, packed, or held meets standards
designed to assure that the biological product continues to
be safe, pure, and potent.

``(ii) Determination by secretary.--The Secretary may
determine, in the Secretary's discretion, that an element
described in clause (i)(I) is unnecessary in an application
submitted under this subsection.
``(iii) Additional information.--An application submitted
under this subsection--

``(I) shall include publicly available information
regarding the Secretary's previous determination that the
reference product is safe, pure, and potent; and
``(II) may include any additional information in support of
the application, including publicly available information
with respect to the reference product or another biological
product.

``(B) Interchangeability.--An application (or a supplement
to an application) submitted under this subsection may
include information demonstrating that the biological product
meets the standards described in paragraph (4).
``(3) Evaluation by secretary.--Upon review of an
application (or a supplement to an

[[Page H12948]]

application) submitted under this subsection, the Secretary
shall license the biological product under this subsection
if--
``(A) the Secretary determines that the information
submitted in the application (or the supplement) is
sufficient to show that the biological product--
``(i) is biosimilar to the reference product; or
``(ii) meets the standards described in paragraph (4), and
therefore is interchangeable with the reference product; and
``(B) the applicant (or other appropriate person) consents
to the inspection of the facility that is the subject of the
application, in accordance with subsection (c).
``(4) Safety standards for determining
interchangeability.--Upon review of an application submitted
under this subsection or any supplement to such application,
the Secretary shall determine the biological product to be
interchangeable with the reference product if the Secretary
determines that the information submitted in the application
(or a supplement to such application) is sufficient to show
that--
``(A) the biological product--
``(i) is biosimilar to the reference product; and
``(ii) can be expected to produce the same clinical result
as the reference product in any given patient; and
``(B) for a biological product that is administered more
than once to an individual, the risk in terms of safety or
diminished efficacy of alternating or switching between use
of the biological product and the reference product is not
greater than the risk of using the reference product without
such alternation or switch.
``(5) General rules.--
``(A) One reference product per application.--A biological
product, in an application submitted under this subsection,
may not be evaluated against more than 1 reference product.
``(B) Review.--An application submitted under this
subsection shall be reviewed by the division within the Food
and Drug Administration that is responsible for the review
and approval of the application under which the reference
product is licensed.
``(C) Risk evaluation and mitigation strategies.--The
authority of the Secretary with respect to risk evaluation
and mitigation strategies under the Federal Food, Drug, and
Cosmetic Act shall apply to biological products licensed
under this subsection in the same manner as such authority
applies to biological products licensed under subsection (a).
``(D) Restrictions on biological products containing
dangerous ingredients.--If information in an application
submitted under this subsection, in a supplement to such an
application, or otherwise available to the Secretary shows
that a biological product--
``(i) is, bears, or contains a select agent or toxin listed
in section 73.3 or 73.4 of title 42, section 121.3 or 121.4
of title 9, or section 331.3 of title 7, Code of Federal
Regulations (or any successor regulations); or
``(ii) is, bears, or contains a controlled substance in
schedule I or II of section 202 of the Controlled Substances
Act, as listed in part 1308 of title 21, Code of Federal
Regulations (or any successor regulations);

the Secretary shall not license the biological product under
this subsection unless the Secretary determines, after
consultation with appropriate national security and drug
enforcement agencies, that there would be no increased risk
to the security or health of the public from licensing such
biological product under this subsection.
``(6) Exclusivity for first interchangeable biological
product.--Upon review of an application submitted under this
subsection relying on the same reference product for which a
prior biological product has received a determination of
interchangeability for any condition of use, the Secretary
shall not make a determination under paragraph (4) that the
second or subsequent biological product is interchangeable
for any condition of use until the earlier of--
``(A) 1 year after the first commercial marketing of the
first interchangeable biosimilar biological product to be
approved as interchangeable for that reference product;
``(B) 18 months after--
``(i) a final court decision on all patents in suit in an
action instituted under subsection (l)(5) against the
applicant that submitted the application for the first
approved interchangeable biosimilar biological product; or
``(ii) the dismissal with or without prejudice of an action
instituted under subsection (l)(5) against the applicant that
submitted the application for the first approved
interchangeable biosimilar biological product; or
``(C)(i) 42 months after approval of the first
interchangeable biosimilar biological product if the
applicant that submitted such application has been sued under
subsection (l)(5) and such litigation is still ongoing within
such 42-month period; or
``(ii) 18 months after approval of the first
interchangeable biosimilar biological product if the
applicant that submitted such application has not been sued
under subsection (l)(5).

For purposes of this paragraph, the term `final court
decision' means a final decision of a court from which no
appeal (other than a petition to the United States Supreme
Court for a writ of certiorari) has been or can be taken.
``(7) Exclusivity for reference product.--
``(A) Effective date of biosimilar application approval.--
Approval of an application under this subsection may not be
made effective by the Secretary until the date that is 12
years after the date on which the reference product was first
licensed under subsection (a).
``(B) Filing period.--An application under this subsection
may not be submitted to the Secretary until the date that is
4 years after the date on which the reference product was
first licensed under subsection (a).
``(C) First licensure.--Subparagraphs (A) and (B) shall not
apply to a license for or approval of--
``(i) a supplement for the biological product that is the
reference product; or
``(ii) a subsequent application filed by the same sponsor
or manufacturer of the biological product that is the
reference product (or a licensor, predecessor in interest, or
other related entity) for--

``(I) a change (not including a modification to the
structure of the biological product) that results in a new
indication, route of administration, dosing schedule, dosage
form, delivery system, delivery device, or strength; or
``(II) a modification to the structure of the biological
product that does not result in a change in safety, purity,
or potency.

``(8) Pediatric studies.--
``(A) Exclusivity.--If, before or after licensure of the
reference product under subsection (a) of this section, the
Secretary determines that information relating to the use of
such product in the pediatric population may produce health
benefits in that population, the Secretary makes a written
request for pediatric studies (which shall include a
timeframe for completing such studies), the applicant or
holder of the approved application agrees to the request,
such studies are completed using appropriate formulations for
each age group for which the study is requested within any
such timeframe, and the reports thereof are submitted and
accepted in accordance with section 505A(d)(3) of the Federal
Food, Drug, and Cosmetic Act the period referred to in
paragraph (7)(A) of this subsection is deemed to be 12 years
and 6 months rather than 12 years.
``(B) Exception.--The Secretary shall not extend the period
referred to in subparagraph (A) of this paragraph if the
determination under section 505A(d)(3) of the Federal Food,
Drug, and Cosmetic Act is made later than 9 months prior to
the expiration of such period.
``(C) Application of certain provisions.--The provisions of
subsections (a), (d), (e), (f), (h), (j), (k), and (l) of
section 505A of the Federal Food, Drug, and Cosmetic Act
shall apply with respect to the extension of a period under
subparagraph (A) of this paragraph to the same extent and in
the same manner as such provisions apply with respect to the
extension of a period under subsection (b) or (c) of section
505A of the Federal Food, Drug, and Cosmetic Act.
``(9) Guidance documents.--
``(A) In general.--The Secretary may, after opportunity for
public comment, issue guidance in accordance, except as
provided in subparagraph (B)(i), with section 701(h) of the
Federal Food, Drug, and Cosmetic Act with respect to the
licensure of a biological product under this subsection. Any
such guidance may be general or specific.
``(B) Public comment.--
``(i) In general.--The Secretary shall provide the public
an opportunity to comment on any proposed guidance issued
under subparagraph (A) before issuing final guidance.
``(ii) Input regarding most valuable guidance.--The
Secretary shall establish a process through which the public
may provide the Secretary with input regarding priorities for
issuing guidance.
``(C) No requirement for application consideration.--The
issuance (or non-issuance) of guidance under subparagraph (A)
shall not preclude the review of, or action on, an
application submitted under this subsection.
``(D) Requirement for product class-specific guidance.--If
the Secretary issues product class-specific guidance under
subparagraph (A), such guidance shall include a description
of--
``(i) the criteria that the Secretary will use to determine
whether a biological product is highly similar to a reference
product in such product class; and
``(ii) the criteria, if available, that the Secretary will
use to determine whether a biological product meets the
standards described in paragraph (4).
``(E) Certain product classes.--
``(i) Guidance.--The Secretary may indicate in a guidance
document that the science and experience, as of the date of
such guidance, with respect to a product or product class
(not including any recombinant protein) does not allow
approval of an application for a license as provided under
this subsection for such product or product class.
``(ii) Modification or reversal.--The Secretary may issue a
subsequent guidance document under subparagraph (A) to modify
or reverse a guidance document under clause (i).
``(iii) No effect on ability to deny license.--Clause (i)
shall not be construed to require the Secretary to approve a
product with respect to which the Secretary has not indicated
in a guidance document that the science and experience, as
described in clause (i), does not allow approval of such an
application.

[[Page H12949]]

``(10) Naming.--The Secretary shall ensure that the
labeling and packaging of each biological product licensed
under this subsection bears a name that uniquely identifies
the biological product and distinguishes it from the
reference product and any other biological products licensed
under this subsection following evaluation against such
reference product.
``(l) Patent Notices; Relationship to Final Approval.--
``(1) Definitions.--For the purposes of this subsection,
the term--
``(A) `biosimilar product' means the biological product
that is the subject of the application under subsection (k);
``(B) `relevant patent' means a patent that--
``(i) expires after the date specified in subsection
(k)(7)(A) that applies to the reference product; and
``(ii) could reasonably be asserted against the applicant
due to the unauthorized making, use, sale, or offer for sale
within the United States, or the importation into the United
States of the biosimilar product, or materials used in the
manufacture of the biosimilar product, or due to a use of the
biosimilar product in a method of treatment that is indicated
in the application;
``(C) `reference product sponsor' means the holder of an
approved application or license for the reference product;
and
``(D) `interested third party' means a person other than
the reference product sponsor that owns a relevant patent, or
has the right to commence or participate in an action for
infringement of a relevant patent.
``(2) Handling of confidential information.--Any entity
receiving confidential information pursuant to this
subsection shall designate one or more individuals to receive
such information. Each individual so designated shall execute
an agreement in accordance with regulations promulgated by
the Secretary. The regulations shall require each such
individual to take reasonable steps to maintain the
confidentiality of information received pursuant to this
subsection and use the information solely for purposes
authorized by this subsection. The obligations imposed on an
individual who has received confidential information pursuant
to this subsection shall continue until the individual
returns or destroys the confidential information, a court
imposes a protective order that governs the use or handling
of the confidential information, or the party providing the
confidential information agrees to other terms or conditions
regarding the handling or use of the confidential
information.
``(3) Public notice by secretary.--Within 30 days of
acceptance by the Secretary of an application filed under
subsection (k), the Secretary shall publish a notice
identifying--
``(A) the reference product identified in the application;
and
``(B) the name and address of an agent designated by the
applicant to receive notices pursuant to paragraph (4)(B).
``(4) Exchanges concerning patents.--
``(A) Exchanges with reference product sponsor.--
``(i) Within 30 days of the date of acceptance of the
application by the Secretary, the applicant shall provide the
reference product sponsor with a copy of the application and
information concerning the biosimilar product and its
production. This information shall include a detailed
description of the biosimilar product, its method of
manufacture, and the materials used in the manufacture of the
product.
``(ii) Within 60 days of the date of receipt of the
information required to be provided under clause (i), the
reference product sponsor shall provide to the applicant a
list of relevant patents owned by the reference product
sponsor, or in respect of which the reference product sponsor
has the right to commence an action of infringement or
otherwise has an interest in the patent as such patent
concerns the biosimilar product.
``(iii) If the reference product sponsor is issued or
acquires an interest in a relevant patent after the date on
which the reference product sponsor provides the list
required by clause (ii) to the applicant, the reference
product sponsor shall identify that patent to the applicant
within 30 days of the date of issue of the patent, or the
date of acquisition of the interest in the patent, as
applicable.
``(B) Exchanges with interested third parties.--
``(i) At any time after the date on which the Secretary
publishes a notice for an application under paragraph (3),
any interested third party may provide notice to the
designated agent of the applicant that the interested third
party owns or has rights under 1 or more patents that may be
relevant patents. The notice shall identify at least 1 patent
and shall designate an individual who has executed an
agreement in accordance with paragraph (2) to receive
confidential information from the applicant.
``(ii) Within 30 days of the date of receiving notice
pursuant to clause (i), the applicant shall send to the
individual designated by the interested third party the
information specified in subparagraph (A)(i), unless the
applicant and interested third party otherwise agree.
``(iii) Within 90 days of the date of receiving information
pursuant to clause (ii), the interested third party shall
provide to the applicant a list of relevant patents which the
interested third party owns, or in respect of which the
interested third party has the right to commence or
participate in an action for infringement.
``(iv) If the interested third party is issued or acquires
an interest in a relevant patent after the date on which the
interested third party provides the list required by clause
(iii), the interested third party shall identify that patent
within 30 days of the date of issue of the patent, or the
date of acquisition of the interest in the patent, as
applicable.
``(C) Identification of basis for infringement.--For any
patent identified under clause (ii) or (iii) of subparagraph
(A) or under clause (iii) or (iv) of subparagraph (B), the
reference product sponsor or the interested third party, as
applicable--
``(i) shall explain in writing why the sponsor or the
interested third party believes the relevant patent would be
infringed by the making, use, sale, or offer for sale within
the United States, or importation into the United States, of
the biosimilar product or by a use of the biosimilar product
in treatment that is indicated in the application;
``(ii) may specify whether the relevant patent is available
for licensing; and
``(iii) shall specify the number and date of expiration of
the relevant patent.
``(D) Certification by applicant concerning identified
relevant patents.--Not later than 45 days after the date on
which a patent is identified under clause (ii) or (iii) of
subparagraph (A) or under clause (iii) or (iv) of
subparagraph (B), the applicant shall send a written
statement regarding each identified patent to the party that
identified the patent. Such statement shall either--
``(i) state that the applicant will not commence marketing
of the biosimilar product and has requested the Secretary to
not grant final approval of the application before the date
of expiration of the noticed patent; or
``(ii) provide a detailed written explanation setting forth
the reasons why the applicant believes--

``(I) the making, use, sale, or offer for sale within the
United States, or the importation into the United States, of
the biosimilar product, or the use of the biosimilar product
in a treatment indicated in the application, would not
infringe the patent; or
``(II) the patent is invalid or unenforceable.

``(5) Action for infringement involving reference product
sponsor.--If an action for infringement concerning a relevant
patent identified by the reference product sponsor under
clause (ii) or (iii) of paragraph (4)(A), or by an interested
third party under clause (iii) or (iv) of paragraph (4)(B),
is brought within 60 days of the date of receipt of a
statement under paragraph (4)(D)(ii), and the court in which
such action has been commenced determines the patent is
infringed prior to the date applicable under subsection
(k)(7)(A) or (k)(8), the Secretary shall make approval of the
application effective on the day after the date of expiration
of the patent that has been found to be infringed. If more
than one such patent is found to be infringed by the court,
the approval of the application shall be made effective on
the day after the date that the last such patent expires.
``(6) Notification of agreements.--
``(A) Requirements.--
``(i) Agreement between biosimilar product applicant and
reference product sponsor.--If a biosimilar product applicant
under subsection (k) and the reference product sponsor enter
into an agreement described in subparagraph (B), the
applicant and sponsor shall each file the agreement in
accordance with subparagraph (C).
``(ii) Agreement between biosimilar product applicants.--If
2 or more biosimilar product applicants submit an application
under subsection (k) for biosimilar products with the same
reference product and enter into an agreement described in
subparagraph (B), the applicants shall each file the
agreement in accordance with subparagraph (C).
``(B) Subject matter of agreement.--An agreement described
in this subparagraph--
``(i) is an agreement between the biosimilar product
applicant under subsection (k) and the reference product
sponsor or between 2 or more biosimilar product applicants
under subsection (k) regarding the manufacture, marketing, or
sale of--

``(I) the biosimilar product (or biosimilar products) for
which an application was submitted; or
``(II) the reference product;

``(ii) includes any agreement between the biosimilar
product applicant under subsection (k) and the reference
product sponsor or between 2 or more biosimilar product
applicants under subsection (k) that is contingent upon,
provides a contingent condition for, or otherwise relates to
an agreement described in clause (i); and
``(iii) excludes any agreement that solely concerns--

``(I) purchase orders for raw material supplies;
``(II) equipment and facility contracts;
``(III) employment or consulting contracts; or
``(IV) packaging and labeling contracts.

``(C) Filing.--
``(i) In general.--The text of an agreement required to be
filed by subparagraph (A) shall be filed with the Assistant
Attorney General and the Federal Trade Commission not later
than--

``(I) 10 business days after the date on which the
agreement is executed; and
``(II) prior to the date of the first commercial marketing
of, for agreements described in subparagraph (A)(i), the
biosimilar product that is the subject of the application or,
for agreements described in subparagraph (A)(ii), any
biosimilar product that is the

[[Page H12950]]

subject of an application described in such subparagraph.

``(ii) If agreement not reduced to text.--If an agreement
required to be filed by subparagraph (A) has not been reduced
to text, the persons required to file the agreement shall
each file written descriptions of the agreement that are
sufficient to disclose all the terms and conditions of the
agreement.
``(iii) Certification.--The chief executive officer or the
company official responsible for negotiating any agreement
required to be filed by subparagraph (A) shall include in any
filing under this paragraph a certification as follows: `I
declare under penalty of perjury that the following is true
and correct: The materials filed with the Federal Trade
Commission and the Department of Justice under section
351(l)(6) of the Public Health Service Act, with respect to
the agreement referenced in this certification: (1) represent
the complete, final, and exclusive agreement between the
parties; (2) include any ancillary agreements that are
contingent upon, provide a contingent condition for, or are
otherwise related to, the referenced agreement; and (3)
include written descriptions of any oral agreements,
representations, commitments, or promises between the parties
that are responsive to such section and have not been reduced
to writing.'.
``(D) Disclosure exemption.--Any information or documentary
material filed with the Assistant Attorney General or the
Federal Trade Commission pursuant to this paragraph shall be
exempt from disclosure under section 552 of title 5, United
States Code, and no such information or documentary material
may be made public, except as may be relevant to any
administrative or judicial action or proceeding. Nothing in
this subparagraph prevents disclosure of information or
documentary material to either body of the Congress or to any
duly authorized committee or subcommittee of the Congress.
``(E) Enforcement.--
``(i) Civil penalty.--Any person that violates a provision
of this paragraph shall be liable for a civil penalty of not
more than $11,000 for each day on which the violation occurs.
Such penalty may be recovered in a civil action--

``(I) brought by the United States; or
``(II) brought by the Federal Trade Commission in
accordance with the procedures established in section
16(a)(1) of the Federal Trade Commission Act.

``(ii) Compliance and equitable relief.--If any person
violates any provision of this paragraph, the United States
district court may order compliance, and may grant such other
equitable relief as the court in its discretion determines
necessary or appropriate, upon application of the Assistant
Attorney General or the Federal Trade Commission.
``(F) Rulemaking.--The Federal Trade Commission, with the
concurrence of the Assistant Attorney General and by rule in
accordance with section 553 of title 5, United States Code,
consistent with the purposes of this paragraph--
``(i) may define the terms used in this paragraph;
``(ii) may exempt classes of persons or agreements from the
requirements of this paragraph; and
``(iii) may prescribe such other rules as may be necessary
and appropriate to carry out the purposes of this paragraph.
``(G) Savings clause.--Any action taken by the Assistant
Attorney General or the Federal Trade Commission, or any
failure of the Assistant Attorney General or the Commission
to take action, under this paragraph shall not at any time
bar any proceeding or any action with respect to any
agreement between a biosimilar product applicant under
subsection (k) and the reference product sponsor, or any
agreement between biosimilar product applicants under
subsection (k), under any other provision of law, nor shall
any filing under this paragraph constitute or create a
presumption of any violation of any competition laws.''.
(b) Definitions.--Section 351(i) of the Public Health
Service Act (42 U.S.C. 262(i)) is amended--
(1) by striking ``In this section, the term `biological
product' means'' and inserting the following: ``In this
section:
``(1) The term `biological product' means'';
(2) in paragraph (1), as so designated, by inserting
``protein (except any chemically synthesized polypeptide),''
after ``allergenic product,''; and
(3) by adding at the end the following:
``(2) The term `biosimilar' or `biosimilarity', in
reference to a biological product that is the subject of an
application under subsection (k), means--
``(A) that the biological product is highly similar to the
reference product notwithstanding minor differences in
clinically inactive components; and
``(B) there are no clinically meaningful differences
between the biological product and the reference product in
terms of the safety, purity, and potency of the product.
``(3) The term `interchangeable' or `interchangeability',
in reference to a biological product that is shown to meet
the standards described in subsection (k)(4), means that the
biological product may be substituted for the reference
product without the intervention of the health care provider
who prescribed the reference product.
``(4) The term `reference product' means the single
biological product licensed under subsection (a) against
which a biological product is evaluated in an application
submitted under subsection (k).''.
(c) Products Previously Approved Under Section 505.--
(1) Requirement to follow section 351.--Except as provided
in paragraph (2), an application for a biological product
shall be submitted under section 351 of the Public Health
Service Act (42 U.S.C. 262) (as amended by this Act).
(2) Exception.--An application for a biological product may
be submitted under section 505 of the Federal Food, Drug, and
Cosmetic Act (21 U.S.C. 355) if--
(A) such biological product is in a product class for which
a biological product in such product class is the subject of
an application approved under such section 505 not later than
the date of enactment of this Act; and
(B) such application--
(i) has been submitted to the Secretary of Health and Human
Services (referred to in this Act as the ``Secretary'')
before the date of enactment of this Act; or
(ii) is submitted to the Secretary not later than the date
that is 10 years after the date of enactment of this Act.
(3) Limitation.--Notwithstanding paragraph (2), an
application for a biological product may not be submitted
under section 505 of the Federal Food, Drug, and Cosmetic Act
(21 U.S.C. 355) if there is another biological product
approved under subsection (a) of section 351 of the Public
Health Service Act that could be a reference product with
respect to such application (within the meaning of such
section 351) if such application were submitted under
subsection (k) of such section 351.
(4) Deemed approved under section 351.--An approved
application for a biological product under section 505 of the
Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355) shall be
deemed to be a license for the biological product under such
section 351 on the date that is 10 years after the date of
enactment of this Act.
(5) Definitions.--For purposes of this subsection, the term
``biological product'' has the meaning given such term under
section 351 of the Public Health Service Act (42 U.S.C. 262)
(as amended by this Act).

SEC. 702. FEES RELATING TO BIOSIMILAR BIOLOGICAL PRODUCTS.

Subparagraph (B) of section 735(1) of the Federal Food,
Drug, and Cosmetic Act (21 U.S.C. 379g(1)) is amended by
inserting ``, including licensure of a biological product
under section 351(k) of such Act'' before the period at the
end.

SEC. 703. AMENDMENTS TO CERTAIN PATENT PROVISIONS.

(a) Section 271(e)(2) of title 35, United States Code is
amended--
(1) in subparagraph (A), by striking ``or'' after
``patent,'';
(2) in subparagraph (B), by adding ``or'' after the comma
at the end;
(3) by inserting the following after subparagraph (B):
``(C) a statement under section 351(l)(4)(D)(ii) of the
Public Health Service Act,''; and
(4) in the matter following subparagraph (C) (as added by
paragraph (3)), by inserting before the period the following:
``, or if the statement described in subparagraph (C) is
provided in connection with an application to obtain a
license to engage in the commercial manufacture, use, or sale
of a biological product claimed in a patent or the use of
which is claimed in a patent before the expiration of such
patent''.
(b) Section 271(e)(4) of title 35, United States Code, is
amended by striking ``in paragraph (2)'' in both places it
appears and inserting ``in paragraph (2)(A) or (2)(B)''.

The SPEAKER pro tempore. Pursuant to House Resolution 903, the
gentleman from Ohio (Mr. Boehner) and a Member opposed each will
control 30 minutes.
The Chair recognizes the gentleman from Ohio.

{time}  2015

Mr. BOEHNER. Mr. Speaker, all of us know that our health care
delivery system needs help. There could be broad bipartisan agreement
on the kinds of steps that we need to take in order to lower the cost
of health care in America and expand access. The bill before us, in my
view, is a big government takeover of our health care system that will
replace the current health care that Americans get.
Republicans have offered better solutions all year on the major bills
that have come to this floor. I think we had a much better solution on
the stimulus bill that would have created twice the jobs at half the
cost. I think our better solution on the budget clearly had less
spending, less debt and lower deficits.
I think our all-of-the-above American energy plan was a much better
solution to the national energy tax, the so-called cap-and-trade bill,
that was on this floor in June. I believe that what we have before us,
as a Republican substitute, is a commonsense plan that takes steps
towards reducing the cost of health insurance in America and expand
access. Simple things, like allowing people to buy insurance across
State lines, allowing groups of

[[Page H12951]]

individuals or small businesses to group together for the purposes of
buying health insurance like big businesses and unions can today. How
about getting rid of junk lawsuits that drive up the cost of health
care in America and the defensive medicine that doctors have to
practice as a result.
I think what we have before us and the bill that we are offering is a
commonsense approach that does take major steps in the right direction
to bring down the cost of health care and to expand access.
I reserve the balance of my time.
Mr. WAXMAN. Mr. Speaker, I seek to control the time in opposition,
and I ask unanimous consent that the time for opposition speakers on
the substitute amendment be divided such that the first 10 minutes is
controlled by Chairman Miller of the Committee on Education and Labor;
the second 10 minutes is controlled by Chairman Rangel of the Committee
on Ways and Means; and the final 10 minutes is controlled by Chairman
Waxman of the Committee on Energy and Commerce.
The SPEAKER pro tempore. The gentleman from California (Mr. Waxman)
is recognized to control the time in opposition.
Without objection, that time will be so divided, subject to the
Chair's discretion as to the order of recognition.
There was no objection.
The SPEAKER pro tempore. The Chair recognizes the gentleman from
California (Mr. Miller).
Mr. GEORGE MILLER of California. Mr. Speaker, I yield 2 minutes to
the gentleman from New York (Mr. Tonko).
Mr. TONKO. Mr. Speaker, I am here to speak in support of the
Affordable Health Care for America Act, one of the most important
pieces of legislation this body has considered since the passage of
Medicare in 1965 and Social Security in 1935.
Mr. Speaker, every Member of this body has been listening to her or
his constituents, and they are saying that they are ready for health
insurance reform. They need health insurance reform.
We listened when seniors said they wanted better care from their
doctors, and the doughnut hole eliminated. This bill does that. We
listened when young adults told us they were having trouble finding
insurance and wanted to stay on their parents' insurance until age 27.
This bill does that. We listened when the uninsured told us
heartbreaking stories about going without needed health care and asked
us to give them affordable, quality health care insurance. This bill
does that. We listened when the insured told us they were paying too
much for insurance and they needed more protections for their health
insurance. This bill does that.
Our colleagues on the other side of the aisle have not listened. They
are offering a substitute bill that would not accomplish any of the
things our constituents have asked for. Instead, they are offering a
bill that does not end the discrimination based on preexisting
conditions; does not reduce the number of uninsured Americans; does not
offer assistance to those struggling to afford health insurance; does
not repeal the antitrust exemption for health insurers; and does not
stop price gouging by insurance companies. Our bill does all these
things and more.
Mr. Speaker, the Affordable Health Care for America Act not only
brings quality health care within reach of tens of millions of
Americans, it enhances the care that those with insurance and Medicare
already receive. This bill is as much about the insured as it is about
the uninsured. It is a monumental bill. I urge defeat of the Republican
substitute and, indeed, encourage passage of H.R. 3962.
The SPEAKER pro tempore. Without objection, the gentleman from
Michigan will control the time on the proponent's side.
There was no objection.
Mr. CAMP. Mr. Speaker, I yield myself 4 minutes.
Mr. Speaker, the American people deserve and demand a commonsense
approach to health care reform that, one, makes health care more
affordable; two, that guarantees all Americans, regardless of
preexisting condition, have access to affordable health care; and,
three, does so without raising taxes, without increasing the deficit
and without the Federal Government making health care decisions that
should be made by patients and doctors.
The Common Sense Health Care Reform and Affordability Act, the House
Republican health care bill, does that. The plan offered today by the
Speaker does not.
Just some of the highlights of the Republicans' Common Sense Health
Care Reform and Affordability Act include:
Lowering health care premiums: The Republican plan will lower health
care premiums for American families and small businesses, addressing
Americans' number-one priority for health care reform.
According to the Congressional Budget Office, the Republican health
care reforms would reduce premiums by up to 3 percent for Americans who
get insurance through a large business, up to 8 percent for Americans
without employer-sponsored insurance, and up to 10 percent for those
working for a small business. CBO has not made a claim that the
Democrats' bill would lower premiums at all.
What do these numbers mean? It means families who do not have health
insurance in 2016 through their job could buy health insurance that is
$5,000 less expensive than the cheapest plan the Democrats offer.
The Republican plan guarantees access to affordable health care for
those with preexisting conditions. Republicans create universal access
programs that expand and reform high-risk pools and reinsurance
programs to guarantee that all Americans, regardless of preexisting
conditions or past illnesses, have access to affordable care, while
lowering costs for all Americans.
The Republican plan reduces the number of junk lawsuits, which saves
taxpayers' money and lowers premiums, by enacting medical liability
reforms modeled after the successful State laws of California and
Texas.
The Republican plan prevents insurers from wrongly canceling a policy
unless a person commits fraud.
The Republican plan encourages Small Business Health Plans so these
employers can pool together and offer health care at lower prices, just
as large corporations and labor unions do today.
The Republican plan encourages innovative programs by rewarding
States that reduce premiums and the number of uninsured. In comparison,
the Democrat bill adds a new unfunded mandate States cannot afford with
their over $400 billion expansion of Medicaid.
The Republican plan allows Americans to buy insurance across State
lines and find the health care plan that best meets their needs at a
cost they can afford.
The Republican plan promotes prevention and wellness by more than
doubling the financial incentives employers may reward employees who
adopt healthier lifestyles.
Republicans enhance health savings accounts by allowing Americans to
use HSA funds to pay premiums for high deductible health insurance.
And the Republican plan allows dependents to remain on their parents'
policies up to the age of 25.
The health insurance reforms in the Republican bill will
significantly reduce health care premiums, insure millions of
Americans, guarantee those with preexisting conditions have access to
quality, affordable care.
We do all of this without raising taxes, without spending $1 trillion
we don't have, without cutting Medicare and without putting some new
health czar in between doctors and patients, which is what the Democrat
majority does in their government takeover bill.
Clearly the bill offered by the Speaker is not what the American
people want. Americans are clamoring for lower cost health care and
that is what the Republican plan offers.
I urge my colleagues to reject the Democrats' government takeover of
health care and vote ``yes'' on the Republican substitute that will
lower health care premiums.
I reserve the balance of my time.

Announcement by the Speaker Pro Tempore

The SPEAKER pro tempore. The Chair would remind Members not to
traffic the well when another Member is under recognition.
Mr. GEORGE MILLER of California. Mr. Speaker, I yield 2\1/2\ minutes
to the gentleman from Massachusetts (Mr. Tierney), a member of the
committee.

[[Page H12952]]

Mr. TIERNEY. I thank the gentleman.
Since 1995, when our Republican colleagues held the majority in the
House of Representatives, until 2007 when they relinquished that and
the voters threw them out, they had done exactly nothing, nothing, with
respect to the health care crisis in this country.
Now they want to come in and they want to do something. They want to
have you pay less for getting less. This is their great plan.
The one thing they tried to do in 2003 would put pharmaceutical
prescription drugs in Medicare which they did by giving seniors a so-
called doughnut hole they had to pay for and costing us $600 billion on
our current debt.
My friends, the only ones they made happy then were the
pharmaceutical companies, and the only ones they want to make happy now
are the private insurance companies. They want to try to kill reform.
If they can't kill reform, they want to give them this gift of a
Republican substitute.
While they sat idle since 1995, family health insurance policies rose
from 7 percent of median income to 17 percent. Sixty percent of
families reporting bankruptcies did so in part because of health care
costs. Forty-six million Americans went uninsured, 85 percent of those
in working families.
Small business premiums went up 129 percent. Twenty-eight million of
our uninsured are small business owners, employees or their families.
Small businesses are projected to lose $52.1 billion going forward in
the next decade if we continue on the Republican path of do nothing.
The question is, who is on our side? Who is on the side of the
consumers, the individuals, the small businesses and the families, and
that is the bill that the Democrats have put forward on this floor. It
is affordable; it is health care for every American.
If you compare the two bills, you will see the Congressional Budget
Office says the Republicans may--may--save you from 0 to 3 percent on
80 percent of the private premiums.
The Democratic bill saves you 12 percent. The Democratic bill covers
96 percent of Americans. The Republicans in 2019 will leave you exactly
where you are today, covering only 83 percent of the people, leaving by
that time 52 million uninsured.
We will end the discrimination against people with preexisting
conditions. They will study it.
We will have an exchange for small businesses and employees so they
get better prices comparable to what large companies have now been able
to get. They will do nothing of the kind except let you shop for a
place, but to get your insurance it might cost you less because you get
less, because you will have a race to the bottom, where insurance
companies will be able to avoid consumer protections of States and
practice fraud almost indiscriminately. There will be no way of cutting
it back. You pay less because you get less.
Mr. CAMP. Mr. Speaker, I yield myself 15 seconds.
When Republicans were in the majority, we passed a children's health
initiative; a prescription drug plan for seniors; we put wellness into
Medicare; we established portability so people could change jobs and
keep their health care; and we established health savings accounts. Our
record on health care is strong. What we need is this continuation of
this step-by-step approach to comprehensive health care reform.
I would now yield 5 minutes to the distinguished gentleman from
Indiana (Mr. Pence).
(Mr. PENCE asked and was given permission to revise and extend his
remarks.)
Mr. PENCE. Mr. Speaker, I rise in support of the Republican
substitute.
After months of overwhelming public opposition to a government
takeover of health care, liberal Democrats here in Washington are
choosing to ignore the clear voice of the American people, bringing
forth a freight train of runaway Federal spending, bloated bureaucracy,
mandates and higher taxes.
And even a few courageous Democrats have been willing to speak out.
In opposing the bill, the distinguished Democrat chairman of the Armed
Services Committee, Ike Skelton, a man who knew President Truman, said
that he, quote, had serious concerns for Missourians who have private
insurance plans they like.
And my Democrat colleague, Dan Boren of Oklahoma, said, and I quote,
the worst thing we could do in a recession is raise taxes, and this
bill does just that.

{time}  2030

As these Democrat colleagues attest, if the Pelosi health care bill
passes today, you probably will lose your health insurance, and you
might just lose your job. The Pelosi health care plan targets us when
we are most vulnerable. Illness, our own, or, more importantly, the
illness of a parent, spouse or a child, has the capacity to suspend our
priorities. What was important before the crisis grows dim in the harsh
light of disease affecting a loved one. The result, little by little,
in the midst of a family crisis we yield our freedoms and our resources
to the ever-growing appetite of the Federal Government.
But if liberal Democrats think this is what our Nation wants, they
don't know the America that I know.
Mike Schwaller is my cousin. He is an extraordinary young man. He has
been struggling with cancer, but throughout has maintained his faith in
Christ and his courage. He has been an inspiration to us all.
Mike wrote me an email the other day, and he gave me permission to
share it. As a cancer patient with limited treatment options, he is
awaiting insurance approval for experimental treatment. He seems like
just the kind of American that my Democrat colleagues keep telling us
want government-run insurance. But they don't know Mike.
As he wrote about his coverage recently, he said, If this was a
government bureaucracy, I have no faith that it would be processed in a
timely manner, and even then, if it would be approved. The idea of a
public health care option, he wrote, as a chronic cancer patient scares
the living hell out of me. I feel that at this moment in time you are
fighting for me, and my life. Please, please, don't give up or give in.
Michael, we won't.
The truth is, this debate is not just about health care. It is about
who we are as a nation. As President Reagan said, it is about ``whether
we abandon the American revolution and confess that a little
intellectual elite in a far distant capital can plan our lives better
for us than we can plan them for ourselves.''
You know, earlier today I greeted about 50 Hoosiers, mostly in
wheelchairs, unit caps and uniforms, down at the World War II Memorial.
These heroes were gathered for their first and maybe their only visit
to that monument built in their honor.
As I made my way back to the Capitol, I thought about those brave men
and what sustained them in those days where the survival of democracy
hung in the balance. I believe it must have been because they were
fighting for a cause more important than their health or even their
lives, and that cause was freedom.
In the coming hours, we are going to take a vote of incalculable
significance to the American people, and we will see what our so-called
Blue Dog Democrat colleagues are made of. We will see whether Democrats
who profess to believe in limited government will take a stand, or
whether they will fold under the weight of the Democratic majority in
the White House.
Look, I know from personal experience, it is no easy thing to take on
your President or your party on a major piece of legislation. But let
me assure my colleagues, decent Americans all, if you will take this
stand for freedom, for the right to live and work and care for a family
without the unnecessary intrusion of the government, I believe with all
my heart that you will know for the rest of your lives just what those
men in wheelchairs have known every day since they came home, that when
freedom hung in the balance, you did freedom's work, and the American
people will never forget it.
Mr. GEORGE MILLER of California. I yield 1\1/2\ minutes to the
gentleman from Virginia (Mr. Scott), a member of the committee.
(Mr. SCOTT of Virginia asked and was given permission to revise and
extend his remarks.)
Mr. SCOTT of Virginia. Mr. Speaker, all afternoon we have heard about
the freedom to be uninsured. Seniors in my

[[Page H12953]]

district do not want us to repeal government-run Medicare so that they
can enjoy a freedom to be uninsured, and those without insurance now do
not view themselves as enjoying some freedom. They want insurance.
The Republican substitute responds to the comprehensive Affordable
Healthcare for America Act with a bill that fails to reduce costs,
fails to cover uninsured Americans, and it may study, but it does not
help, those with preexisting conditions. It does, however, attack
innocent victims of medical malpractice.
One recent study showed that medical malpractice represents less than
one-third of one percent of all health care costs, and yet the
Republican substitute seeks to blame our broken health care insurance
system on innocent victims of malpractice. For those victims, the bill
limits the ability to hire a lawyer, complicates the lawsuit, shifts
the cost of medical malpractice from the doctor to the victim's own
private insurance, and, in some cases, causes the injured victims to
lose the right to sue before they even know they have been injured.
None of these unfair provisions were passed during previous attempts
when the Republicans controlled the House, the Senate and the White
House, and they should not be passed now.
The substitute should be defeated.
Mr. CAMP. Mr. Speaker, I yield 3 minutes to the distinguished
gentleman from Michigan (Mr. McCotter).
Mr. McCOTTER. I thank the gentleman.
Mr. Speaker, as the health redistribution bill before us attempts to
put its skid marks on history, it further proves Democrats are the
party of the past. Their antiquated government-run takeover of
Americans' health care is as ill-suited to our times as a leeching is
to laser surgery.
We do not live on a government-run globe. We live in a people-powered
world, one belatedly awakening to America's revolutionary experiment in
human freedom and self-government. Today, from the palms of our hands,
we can traverse distant strands of Earth to access friends and goods.
Why in the world would we put in the palm of a bureaucrat's hand our
health care?
Yet, this is precisely what the hoary voices of hidebound ideologues
demand; namely, that our generation's innovation revolution and its
unprecedented expansion of human empowerment be buried beneath big
government.
They are gravely mistaken. Amidst our constantly changing and
challenging times during this age of globalization, our generation's
innovation revolution is burying big government in the ash bin of
history.
Thus, the public and Republicans oppose the Democrat's fossilized
model of a mammoth government-run takeover of Americans' health care.
Instead, we embrace and harness our generation's innovation revolution
to empower Americans as citizens and consumers and advance patient-
centered wellness.
Our plan will increase the supply of health care to meet rising
demand and reduce costs through such sensible, affordable, and helpful
reforms as ending exclusions for preexisting conditions, reforming
medical liability laws, expanding Health Savings Accounts, allowing
small businesses to band together to provide coverage for employees,
permitting health insurance sales across State lines, and incentivizing
preventative health care and wellness.
All this can be achieved without trillions of dollars in new
spending, taxes, deficit and debt, and without big government
controlling your health care decisions.
Trapped in the past, there are those who ignore behind closed doors
the opportunities of our age. If Democrats impose their government-run
takeover of health care on the American people, the consequences will
be higher costs, lower quality, fewer choices, and lost jobs during
this painful recession.
But for those with an abiding faith in our free Republic's people and
their future, there is a better way--maximizing America's innovation
revolution to advance patient-centered wellness in our people-powered
world.
Pray we do.
Mr. GEORGE MILLER of California. I yield 2 minutes to the gentleman
from New Jersey (Mr. Andrews), a member of the committee.
Mr. ANDREWS. Mr. Speaker, when you can't win an argument on the
facts, you resort to emotion. The minority can't win the argument with
insured people because they preserve the right of insurance companies
to discriminate on the basis of preexisting conditions.
They can't win the argument with senior citizens because they ignore
the doughnut hole that they created in 2003 in the Medicare part D.
And they don't ignore the uninsured. I will give them some credit for
that. There are going to be 50 million uninsured in 2010. They do
change that. Their plan would make it 55 million uninsured 10 years
from now.
So they are standing on a motion, and we hear a Member say this: ``We
cannot stand idly by now, as the Nation is urged to embark on an ill-
conceived adventure in government medicine, the end of which no one can
see, and from which the patient is certain to be the ultimate
sufferer.''
But the Member wasn't a current Member, and the time wasn't now, and
the issue wasn't this bill. The Member was Durward Hall, the time was
1965, and the issue was Medicare.
They were wrong then, they are wrong now, and their substitute is
wrong. You should vote no.
Mr. GEORGE MILLER of California. I yield myself 2 minutes.
Mr. Speaker, if the Republicans' health care plan was a plan for a
fire department, they would rush into a burning building, and they
would rush out and leave everybody behind. If their plan was an
evacuation plan, it would be like Katrina. When they got all done
evacuating people, they left them all behind.
They say their plan is inexpensive. They say their plan saves
somebody money. But 10 years from now there are as many uninsured as
there are now.
At the end of their watch, after 12 years of control of this
Congress, 8 years of control of the White House at the same time, they
left behind 37 million Americans without health insurance. That is what
they left behind on their watch. Now they come forth with a plan for
the future, and over the next decade they are going to leave behind 50
million Americans.
Want to buy it? Want to try it? Want to sell it? Come on, America.
Buy this one. You are guaranteed to be left behind if you are left
behind today.
What a plan. Ha. God save us.
Mr. CAMP. At this time I yield 3 minutes to the distinguished
gentleman from Texas (Mr. Barton), the ranking member of the Energy and
Commerce Committee.
(Mr. BARTON of Texas asked and was given permission to revise and
extend his remarks.)
Mr. BARTON of Texas. Mr. Speaker, I asked to go after the
distinguished chairman of the Education and Labor Committee because
what we have here is a failure to communicate, or perhaps a difference
in philosophy.
The Democrats have decided that the bottom line is coverage. By
golly, coverage no matter what. Whether you want to be covered or not,
you are going to be. We are going to have an employer mandate. We are
going to have an employee mandate and an individual mandate. We are
going to have a premium mandate.
We are going to have how you cover the insurance, a ``comparative
research council,'' to dictate the practice of medicine. We are going
to raise Medicaid to 150 percent of poverty, and automatically enroll
every individual in this country who is unmarried, whether they want to
be or not.
We are going to tell every young American who has decided that they
don't want to pay those premiums, they want to save up to get married
or to buy a home, that, by golly, they are going to have to take
insurance, and they are going to pay three to four times what they
would under the current system because there is only a two-to-one
ratio. So they are going to get their coverage, at a cost of $1.2
trillion.
Now, we have a different philosophy. We think you need to control
costs, but we also agree that you have to provide access to the private
insurance market if you can't get it today and you want it.
Congressman Miller talks about the 40 to 50 million Americans that
are not insured, and he is right. But of those 40 to 50 million, 15 to
20 million are in this country illegally. Ten or 15 million are young
Americans who don't want insurance.

[[Page H12954]]

When you really boil it down, there are 5 to 10 million Americans who
have a preexisting condition or work where insurance is not provided
and they can't afford it.

{time}  2045

Our plan covers them. It gives them the opportunity. That doesn't
give them the money, but it gives them the opportunity. So we have a
difference in a philosophy.
We don't believe in mandates and make no apology about it, but we do
believe in the individual opportunity. We believe in individual choice.
We believe in the American system of free enterprise. We believe in
lowered taxes, and we believe in a plan that's going to lower premiums
an average of $5,000 per person per year for the next 10 years. That's
what CBO says. That's not me. That's the CBO.
So there is a choice. Bigger government, more mandates, more control,
less freedom, or lower costs, more opportunity, more freedom, more
choice. I vote for more freedom.
Vote ``no'' on the Big Government plan. Vote ``yes'' on the
individual opportunity plan.
Mr. RANGEL. At this time, I yield 1 minute to the gentleman from
California (Mr. Stark), the chairman of the Ways and Means Subcommittee
on Health.
I would like to take this time to thank him for the great work he's
done over the years, not just for our committee, but for this Congress,
and I would like to thank him publicly.
Mr. STARK. I thank the chairman for yielding.
Mr. Speaker, the Republican substitute is not a substitute on health
reform. It substitutes gifts to the wealthy insurance companies for
morality and dignity. Their bill spends $61 billion over the next
decade, and what would the American public get for that investment? It
would get 5 million more uninsured people than we have in America
today. That's not a conservative solution. It's no solution at all.
Our legislation expands coverage to 36 million more Americans,
reforms the insurance market to end abusive practices, provides
financial assistance to lower-income and middle-income families,
creates a public health insurance option that will make health
insurance companies compete on quality, provides security for our
seniors, and protects our children's futures by not adding one dime to
the deficit.
A vote for the Republican substitute is nothing more than a vote for
transferring money to wealthy insurance companies. Vote ``no'' on the
Republican substitute and ``yes'' to provide affordable, quality health
care for all Americans.
Mr. CAMP. At this time, I yield 1 minute to the gentleman from South
Carolina (Mr. Brown).
Mr. BROWN of South Carolina. Mr. Speaker, I rise in strong support of
the Republican amendment and true health care reform. Our plan makes
the cost-saving changes so sorely needed in our health care system
without forcing our children and grandchildren into unending debt.
This amendment will allow insurance to be bought across State lines
to drive down costs and allow small businesses to band together in
order to negotiate fair and affordable coverage. Furthermore, this
amendment improves quality, putting you and your doctor in charge of
your care by removing the powers of insurance companies and trial
lawyers.
Finally, this amendment ensures that the taxpayer dollars my
constituents in South Carolina's First Congressional District pay into
the Federal Treasury never find their way into abortion clinics.
Mr. Speaker, Republicans have a better plan. I urge all of my
colleagues to support this amendment and urge them to vote ``no'' on
final passage.
Mr. RANGEL. Mr. Speaker, I yield 2 minutes to the gentleman from
Washington, Dr. McDermott, who worked his whole career down here to
improve the quality of health care for all Americans.
(Mr. McDERMOTT asked and was given permission to revise and extend
his remarks.)
Mr. McDERMOTT. Mr. Speaker, the Republican health plan and proposal
has been in effect since 1995. A friend of mine came to New York, had
some problems, got on the phone to call a doctor, and the first
question that is always asked is what kind of insurance do you have.
When he said he didn't have any, they said, Well, we can't take care of
you unless you come to the office with $250 in cash. We'll see you if
you do that. He said, I don't have that kind of money. They said, Then
go to the emergency room. That's where 50 million people in this
country are today. Go to the emergency room if you can't come with the
cash to hand it to the doctor.
My office phone today has been ringing off the hook with people
demanding that we have health care now. The Republican alternative
doesn't help anyone, except protects the insurance companies. The
bankruptcy of this plan is pretty clear to everybody. Health analysts,
the media, The New York Times, the CBO all agree that the Republican
plan would leave 42 million people with nothing.
Now, the Republican plan does nothing to help the seniors. It really
isn't a plan. It's just a bunch of stuff they scraped up off the floor
that they had laying around for 12 years and did nothing.
Now, why don't they put forward a plan? Well, I will tell you. I've
cracked the code. This plan they brought out here, they either haven't
read their own bill--because you couldn't keep a straight face and come
out here and say it was a plan--or they would rather spend more time
hating government than helping people. Remember what they did in New
Orleans. That's what their attitude about government is. Don't make it
work for the people. Just let people understand, You're on your own,
folks. That's our plan. We believe in freedom; you're free to be on
your own. But most people can't take care of their health care problems
on their own. They're lucky if they can.
Vote against this proposal, and vote for the bill.
The phones in my office have been ringing off the hook because my
constituents want secure quality affordable healthcare now. Meanwhile
the Republicans have put forward an alternative that doesn't help
anyone but protect insurance companies.
The bankruptcy of the Republican plan is not just my opinion--
analysts, the media, and the Congressional Budget Office all agree the
Republican plan will leave 42 million out in the cold. The Republican
plan does nothing to help people with pre-existing conditions or to
help seniors. The Republican plan is no plan.
How could they have put forward a plan that doesn't solve any of the
healthcare problems Americans face? Well, I may have cracked the code.
Either they haven't read their own bill or they'd rather spend more
time hating government than helping people.
The Republican approach is just a continuation of the status quo
while the Democratic plan covers 96% of Americans. My constituents have
demanded action. The time is now.
Mr. RANGEL. No one has worked harder on this bill than Congressman
Lloyd Doggett from Texas, and it's my honor to now yield 2 minutes to
the gentleman.
Mr. DOGGETT. To help cover huge medical bills in Bastrop, Texas, they
held a Main Street pancake supper, an auction at the American Legion.
Well, essential health care shouldn't depend on the kindness of
strangers or the goodness of neighbors and certainly not on the ``just
say no'' of the Republican Party or the weak TEA parties brewed up by
the insurance lobby.
Now, belatedly, they offer a scheme as skimpy as a hospital gown.
They do nothing to help seniors. Their proposal is inefficient, it's
ineffective, and it's wasteful. Masquerading as reform, their bill
authorizes insurers to continue denying coverage for preexisting health
conditions, such as acne or a C-section. Republican obstructionism has
itself become one giant preexisting condition to meaningful change.
This is a typical old-time Republican medicine show. Do a little bit
for 5 percent of the people. Do nothing for the other 95 percent of the
uninsured, and leave the portion of American families who are uninsured
the same tomorrow as today. The only thing they propose more of is more
insurance policy loopholes.
Freedom. They want the freedom to go broke after a medical emergency,
the freedom to have more bankruptcies, medical bills--the number one
cause of personal bankruptcy in America today. We cannot secure
bipartisan support for health insurance reform tonight because they
don't support any real solutions for the uninsured.

[[Page H12955]]

Our Democratic plan is a lifesaver for 12 times as many Americans,
and it's a dollar saver, responsibly reducing the national debt by $36
billion more than this phony Republican scheme.
Now is the time for a truly historic choice. The Republicans have
chosen to side again with the big insurance monopolies. We choose to
strengthen Medicare. We chose to stand up for the millions of
struggling families who have been denied health care access for too
long.
Mr. RANGEL. Could I ask how much time I have remaining, Mr. Speaker?
The SPEAKER pro tempore. The gentleman from New York has 5 minutes
remaining.
Mr. RANGEL. I yield 2 minutes of that time to the gentleman from
Oregon (Mr. Blumenauer) and ask him to share the great contribution he
has made and the loopholes we find in the Republican substitute.
Mr. BLUMENAUER. I appreciate the gentleman's courtesy.
I hope every American examines the plan that has been offered to us
by the Republicans.
Our citizens are outraged by practices of taking away insurance when
you need it or denying coverage for preexisting conditions. Our bill
fixes it. You won't find it in the Republican bill. Republicans strip
out provisions so important to Oregon and other low-cost, high-quality
States. Republicans do not deal with those vast regional disparities.
They ignore the extra costs faced by seniors caught in the
prescription drug doughnut hole while Democrats provide financial
relief within the next 2 months. If Republicans have their way, there
will be more uninsured Americans in 10 years than there are today.
Weaker protections ignore the needs of the most vulnerable, yet the CBO
says the Republican plan will increase the deficit by $36 billion more
than the Democratic plan.
Mr. Speaker, this is a colossal failure of imagination. The
Republicans could have passed this package any time during the 6 years
they and George Bush ran everything. They didn't bother because it
wasn't worth it.
Last March, Republican Minority Leader Boehner famously said that his
Members shouldn't legislate. With this package as the best they could
do, the Republicans have met the challenge not to legislate.
Mr. CAMP. Mr. Speaker, at this time, I yield 3 minutes to the
gentleman from Missouri (Mr. Blunt).
Mr. BLUNT. Mr. Speaker, I thank the gentleman for yielding.
The Republican Congresses did send important parts of this plan, the
House, to the other body. We sent lawsuit abuse reform seven times. We
sent associated health plans at least a half dozen times. They didn't
get to the floor. We continue to send the elements of this plan that
save every taxpayer money and also save every insured American money.
This is the only plan that reduces the cost of insurance for every
group of insured Americans.
One of the goals that the President set for health care reform was to
reduce the cost of premiums. This is the only plan that does that. It
does it for individuals. It does it for small businesses. It does it
for large groups.
This is a plan where we could provide access to coverage for everyone
regardless of preexisting conditions. Now, we don't spend $1.3 trillion
to do that. We spend about $23 billion to make the risk pools work
better and ensure access for everybody. We're for access for everybody
to coverage; we're just not for spending $1 trillion to create that
access.
This plan lowers premiums. It prohibits insurance companies from
canceling policies. It prohibits insurance companies from capping the
lifetime expenditures that those policies might incur.
One of the reasons that there were more people uninsured at the end
of the 10 years under this plan is, when our friends on the other side
insisted on the children's health insurance plan, they put everybody
that goes on that plan in the first 5 years back into no insurance in
the last 5 years. Look at the numbers. That's where those numbers go
up. You could pretend that our plan puts the numbers up. We're not the
one that said we're going to insure all children for 5 years and in the
second 5 years they're back to where they are today. Check the numbers.
Look at what this does for premiums. Look at what this does for
families. Look at what this does for individuals.
This is a plan that truly does keep what works and fixes what's
broken. The President repeatedly has said, Everyone, if you like what
you have, you should be able to keep it. This is the only plan that
would allow that pledge to be made and be kept.
Mr. Speaker, I encourage my colleagues to support this plan. Let's
take these first steps that work without bankrupting the American
people. I urge support of this plan.
The SPEAKER pro tempore. The gentleman from New York has 3\1/2\
minutes remaining.
Mr. RANGEL. Mr. Speaker, I yield 2 minutes to the gentleman from
Wisconsin, Ron Kind, and thank him for the great contributions he has
made to looking at health care the way it should be, and that is value
and not volume.
(Mr. KIND asked and was given permission to revise and extend his
remarks.)

{time}  2100

Mr. KIND. Mr. Speaker, let's be clear. We really face three choices
here tonight: our plan, their plan, and the consequences of doing
nothing.
But we know what inaction will bring already. We will pay more, we
will get less, and we will bankrupt ourselves as a Nation due to rising
health care costs. So let's just take a moment and compare the two
plans before us this evening.
According to the Congressional Budget Office, not only is our health
care reform plan completely paid for, but we reduce the national
deficit by $109 billion in the first 10 years alone; they by only $68
billion. We cover an additional 36 million uninsured Americans in this
country; they increase the number of uninsured from 47 million today to
over 52 million by 2019. We cover 96 percent of Americans under our
plan; they, 83 percent. We give small businesses tax credits to use in
the national exchange to make it more affordable for them; they do
nothing. We ban the discrimination based on preexisting conditions;
they do nothing. We close the doughnut hole for seniors in Medicare;
they do nothing.
But, most importantly, they do nothing to reform how health care is
delivered and how we pay for it in this country. We change the fee-for-
service payment under Medicare, which is all volume based, to a
reimbursement system that rewards quality and the value of care. Why is
this important? Because studies show that we are spending over $800
billion every year on tests and procedures that don't work. They don't
improve patient care, and because of overtreatment in too many
instances, we're making patients worse off rather than better off.
Our payment reform plan has the best potential of increasing the
quality of care for all Americans at a substantially lower price. They
do nothing.
Mr. Speaker, just 2 months ago President Obama stood in this Chamber
and reminded us what the true character of the American spirit is all
about. He reminded us that we did not come here to fear our future, but
to shape it. That is the historic opportunity that we have before us
this evening.
The SPEAKER pro tempore. The time of the gentleman has expired.
Mr. RANGEL. I yield the gentleman an additional 30 seconds.
Mr. KIND. I thank the gentleman.
I ask my colleagues to support true reform and provide all Americans
with access to affordable and quality care that they all deserve.
Mr. RANGEL. Mr. Speaker, I yield myself the balance of my time.
I'm not going to be as difficult with the Republicans as some of my
colleagues because I'm glad at the end of the day they finally
understood the problem. And even though it was only Tuesday that they
actually put something together for us to look at, at least we know
that some of them are going in the right direction.
It's going to be tragic to explain this to the American people not
only now but in the future as to when they had a great opportunity.
They lost it on Social Security. They said government would become too
big. They lost it on Medicaid. They said that would be too much for the
poor folks, that they should have freedom instead of health care. And
they certainly lost it in

[[Page H12956]]

Medicare where they made it appear as though it was going to be a Big
Government takeover.
And now it just seems to me that they've proven how well government
can do in these programs. And the fact that in lieu of just plain
freedom, in lieu of telling people that they can get insurance if
they're at risk, the whole idea that they're proud of people who cannot
afford to do this at least to have the opportunity to do it.
So, Mr. Speaker, I just hope that some of those on the other side
might allow morality to go beyond just party loyalty.
At this time it gives me pleasure to present to this body Chairman
Waxman, who has done so much to make this a reality.
Mr. CAMP. Mr. Speaker, I reserve the balance of my time.
Mr. WAXMAN. Mr. Speaker, I'm pleased to yield 1 minute to the
gentleman from Vermont (Mr. Welch).
Mr. WELCH. Mr. Speaker, tonight the question before Congress is
neither new nor complicated: Will we do what it takes to make health
care affordable and available to all Americans?
Our predecessors in Congress faced similar choices when they extended
voting rights to all Americans, established Social Security and
Medicare for all seniors. Mr. Speaker, Congress faced those challenges
and we are the better for it. We did so not without conflict and
controversy but with some bipartisan support.
Tonight is different, unique. Our Republican friends have assured us
that not a single member of their caucus will vote for health care
reform. Every single person will vote ``no.''
The Republicans' alternative says to Americans with a preexisting
condition, you are on your own. To the 47 million Americans without
insurance, you're on your own. To the millions of Americans who can't
afford the coverage that they have, you're on your own.
Our health care bill has a different philosophy, the one that
prevailed when Democrats, and some Republicans, passed Social Security,
voting rights, and Medicare: We are in it together.
Mr. WAXMAN. Mr. Speaker, I'm pleased to yield 2 minutes to a very
distinguished member of our committee, the chairman of the Energy
Subcommittee, previously chairman of the Telecommunications
Subcommittee, and a very highly respected Member of this body, the
gentleman from Massachusetts (Mr. Markey).
Mr. MARKEY of Massachusetts. The Republican plan is really quite
simple: you're on your own.
The Republican plan tells Americans if you get sick and you don't
have insurance, you're on your own. The Republican plan tells Americans
if you are denied coverage because of a preexisting condition, you're
on your own.
The Republican leaders in Washington seem to be suffering from their
own preexisting condition: a heart of stone. If you kicked them in the
heart, you would break your toe.
They say that the Democratic plan will put the government between you
and your doctor, but the doctors who make up the American Medical
Association support the Democratic bill and not the Republican bill.
The Republicans claim the Democratic bill will hurt seniors, but AARP
has endorsed the Democratic bill and not the Republican bill. Why does
AARP support the Democratic bill? Because the Democratic bill will
close the Medicare part D doughnut hole for seniors. The Republican
bill does not. We provide support for low-income seniors; they do not.
We will extend the solvency of Medicare; they do not. Right now 60
percent of all bankruptcies in America are because of medical expenses.
The Democratic bill makes sure that never happens again; the Republican
bill does not.
You know, the GOP used to stand for Grand Old Party. Now it stands
for ``grandstand, oppose, and pretend.'' They grandstand with phony
claims about nonexistent death panels. They oppose any real reform. And
with this substitute they pretend to offer a solution while really
doing nothing. GOP: grandstand, oppose, and pretend.
And make no mistake about it, the Republican substitute is not real
reform. It does nothing to curb skyrocketing health care costs. It does
nothing to provide real insurance coverage to millions who are now
uninsured. It does nothing to stop the unfair practices of insurance
companies.
I urge my colleagues to vote ``no'' on the Republican ``do-nothing''
substitute.
Mr. CAMP. Mr. Speaker, I yield 1 minute to the gentleman from Florida
(Mr. Mica).
Mr. MICA. Mr. Speaker, this is a sad day for the Congress and
particularly a sad day for Americans who lack health care coverage.
While Democrat efforts to resolve health care problems may be well
intended, in fact they totally miss the mark. People want lower
premiums, increased access, less cost, and less red tape. They want
choice and quality health care.
Instead, the Democrat health care plan dramatically expands
government, cuts Medicare, and imposes significant costs to taxpayers.
The creation of 118 new Federal programs, agencies, and czars adds
bureaucracy and red tape rather than providing a cure to bring health
care costs down and accessibility up. The $729 billion in new taxes on
Americans and small businesses will result in a loss of 5.5 million
more jobs at a time when our country can least afford it and
unemployment has topped a record 10.2 percent.
I oppose the cuts of nearly a half trillion dollars in Medicare. This
is the wrong solution at the wrong time.
Mr. WAXMAN. Mr. Speaker, I'm pleased at this time to yield 1 minute
to the gentleman from Texas (Mr. Gonzalez).
Mr. GONZALEZ. Mr. Speaker, I rise in strong opposition to the
substitute.
This substitute includes medical liability reforms that draw on the
Texas model. I'm from Texas. Let me tell you about the Texas
experience.
We were promised that medical malpractice reform in Texas would
result in attracting doctors to underserved areas. Today, Texas ranks
43rd out of the 50 States in the number of doctors per capita.
We were promised that it would rein in health costs. Health care
costs in Texas with Medicare alone rose 24 percent in the 3 years after
Texas tort reform.
We were told that it would reduce the cost of health care insurance
for Texans. Premiums actually increased 86.8 percent from the years
2000 to 2007. The average insurance policy for a family in Texas went
from $6,638 to $12,403.
We were told that it would make health insurance plans more readily
available for Texans. Today, Texas has the highest rate of uninsured
adults and the highest rate of uninsured children.
If ever there was a time not to mess with Texas, it is tonight. Vote
``no'' on the substitute.
Mr. WAXMAN. Mr. Speaker, I'm pleased at this time to yield 2 minutes
to the gentleman from New York (Mr. Weiner), an important member of our
committee and a leader in health care reform.
Mr. WEINER. You know, there are honorable people on both sides of
this debate; but there are moments that come along, and they come along
about every generation or so, that make it clear why this side of the
aisle are Republicans and why we're Democrats.
In 1935 when there was the Social Security Act and we decided we
weren't going to allow 30 percent of seniors to slip into poverty,
Democrats proposed, Democrats passed; Republicans opposed Social
Security.
In 1965 when Medicare was passed, Democrats proposed, Democrats
supported; Republicans opposed, and now Medicare is a fact of life. And
the very same arguments that were made against Medicare then are being
made tonight.
I hear this talk about the single-payer plan that's going to creep
over. I can tell you I wanted a single-payer plan. I would like it to
be there, but it's not. But you opposed it then, and now you claim to
support it.
There's been a lot of talk about how big the bill is, but here's what
it's all about: this is what Members of Congress get. This is a
guidebook with affordable health care plans, many choices, deep
discounts because we pool people together, minimum standards for each
plan. This is what Members of Congress get, but they don't want you,
the American people, to get it.
This is what it's about: they say they want to protect Medicare, but
it was

[[Page H12957]]

they who wanted to eliminate it. They say they want to protect Social
Security. It was they who wanted to privatize it. Now they say we don't
want to cover those who are uninsured because you shouldn't care.
Well, I say to my colleagues, who pay those bills? The bill fairy?
Who pays those bills are you, the taxpayer. They say they want you to
pay those, too.
When you look at how big the bills are, remember this document. Eight
million Americans who work for the Federal Government, including my
colleagues, get this document in the mail. They get good health care.
We want it for you. They're going to get Medicare at 65. They don't say
we don't want Medicare because we don't believe in single-payer. They
want it because they want to take and take and take, but they don't
want it for you.
The Democrats want this for you and the Republican Party just wants
it for themselves.

{time}  2115

Announcement by the Speaker Pro Tempore

The SPEAKER pro tempore. The Chair would remind Members to address
their remarks to the Chair.
Mr. CAMP. Mr. Speaker, I yield myself 15 seconds.
As a Senator from Maine who voted for the Senate finance bill
remarked on the House legislation pending said, I do not know what
world they live in, but all I know is it is totally detached from the
average person, the average business owner who is struggling to keep
their doors open, and to have that level of taxation is breathtaking in
its dimension. I just think it is so out of proportion with reality,
with Main Street, America, that it is hard to believe, frankly.
I now yield 5 minutes to a distinguished member of the Ways and Means
Committee, the distinguished minority whip from Virginia (Mr. Cantor).
Mr. CANTOR. Mr. Speaker, today brings the culmination of an extensive
and spirited debate over health care reform. Both parties agree that
the status quo is unacceptable. Obviously, we disagree on how to fix
what is broken. And as the gentleman from New York just said, there are
times in this body when we really can tell the difference between us
Republicans and you Democrats, and this is certainly one of them.
Mr. Speaker, the Democrat solution is a 1,990-page, trillion-dollar
overhaul of the health care system we know, a sweeping new entitlement
that raises taxes, cuts benefits to seniors and, Mr. Speaker, it spends
over a trillion dollars that we don't have.
Republicans believe there is a better way. We have proposed an
alternative approach that offers a stark contrast to the majority's
plan. It is a fiscally responsible and reasoned approach.
The majority's proposal overturns the whole system. We keep what
works and then try to fix what is wrong.
Their bill puts the government between families and their doctors.
Ours doesn't.
Their plan cuts Medicare benefits to seniors. Ours retains them.
Their proposal blows a hole in the deficit. Ours actually saves
money.
Their bill imposes penalties and mandates on our small businesses
that cost jobs. Ours does not.
Specifically, Mr. Speaker, our bill will help you access health care
if you lose or change your job. And it will ensure that you have access
to medical care if you have a preexisting condition. And we also, Mr.
Speaker, deliver on something that the majority refuses to even talk
about, and that's real, meaningful medical liability reform.
And most importantly, Mr. Speaker, we produce cost savings for
workers, families, and small businesses. The Congressional Budget
Office says that the Democrats' new government-run system won't reduce
costs. CBO says our legislation lowers health care costs. In fact, CBO
says that the Republican plan cuts premiums by up to 10 percent for
employees covered by small businesses, up to 8 percent for those not
covered by employers, and up to 3 percent for employees covered by
large businesses.
Mr. Speaker, in the face of 10.2 percent unemployment, Americans want
jobs. They want less government spending and more economic security.
The majority's bill shows they have not listened. Ours shows we have.
Interestingly, Mr. Speaker, the only bipartisanship on Capitol Hill
today will be in opposition to Speaker Pelosi's trillion-dollar-plus
government overhaul of America's health care system.
With that, Mr. Speaker, I urge passage of this substitute.
Mr. WAXMAN. Mr. Speaker, I ask unanimous consent that the 2 minutes
that has been reserved for the Education and Labor Committee debate
time in opposition to the Republican substitute be transferred to the
Energy and Commerce Committee's time.
The SPEAKER pro tempore. Is there objection to the request of the
gentleman from California?
There was no objection.
Mr. WAXMAN. Mr. Speaker, at this time I yield 1 minute to the
gentlewoman from the District of Columbia (Ms. Norton).
Ms. NORTON. Mr. Speaker, I thank the gentleman for yielding and for
the extraordinary work that he and others have done on this bill.
The extraordinary diversity of our Democratic Caucus, Mr. Speaker,
from right to left, has ensured that this bill represents a cross-
section of our country, urban, suburban and rural. The incredible
diversity of our Democratic Caucus, representing Republicans, right-
leaning, moderate, and progressive areas meant that we could not come
to this floor today without a bill that sensitively put all of America
together into one convincing bill. That is why we have produced a bill
that satisfies deficit hawks who are more wary of increasing deficits
than of most other issues, as well as single-payer advocates who
believe that only Medicare for all can markedly reduce costs while
providing adequate health care for the middle class and the uninsured.
Thus, there can be no doubt this evening that the Affordable Health
Care for America Act is a balanced bill and the best bill for the
citizens of the United States of America.
The extraordinary diversity of our Democratic Caucus--from right to
left has ensured that this bill represents a cross-section of the our
country--urban, suburban, and rural. The incredible diversity of our
Democratic Caucus, representing Republican, right-leaning, moderate,
and progressive areas, meant that we could come to this floor today
only with a bill that sensitively put all of America together into one
convincing bill. That is why we have produced a bill that satisfies
deficit hawks, who are more wary of increasing deficits than of most
other issues, as well as single-payer advocates, who believe that only
Medicare for all can markedly reduce costs while providing adequate
health care to the middle class and the uninsured. Thus, there can be
no doubt that the Affordable Health Care for America Act is the best
bill for the citizens of the United States of America.
The bill's greatest achievements are that it would reduce the deficit
over the next 10 years and into the future while covering 96 percent of
the American people; would end discrimination by insurers who dropped
or refused to renew or sell coverage because of health status and would
ensure that coverage is affordable by providing subsidies for people in
employer-based health care or through an insurance exchange of private
insurers and a consumer option to drive down the cost of health care
while operating on a level playing field with other insurers.

Parliamentary Inquiry

Mr. GOHMERT. Parliamentary inquiry.
The SPEAKER pro tempore. The gentleman will state his parliamentary
inquiry.
Mr. GOHMERT. Mr. Speaker, my understanding of the rules is that there
is required to be a copy of the bill, and since we have a manager's
amendment, that is supposed to be somewhere. A number of us have been
trying to find a copy of the manager's amendment since we are going to
be voting on it. I hear some aahs, but isn't there supposed to be a
copy, and if so, where would that copy be, since we are about to do
this to the American people?
The SPEAKER pro tempore. The official papers are at the desk.
Mr. GOHMERT. And I was just at the desk, Mr. Speaker, so
parliamentary inquiry: If you could direct me to that place on the desk
where the 200 pages are, it would be very helpful.
The SPEAKER pro tempore. The Clerk has the official papers.
Additional copies are in the lobby and Members have been carrying them
around all day.
Mr. GOHMERT. Parliamentary inquiry. Does the Speaker know where a
copy, as the rule requires, is at the desk so that we can come up and
see it at the desk as a requirement of the rules?

[[Page H12958]]

The SPEAKER pro tempore. The Clerk has custody of the official
papers.
Mr. GOHMERT. I take that as a ``no.''
The SPEAKER pro tempore. The gentleman from Michigan has 4 minutes
remaining, and the gentleman from California has the right to close.
Mr. CAMP. We will reserve our time.
Mr. WAXMAN. We are ready to close, so use your time. Use it or lose
it.
Mr. CAMP. At this time, Mr. Speaker, I yield the customary 1 minute
to the distinguished minority leader, the gentleman from Ohio (Mr.
Boehner).
Mr. BOEHNER. Let me thank my colleague for yielding, and thank him
and our ranking members for the job they have done putting our
substitute together.
Ladies and gentlemen, before I came here, I ran a small business.
While I was running my small business, it became pretty clear to me
that government was growing in my view out of control. More
regulations, more taxes, more compliance costs, both for my suppliers,
for my customers, and for my own little small business. It seemed to me
that government was choking the goose that was laying the golden egg.
You know, we were all lucky enough to be raised in America, most of
us born in America, the greatest country in the world. And it is a
great country because Americans have had the freedom, the freedom to
succeed, the freedom of opportunity. But I think all of us can
understand that the bigger government gets, the more that it takes from
the American people, the more money that individuals have to spend to
comply with all of these regulations, is less money that is left in
American families' pockets, small business's pockets, and as a result
the opportunities, the opportunities available for our citizens get
diminished.
We live in a great country. But it can only be great if we are
willing to allow the freedom that Americans have had to succeed to
remain. That freedom has been dimming. The bright lights of freedom
have been dimming for decades because government continues to grow. One
only has to look at what has happened this year to wonder why we are
here tonight doing this. We all know we have had a difficult economic
shock in our country over the last year.
So we see a stimulus bill that came to this floor with a promise that
we were going to create jobs, jobs, jobs. And unemployment wasn't going
to exceed 8 percent. Now we have unemployment rates at 10.2 percent and
over 3 million Americans have lost their jobs. So all of a sudden we
have a budget on the floor, a trillion-and-a-half-dollar deficit this
year, and trillion-dollar deficits on average for as far as the eye can
see. And I don't think there is a Member on either side of the aisle
who doesn't realize that this is unsustainable, that this will wreak
havoc on our country and wreak havoc on the future for our kids and our
grandkids.
If there is one obligation that we have, it is to ensure that the
American dream that is available to all of us is available for our kids
and our grandkids. And trillion-dollar deficits for as far as the eye
can see are not sustainable and will ruin their future.
But no, it wasn't enough. All of a sudden we have to have this
national energy tax on the floor in June. It is called cap-and-trade
because no one in America really knows what that means, but it is a
giant energy tax. And it would tax anybody who drives a car, anybody
who works at a place that uses electricity. Anyone who would have the
audacity to flip on a light switch is going to pay a higher tax.

{time}  2130

Not only are we going to pay higher taxes and have less energy and
higher energy costs in America, it will ship millions of American jobs
overseas at a time when Americans are asking, Where are the jobs? And
the policies that have been coming down the pike all year have done
nothing more than diminish the possibility that we will be creating the
jobs that Americans so desperately want. That still wasn't enough. Now
we are going to bring this 2,000-page bill to the floor of the House.
It's going to cost over $1.3 trillion and will kill millions more
American jobs.
The American people want us to focus on getting our economy moving
again because they are looking for work. They want to make sure that
those who have their job can keep it. What has happened here all year
is we're moving policies that are going to destroy the ability of the
private sector to create those jobs. But I don't think there is
anything that will diminish the job prospect in America more, of all
the things that have happened this year, than this health care bill.
Now, you just think about this bill that we have in front of us. It
is going to raise taxes. It is going to raise insurance premiums for
those who have insurance. It's full of mandates. And as if that's not
enough, we are going to cut Medicare.
Now, the President said that if you like the health insurance you
have, you can keep it. And I know the President was sincere in that,
but that is not what this bill represents and there's not a Member in
this Chamber that doesn't understand that. Because if you're a Medicare
Advantage enrollee, like 27,000 of my constituents, the Congressional
Budget Office says that 80 percent of them are going to lose their
Medicare Advantage.
If you look at this bill and you look at the employer mandate in this
bill, you will find out that if employers don't provide health
insurance, there is a tax. And for many employers, the tax will be
cheaper than the actual cost of health insurance. A lot of employers in
America are going to look up and say, Listen, I'd rather pay the tax,
and my employees are going to have to go fend for themselves and end up
in the government plan.
But it doesn't stop there. This bill also requires that every
employer plan that is offered today has to be approved once again by
the Department of Labor and the health choices czar; big compliance
cost there. Some employers are going to say, Listen, this isn't worth
it. Because it's not just getting the plan reapproved again. It has to
go through the health choices czar so that the health choices czar can
determine whether your plan is adequate according to some Federal
bureaucrat. And so a lot of employers, they're just going to get out of
it. They're not going to do it. And what is going to happen to those
employees who like the coverage they have today? They are going to end
up in the government plan.
But no, no, it doesn't stop there. We have an individual mandate in
this bill in front of us that says every American is going to buy
health insurance whether you want it or not. And if you don't want it,
you're going to pay a tax. And if you don't pay the tax--listen to
this. If you don't pay the tax, you're going to be subject to a fine of
up to $250,000 and imprisonment up to 5 years. Now, this is the most
unconstitutional thing I've ever seen in my life. The idea that we can
tell Americans, force Americans by some law that they have to buy
health insurance or we're going to fine you and send you to jail.
But there has been all this focus on the employer mandate and on the
individual mandate, on the government option, but let me tell you where
there hasn't been much attention, and that is the giant bureaucracy
that is being built here in Washington in the Federal Government to
take control of Americans' health care system and force you out of the
insurance you have and into some government-run plan.
I know most of my colleagues, they might think this is hyperbole or
it might sound political. Let me tell you, it isn't. Well, just listen
to this. Most of my colleagues on the left have been down here today.
They are for this because it does in fact set up this big
infrastructure for the government to eventually take control of all of
our health care and just go to a single-payer system.
Now, it starts with the exchange that's in this bill. Once it takes
effect, the health exchange, you can't buy private insurance on your
own. You can't go out and buy insurance. You have to go to the
exchange, and the exchange will decide for you which plans are offered
to you. So, if you change your job or you don't like what you have,
guess what? You get to go to the government's health exchange to get
your insurance.
But it's just not the government option that I'm talking about. When
you look at this infrastructure that's there, it is going to require
tens of thousands

[[Page H12959]]

of new Federal employees. The American people want two things from
health care reform: They want lower cost and they want more choices. I
think the underlying bill here tonight does exactly the opposite. It
raises the cost of health insurance and creates this new
megabureaucracy to make health care decisions that should be left to
doctors and their patients.
So let's talk about this bureaucracy for a moment. If you go to page
131, section 241 provides for an unelected ``Health Choices
Commissioner'' who would run a ``Health Choices Administration,'' an
independent agency of the executive branch.
Now, here are some of the examples of the powers of this new health
choice commissioner--let's just call him the health czar. On page 167
through 172, in section 303, the health czar will decide which
treatment patients could receive and at what cost. Or you can go to
page 132, section 242, the health choices czar would decide which
private plans would be allowed to participate in the exchange.
Then you go to page 127, section 234. This new health czar will
regulate all insurance plans both in and out of the exchange.
Then you go to page 162 to 165, section 302, the health choices czar
will determine which employers are going to be allowed to participate
in the exchange.
Then you go to page 174 to 178, section 304(b), the health choices
czar will decide which physicians and hospitals get to participate in
the government-run plan.
Then you go to page 197 to 202, section 308, the health choices czar
will determine which States are allowed to operate their own exchange
and to terminate any previously approved State exchange at any time.
Then you go to page 170 and 171, section 303(d), the health choices
czar can override State laws regarding covered health benefits. It's in
the bill. Go read it.
Page 133, section 242(a)(2). This person will determine how trillions
of taxpayer and employer dollars would be spent within the exchange.
And page 133, section 242, ``conduct random compliant audits.'' The
person still has more powers here.
Page 183, section 305, automatically enroll Americans into the
exchange if they don't have coverage, including potentially forcing
these individuals into the government-run plan. Now, this is referred
to as ``random assignment.''
This commissioner is charged with establishing ``waiting lists'' and
defining such terms as ``dependent,'' ``service area,'' ``premium
rating area,'' ``employee,'' ``part-time employee,'' and ``full-time
employee.'' Let's all be honest, this is the czar to end all czars.

But it doesn't stop there. When you look at this expanding
bureaucracy created in the Federal Government, on page 1322, section
2401, it creates a new Center for Quality Improvement to prioritize
areas for identification, development, evaluation, and implementation
of best practices for quality improvement of best practices for the
delivery of health care services. We've already got Centers for Quality
Improvement. We've got doctors, nurses, surgeons, hospitals,
laboratories, rehab facilities. But no, no, we're going to have more
bureaucracy than that. We're not even close to the end of this
bureaucracy.
Page 1183, section 1904 provides for $750 million in Federal funding
for a new entitlement program to offer ``knowledge of realistic
expectations of age-appropriate child behaviors'' and ``skills to
interact with their child.'' So not only is the Federal Government
going to legislate what's good for medical practices, now we're going
to put $750 million into a program to help legislate how parents should
parent.
Page 1198, section 1907, we establish a Center for Medicare and
Medicaid innovation within the Centers for Medicare and Medicaid
Services to legislate innovation as part of a bill that cuts, I think,
the most innovative Medicare program we have, that's Medicare
Advantage. But we still have more.
Page 25, section 101 authorizes the Secretary of Health and Human
Services to reduce benefits, increase premiums, and establish waiting
lists to make up for funding in the shortfalls of high-risk pools.
That's right there in the bill, ``establish waiting lists.''
Pages 734, 738, and 1162, sections 1401 and 1802 create the Center
for Comparative Effectiveness Research and the Comparative
Effectiveness Research Commission and the Comparative Effectiveness
Research Trust Fund. These are bureaucracies that will decide which
treatments are most effective. But the bill does not provide any
protection to doctors and patients that they all get to decide what's
in their own best interest.
Then we get into a lot more duplicative Federal programs. Page 1432,
section 2531 provides for incentive payments to States that enact new
medical liability laws, but only if such laws do ``not limit attorneys'
fees or impose caps on damages.'' So we're telling States to solve the
problems, but also telling them not to use the tools that work most
effectively in the States that are using them.
Page 1624, section 2589 creates a new Personal Care Attendant
Workforce Advisory Panel. Let me say that again, a Personal Care
Attendant Workforce Advisory Panel made up in part by personal care
workers, including their union representatives, to study working
conditions and salaries of these workers. What does this have to do
with lowering health care costs?
Page 1968, section 3103 establishes a ``Committee for the
Establishment of the Native American Health and Wellness Foundation.''
So we're going to set up a committee whose job it is is to set up a
foundation, and we're going to take half a million dollars of
Americans' money to do this.
Page 1330, section 2402 creates a new Assistant Secretary for Health
Information. I guess this is another job saved or created.
Page 1391, section 2524 creates a ``No Child Left Unimmunized Against
Influenza'' demonstration grant program to test the feasibility of
using the Nation's elementary schools and secondary schools as
influenza vaccination centers. Aren't we doing this already?
Page 1253, section 2231 creates a new Public Health Workforce Corps
for the purpose of ``ensuring an adequate supply of health
professionals.'' The bill also creates a ``Public Health Workforce
Scholarship Program'' and a ``Public Health Workforce Loan Forgiveness
Program.'' All of this duplicates the existing National Health Services
Corps.
Page 1478, section 2552, the bill creates an Emergency Care
Coordination Center in the Office of the Assistant Secretary for
Preparedness and Response charged with working in coordination with the
Federal Interagency Committee on Emergency Medical Services. And the
Emergency Care Coordinator Center seeks out the advice of a Council of
Emergency Care.
We're not finished yet. How about this one? Page 1515, section
2572(b) imposes a labeling requirement on all vending machines
nationwide. In addition to that, we require all restaurants with more
than 20 locations to post the calorie count exactly next to--and we
spell this out in the law--right next to the menu, whether it's the
drive-in menu, the menu on the board, the one they hand out to you. Oh,
yeah. We're going to require every restaurant with more than 20
locations to do this. Oh, but that's not enough.

{time}  2145

Page 872, section 1433 requires the director of food services at
nursing facilities that participate in Medicare or Medicaid to hold
``military, academic, or other qualifications'' as determined by
Federal bureaucrats. So now we are going to legislate the work
requirements in the background of all this off.
But I think this is the best part of the bureaucracy: on page 122,
section 233(a)(3) of this 2,032-page bill, it requires the commissioner
to ``issue guidance on best practices of plain language writing.'' Oh,
yes, it's right here in the bill. Go look at it.
Ladies and gentlemen, we know what's going on here. There are
problems in our current health care system that we all want to address.
I heard all the criticisms of our bill and the fact that it doesn't do
everything that everybody wants it to do.
But do you know what it does do?
It lowers the cost of health insurance, and it solves the problem of
those with preexisting conditions, and it begins to insure more
Americans. That's what the American people want, a step-by-step
approach to making the best health care system in the world better.

[[Page H12960]]

We can do that. What we don't need to do is to create this giant
bureaucracy, spend all of this tax money, and imprison our children's
future by passing this 2,000-page bill.
So, I think we do have a better solution, a commonsense solution that
Americans will support.
So, tonight, here we are. We have a choice. We can pass the 2,000-
page bill. We can raise taxes. We can cut Medicare. We can impose all
of these mandates on employers that are going to drive employment down
and unemployment up, or we can take some commonsense approach.
As I said during my remarks, our job is to do our best to make sure
that our kids and grandkids have a better chance of the American Dream
than we did. I understand that we've got some tough choices to make,
but that's what the American people sent us here to do is to make those
tough choices. I'm not going to put my kids further in debt. I'm not
going to dim the lights of freedom for my kids and theirs nor for
anyone's in this country if I can avoid it.
So we have a choice. We can do what's right for the future, or we can
continue down this path toward bigger and bigger government. I came
here to fight for freedom. I came here to renew the American Dream for
our kids and our grandkids.
So I would ask my colleagues to think about that choice. Vote for the
Republican alternative, and whatever you do, please vote ``no'' for the
underlying bill.
Mr. WAXMAN. Mr. Speaker, to close the debate on the Democratic side,
I yield the balance of my time to the dean of the House, to the lead
author of the underlying bill and to a man who has fought longer for
national health insurance than anyone in this institution. I yield the
balance of my time to Representative John Dingell from the State of
Michigan.
The SPEAKER pro tempore. The gentleman from Michigan is recognized
for 5 minutes.
(Mr. DINGELL asked and was given permission to revise and extend his
remarks.)
Mr. DINGELL. Mr. Speaker, I am here tonight to urge my colleagues to
vote against the Republican substitute and for the bill reported by
three committees after long and hard work.
I want to tell the House--all Members--how proud I am of the
discussion that has taken place today. I want to commend the three
committees and their chairmen, including my good friend, the chairman
of our committee, Mr. Waxman, for the work they have done.
You, Madam Speaker and the leadership, we thank you for the
extraordinary leadership which you have given us in bringing this to
the point where we are tonight. Thank you.
I won't begin by spending much time on the bill offered by my
Republican colleagues. It is really no substitute for H.R. 3962.
According to The New York Times--and I think this sufficiently disposes
of the matter--the Republican amendment does ``almost nothing to reduce
the scandalously high number of Americans who have no insurance, and it
makes only a token stab at slowing the relentlessly rising costs of
medical care.''
Interestingly enough, under the Republican amendment, individuals
would pay up to $2,821 more, and families would pay up to $8,188 more
under the Republican plan when compared with H.R. 3962. It's not in the
public interest that we should do that.
Having said that, this is historic legislation. It addresses two of
the most terrifying problems we have in this country:
The first is what was the problem when my dad introduced the first
legislation in 1943, that there are now some 47 million Americans
without health care. This will give many of them adequate health care
and a decent choice of what they will have before them at the best
possible price through an exchange, which will make it possible for
them to choose without having to worry about understanding the language
of Philadelphia lawyers and reading fine print that can only be read
with a magnifying glass.
The bill does something more. It takes care of an economic problem
that will be visited on us in 2080 when the costs of health care will
equal the gross domestic product of the United States. That will bring
us to a fine economic mess if we permit that to happen. Health care and
GDP costs will be equal.
Now, the bill carries out the President's suggestions: deficit
neutral. It provides coverage for 96 percent of Americans. It offers
everyone, regardless of income, age, health status, the peace of mind
that comes from knowing that they will have real access to affordable
health insurance when they need it.
It does away with preexisting conditions, which the bill offered by
my friends in the minority does not; and it sees to it that, when you
go to bed at night, you're going to wake up knowing in the morning that
you're going to have health insurance. It can't have been dropped by
your employer, and it can't have been canceled by your insurance.
There is a practice, on which we just had hearings, that is engaged
in by the insurance companies. It is called ``rescission.'' They can
cancel your insurance policy by the simple device of rescinding your
policy because they say you have some preexisting conditions, and they
can do it while you're on the gurney, being rolled into the operating
amphitheater.
The bill is going to give choice and honest competition. It is going
to bring security to our seniors, and it is going to reduce out-of-
control health care costs that are crushing American business.
It costs $4 an hour less to make a car in Canada than it does in
Michigan. Why? Because the Canadians have a program of national health
insurance which ensures that the manufacturer can compete and out-
compete Americans because he doesn't carry that economic burden.
Today, this may be a tough vote, but it was in 1935 when we passed
Social Security. I hear my colleagues tell us that the economy, jobs
and financial system overhaul, are desperately needed. True. But that
was the case in '35 when we passed the Social Security Act.
Now I hear my Republican colleagues tell us this is going to stand
between--or permit a government bureaucrat to stand between the insured
and the doctor and each other. In point of fact, it is going to permit
the government to stand between the insurance bureaucrat and the
insured, and it is going to stand between him and the doctor so that
the doctor can provide the care he wants.
The problems this historic legislation aims to address are real and
worsening for American citizens, business, and governments. When my Dad
introduced this legislation sixty some years ago, it was a simple
humanitarian problem. Today it is one of impending economic disaster to
America.
H.R. 3962 meets the goals President Obama outlined for us earlier
this year: it is deficit neutral; it provides coverage for 96 percent
of Americans; and it offers everyone, regardless of income, age or
health status, the peace of mind that comes from knowing they will have
real access to quality, affordable health insurance when they need it;
that preexisting conditions will not bar them from insurance; that loss
of job or dropping of coverage by employer will not deny insurance.
This bill will stop discrimination against people with pre-existing
conditions, and it will stop rescission--the practice in which an
insurer searches for problems with patients' policies while they are
waiting on a gurney for emergency care.
Additionally, this bill will ensure choice and honest competition;
bring security to our seniors; and will reduce the out-of-control
health care costs that are crushing American businesses.
Now is the time for health care reform. We can't afford to wait. We
must offer big solutions for the big problems that face the American
people. We must succeed.
Mr. Speaker, I have heard from a number of my colleagues, and I
appreciate the fact the vote before us today is a tough vote.
I understand there are numerous competing issues confronting the
American people--the economy, jobs, financial system overhaul. That was
so in 1935 when we enacted Social Security over just about the same
objections.
However, we know that no issue has caused the American people to
suffer longer than the issue of inaccessible health care.
History and the American people will ask what we did here this day
when presented with a real opportunity to ease the strain of rising
health care costs and provide quality, affordable health coverage for
all.
Mr. Speaker, the vote for me today will be on behalf of American
families who are forced to decide whether they will pay the mortgage or
their health insurance premium.

[[Page H12961]]

My vote today is for American business--big and small. They are
confronted with the real burden of providing quality health care for
their workers or fall victim to their foreign competitors.
My vote today is for the federal government, and state and local
governments throughout the country which are being stretched to make
room for larger and larger health bills.
Mr. Speaker, my vote today is also personal.
It is a vote to fulfill the legacy left by a little, skinny Polack
with a broken nose and a mustache who served as a proud Member of this
distinguished body.
My father, John D. Dingell, Sr., was a part of the original New
Dealers--a brand of big thinking Democrats--who believed that health
care is a right, not a privilege and government had a responsibility to
protect it people; provide for their basic rights; and ensure
opportunity for all.
So, it is in that tradition that I urge my colleagues to act today to
pass this bill.
Join with the AMA, the AARP, the Consumers Union, the American Cancer
Society, the different medical specialist groups, the Nurses and others
who support this bill.
Mr. Speaker, we have an opportunity today, to do something meaningful
for the American people and for American business.
We can take advantage of this opportunity or we can shirk our
responsibilites and allow the calamitous situation that faces our
people to contine to grow out of hand, overwhelm the federal budget,
force more and more families into bankruptcy, and shift more jobs
overseas.
Reform is neither easy nor cheap, but the cost of inaction is far
greater--in terms of lost lives, quality of life and dollars. If we
don't reduce costs we face certain economic disaster.
So, today, we must overcome the naysayers, the loyal opposition, the
lies about our plan, the fear that causes us to think the status quo is
the safe thing to do.
We must overcome all of these things and we must act boldly, with
conviction, and deliberately--not because of our own righteousness--but
because there is no other acceptable alternative.
I urge my colleagues to vote ``yes'' on H.R. 3962 and give the
American people the relief they so desperately need.
Ms. RICHARDSON. Mr. Speaker, I rise today to oppose the Boehner
amendment and in strong support of H.R. 3962, the Affordable Health
Care for America Act of 2009, because this bill is good for seniors,
good for women, good for small businesses, and good for all Americans.
President Theodore Roosevelt proposed national health insurance in
1908. Forty years later in 1948, President Truman proposed it again.
Under the leadership of Lyndon B. Johnson and a Democratic Congress,
Medicare was enacted in 1965 which provided health care for senior
citizens.
Today, we write another great chapter in the remarkable history of
this country. Today, we extend to tens of millions of our fellow
citizens the security that comes from knowing that they will have
health care that is there when they need it and won't bankrupt their
families.
The health care system we have now is not working for middle and
working class families, not working for businesses trying to compete in
a global economy, not working for taxpayers or for the uninsured.
There are 54 million Americans who are uninsured who need us to
reform this broken system. One in five Californians are uninsured or
underinsured. These numbers are staggering and if we do nothing, they
will only grow worse.
Mr. Speaker, the Affordable Health Care for Americans Act is the
answer to the broken health care system. This bill provides American
families with stability and peace of mind. Never again will they have
to choose between their health and their livelihood.
This bill provides American families with higher quality health care.
It leaves important health decisions up to patients and doctors, not to
insurance companies.
Finally, this bill lowers costs for American families. It eliminates
co-pays and deductibles for preventive care while putting an annual cap
on out-of-pocket expenses for American families.
Now, we need to stop playing politics and focus on actually improving
people's lives. H.R. 3962 will reform the health care system so that it
provides quality, affordable coverage that cannot be taken away. It
eliminates discrimination based on gender and preexisting conditions.
It eliminates the prescription drug donut hole for seniors. It ends the
era of no and begins the era of yes for millions of Americans seeking
coverage.
The hour is late, and the need is great. I urge my colleagues to vote
``no'' on the Boehner Amendment and ``yes'' on H.R. 3962.
Mr. GALLEGLY. Mr. Speaker, I rise in support of the amendment offered
by Mr. Boehner. I have long supported changes to current health care
system which reduce health care costs through increased efficiency and
provide affordable insurance for people with preexisting conditions.
But, at the same time, any changes to our current system should ensure
doctors and patients are allowed to make health care decisions--not
government bureaucrats.
Therefore, I support real health insurance reform and support the
version offered by the Minority Leader, which would:
Lower health care premiums for working families,
Allow small businesses to join together in order to buy reasonably
priced health insurance,
Reduce medical costs by limiting frivolous medical malpractice
lawsuits,
Prevent insurers from unjustly cancelling health insurance policies,
and Establish universal access programs that provide affordable
insurance for people with preexisting conditions.
Mr. Speaker, we should not consider changes of this magnitude without
a complete report from the nonpartisan Congressional Budget Office,
CBO. The preliminary estimate from the CBO puts the cost of H.R. 3962
at more than $1.05 trillion, but many independent experts believe this
bill will actually increase Federal expenditures by more than $1.3
trillion.
In addition, this bill would impose $730 billion in new taxes and
mandates on individuals and small businesses. Most economists,
including CBO experts, have concluded that these requirements could
increase unemployment by discouraging businesses from hiring low-wage
workers. It could also lead to wage stagnation as payroll is diverted
to comply with new Federal mandates on health care coverage.
I am also concerned about the impact of this proposal on Medicare
beneficiaries. H.R. 3962 would cut $400 billion from Medicare over 10
years, including a $170 billion reduction to Medicare Advantage plans,
which provides insurance coverage for many seniors.
Finally, H.R. 3962 does not address the problem of frivolous
malpractice lawsuits in a meaningful way. These suits lead to the
practice of expensive, defensive medicine and raise the health care
expenses of all patients.
I urge my colleagues to reject H.R. 3962 and support the amendment
offered by Mr. Boehner.
Mr. SAM JOHNSON of Texas. Mr. Speaker, today, I want to add my
support for the Republican substitute amendment, the Common-sense
Health Care Reform and Affordability Act. This amendment is a patient
centered solution to healthcare reform that our country can afford and
that members on both sides of the aisle can support. It also addresses
the number one concern on the mind of all Americans in this country:
the high cost of health care.
The Congressional Budget Office has estimated that this Republican
substitute amendment would reduce health insurance premiums by up to 8
percent for those families who currently do not have access to
employer-provided coverage. My constituents have told me over and over
again that the cost of healthcare is too high. They need healthcare
that is more affordable, accessible and available and the Commonsense
Health Care Reform and Affordability Act provides just that.
Included in the Republican substitute amendment is my bill, H.R.
2607, the Small Business Health Fairness Act. This legislation allows
small businesses to band together to purchase health insurance so they
can enjoy the same bargaining power large corporations and labor unions
have at the purchasing table. In all parts of our economy we know that
buying in bulk reduces the price tag, and healthcare is no different.
Government-forced healthcare is not the way to solve our health care
problem. We can and have to do better.
With almost 60 percent of the uninsured population tied to a small
business, this provision in the Commonsense Health Care Reform and
Affordability Act, helps bring access to affordable healthcare to those
that currently don't have it. Clearly, there are better ways to make
healthcare more accessible for American families--and this Republican
substitute is it.
Real healthcare reform should protect doctors and hospitals from
frivolous lawsuits, so they can stop practicing defensive medicine and
instead focus on practicing patient-focused care. This amendment
extends medical liability reform that has been successful in several
States to the rest of the Nation, saving lives and saving money.
Another provision in the Republican substitute amendment I am proud
to support is the State Innovations Program. The amendment provides
incentives to States who adopt reforms that reduce the cost of health
insurance and expand coverage to the citizens of their States.
This provision allows States the freedom to solve their health
problems on their own. Speaker Pelosi's health-care bill focuses on the
Federal Government trying to fix what is broken with our health care.
But in my great State of Texas, I believe those that are best

[[Page H12962]]

equipped to solve our healthcare problems are Texans. It is time for
real reform that works and not the same old answers of more money and
more government.
Finally, this amendment protects American innovation while ensuring
patients will have more cutting edge treatment options in the area
called ``follow on biologics.'' The Commonsense Health Care Reform and
Affordability Act contains a provision that will create a pathway for
new, life saving products while maintaining the proper incentives for
companies to research and strive to discover them. Most importantly,
this provision will ensure that many of the jobs created in this
industry will stay in the United States.
The Commonsense Health Care Reform and Affordability Act is exactly
the solution the American public has asked Congress to pass. It saves
money, lowers the cost of health care, protects the patient-doctor
relationship and keeps the government out of personal healthcare
decisions. I ask my colleagues to join me in supporting this amendment
today.
Mr. CAMP. Mr. Speaker, I yield back the balance of my time.
Mr. WAXMAN. Mr. Speaker, I yield back the balance of my time.
The SPEAKER pro tempore. The question is on the amendment offered by
the gentleman from Ohio (Mr. Boehner).
The question was taken; and the Speaker pro tempore announced that
the noes appeared to have it.
Mr. CAMP. Mr. Speaker, on that I demand the yeas and nays.
The yeas and nays were ordered.
The SPEAKER pro tempore. Pursuant to section 2 of House Resolution
903, further proceedings on this question will be postponed.

Announcement by the Speaker Pro Tempore

The SPEAKER pro tempore. Pursuant to section 2 of House Resolution
903, proceedings will now resume on the amendments printed in parts C
and D of House Report 111-330 on which further proceedings were
postponed, in the following order:
Amendment printed in part C by Mr. Stupak of Michigan.
Amendment printed in part D by Mr. Boehner of Ohio.
The Chair will reduce to 5 minutes the time for any electronic vote
after the first vote in this series.

Amendment Offered by Mr. Stupak

The SPEAKER pro tempore. The unfinished business is the vote on the
amendment offered by the gentleman from Michigan (Mr. Stupak) on which
the yeas and nays were ordered.
The Clerk will redesignate the amendment.
The Clerk redesignated the amendment.
The SPEAKER pro tempore. The question is on the amendment.
The vote was taken by electronic device, and there were--yeas 240,
nays 194, answered ``present'' 1, not voting 0, as follows:

[Roll No. 884]

YEAS--240

Aderholt
Akin
Alexander
Altmire
Austria
Baca
Bachmann
Bachus
Barrett (SC)
Barrow
Bartlett
Barton (TX)
Berry
Biggert
Bilbray
Bilirakis
Bishop (GA)
Bishop (UT)
Blackburn
Blunt
Boccieri
Boehner
Bonner
Bono Mack
Boozman
Boren
Boustany
Brady (TX)
Bright
Broun (GA)
Brown (SC)
Brown-Waite, Ginny
Buchanan
Burgess
Burton (IN)
Buyer
Calvert
Camp
Campbell
Cantor
Cao
Capito
Cardoza
Carney
Carter
Cassidy
Castle
Chaffetz
Chandler
Childers
Coble
Coffman (CO)
Cole
Conaway
Cooper
Costa
Costello
Crenshaw
Cuellar
Culberson
Dahlkemper
Davis (AL)
Davis (KY)
Davis (TN)
Deal (GA)
Dent
Diaz-Balart, L.
Diaz-Balart, M.
Donnelly (IN)
Doyle
Dreier
Driehaus
Duncan
Ehlers
Ellsworth
Emerson
Etheridge
Fallin
Flake
Fleming
Forbes
Fortenberry
Foxx
Franks (AZ)
Frelinghuysen
Gallegly
Garrett (NJ)
Gerlach
Gingrey (GA)
Gohmert
Goodlatte
Gordon (TN)
Granger
Graves
Griffith
Guthrie
Hall (TX)
Harper
Hastings (WA)
Heller
Hensarling
Herger
Hill
Hoekstra
Holden
Hunter
Inglis
Issa
Jenkins
Johnson (IL)
Johnson, Sam
Jones
Jordan (OH)
Kanjorski
Kaptur
Kildee
King (IA)
King (NY)
Kingston
Kirk
Kline (MN)
Lamborn
Lance
Langevin
Latham
LaTourette
Latta
Lee (NY)
Lewis (CA)
Linder
Lipinski
LoBiondo
Lucas
Luetkemeyer
Lummis
Lungren, Daniel E.
Lynch
Mack
Manzullo
Marchant
Marshall
Matheson
McCarthy (CA)
McCaul
McClintock
McCotter
McHenry
McIntyre
McKeon
McMorris Rodgers
Melancon
Mica
Michaud
Miller (FL)
Miller (MI)
Miller, Gary
Mollohan
Moran (KS)
Murphy, Tim
Murtha
Myrick
Neal (MA)
Neugebauer
Nunes
Oberstar
Obey
Olson
Ortiz
Paul
Paulsen
Pence
Perriello
Peterson
Petri
Pitts
Platts
Poe (TX)
Pomeroy
Posey
Price (GA)
Putnam
Radanovich
Rahall
Rehberg
Reichert
Reyes
Rodriguez
Roe (TN)
Rogers (AL)
Rogers (KY)
Rogers (MI)
Rohrabacher
Rooney
Ros-Lehtinen
Roskam
Ross
Royce
Ryan (OH)
Ryan (WI)
Salazar
Scalise
Schmidt
Schock
Sensenbrenner
Sessions
Shimkus
Shuler
Shuster
Simpson
Skelton
Smith (NE)
Smith (NJ)
Smith (TX)
Snyder
Souder
Space
Spratt
Stearns
Stupak
Sullivan
Tanner
Taylor
Teague
Terry
Thompson (PA)
Thornberry
Tiahrt
Tiberi
Turner
Upton
Walden
Wamp
Westmoreland
Whitfield
Wilson (OH)
Wilson (SC)
Wittman
Wolf
Young (AK)
Young (FL)

NAYS--194

Abercrombie
Ackerman
Adler (NJ)
Andrews
Arcuri
Baird
Baldwin
Bean
Becerra
Berkley
Berman
Bishop (NY)
Blumenauer
Boswell
Boucher
Boyd
Brady (PA)
Braley (IA)
Brown, Corrine
Butterfield
Capps
Capuano
Carnahan
Carson (IN)
Castor (FL)
Chu
Clarke
Clay
Cleaver
Clyburn
Cohen
Connolly (VA)
Conyers
Courtney
Crowley
Cummings
Davis (CA)
Davis (IL)
DeFazio
DeGette
Delahunt
DeLauro
Dicks
Dingell
Doggett
Edwards (MD)
Edwards (TX)
Ellison
Engel
Eshoo
Farr
Fattah
Filner
Foster
Frank (MA)
Fudge
Garamendi
Giffords
Gonzalez
Grayson
Green, Al
Green, Gene
Grijalva
Gutierrez
Hall (NY)
Halvorson
Hare
Harman
Hastings (FL)
Heinrich
Herseth Sandlin
Higgins
Himes
Hinchey
Hinojosa
Hirono
Hodes
Holt
Honda
Hoyer
Inslee
Israel
Jackson (IL)
Jackson-Lee (TX)
Johnson (GA)
Johnson, E. B.
Kagen
Kennedy
Kilpatrick (MI)
Kilroy
Kind
Kirkpatrick (AZ)
Kissell
Klein (FL)
Kosmas
Kratovil
Kucinich
Larsen (WA)
Larson (CT)
Lee (CA)
Levin
Lewis (GA)
Loebsack
Lofgren, Zoe
Lowey
Lujan
Maffei
Maloney
Markey (CO)
Markey (MA)
Massa
Matsui
McCarthy (NY)
McCollum
McDermott
McGovern
McMahon
McNerney
Meek (FL)
Meeks (NY)
Miller (NC)
Miller, George
Minnick
Mitchell
Moore (KS)
Moore (WI)
Moran (VA)
Murphy (CT)
Murphy (NY)
Murphy, Patrick
Nadler (NY)
Napolitano
Nye
Olver
Owens
Pallone
Pascrell
Pastor (AZ)
Payne
Pelosi
Perlmutter
Peters
Pingree (ME)
Polis (CO)
Price (NC)
Quigley
Rangel
Richardson
Rothman (NJ)
Roybal-Allard
Ruppersberger
Rush
Sanchez, Linda T.
Sanchez, Loretta
Sarbanes
Schakowsky
Schauer
Schiff
Schrader
Schwartz
Scott (GA)
Scott (VA)
Serrano
Sestak
Shea-Porter
Sherman
Sires
Slaughter
Smith (WA)
Speier
Stark
Sutton
Thompson (CA)
Thompson (MS)
Tierney
Titus
Tonko
Towns
Tsongas
Van Hollen
Velazquez
Visclosky
Walz
Wasserman Schultz
Waters
Watson
Watt
Waxman
Weiner
Welch
Wexler
Woolsey
Wu
Yarmuth

ANSWERED ``PRESENT''--1

Shadegg

{time}  2220

Mr. COHEN and Ms. JACKSON-LEE of Texas changed their vote from
``yea'' to ``nay.''
Messrs. SPRATT and LEWIS of California changed their vote from
``nay'' to ``yea.''
So the amendment was agreed to.
The result of the vote was announced as above recorded.
A motion to reconsider was laid on the table.

Amendment Offered by Mr. Boehner

The SPEAKER pro tempore. The unfinished business is the vote on the
amendment offered by the gentleman from Ohio (Mr. Boehner) on which the
yeas and nays were ordered.
The Clerk will redesignate the amendment.
The Clerk redesignated the amendment.
The SPEAKER pro tempore. The question is on the amendment.
This is a 5-minute vote.
The vote was taken by electronic device, and there were--ayes 176,
noes 258, not voting 0, as follows:

[Roll No. 885]

YEAS--176

Aderholt
Akin
Alexander
Austria
Bachmann
Bachus
Barrett (SC)
Bartlett
Barton (TX)
Biggert
Bilbray
Bilirakis
Bishop (UT)
Blackburn
Blunt
Boehner
Bonner
Bono Mack
Boozman
Boustany
Brady (TX)

[[Page H12963]]

Broun (GA)
Brown (SC)
Brown-Waite, Ginny
Buchanan
Burgess
Burton (IN)
Buyer
Calvert
Camp
Campbell
Cantor
Cao
Capito
Carter
Cassidy
Castle
Chaffetz
Coble
Coffman (CO)
Cole
Conaway
Crenshaw
Culberson
Davis (KY)
Deal (GA)
Dent
Diaz-Balart, L.
Diaz-Balart, M.
Dreier
Duncan
Ehlers
Emerson
Fallin
Flake
Fleming
Forbes
Fortenberry
Foxx
Franks (AZ)
Frelinghuysen
Gallegly
Garrett (NJ)
Gerlach
Gingrey (GA)
Gohmert
Goodlatte
Granger
Graves
Guthrie
Hall (TX)
Harper
Hastings (WA)
Heller
Hensarling
Herger
Hoekstra
Hunter
Inglis
Issa
Jenkins
Johnson, Sam
Jones
Jordan (OH)
King (IA)
King (NY)
Kingston
Kirk
Kline (MN)
Lamborn
Lance
Latham
LaTourette
Latta
Lee (NY)
Lewis (CA)
Linder
LoBiondo
Lucas
Luetkemeyer
Lummis
Lungren, Daniel E.
Mack
Manzullo
Marchant
McCarthy (CA)
McCaul
McClintock
McCotter
McHenry
McKeon
McMorris Rodgers
Mica
Miller (FL)
Miller (MI)
Miller, Gary
Moran (KS)
Murphy, Tim
Myrick
Neugebauer
Nunes
Olson
Paul
Paulsen
Pence
Petri
Pitts
Platts
Poe (TX)
Posey
Price (GA)
Putnam
Radanovich
Rehberg
Reichert
Roe (TN)
Rogers (AL)
Rogers (KY)
Rogers (MI)
Rohrabacher
Rooney
Ros-Lehtinen
Roskam
Royce
Ryan (WI)
Scalise
Schmidt
Schock
Sensenbrenner
Sessions
Shadegg
Shimkus
Shuster
Simpson
Smith (NE)
Smith (NJ)
Smith (TX)
Souder
Stearns
Sullivan
Terry
Thompson (PA)
Thornberry
Tiahrt
Tiberi
Turner
Upton
Walden
Wamp
Westmoreland
Whitfield
Wilson (SC)
Wittman
Wolf
Young (AK)
Young (FL)

NAYS--258

Abercrombie
Ackerman
Adler (NJ)
Altmire
Andrews
Arcuri
Baca
Baird
Baldwin
Barrow
Bean
Becerra
Berkley
Berman
Berry
Bishop (GA)
Bishop (NY)
Blumenauer
Boccieri
Boren
Boswell
Boucher
Boyd
Brady (PA)
Braley (IA)
Bright
Brown, Corrine
Butterfield
Capps
Capuano
Cardoza
Carnahan
Carney
Carson (IN)
Castor (FL)
Chandler
Childers
Chu
Clarke
Clay
Cleaver
Clyburn
Cohen
Connolly (VA)
Conyers
Cooper
Costa
Costello
Courtney
Crowley
Cuellar
Cummings
Dahlkemper
Davis (AL)
Davis (CA)
Davis (IL)
Davis (TN)
DeFazio
DeGette
Delahunt
DeLauro
Dicks
Dingell
Doggett
Donnelly (IN)
Doyle
Driehaus
Edwards (MD)
Edwards (TX)
Ellison
Ellsworth
Engel
Eshoo
Etheridge
Farr
Fattah
Filner
Foster
Frank (MA)
Fudge
Garamendi
Giffords
Gonzalez
Gordon (TN)
Grayson
Green, Al
Green, Gene
Griffith
Grijalva
Gutierrez
Hall (NY)
Halvorson
Hare
Harman
Hastings (FL)
Heinrich
Herseth Sandlin
Higgins
Hill
Himes
Hinchey
Hinojosa
Hirono
Hodes
Holden
Holt
Honda
Hoyer
Inslee
Israel
Jackson (IL)
Jackson-Lee (TX)
Johnson (GA)
Johnson (IL)
Johnson, E. B.
Kagen
Kanjorski
Kaptur
Kennedy
Kildee
Kilpatrick (MI)
Kilroy
Kind
Kirkpatrick (AZ)
Kissell
Klein (FL)
Kosmas
Kratovil
Kucinich
Langevin
Larsen (WA)
Larson (CT)
Lee (CA)
Levin
Lewis (GA)
Lipinski
Loebsack
Lofgren, Zoe
Lowey
Lujan
Lynch
Maffei
Maloney
Markey (CO)
Markey (MA)
Marshall
Massa
Matheson
Matsui
McCarthy (NY)
McCollum
McDermott
McGovern
McIntyre
McMahon
McNerney
Meek (FL)
Meeks (NY)
Melancon
Michaud
Miller (NC)
Miller, George
Minnick
Mitchell
Mollohan
Moore (KS)
Moore (WI)
Moran (VA)
Murphy (CT)
Murphy (NY)
Murphy, Patrick
Murtha
Nadler (NY)
Napolitano
Neal (MA)
Nye
Oberstar
Obey
Olver
Ortiz
Owens
Pallone
Pascrell
Pastor (AZ)
Payne
Perlmutter
Perriello
Peters
Peterson
Pingree (ME)
Polis (CO)
Pomeroy
Price (NC)
Quigley
Rahall
Rangel
Reyes
Richardson
Rodriguez
Ross
Rothman (NJ)
Roybal-Allard
Ruppersberger
Rush
Ryan (OH)
Salazar
Sanchez, Linda T.
Sanchez, Loretta
Sarbanes
Schakowsky
Schauer
Schiff
Schrader
Schwartz
Scott (GA)
Scott (VA)
Serrano
Sestak
Shea-Porter
Sherman
Shuler
Sires
Skelton
Slaughter
Smith (WA)
Snyder
Space
Speier
Spratt
Stark
Stupak
Sutton
Tanner
Taylor
Teague
Thompson (CA)
Thompson (MS)
Tierney
Titus
Tonko
Towns
Tsongas
Van Hollen
Velazquez
Visclosky
Walz
Wasserman Schultz
Waters
Watson
Watt
Waxman
Weiner
Welch
Wexler
Wilson (OH)
Woolsey
Wu
Yarmuth

{time}  2228

So the amendment was rejected.
The result of the vote was announced as above recorded.
A motion to reconsider was laid on the table.
The SPEAKER pro tempore. Pursuant to House Resolution 903, the
previous question is ordered on the bill, as amended.
The question is on the engrossment and third reading of the bill.
The bill was ordered to be engrossed and read a third time, and was
read the third time.

Motion to Recommit

Mr. CANTOR. Mr. Speaker, I have a motion to recommit at the desk.
The SPEAKER pro tempore. Is the gentleman opposed to the bill?
Mr. CANTOR. Yes, Mr. Speaker, in its current form.
The SPEAKER pro tempore. Pursuant to House Resolution 903, the motion
is considered as read.
The text of the motion is as follows:

Mr. Cantor moves to recommit the bill, H.R. 3962, to the
Committee on Energy and Commerce with instructions to report
the same back to the House forthwith with the following
amendments:
Page 1209, after line 15, insert the following new title
(and conform the table of contents of division B, and the
table of divisions, titles and subtitles in section 1(b),
accordingly):

TITLE X--SENIORS PROTECTION AND MEDICARE REGIONAL PAYMENT EQUITY FUND

SEC. 1911. FINDINGS.

Congress finds the following:
(1) When analyzing the Medicare cuts in division B, The
Office of the Actuary (OACT) of the Centers for Medicare &
Medicaid Services noted that ``The additional demand for
health services could be difficult to meet initially with
existing health provider resources and could lead to price
increases, cost-shifting, and changes in providers'
willingness to treat patients with low-reimbursement health
coverage.''.
(2) When analyzing the Medicare cuts contained in division
B, OACT predicts that, ``Over time, a sustained reduction in
payment updates, based on productivity expectations that are
difficult to attain, would cause Medicare payment rates to
grow more slowly than, and in a way that was unrelated to,
the provider's costs of furnishing services to beneficiaries.
Thus, providers for whom Medicare constitutes a substantive
portion of their business could find it difficult to remain
profitable and might end their participation in the program
(possibly jeopardizing access to care for beneficiaries).''.
(3) The Medicare Payment Advisory Commission (MedPAC) found
that 28 percent of seniors currently have difficulty finding
a new physician to treat them.
(4) Medicare geographic payment inequities are well
documented and have been extensively studied.
(5) The Congressional Budget Office states that per capita
health care spending varies widely across the United States.
(6) Low-cost, high-quality States are setting the national
standard for Medicare yet they are penalized by the current
Medicare reimbursement formula.
(7) Geographic payment inequities must be resolved for
health care reform to be successful and for Medicare to
achieve long-term sustainability.
(8) Rural counties face unique challenges in delivering
health care.
(9) MedPAC finds that every senior currently has the
ability to enroll in a Medicare Advantage plan instead of the
traditional government program. The Commission predicts that
because of Medicare cuts contained in division B, 1 in 5
seniors will no longer have this choice and be forced to
receive their Medicare benefits from the traditional program.
(10) OACT predicts that the Medicare cuts contained in
division B will reduce seniors' projected enrollment in
Medicare Advantage plans by 64 percent.
(11) MedPAC estimates that, on average, Medicare physician
reimbursements are 20 percent lower than the reimbursements
physicians receive from private health plans.
(12) MedPAC predicts that, on average, Medicare hospital
reimbursements will be 6.9 percent below the cost of
providing care in 2009.

SEC. 1912. SENIORS PROTECTION AND MEDICARE REGIONAL PAYMENT
EQUITY FUND.

(a) Establishment.--The Secretary of Health and Human
Services (in this section referred to as the ``Secretary'')
shall establish under this title a Seniors Protection and
Medicare Regional Payment Equity Fund (in this section
referred to as the ``Fund'') which shall be available to the
Secretary to provide for improvements (described in
subsection (b)(1)) under the Medicare program under title
XVIII of the Social Security Act.
(b) Improvements Made by Fund.--
(1) In general.--The improvements described in this
paragraph are the following:
(A) Correcting payment inequities.--In order to correct
inequities in Medicare payment policies that punish high-
quality, low-cost counties (as defined in paragraph (2)) and
to promote high quality, cost effective patient care, by
providing additional funding to Medicare providers located in
such counties.
(B) Preserving seniors' choice.--In order to preserve
seniors' ability to choose the Medicare health benefits that
best meet their needs, by providing additional funding

[[Page H12964]]

to ensure that every Medicare beneficiary continues to have
access to at least 1 Medicare Advantage plan under part C of
the Medicare program.
(C) Access to medically necessary care and treatment.--By
providing such additional funding as may be necessary to
ensure access by Medicare beneficiaries to medically
necessary care and treatment, including care and treatment
furnished by physicians, hospitals, and other health care
providers under the Medicare program, without wait lines or
coverage determinations based solely on the basis of cost.
(2) High quality, low-cost county defined.--In this
subsection, the term ``high quality, low-cost county'' means
a county (or equivalent area) in which, as determined by the
Secretary--
(A) the quality of care exceeds the national average; and
(B) the per beneficiary fee-for-service Medicare costs are
substantially lower than the national average.
(c) Funding.--
(1) In general.--There shall be available to the Fund--
(A) $13,500,000,000 for expenditures from the Fund during
5-year period beginning with 2010; and
(B) $40,500,000,000 for expenditures from the Fund during
the 5-year period beginning with 2015.

Such amounts reflect savings in Federal expenditures and
increases in Federal revenues estimated to result from the
provisions of division E.
(2) Funding limitation.--Amounts in the Fund shall be
available in advance of appropriations but only if the total
amount obligated from the Fund does not exceed the amount
available to the Fund under paragraph (1). The Secretary may
obligate funds from the Fund only if the Secretary determines
(and the Chief Actuary of the Centers for Medicare & Medicaid
Services and the appropriate budget officer certify) that
there are available in the Fund sufficient amounts to cover
all such obligations incurred consistent with the previous
sentence.
Add at the end the following (and conform the table of
divisions, titles, and subtitles in section 1(b)
accordingly):

DIVISION E--ENACTING REAL MEDICAL LIABILITY REFORM

TABLE OF CONTENTS OF DIVISION

Sec. 4101. Encouraging speedy resolution of claims.
Sec. 4102. Compensating patient injury.
Sec. 4103. Maximizing patient recovery.
Sec. 4104. Additional health benefits.
Sec. 4105. Punitive damages.
Sec. 4106. Authorization of payment of future damages to claimants in
health care lawsuits.
Sec. 4107. Definitions.
Sec. 4108. Effect on other laws.
Sec. 4109. State flexibility and protection of states' rights.
Sec. 4110. Applicability; effective date.

SEC. 4101. ENCOURAGING SPEEDY RESOLUTION OF CLAIMS.

The time for the commencement of a health care lawsuit
shall be 3 years after the date of manifestation of injury or
1 year after the claimant discovers, or through the use of
reasonable diligence should have discovered, the injury,
whichever occurs first. In no event shall the time for
commencement of a health care lawsuit exceed 3 years after
the date of manifestation of injury unless tolled for any of
the following--
(1) upon proof of fraud;
(2) intentional concealment; or
(3) the presence of a foreign body, which has no
therapeutic or diagnostic purpose or effect, in the person of
the injured person.

Actions by a minor shall be commenced within 3 years from the
date of the alleged manifestation of injury except that
actions by a minor under the full age of 6 years shall be
commenced within 3 years of manifestation of injury or prior
to the minor's 8th birthday, whichever provides a longer
period. Such time limitation shall be tolled for minors for
any period during which a parent or guardian and a health
care provider or health care organization have committed
fraud or collusion in the failure to bring an action on
behalf of the injured minor.

SEC. 4102. COMPENSATING PATIENT INJURY.

(a) Unlimited Amount of Damages for Actual Economic Losses
in Health Care Lawsuits.--In any health care lawsuit, nothing
in this division shall limit a claimant's recovery of the
full amount of the available economic damages,
notwithstanding the limitation in subsection (b).
(b) Additional Noneconomic Damages.--In any health care
lawsuit, the amount of noneconomic damages, if available, may
be as much as $250,000, regardless of the number of parties
against whom the action is brought or the number of separate
claims or actions brought with respect to the same injury.
(c) No Discount of Award for Noneconomic Damages.--For
purposes of applying the limitation in subsection (b), future
noneconomic damages shall not be discounted to present value.
The jury shall not be informed about the maximum award for
noneconomic damages. An award for noneconomic damages in
excess of $250,000 shall be reduced either before the entry
of judgment, or by amendment of the judgment after entry of
judgment, and such reduction shall be made before accounting
for any other reduction in damages required by law. If
separate awards are rendered for past and future noneconomic
damages and the combined awards exceed $250,000, the future
noneconomic damages shall be reduced first.
(d) Fair Share Rule.--In any health care lawsuit, each
party shall be liable for that party's several share of any
damages only and not for the share of any other person. Each
party shall be liable only for the amount of damages
allocated to such party in direct proportion to such party's
percentage of responsibility. Whenever a judgment of
liability is rendered as to any party, a separate judgment
shall be rendered against each such party for the amount
allocated to such party. For purposes of this section, the
trier of fact shall determine the proportion of
responsibility of each party for the claimant's harm.

SEC. 4103. MAXIMIZING PATIENT RECOVERY.

(a) Court Supervision of Share of Damages Actually Paid to
Claimants.--In any health care lawsuit, the court shall
supervise the arrangements for payment of damages to protect
against conflicts of interest that may have the effect of
reducing the amount of damages awarded that are actually paid
to claimants. In particular, in any health care lawsuit in
which the attorney for a party claims a financial stake in
the outcome by virtue of a contingent fee, the court shall
have the power to restrict the payment of a claimant's damage
recovery to such attorney, and to redirect such damages to
the claimant based upon the interests of justice and
principles of equity. In no event shall the total of all
contingent fees for representing all claimants in a health
care lawsuit exceed the following limits:
(1) 40 percent of the first $50,000 recovered by the
claimant(s).
(2) 33\1/3\ percent of the next $50,000 recovered by the
claimant(s).
(3) 25 percent of the next $500,000 recovered by the
claimant(s).
(4) 15 percent of any amount by which the recovery by the
claimant(s) is in excess of $600,000.
(b) Applicability.--The limitations in this section shall
apply whether the recovery is by judgment, settlement,
mediation, arbitration, or any other form of alternative
dispute resolution. In a health care lawsuit involving a
minor or incompetent person, a court retains the authority to
authorize or approve a fee that is less than the maximum
permitted under this section. The requirement for court
supervision in the first two sentences of subsection (a)
applies only in civil actions.

SEC. 4104. ADDITIONAL HEALTH BENEFITS.

In any health care lawsuit involving injury or wrongful
death, any party may introduce evidence of collateral source
benefits. If a party elects to introduce such evidence, any
opposing party may introduce evidence of any amount paid or
contributed or reasonably likely to be paid or contributed in
the future by or on behalf of the opposing party to secure
the right to such collateral source benefits. No provider of
collateral source benefits shall recover any amount against
the claimant or receive any lien or credit against the
claimant's recovery or be equitably or legally subrogated to
the right of the claimant in a health care lawsuit involving
injury or wrongful death. This section shall apply to any
health care lawsuit that is settled as well as a health care
lawsuit that is resolved by a fact finder. This section shall
not apply to section 1862(b) (42 U.S.C. 1395y(b)) or section
1902(a)(25) (42 U.S.C. 1396a(a)(25)) of the Social Security
Act.

SEC. 4105. PUNITIVE DAMAGES.

(a) In General.--Punitive damages may, if otherwise
permitted by applicable State or Federal law, be awarded
against any person in a health care lawsuit only if it is
proven by clear and convincing evidence that such person
acted with malicious intent to injure the claimant, or that
such person deliberately failed to avoid unnecessary injury
that such person knew the claimant was substantially certain
to suffer. In any health care lawsuit where no judgment for
compensatory damages is rendered against such person, no
punitive damages may be awarded with respect to the claim in
such lawsuit. No demand for punitive damages shall be
included in a health care lawsuit as initially filed. A court
may allow a claimant to file an amended pleading for punitive
damages only upon a motion by the claimant and after a
finding by the court, upon review of supporting and opposing
affidavits or after a hearing, after weighing the evidence,
that the claimant has established by a substantial
probability that the claimant will prevail on the claim for
punitive damages. At the request of any party in a health
care lawsuit, the trier of fact shall consider in a separate
proceeding--
(1) whether punitive damages are to be awarded and the
amount of such award; and
(2) the amount of punitive damages following a
determination of punitive liability.

If a separate proceeding is requested, evidence relevant only
to the claim for punitive damages, as determined by
applicable State law, shall be inadmissible in any proceeding
to determine whether compensatory damages are to be awarded.
(b) Determining Amount of Punitive Damages.--
(1) Factors considered.--In determining the amount of
punitive damages, if awarded, in a health care lawsuit, the
trier of fact shall consider only the following--
(A) the severity of the harm caused by the conduct of such
party;
(B) the duration of the conduct or any concealment of it by
such party;
(C) the profitability of the conduct to such party;
(D) the number of products sold or medical procedures
rendered for compensation, as the

[[Page H12965]]

case may be, by such party, of the kind causing the harm
complained of by the claimant;
(E) any criminal penalties imposed on such party, as a
result of the conduct complained of by the claimant; and
(F) the amount of any civil fines assessed against such
party as a result of the conduct complained of by the
claimant.
(2) Maximum award.--The amount of punitive damages, if
awarded, in a health care lawsuit may be as much as $250,000
or as much as two times the amount of economic damages
awarded, whichever is greater. The jury shall not be informed
of this limitation.

SEC. 4106. AUTHORIZATION OF PAYMENT OF FUTURE DAMAGES TO
CLAIMANTS IN HEALTH CARE LAWSUITS.

(a) In General.--In any health care lawsuit, if an award of
future damages, without reduction to present value, equaling
or exceeding $50,000 is made against a party with sufficient
insurance or other assets to fund a periodic payment of such
a judgment, the court shall, at the request of any party,
enter a judgment ordering that the future damages be paid by
periodic payments. In any health care lawsuit, the court may
be guided by the Uniform Periodic Payment of Judgments Act
promulgated by the National Conference of Commissioners on
Uniform State Laws.
(b) Applicability.--This section applies to all actions
which have not been first set for trial or retrial before the
effective date of this division.

SEC. 4107. DEFINITIONS.

In this division:
(1) Alternative dispute resolution system; adr.--The term
``alternative dispute resolution system'' or ``ADR'' means a
system that provides for the resolution of health care
lawsuits in a manner other than through a civil action
brought in a State or Federal court.
(2) Claimant.--The term ``claimant'' means any person who
brings a health care lawsuit, including a person who asserts
or claims a right to legal or equitable contribution,
indemnity, or subrogation, arising out of a health care
liability claim or action, and any person on whose behalf
such a claim is asserted or such an action is brought,
whether deceased, incompetent, or a minor.
(3) Collateral source benefits.--The term ``collateral
source benefits'' means any amount paid or reasonably likely
to be paid in the future to or on behalf of the claimant, or
any service, product, or other benefit provided or reasonably
likely to be provided in the future to or on behalf of the
claimant, as a result of the injury or wrongful death,
pursuant to--
(A) any State or Federal health, sickness, income-
disability, accident, or workers' compensation law;
(B) any health, sickness, income-disability, or accident
insurance that provides health benefits or income-disability
coverage;
(C) any contract or agreement of any group, organization,
partnership, or corporation to provide, pay for, or reimburse
the cost of medical, hospital, dental, or income-disability
benefits; and
(D) any other publicly or privately funded program.
(4) Compensatory damages.--The term ``compensatory
damages'' means objectively verifiable monetary losses
incurred as a result of the provision of, use of, or payment
for (or failure to provide, use, or pay for) health care
services or medical products, such as past and future medical
expenses, loss of past and future earnings, cost of obtaining
domestic services, loss of employment, and loss of business
or employment opportunities, damages for physical and
emotional pain, suffering, inconvenience, physical
impairment, mental anguish, disfigurement, loss of enjoyment
of life, loss of society and companionship, loss of
consortium (other than loss of domestic service), hedonic
damages, injury to reputation, and all other nonpecuniary
losses of any kind or nature. The term ``compensatory
damages'' includes economic damages and noneconomic damages,
as such terms are defined in this section.
(5) Contingent fee.--The term ``contingent fee'' includes
all compensation to any person or persons which is payable
only if a recovery is effected on behalf of one or more
claimants.
(6) Economic damages.--The term ``economic damages'' means
objectively verifiable monetary losses incurred as a result
of the provision of, use of, or payment for (or failure to
provide, use, or pay for) health care services or medical
products, such as past and future medical expenses, loss of
past and future earnings, cost of obtaining domestic
services, loss of employment, and loss of business or
employment opportunities.
(7) Health care lawsuit.--The term ``health care lawsuit''
means any health care liability claim concerning the
provision of health care goods or services or any medical
product affecting interstate commerce, or any health care
liability action concerning the provision of health care
goods or services or any medical product affecting interstate
commerce, brought in a State or Federal court or pursuant to
an alternative dispute resolution system, against a health
care provider, a health care organization, or the
manufacturer, distributor, supplier, marketer, promoter, or
seller of a medical product, regardless of the theory of
liability on which the claim is based, or the number of
claimants, plaintiffs, defendants, or other parties, or the
number of claims or causes of action, in which the claimant
alleges a health care liability claim. Such term does not
include a claim or action which is based on criminal
liability; which seeks civil fines or penalties paid to
Federal, State, or local government; or which is grounded in
antitrust.
(8) Health care liability action.--The term ``health care
liability action'' means a civil action brought in a State or
Federal court or pursuant to an alternative dispute
resolution system, against a health care provider, a health
care organization, or the manufacturer, distributor,
supplier, marketer, promoter, or seller of a medical product,
regardless of the theory of liability on which the claim is
based, or the number of plaintiffs, defendants, or other
parties, or the number of causes of action, in which the
claimant alleges a health care liability claim.
(9) Health care liability claim.--The term ``health care
liability claim'' means a demand by any person, whether or
not pursuant to ADR, against a health care provider, health
care organization, or the manufacturer, distributor,
supplier, marketer, promoter, or seller of a medical product,
including, but not limited to, third-party claims, cross-
claims, counter-claims, or contribution claims, which are
based upon the provision of, use of, or payment for (or the
failure to provide, use, or pay for) health care services or
medical products, regardless of the theory of liability on
which the claim is based, or the number of plaintiffs,
defendants, or other parties, or the number of causes of
action.
(10) Health care organization.--The term ``health care
organization'' means any person or entity which is obligated
to provide or pay for health benefits under any health plan,
including any person or entity acting under a contract or
arrangement with a health care organization to provide or
administer any health benefit.
(11) Health care provider.--The term ``health care
provider'' means any person or entity required by State or
Federal laws or regulations to be licensed, registered, or
certified to provide health care services, and being either
so licensed, registered, or certified, or exempted from such
requirement by other statute or regulation.
(12) Health care goods or services.--The term ``health care
goods or services'' means any goods or services provided by a
health care organization, provider, or by any individual
working under the supervision of a health care provider, that
relates to the diagnosis, prevention, or treatment of any
human disease or impairment, or the assessment or care of the
health of human beings.
(13) Malicious intent to injure.--The term ``malicious
intent to injure'' means intentionally causing or attempting
to cause physical injury other than providing health care
goods or services.
(14) Medical product.--The term ``medical product'' means a
drug, device, or biological product intended for humans, and
the terms ``drug'', ``device'', and ``biological product''
have the meanings given such terms in sections 201(g)(1) and
201(h) of the Federal Food, Drug and Cosmetic Act (21 U.S.C.
321(g)(1) and (h)) and section 351(a) of the Public Health
Service Act (42 U.S.C. 262(a)), respectively, including any
component or raw material used therein, but excluding health
care services.
(15) Noneconomic damages.--The term ``noneconomic damages''
means damages for physical and emotional pain, suffering,
inconvenience, physical impairment, mental anguish,
disfigurement, loss of enjoyment of life, loss of society and
companionship, loss of consortium (other than loss of
domestic service), hedonic damages, injury to reputation, and
all other nonpecuniary losses of any kind or nature.
(16) Punitive damages.--The term ``punitive damages'' means
damages awarded, for the purpose of punishment or deterrence,
and not solely for compensatory purposes, against a health
care provider, health care organization, or a manufacturer,
distributor, or supplier of a medical product. Punitive
damages are neither economic nor noneconomic damages.
(17) Recovery.--The term ``recovery'' means the net sum
recovered after deducting any disbursements or costs incurred
in connection with prosecution or settlement of the claim,
including all costs paid or advanced by any person. Costs of
health care incurred by the plaintiff and the attorneys'
office overhead costs or charges for legal services are not
deductible disbursements or costs for such purpose.
(18) State.--The term ``State'' means each of the several
States, the District of Columbia, the Commonwealth of Puerto
Rico, the Virgin Islands, Guam, American Samoa, the Northern
Mariana Islands, the Trust Territory of the Pacific Islands,
and any other territory or possession of the United States,
or any political subdivision thereof.

SEC. 4108. EFFECT ON OTHER LAWS.

(a) Vaccine Injury.--
(1) To the extent that title XXI of the Public Health
Service Act establishes a Federal rule of law applicable to a
civil action brought for a vaccine-related injury or death--
(A) this division does not affect the application of the
rule of law to such an action; and
(B) any rule of law prescribed by this division in conflict
with a rule of law of such title XXI shall not apply to such
action.
(2) If there is an aspect of a civil action brought for a
vaccine-related injury or death

[[Page H12966]]

to which a Federal rule of law under title XXI of the Public
Health Service Act does not apply, then this division or
otherwise applicable law (as determined under this division)
will apply to such aspect of such action.
(b) Other Federal Law.--Except as provided in this section,
nothing in this division shall be deemed to affect any
defense available to a defendant in a health care lawsuit or
action under any other provision of Federal law.

SEC. 4109. STATE FLEXIBILITY AND PROTECTION OF STATES'
RIGHTS.

(a) Health Care Lawsuits.--The provisions governing health
care lawsuits set forth in this division preempt, subject to
subsections (b) and (c), State law to the extent that State
law prevents the application of any provisions of law
established by or under this division. The provisions
governing health care lawsuits set forth in this division
supersede chapter 171 of title 28, United States Code, to the
extent that such chapter--
(1) provides for a greater amount of damages or contingent
fees, a longer period in which a health care lawsuit may be
commenced, or a reduced applicability or scope of periodic
payment of future damages, than provided in this division; or
(2) prohibits the introduction of evidence regarding
collateral source benefits, or mandates or permits
subrogation or a lien on collateral source benefits.
(b) Protection of States' Rights and Other Laws.--(1) Any
issue that is not governed by any provision of law
established by or under this division (including State
standards of negligence) shall be governed by otherwise
applicable State or Federal law.
(2) This division shall not preempt or supersede any State
or Federal law that imposes greater procedural or substantive
protections for health care providers and health care
organizations from liability, loss, or damages than those
provided by this division or create a cause of action.
(c) State Flexibility.--No provision of this division shall
be construed to preempt--
(1) any State law (whether effective before, on, or after
the date of the enactment of this Act) that specifies a
particular monetary amount of compensatory or punitive
damages (or the total amount of damages) that may be awarded
in a health care lawsuit, regardless of whether such monetary
amount is greater or lesser than is provided for under this
division, notwithstanding section 4102(a); or
(2) any defense available to a party in a health care
lawsuit under any other provision of State or Federal law.

SEC. 4110. APPLICABILITY; EFFECTIVE DATE.

This division shall apply to any health care lawsuit
brought in a Federal or State court, or subject to an
alternative dispute resolution system, that is initiated on
or after the date of the enactment of this Act, except that
any health care lawsuit arising from an injury occurring
prior to the date of the enactment of this Act shall be
governed by the applicable statute of limitations provisions
in effect at the time the injury occurred.

The SPEAKER pro tempore. Pursuant to the rule, the gentleman from
Virginia is recognized for 5 minutes in support of the motion.

{time}  2230

Mr. CANTOR. Mr. Speaker, any physician in America will tell you that
the simplest way to reduce health care costs is to enact real medical
liability reform. The fear of being sued by opportunistic trial lawyers
is pervasive in the practice of medicine. Our system wastes billions on
defensive medicine that should be going to patient care. That's why
real medical liability reform is needed. In fact, CBO estimates that as
much as $54 billion can be saved by the Federal Government alone. It is
totally unacceptable that this money is being spent in the courtroom
instead of the operating room.
At the same time, the majority has promised the American people that
their health care bill will lower costs, yet the bill before us today,
Mr. Speaker, contains no medical liability reforms. And why not? The
truth comes from one of the Democrats' own, no less than former DNC
Chair and physician Howard Dean, who said last August, The reason that
tort reform is not in the bill is because the people that wrote it did
not want to take on the trial lawyers in addition to everybody else
they were taking on, and that is the plain and simple truth.
Mr. Speaker, the Republican motion to recommit adds real meaningful
medical liability and reform and uses its $54 billion in savings to
create a fund that will protect seniors, especially those in rural
areas, from the steep cuts to Medicare in the Democrats' reform
package. It gives Members the chance to prioritize the health of our
Nation's seniors instead of lining the bank accounts of trial lawyers.
It's time to get trial lawyers out of the clinics and the operating
rooms and leave patient care to the people trained to handle it best--
our doctors.
Mr. Speaker, to talk about this further, I now yield to the
gentlewoman from Florida, Congresswoman Brown-Waite.
Ms. GINNY BROWN-WAITE of Florida. Betty, a constituent of mine,
recently told me that if it weren't for Medicare Advantage, she would
be dead. You see, Medicare Advantage covers catastrophic costs
traditional Medicare does not. The bill before us today seeks to
eliminate that coverage for millions of seniors, but you have a chance
to make it right here, ladies and gentlemen.
The choice on the motion is simple. You can put your seniors first or
your trial lawyer contributors. A Member can vote to open up the
coffers of the U.S. Treasury to trial lawyers or restore some of the
cuts our seniors will suffer under the Pelosi bill and ObamaCare.
Remember, this bill creates 111 new bureaucracies and entitlements, but
the only one it cuts, ladies and gentlemen, the only one it cuts is
Medicare. It's always been my position that any money cut from Medicare
should be used to save Medicare, not to bail out the trial attorneys.
Democrats have denied seniors the protection they promised. They cut
Medicare to create new benefits for the young, healthy, and the
wealthy. We know where the Democrat leadership stands on this issue.
The Speaker put her trial lawyer cash cows ahead of our seniors. AARP
put their profits ahead of our seniors.
With this motion, you have a chance to restore some of our cuts. No
excuses about this amendment killing the bill can be made. No word
games can get you out of this. This has to be a vote for the seniors of
America. Please remember your constituents will be watching.
Mr. CANTOR. Mr. Speaker, I now yield to the gentleman from Washington
(Mr. Reichert).
Mr. REICHERT. Thank you.
This motion was and will protect seniors from drastic cuts to
Medicare and stop expensive lawsuits that increase the costs of health
care for every American. We've heard, If you like it, you can keep it,
but the bill before us is a direct assault on America's seniors,
cutting $500 billion from Medicare.
Under this bill, one out of every five seniors will lose the Medicare
health plan they chose. Because of regional payment disparities in many
parts of this country, Medicare Advantage plans are the only way
seniors can receive needed care. It's the only way that seniors can
choose their doctors, and it's the only way that seniors can choose the
preventive treatment they need.
This motion is about choice. It's about living in a free country.
It's about having freedom. Mr. Speaker, this commonsense motion will
protect seniors' health care, lower health care costs, and preserve
freedom.
Mr. HOYER. Mr. Speaker, I rise in opposition to the motion to
recommit.
The SPEAKER pro tempore. The gentleman from Maryland is recognized
for 5 minutes.
Mr. HOYER. Mr. Speaker, I yield to the gentleman from Iowa (Mr.
Braley).
Mr. BRALEY of Iowa. Mr. Speaker, during this entire health care
debate, we've heard a lot from our friends on the other side of the
aisle about something called medical liability reform, but all day as
they've been talking about this point, you have not heard one word
about patient safety. If you want to talk about real meaningful health
care reform, it's important to talk about the most critical aspect of
true, meaningful health care reform--standing up for patients. Who will
speak for the patients?
Mr. Speaker, we know who will speak for the patients. We have the
reports from the highly respected nonpartisan Institute of Medicine on
patient safety. The first one is on patient safety, Achieving a New
Standard for Care. The second one, Preventing Medication Errors, and To
Err Is Human: Building a Safer Health System.
What did the Institute of Medicine tell us about the state of patient
safety? They told us that the most significant way to reduce the costs
of medical malpractice is to emphasize patient safety by reducing the
number of preventable medical errors. They also told us that's the only
way we're going to

[[Page H12967]]

bring about meaningful health care reform. They also told us that
medical errors kill as many as 98,000 Americans every year; and that,
if it were ranked by the Centers for Disease Controls, would be the
sixth leading cause of deaths in America.

{time}  2240

They also told us that every year there are 15 million incidents of
medical harm in this country and that patient safety is
indistinguishable from the delivery of medical care. That's why they
aren't telling you about what the Institutes of Medicine reported the
cost of medical errors is in this country.
They reported in their studies that every year medical errors add $17
billion to $28 billion of cost, most of it in additional medical care
that we end up paying for as consumers of health care. When you
multiply that over the 10 years of this bill, that means it's costing
us $170 billion to $280 billion if we continue to ignore this problem.
That's why Democrats and the Institutes of Medicine are standing up for
patients, and that's why you should reject this motion to recommit.
You hear our friends talk about what happened in California in 1976
when they put a $250,000 cap on payments for quality-of-life damages.
What they don't tell you is that the value of that cap today in 2009 is
$64,000, and if you adjust that cap at the same rate of medical
inflation, it would be worth $1.9 million. That's what's wrong.
Mr. HOYER. I thank the gentleman for his comments.
My colleagues, I ask you to reject this amendment. Our colleagues on
the other side of the aisle demanded 72 hours' notice for the bill and
they've gotten 4 or 5 months' notice. They gave us 72 seconds to
consider this amendment.
This amendment deals with some very complicated subjects; and it
provides, of course, as we are not surprised that it would, for
substantial billions of dollars back to the insurance companies. That's
what their objective is. And, yes, they say something about equity of
distribution of money. No study.
We set up a very careful study to make sure that the people's money
is distributed to the States in an equitable, fair, effective fashion.
That is why we ought to reject this amendment for which we received no
notice, no consideration, no discussion in the public. The Republicans
have been outraged about that.
I ask our party, I ask each one of us, to reject this motion to
recommit and pass this bill.
The SPEAKER pro tempore. Without objection, the previous question is
ordered on the motion to recommit.
There was no objection.
The SPEAKER pro tempore. The question is on the motion to recommit.
The question was taken; and the Speaker pro tempore announced that
the noes appeared to have it.

Recorded Vote

Mr. CANTOR. Mr. Speaker, I demand a recorded vote.
A recorded vote was ordered.
The vote was taken by electronic device, and there were--ayes 187,
noes 247, not voting 0, as follows:

[Roll No. 886]

AYES--187

Aderholt
Akin
Alexander
Austria
Bachmann
Bachus
Barrett (SC)
Bartlett
Barton (TX)
Biggert
Bilbray
Bilirakis
Bishop (UT)
Blackburn
Blunt
Boehner
Bonner
Bono Mack
Boozman
Boren
Boustany
Brady (TX)
Bright
Broun (GA)
Brown (SC)
Brown-Waite, Ginny
Buchanan
Burgess
Burton (IN)
Buyer
Calvert
Camp
Campbell
Cantor
Cao
Capito
Cardoza
Carter
Cassidy
Castle
Chaffetz
Childers
Coble
Coffman (CO)
Cole
Conaway
Costa
Crenshaw
Cuellar
Culberson
Davis (KY)
Deal (GA)
Dent
Diaz-Balart, L.
Diaz-Balart, M.
Dreier
Ehlers
Ellsworth
Emerson
Fallin
Flake
Fleming
Forbes
Fortenberry
Foxx
Franks (AZ)
Frelinghuysen
Gallegly
Garrett (NJ)
Gerlach
Gingrey (GA)
Gohmert
Goodlatte
Gordon (TN)
Granger
Graves
Griffith
Guthrie
Hall (TX)
Harper
Hastings (WA)
Heller
Hensarling
Herger
Hoekstra
Hunter
Inglis
Issa
Jenkins
Johnson, Sam
Jones
Jordan (OH)
King (IA)
King (NY)
Kingston
Kirk
Kline (MN)
Lamborn
Lance
Latham
LaTourette
Latta
Lee (NY)
Lewis (CA)
Linder
LoBiondo
Lucas
Luetkemeyer
Lummis
Lungren, Daniel E.
Mack
Manzullo
Marchant
Matheson
McCarthy (CA)
McCaul
McClintock
McCotter
McHenry
McKeon
McMorris Rodgers
Mica
Miller (FL)
Miller (MI)
Miller, Gary
Minnick
Moran (KS)
Murphy (NY)
Murphy, Tim
Myrick
Neugebauer
Nunes
Olson
Paulsen
Pence
Petri
Pitts
Platts
Poe (TX)
Pomeroy
Posey
Price (GA)
Putnam
Radanovich
Rehberg
Reichert
Roe (TN)
Rogers (AL)
Rogers (KY)
Rogers (MI)
Rohrabacher
Rooney
Ros-Lehtinen
Roskam
Royce
Ryan (WI)
Scalise
Schmidt
Schock
Sensenbrenner
Sessions
Shadegg
Shimkus
Shuster
Simpson
Smith (NE)
Smith (NJ)
Smith (TX)
Souder
Stearns
Sullivan
Terry
Thompson (PA)
Thornberry
Tiahrt
Tiberi
Turner
Upton
Walden
Wamp
Westmoreland
Whitfield
Wilson (SC)
Wittman
Wolf
Young (AK)
Young (FL)

NOES--247

Abercrombie
Ackerman
Adler (NJ)
Altmire
Andrews
Arcuri
Baca
Baird
Baldwin
Barrow
Bean
Becerra
Berkley
Berman
Berry
Bishop (GA)
Bishop (NY)
Blumenauer
Boccieri
Boswell
Boucher
Boyd
Brady (PA)
Braley (IA)
Brown, Corrine
Butterfield
Capps
Capuano
Carnahan
Carney
Carson (IN)
Castor (FL)
Chandler
Chu
Clarke
Clay
Cleaver
Clyburn
Cohen
Connolly (VA)
Conyers
Cooper
Costello
Courtney
Crowley
Cummings
Dahlkemper
Davis (AL)
Davis (CA)
Davis (IL)
Davis (TN)
DeFazio
DeGette
Delahunt
DeLauro
Dicks
Dingell
Doggett
Donnelly (IN)
Doyle
Driehaus
Duncan
Edwards (MD)
Edwards (TX)
Ellison
Engel
Eshoo
Etheridge
Farr
Fattah
Filner
Foster
Frank (MA)
Fudge
Garamendi
Giffords
Gonzalez
Grayson
Green, Al
Green, Gene
Grijalva
Gutierrez
Hall (NY)
Halvorson
Hare
Harman
Hastings (FL)
Heinrich
Herseth Sandlin
Higgins
Hill
Himes
Hinchey
Hinojosa
Hirono
Hodes
Holden
Holt
Honda
Hoyer
Inslee
Israel
Jackson (IL)
Jackson-Lee (TX)
Johnson (GA)
Johnson (IL)
Johnson, E. B.
Kagen
Kanjorski
Kaptur
Kennedy
Kildee
Kilpatrick (MI)
Kilroy
Kind
Kirkpatrick (AZ)
Kissell
Klein (FL)
Kosmas
Kratovil
Kucinich
Langevin
Larsen (WA)
Larson (CT)
Lee (CA)
Levin
Lewis (GA)
Lipinski
Loebsack
Lofgren, Zoe
Lowey
Lujan
Lynch
Maffei
Maloney
Markey (CO)
Markey (MA)
Marshall
Massa
Matsui
McCarthy (NY)
McCollum
McDermott
McGovern
McIntyre
McMahon
McNerney
Meek (FL)
Meeks (NY)
Melancon
Michaud
Miller (NC)
Miller, George
Mitchell
Mollohan
Moore (KS)
Moore (WI)
Moran (VA)
Murphy (CT)
Murphy, Patrick
Murtha
Nadler (NY)
Napolitano
Neal (MA)
Nye
Oberstar
Obey
Olver
Ortiz
Owens
Pallone
Pascrell
Pastor (AZ)
Paul
Payne
Perlmutter
Perriello
Peters
Peterson
Pingree (ME)
Polis (CO)
Price (NC)
Quigley
Rahall
Rangel
Reyes
Richardson
Rodriguez
Ross
Rothman (NJ)
Roybal-Allard
Ruppersberger
Rush
Ryan (OH)
Salazar
Sanchez, Linda T.
Sanchez, Loretta
Sarbanes
Schakowsky
Schauer
Schiff
Schrader
Schwartz
Scott (GA)
Scott (VA)
Serrano
Sestak
Shea-Porter
Sherman
Shuler
Sires
Skelton
Slaughter
Smith (WA)
Snyder
Space
Speier
Spratt
Stark
Stupak
Sutton
Tanner
Taylor
Teague
Thompson (CA)
Thompson (MS)
Tierney
Titus
Tonko
Towns
Tsongas
Van Hollen
Velazquez
Visclosky
Walz
Wasserman Schultz
Waters
Watson
Watt
Waxman
Weiner
Welch
Wexler
Wilson (OH)
Woolsey
Wu
Yarmuth

{time}  2259

So the motion to recommit was rejected.
The result of the vote was announced as above recorded.
The SPEAKER pro tempore. The question is on the passage of the bill.
The question was taken; and the Speaker pro tempore announced that
the ayes appeared to have it.

Recorded Vote

Mr. BURTON of Indiana. Mr. Speaker, I demand a recorded vote.
A recorded vote was ordered.
The SPEAKER pro tempore. Pursuant to clause 8 of rule XX, this 15-
minute vote on passage of the bill will be followed by a 5-minute vote
on the motion to suspend the rules on House Resolution 895.
The vote was taken by electronic device, and there were--ayes 220,
noes 215, not voting 0, as follows:

[Roll No. 887]

AYES--220

Abercrombie
Ackerman
Andrews
Arcuri
Baca
Baldwin

[[Page H12968]]

Bean
Becerra
Berkley
Berman
Berry
Bishop (GA)
Bishop (NY)
Blumenauer
Boswell
Brady (PA)
Braley (IA)
Brown, Corrine
Butterfield
Cao
Capps
Capuano
Cardoza
Carnahan
Carney
Carson (IN)
Castor (FL)
Chu
Clarke
Clay
Cleaver
Clyburn
Cohen
Connolly (VA)
Conyers
Cooper
Costa
Costello
Courtney
Crowley
Cuellar
Cummings
Dahlkemper
Davis (CA)
Davis (IL)
DeFazio
DeGette
Delahunt
DeLauro
Dicks
Dingell
Doggett
Donnelly (IN)
Doyle
Driehaus
Edwards (MD)
Ellison
Ellsworth
Engel
Eshoo
Etheridge
Farr
Fattah
Filner
Foster
Frank (MA)
Fudge
Garamendi
Giffords
Gonzalez
Grayson
Green, Al
Green, Gene
Grijalva
Gutierrez
Hall (NY)
Halvorson
Hare
Harman
Hastings (FL)
Heinrich
Higgins
Hill
Himes
Hinchey
Hinojosa
Hirono
Hodes
Holt
Honda
Hoyer
Inslee
Israel
Jackson (IL)
Jackson-Lee (TX)
Johnson (GA)
Johnson, E. B.
Kagen
Kanjorski
Kaptur
Kennedy
Kildee
Kilpatrick (MI)
Kilroy
Kind
Kirkpatrick (AZ)
Klein (FL)
Langevin
Larsen (WA)
Larson (CT)
Lee (CA)
Levin
Lewis (GA)
Lipinski
Loebsack
Lofgren, Zoe
Lowey
Lujan
Lynch
Maffei
Maloney
Markey (MA)
Matsui
McCarthy (NY)
McCollum
McDermott
McGovern
McNerney
Meek (FL)
Meeks (NY)
Michaud
Miller (NC)
Miller, George
Mitchell
Mollohan
Moore (KS)
Moore (WI)
Moran (VA)
Murphy (CT)
Murphy, Patrick
Murtha
Nadler (NY)
Napolitano
Neal (MA)
Oberstar
Obey
Olver
Ortiz
Owens
Pallone
Pascrell
Pastor (AZ)
Payne
Pelosi
Perlmutter
Perriello
Peters
Pingree (ME)
Polis (CO)
Pomeroy
Price (NC)
Quigley
Rahall
Rangel
Reyes
Richardson
Rodriguez
Rothman (NJ)
Roybal-Allard
Ruppersberger
Rush
Ryan (OH)
Salazar
Sanchez, Linda T.
Sanchez, Loretta
Sarbanes
Schakowsky
Schauer
Schiff
Schrader
Schwartz
Scott (GA)
Scott (VA)
Serrano
Sestak
Shea-Porter
Sherman
Sires
Slaughter
Smith (WA)
Snyder
Space
Speier
Spratt
Stark
Stupak
Sutton
Thompson (CA)
Thompson (MS)
Tierney
Titus
Tonko
Towns
Tsongas
Van Hollen
Velazquez
Visclosky
Walz
Wasserman Schultz
Waters
Watson
Watt
Waxman
Weiner
Welch
Wexler
Wilson (OH)
Woolsey
Wu
Yarmuth

NOES--215

Aderholt
Adler (NJ)
Akin
Alexander
Altmire
Austria
Bachmann
Bachus
Baird
Barrett (SC)
Barrow
Bartlett
Barton (TX)
Biggert
Bilbray
Bilirakis
Bishop (UT)
Blackburn
Blunt
Boccieri
Boehner
Bonner
Bono Mack
Boozman
Boren
Boucher
Boustany
Boyd
Brady (TX)
Bright
Broun (GA)
Brown (SC)
Brown-Waite, Ginny
Buchanan
Burgess
Burton (IN)
Buyer
Calvert
Camp
Campbell
Cantor
Capito
Carter
Cassidy
Castle
Chaffetz
Chandler
Childers
Coble
Coffman (CO)
Cole
Conaway
Crenshaw
Culberson
Davis (AL)
Davis (KY)
Davis (TN)
Deal (GA)
Dent
Diaz-Balart, L.
Diaz-Balart, M.
Dreier
Duncan
Edwards (TX)
Ehlers
Emerson
Fallin
Flake
Fleming
Forbes
Fortenberry
Foxx
Franks (AZ)
Frelinghuysen
Gallegly
Garrett (NJ)
Gerlach
Gingrey (GA)
Gohmert
Goodlatte
Gordon (TN)
Granger
Graves
Griffith
Guthrie
Hall (TX)
Harper
Hastings (WA)
Heller
Hensarling
Herger
Herseth Sandlin
Hoekstra
Holden
Hunter
Inglis
Issa
Jenkins
Johnson (IL)
Johnson, Sam
Jones
Jordan (OH)
King (IA)
King (NY)
Kingston
Kirk
Kissell
Kline (MN)
Kosmas
Kratovil
Kucinich
Lamborn
Lance
Latham
LaTourette
Latta
Lee (NY)
Lewis (CA)
Linder
LoBiondo
Lucas
Luetkemeyer
Lummis
Lungren, Daniel E.
Mack
Manzullo
Marchant
Markey (CO)
Marshall
Massa
Matheson
McCarthy (CA)
McCaul
McClintock
McCotter
McHenry
McIntyre
McKeon
McMahon
McMorris Rodgers
Melancon
Mica
Miller (FL)
Miller (MI)
Miller, Gary
Minnick
Moran (KS)
Murphy (NY)
Murphy, Tim
Myrick
Neugebauer
Nunes
Nye
Olson
Paul
Paulsen
Pence
Peterson
Petri
Pitts
Platts
Poe (TX)
Posey
Price (GA)
Putnam
Radanovich
Rehberg
Reichert
Roe (TN)
Rogers (AL)
Rogers (KY)
Rogers (MI)
Rohrabacher
Rooney
Ros-Lehtinen
Roskam
Ross
Royce
Ryan (WI)
Scalise
Schmidt
Schock
Sensenbrenner
Sessions
Shadegg
Shimkus
Shuler
Shuster
Simpson
Skelton
Smith (NE)
Smith (NJ)
Smith (TX)
Souder
Stearns
Sullivan
Tanner
Taylor
Teague
Terry
Thompson (PA)
Thornberry
Tiahrt
Tiberi
Turner
Upton
Walden
Wamp
Westmoreland
Whitfield
Wilson (SC)
Wittman
Wolf
Young (AK)
Young (FL)

Announcement by the Speaker Pro Tempore

The SPEAKER pro tempore (during the vote). The Chair will remind all
persons in the gallery that they are here as guests of the House and
that any manifestation of approval or disapproval of proceedings or
other audible conversation is in violation of the rules of the House.

Announcement by the Speaker

The SPEAKER (during the vote). There are 2 minutes remaining in the
vote.

{time}  2316

So the bill was passed.
The result of the vote was announced as above recorded.
A motion to reconsider was laid on the table.

____________________