Josephine Butler United States Health Service Act

in section 3(o), by striking sections 6 and 7 and inserting sections 6, 7, and 7A;

in section 13—

in section 14(d), by striking 6 and 7 and inserting 6, 7, and 7A;

in section 15(a), by striking section 6 or section 7 and inserting section 6, 7, or 7A;

in section 16—

in section 18(a)—

the promotion of health and well-being through health education programs to be carried out in facilities of the Service as well as in workplaces, schools, and elsewhere utilizing all appropriate media, and by assisting other Government agencies in taking appropriate actions to promote health and well-being;

the prevention of illness, injury, and death through education and advocacy addressed to the social, occupational, and environmental causes of ill health; through the provision of appropriate preventive services including social, medical, occupational, and environmental health services, on both an emergency and sustained basis; through screening and other early detection programs to identify and ameliorate the primary causes of ill health; and, where appropriate, through actions taken on an emergency basis to halt environmental threats to life and health;

the diagnosis and treatment of illness and injury, including emergency medical services, comprehensive outpatient and inpatient health care services, occupational health services, mental health services, dental care, vision care, long-term care, and home health services;

the rehabilitation of the sick and disabled, including physical, psychological, occupational, and other specialized therapies; and

the provision of drugs, therapeutic devices, appliances, equipment, and other medical supplies (including eyeglasses, other visual aids, dental aids, hearing aids, and prosthetic devices) certified effective in the National Pharmacy and Medical Supply Formulary (published under section 432(a)) and furnished or prescribed by authorized health workers.

ambulance and other transportation services to insure ready and timely access to necessary health care;

child care services for individuals who, during the time they receive outpatient health care services from the Service or are working in a health care facility of the Service, are responsible for a child’s care;

homemaking and home health services—

such counseling and social service assistance as will avoid the unnecessary provision of health care services.

In general

The National Health Board and its local authorities shall, not later than the effective date of health services and to the maximum extent feasible, establish and maintain such health care facilities as are necessary for the efficient and effective delivery to individuals of comprehensive primary health care services (defined in paragraph (2)), specialized health care services (defined in paragraph (3)), special services (defined in paragraph (4)) and community-oriented health measures (defined in paragraph (5)). Such health care facilities shall be established and maintained in a manner that, as soon as possible and to the greatest extent feasible, provides services in each community through a single comprehensive health center.

Comprehensive primary health care services defined

As used in paragraph (1), the term comprehensive primary health care services means those basic outpatient health care services typically needed for the promotion of health and the prevention and treatment of common illnesses and includes the following health care services—

Specialized health care services defined

As used in paragraph (1), the term specialized health care services means those health care services of a specialized nature (whether delivered in an inpatient or outpatient setting) which, applying guidelines established by the National Health Board, may be provided most effectively and efficiently in a community setting.

Special services defined

As used in paragraph (1), the term special services means supportive services and the facilities (including nursing homes and multiservice centers) in which such services are provided for individuals who are physically or mentally handicapped, mentally ill, infirm, or chronically ill, so as to promote the integration and functioning of such individuals within the community.

Community-oriented health measures defined

As used in paragraph (1), the term community-oriented health measures includes efforts to focus organized community activities upon the promotion of health and the prevention of illness and injury, support for self-help and mutual aid groups offering health promotion and rehabilitative support programs; surveillance of potential threats to community health, and prompt action to protect against such threats, and includes outreach efforts to ensure that all residents are aware of and able to utilize the health services of the Service, as needed.

general hospitals for the efficient and effective delivery of health care services to individuals requiring inpatient diagnosis, treatment, care, and rehabilitation for injury or illness; and

such other health care facilities as are necessary, using guidelines established by the National Health Board to promote the efficient and effective delivery of health care services.

specialized medical facilities for the efficient and effective delivery of highly specialized health care services, using guidelines it shall establish, to individuals requiring highly specialized treatment, care, and rehabilitation for injury or illness;

health care and supplemental services for individuals whose health care are related to occupational or other factors, including individuals residing within a region on a temporary or seasonal basis (including migratory agricultural workers) and individuals confined to prisons and other correctional institutions; and

such other health care facilities as are necessary to promote the efficient and effective delivery of health care services.

Health promotion through education on personal health matters, nutrition, the avoidance of illness, and the effective use of health care services with particular emphasis on the appropriate and safe use (discouraging the overuse) of drugs and medical techniques.

Maintenance and appropriate transmission and transferal of personal health records for each user of the services consistent with section 201(9).

Referral services, including referrals, where appropriate, to other health care facilities.

Supplemental services (described in section 213(b)), as appropriate.

Assistance to individuals who, because of language or cultural differences or educational or other handicaps, are unable fully to utilize the services available from and delivered by the Board.

Information (A) on the rights ensured under this Act, (B) on the guidelines and standards established by the Board, and (C) on how the Board is implementing such rights and applying such guidelines and standards.

Information on the grievance mechanisms established pursuant to subtitle A of title IV and on legal services available to pursue grievances against the Board.

Environmental health inspection and monitoring services, including investigations relating to the prevention of communicable diseases, in cooperation with State and local authorities.

Research and data gathering on the leading causes of ill health and injury and on health care delivery, in accordance with section 421.

In the case of each inpatient health care facility, discharge planning and followup services (A) to identify patients who will need continuing care after discharge from the facility and (B) to plan, with the patient and the patient’s family, arrangements and referrals to meet such postdischarge needs.

Effective delivery

In its establishment of health care facilities, the National Health Board shall seek to minimize fragmentation and duplication in delivery of health care and other services so as to promote the effective and efficient delivery of such services.

Coordination

The Board shall provide mechanisms to coordinate care across political and geographic boundaries as necessary.

Assuring availability and accessibility of services

The Board shall take whatever additional steps are necessary to ensure that all of the health services required under this title are available and accessible in a timely manner to adults, infants, children, and individuals with disabilities in its region. Toward that end, it shall—

Definitions

For purposes of this subsection:

In general

The National Health Board shall authorize the National Institute of Evaluative Clinical Research described in section 422 to establish evidence-based clinical decision criteria, where feasible, that shall apply throughout the Nation.

Clinical decision criteria defined

For purposes of this section, the term clinical decision criteria means the recorded (written or otherwise) screening procedures, decision abstracts, clinical protocols, and practice guidelines used as an important basis to determine the necessity and appropriateness of health care services, in combination with the facts of particular cases, the judgment of health care professionals, and the preferences of users. Such criteria shall be clearly documented and available to all health workers and shall include a mechanism for periodically updating such criteria.

requiring the provision of services; and

providing reimbursement for the provision of specified health care services in accordance with procedures and schedules in effect under title XVIII of the Social Security Act immediately before the effective date of health services.

In general

Each health care facility shall be subject to policies and organizational plans consistent with this section and with parts A and C of title III (relating to the health labor force) for the operation of such facility and shall establish procedures to ensure that the facility is operated in accordance with such policies and plans.

Health worker and user control

The National Health Board and its regional and local authorities shall establish policies and mechanisms for control of health care facilities by health care workers who are employed in, and users who receive services from, the respective facility, and shall promulgate rules preventing a financial conflict of interest by decisionmaking bodies.

In general

No individual entitled to make decisions regarding establishment, allocation, or operation of a health facility may engage in the private delivery of health care services.

Private delivery of health care services defined

For the purposes of this subsection, the term private delivery of health care services means the delivery of health care services for which an individual, group, or organization receives remuneration from any source other than the Health Service Trust Fund established in section 511.

Hours of operation

Any health care facility which provides health care services on an outpatient basis shall be open during hours that will permit all users to make use of such services.

Effective delivery

In its establishment of health care facilities under this section, the Board shall seek to minimize fragmentation and duplication in delivery of health care and other services so as to promote the effective and efficient delivery of such services.

In general

The following services shall be provided:

Voluntary

The services described in paragraph (1) shall be delivered without coercion or harassment, with complete confidentiality, and without prior approval of individuals other than the individual receiving the services.

Accompaniment

An individual shall be permitted to be accompanied by a person of the individual’s choice during the provision of the services described in paragraph (1) to the extent this would not significantly increase the medical risk to the individual.

the individual has given voluntary written consent to the treatment or procedure after being given complete information on the effect of the treatment or procedure on the individual’s reproductive capacity, and on possible alternative treatments and procedures, at least 30 days before beginning the treatment or procedure, and

the individual has, after such 30-day waiting period, again given written consent to the performance of the treatment or procedure, except that in the case of a woman who has given initial written consent to a sterilization she may be sterilized in less than 30 days following such consent (but in no case in less than 72 hours)—

giving birth at home, in a birth center (if available), or in a hospital;

the presence during childbirth of a person or persons of her choosing;

the position for labor and delivery which she chooses;

caring for her infant at her bedside;

feeding her infant according to the method and schedule of her choice; and

selecting the birth attendant of her own choice.

certified (in accordance with this subtitle) as competent to perform the work under such job category, and

authorized to perform such work by the employer of such worker.

Classification

The National Health Board shall establish such guidelines for the classification, certification, and employment of health workers by job category as it determines to be necessary—

Considerations

In establishing guidelines under paragraph (1), the National Health Board shall provide for (A) sufficient flexibility to permit utilization of health workers most effectively to meet the health needs of the region, and (B) sufficient uniformity to permit mobility of health workers among the regions.

Establishment

For each job category (other than a job category determined by the National Health Board to involve highly specialized skills requiring advanced specialty training), the National Health Board shall, taking into account the guidelines established under subsection (a), establish certification standards which shall specify—

Specifications

For each job category established and determined by the National Health Board to involve highly specialized skills requiring advanced specialty training, the National Health Board shall make the specifications described in subparagraphs (A) through (D) of paragraph (1).

Periodic review

Standards for a job category under this subsection shall be periodically reviewed to supplement, modify, or eliminate such standards as will facilitate the delivery of quality health care services under this Act.

Quality protection

In general

Except as provided in paragraph (2), the Board shall establish a procedure for converting existing educational facilities for health services workers to create health team schools (each in this subtitle referred to as a school) in accordance with this section to provide programs of initial and continuing basic education in health care delivery for health workers in all job categories, and to provide initial continuing advanced education in health care specialties and health science specialty fields. Such schools shall be established and functioning not later than 4 years after the effective date of health services.

Use of funds

Schools shall be funded exclusively by the Service, shall not charge nor accept tuition or fees for enrollment, and shall provide each student with an adequate allowance for living expenses, educational supplies, and any child care expenses.

The activities of each school shall be designed to meet the health needs of the population.

The number of students enrolled in each educational program in a school shall be based on the needs for health workers within a given area, defined by geographic and political boundaries.

Schools shall integrate the education of health workers in the different job categories (established under subtitle A) so as to permit health workers to be educated and certified for successively higher levels of health care work.

Each school’s admissions policies, curriculum policies, faculty hiring procedures, and governance plan shall be established and implemented in accordance with subsections (c) through (f), respectively, and with the fullest possible participation of the community health workers, staff, and students in its region.

A school may not use individuals who are from low-income populations or minority groups, or who are women or confined in mental or penal institutions, as subjects for training or demonstration in numbers that are disproportionate to their numbers in the population of the region, and may not use any individuals as subjects for training or demonstration in a manner beyond that required for the immediate purpose of the training or demonstration or without their explicit consent.

emphasize previous health-related work experience, as evaluated by health workers (including peers), by individuals who have received health care services from the applicant, and by faculty members;

minimize the use of criteria of academic performance other than such criteria as have been shown to be significantly related to future work performance;

give preference to segments of the population of the region underrepresented among health workers;

to the extent consistent with paragraph (3), provide for admission of individuals so that the student body approximates the population of the region by race, sex, family income, and language; and

require that the applicant agree, if accepted into the school, to perform health care services in accordance with section 312.

give priority in study and field work to the leading causes of illness and death in the region, including environmental, biological, and social determinants of mortality and morbidity;

give special consideration to studying the social, as well as biological, causation and prevention of illness and disease, and to the differing health care needs of populations facing special health risks and having special cultures and lifestyles within the region;

provide that all students shall take a common, initial sequence of courses and that students preparing for more advanced types of health work shall take studies that are progressively more specialized and differentiated;

emphasize work study experience in all types of health care facilities in the region, including community and workplace facilities, facilities for the aged, mentally ill, and mentally retarded, health care facilities in prisons and other correctional institutions, alcohol and drug rehabilitation facilities, environmental health facilities, and all other health care facilities of the Service in communities and districts in the region;

emphasize the appropriate and safe use, and discourage the overuse, of drugs and medical techniques; and

facilitate the development by all health workers of skills in decisionmaking and assessment of user needs in cooperation with other health workers and with users.

In general

No individual may be enrolled in a school unless the individual agrees to perform health care services as an employee of the Service in the job category for which training is being provided—

Deferral

An individual’s obligation to perform service under an agreement described in paragraph (1) shall be deferred only for a period during which the individual is physically or mentally incapable of performing such service.

Completion of service required

No individual who has made an agreement described in paragraph (1) may be employed other than in accordance with subsection (c), until the individual has completed the period of obligated service in accordance with this section.

Penalty for breach of agreement

Except as provided in paragraph (5), if an individual breaches an agreement under paragraph (1) by failing (for any reason) either to begin such individual’s service obligation or to complete such service obligation, the Service shall be entitled to recover from the individual an amount determined in accordance with the formula A=C (1–s / (t)) in which—

Cancellation

Upon completion by the individual for whom the payments are to be made of the first year of employment with the Service, the National Health Board shall pay 30 percent of the principal of, and the interest on, each loan described in subsection (a) which is outstanding on the date he began such employment.

Upon completion by that individual of the second year of such employment, the National Health Board shall pay another 30 percent of the principal of, and the interest on, each such loan.

Upon completion by that individual of a third year of such employment, the National Health Board shall pay another 25 percent of the principal of, and the interest on, each such loan.

Upon completion by that individual of a fourth year of such employment, the National Health Board shall pay the remaining 15 percent of the principal of, and all remaining interest on, each such loan.

employment and promotion in the Service in the same manner as is provided for employment and promotion under the Federal civil service system;

meaningful opportunities for career advancement;

encouragement of health workers to use up to 10 percent of their work time for continuing education under subtitle B without loss of pay or other job rights; and

full protection of employees’ rights by providing an opportunity for a fair hearing on adverse actions with representation of their own choosing.

in a collective bargaining agreement negotiated on behalf of and applicable to them; or

in procedures established by the Service and approved by the Office of Personnel Management.

Application of civil Service retirement

Chapter 83 of title 5, United States Code (relating to civil service retirement), applies to employees of the Service except to the extent provided in a collective bargaining agreement negotiated on behalf of and applicable to them.

Withholding

The Service shall withhold from pay and shall pay into the Civil Service Retirement and Disability Fund the amounts specified in chapter 83 of title 5, United States Code, as required under paragraph (1). The Service, upon request of the Office of Personnel Management, but not less frequently than annually, shall pay to the Office the costs reasonably related to the administration of Fund activities for employees of the Service.

Terms of employment

Compensation, benefits, and other terms and conditions of employment in effect on the effective date of health services for employees of the Federal Government performing functions that are provided under this Act by the Service, shall apply to all employees of the Service performing similar functions until changed by the Service in accordance with this Act. Subject to the provisions of this Act, the provisions of subchapter I of chapter 85 and chapter 87 of title 5, United States Code (relating to unemployment compensation and life insurance), apply to employees of the Service unless varied, added to, or substituted for in accordance with paragraph (2).

Limitation on variation

No variation, addition, or substitution with respect to fringe benefits shall result in a program of fringe benefits which on the whole is less favorable to employees of the Service than fringe benefits in effect for employees of the Federal Government on the effective date of health services. No variation, addition, or substitution with respect to fringe benefits of employees for whom there is a collective bargaining representative shall be made except by agreement between such representative and the Service.

In general

The provisions of the National Labor Relations Act (42 U.S.C. 141 et seq.) shall apply to the Service and its employees to the extent, not inconsistent with subsection (b), to which such provisions apply to employers (as defined in section 2(2) of such Act), except that—

Strikes permitted

Paragraphs (3) and (4) of section 7311 of title 5, United States Code (prohibiting participation in a strike or an organization asserting the right to strike), shall not apply to employees of the Service.

In general

Collective bargaining agreements between the National Health Board and duly recognized bargaining representatives of employees of the Service may include procedures for resolution by the parties of grievances and adverse actions arising under the agreement, including procedures culminating in binding third party arbitration.

Alternative procedures

The National Health Board and duly recognized bargaining representatives of employees of the Service may by mutual agreement adopt procedures for the resolution by the parties—

Removal from State courts

Upon a certification by the Attorney General that the defendant was acting in the scope of employment at the time of the incident out of which the suit arose, any such civil action or proceeding commenced in a State court shall be removed without bond at any time before trial by the Attorney General to the district court of the United States of the district and division embracing the place wherein it is pending and the proceeding deemed a tort action brought against the United States under the provision of title 28, United States Code, and all references thereto.

Motions to remand

If a United States district court determines on a hearing on a motion to remand held before a trial on the merits that the case so removed is one in which a remedy by suit within the meaning of subsection (a) is not available against the United States, the case shall be remanded to the State court.

Effect of alternative remedies

Where a remedy by suit within the meaning of subsection (a) is not available because of the availability of a remedy through proceedings for compensation or other benefits from the United States as provided by any other law, the case shall be dismissed, but in the event the running of any limitation of time for commencing, or filing an application or claim in, such proceedings for compensation or other benefits shall be deemed to have been suspended during the pendency of the civil action or proceeding under this section.

the employment of individuals having basic legal knowledge and skills as health advocates;

the presence of health advocates—

provision for health advocates to (A) inform, on an ongoing basis, users and health workers of such patient rights and (B) report to the National Health Board any infraction of such rights which is not promptly corrected;

provision for regular meetings between health workers and health advocates, users, and any user representatives to discuss ways of ensuring the fulfillment of such rights through affirmative action of such workers and the National Health Board; and

appropriate action by the National Health Board to ensure that infractions of such rights are promptly and sufficiently corrected.

Establishment of program

The National Health Board shall establish a health rights legal services program and shall provide such program with sufficient legal and administrative personnel, funding, and facilities (A) to ensure that users and health workers receive, free of charge, high quality legal services (including representation in grievance proceedings commenced under section 402) for legal problems related to health rights and health care services, and (B) to improve, through litigation and other activities, the health care system and expand the rights of users and health workers.

Services

The health rights legal services program shall provide directly, by contract with the Legal Services Corporation, or by contract with members of the private bar, for—

Use of contracts

The National Health Board may carry out the functions described in paragraph (1)(B) directly, by contract, or otherwise.

In general

The National Health Board shall provide, in accordance with this section, that any user, health worker, or any user association having a demonstrated interest in health care may commence a grievance proceeding before the Board (or a person or committee designated by such Board) with respect to an alleged violation of this Act. The National Health Board may commence a grievance proceeding before itself (or a person or committee designated by such Board) with respect to an alleged violation of this Act.

Grievances against National Health Board

Grievances against the National Health Board may be presented to and adjudicated by the Inspector General for Health Services or the Inspector’s General local designees. Grievants shall also have access to review in the courts.

By National Health Board

The National Health Board shall provide, subject to paragraphs (2) and (3), for its review (or a review by a person or committee designated by the Board), by appeal to the Board by any party to a proceeding described in subsection (a)(1) or on its own initiative, of an adverse decision.

Limitation once suit commenced

On and after the date a suit with respect to an adverse determination in a grievance proceeding or review proceeding is filed under subsection (e), no review proceeding respecting such proceeding may be commenced by appeal to the Board under paragraph (1), and any such review proceeding which was commenced by appeal to the Board under such paragraph before the date of filing of such suit and is pending on such date shall promptly be discontinued.

Time limit

No review of an adverse administrative decision may be made by appeal or by initiative under this subsection unless the appeal is filed or notice of the initiative is published (as the case may be) not later than 30 days after the publication of the decision.

In general

To provide for participation of the National Health Board in the establishment and administration of occupational safety and health standards, the Occupational Safety and Health Act of 1970 (29 U.S.C. 651 et seq.) is amended—

Effective date

The amendments made by paragraph (1) shall take effect on the effective date of health services.

for its participation in the establishment and administration of occupational safety and health standards under the Occupational Safety and Health Act of 1970; and

for the establishment and operation of workplace health facilities under section 413.

be organized in a manner so as to provide an appropriate number of appropriately skilled health workers to meet occupational and emergency health care needs of employees in the workplace; and

be operated by the community for the community in which the workplace is predominantly located, or, where the National Health Board or its local authority deems appropriate, by the employer, with the cost in either case borne by the employer in each workplace.

Establishment

Employees in each workplace having 25 or more employees shall have the right to establish workplace occupational safety and health committees (each in this subsection referred to as a committee) with members of their choosing.

Membership

Members of committees (composed of the greater of 3 members or one member for each 100 employees in the workplace) shall, without any loss of pay or other job rights—

to monitor safety and health conditions in their workplace whenever they reasonably deem it necessary and with whatever reasonable scientific instruments and expert assistance they choose; and

to remove themselves from the site of any hazard to their safety or health until an authorized inspector has certified that the hazard has been eliminated.

The research shall, to the maximum extent possible, be performed under the direction of, and in association with, agencies representative of the population.

No research shall be conducted within, or using the resources of, an area health facility until it has been reviewed and approved by the National Health Board, or a designated local authority responsible for such facility.

Priority shall be given in health research to the prevention and correction of the leading causes of illness and death, particularly environmental, occupational, nutritional, social, and economic causes.

Priority shall be given in health care delivery research to improvement of the effectiveness and efficiency of ambulatory and primary health care delivery, including research on alternative systems of health care delivery and alternative conceptions of health and health care.

The National Health Board shall encourage and support the conduct of clinical trials that may improve the health of the public. Any clinical trial conducted with the intention of evaluating new preventive, diagnostic, or therapeutic methods or agents shall be conducted only in accordance with established ethical procedures that protect subjects from undue harm. If benefit becomes apparent, by scientific consensus, before the scheduled conclusion of any clinical trial, such trial shall nevertheless be terminated, and the benefit made available to trial participants and the public at large.

No research shall be conducted on a human subject without the subject’s informed written consent.

No research shall be conducted on a human subject while the subject is involuntarily confined to an institution.

The planning and conduct of research under the program, shall take place in cooperation with appropriate officials conducting related research in the Federal Government and agencies and departments of State, territorial, and local governments.

The results of research shall be disseminated to the public and to National Health Board in a manner that will most readily permit the use of such results to improve the health of users and the delivery of health care services.

National Institute of Epidemiology

A National Institute of Epidemiology, which shall—

National Institute of Evaluative Clinical Research

A National Institute of Evaluative Clinical Research, which shall—

National Institute of Health Care Services

A National Institute of Health Care Services, which shall—

National Institute of Pharmacy and Medical Supply

A National Institute of Pharmacy and Medical Supply, which shall—

National Institute of Sociology of Health and Health Care

A National Institute of Sociology of Health and Health Care, which shall—

Publication

The National Health Board, shall, not later than the effective date of health services, publish and disseminate a National Pharmacy and Medical Supply Formulary (in this section referred to as the Formulary).

Contents

The Formulary shall contain a listing of drugs, therapeutic devices, appliances, equipment, and other medical supplies (including eyeglasses, other visual aids, hearing aids, and prosthetic devices) (in this section referred to as drugs and other medical supplies). For each item on such listing the Formulary shall contain (A) the standards of quality for the production of such item, (B) the medical conditions for which the item is certified as effective for purposes of the provision of health care services under this Act, and (C) such other information on such item as the National Health Board determines to be appropriate for the effective and efficient delivery of health care services under this Act.

Updating

The National Health Board shall, at regular intervals, update the contents of the Formulary and publish a price list for items listed in the Formulary, which prices shall reflect the actual costs of manufacture.

In general

The National Health Board shall establish a program, in accordance with this subsection for the purchase and distribution of drugs and other medical supplies for use in health care facilities.

Pricing

Such program shall provide for the purchase of each drug or other medical supply item only (A) following competitive bidding on such item or (B) based on the price listed for such item in the price list published under subsection (a)(3).

Generic distribution

Such program shall provide for the distribution and dispensing of drugs under their generic names.

Generic names defined

For purposes of paragraph (3), the term generic names means the established names, as defined in section 502(e)(2) of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 352(e)(2)).

In general

Subchapter A of chapter 1 of the Internal Revenue Code of 1986 (relating to normal taxes and surtaxes) is amended by adding at the end the following new part:

Clerical amendment

The table of parts of such subchapter A is amended by adding after the item relating to part VII the following new item:

Paragraph (2) of section 170(c) of such Code (relating to charitable, etc., contributions and gifts) is amended by inserting (other than an organization described in subsection (b)(1)(A)(iii)) after (2) A corporation, trust, or community chest, fund, or foundation.

Subsection (e) of section 501 of such Code (relating to cooperative hospital service organizations) is amended by striking the last sentence.

Section 213 of such Code (relating to medical, dental, etc., expenses) is repealed.

The table of sections of part VII of subchapter B of chapter 1 of such Code is amended by striking the item relating to section 213.

Subsection (b) of section 1401 of such Code (relating to rate of tax on self-employment income) is repealed.

Subsection (b) of section 3101 of such Code (relating to rate of tax on employees under the Federal Insurance Contributions Act) is repealed.

Section 3201(a) of such Code (relating to rate of tax imposed on employees under the Railroad Retirement Tax Act) is amended by striking the sum of the rates of tax in effect under subsections (a) and (b) of section 3101 and inserting the rate of tax in effect under section 3101(a).

Section 3211(a)(1) of such Code (relating to rate of tax on employee representatives under the Railroad Retirement Tax Act) is amended by striking subsections (a) and (b) the first place it appears and inserting subsection (a).

Subsection (e) of section 6051 of such Code (relating to railroad employees) is repealed.

hold the Trust Fund;

report to the Congress not later than the first day of April of each year on the operation and status of the Trust Fund during the preceding fiscal year and on its expected operation and status during the current fiscal year and the next 2 fiscal years;

report immediately to the Congress whenever the Board is of the opinion that the amount of the Trust Fund is unduly small; and

review the general policies followed in managing the Trust Fund, and recommend changes in such policies, including necessary changes in the provisions of law which govern the way in which the Trust Fund is to be managed.

Fixing

The National Health Board shall, not later than January 1 of each year, initially fix the maximum amount of funds which may (except as provided in subsection (c)) be obligated during the fiscal year beginning on October 1 of such year for expenditure from the Trust Fund.

Limitation

Such amount shall not exceed for a fiscal year the lesser of—

Refixing

The National Health Board may at any time refix such amount to reflect changes—

restriction of the amount to be made available for obligation will not materially impair the adequacy or quality of health care and supplemental services provided to users, or

improvement in the organization, delivery, or utilization of such services has lessened their aggregate cost (or increase in such cost).

ordinary operating expenses;

preventive health measures, and which measures shall include primary prevention to improve the conditions under which people live that affect health status;

capital expenses;

research expenses; and

special operating expenses, as described in section 532.

the care and treatment of users 65 years of age or older;

the care and treatment of persons confined to full-time residential care institutions, including nursing homes and facilities for the treatment of mental illness;

the special health care needs of low-income users;

the special health care needs of communities of color that experience disparities in health status compared to white populations;

the special health care needs of residents of rural or frontier areas, or noncontiguous States and territories;

special health care needs arising from environmental or occupational health conditions;

special health care needs arising from unexpected occurrences, including epidemics and natural disasters; and

the conduct of environmental health inspection and monitoring services.

Funds for the additional operating expenses associated with the care and treatment of users 65 years of age or older shall be allocated and shall consist of uniform basic capitation amounts multiplied by the number of residents 65 years of age or older in the respective areas. The basic capitation amounts for areas shall be determined by the National Health Board, based upon studies of the additional operating expenses associated with the care and treatment of such residents in such areas.

Funds for the additional operating expenses associated with the care and treatment of persons confined to full-time residential care institutions shall be allocated and shall consist of a uniform basic capitation amount for each kind of institution, multiplied by the number of residents in such institutions in the respective areas. The basic capitation amounts shall be determined by the National Health Board, based upon studies of the additional operating expenses associated with the care and treatment of such persons and the maintenance of such institutions.

Funds shall be allocated to areas for the additional operating expenses associated with the special health care needs of low-income persons. Such payments shall be allocated in proportion to the number of residents in these areas having incomes below the poverty level (as defined by the Secretary of Commerce). The total funds allocated for this purpose shall be no less than 2 percent of the ordinary operating expense funds allocated in accordance with section 531(a).

Funds shall be allocated for the additional operating expenses associated with the special health care needs of communities of color to the extent that they experience disparities in health status compared to white populations. The basic capitation amounts shall be determined by the National Health Board, based upon studies of the additional operating expenses associated with providing the necessary or appropriate health services for communities of color, and the additional expenses associated with eliminating such disparities in health status.

Funds for the additional operating expenses associated with the special health care needs of residents of rural or frontier areas, or noncontiguous States and territories, shall be allocated to communities serving areas of low population density and shall consist of basic capitation amounts multiplied by the number of residents in the respective areas. The basic capitation amounts shall be determined by the National Health Board based upon studies of the additional operating expenses associated with the provision of health care in areas of low population density or extreme geographic access barriers, or both.

Funds for the additional operating expenses associated with special regional health care needs arising from environmental and occupational health problems shall be allocated by the National Health Board in accordance with its determination of such special needs. The total funds allocated for this purpose shall be no greater than 1/2 of 1 percent of the ordinary operating expense funds allocated in accordance with section 531(a).

Funds for the additional operating expenses associated with special health care needs arising from unexpected occurrences shall be retained by the National Health Board in a contingency fund and shall be allocated by the National Health Board in accordance with its determination of such needs. The total funds retained for this purpose in any one fiscal year shall be no greater than 1/2 of 1 percent of the ordinary operating expense funds allocated in such year in accordance with section 531(a).

Funds for the additional operating expenses associated with the conduct of environmental health inspection and monitoring services shall be allocated by the National Health Board for providing such services.

funds for operating expenses, including ordinary operating expenses and special operating expenses;

funds for preventive health measures;

funds for capital expenses; and

funds for research expenses.

shall be in such forms and denominations;

shall be sold at such times and in such amounts;

shall mature at such time or times;

shall be sold at such prices;

shall bear such rates of interest;

may be redeemable before maturity in such manner, at such times, and at such redemption premiums;

may be entitled to such relative priorities of claim on the assets of the Service with respect to principal and interest payments; and

shall be subject to other terms and conditions, as the National Health Board determines.

be negotiable or nonnegotiable and bearer or registered instruments, as specified therein and in any indenture or covenant relating thereto;

contain a recital that they are issued under this section, and such recital shall be conclusive evidence of the regularity of the issuance and sale of such obligations and of their validity;

be lawful investments and may be accepted as security for all fiduciary, trust, and public funds, the investment or deposit of which shall be under the authority or control of any officer or agency of the Government of the United States, and the Secretary of the Treasury or any other officer or agency having authority over or control of any such fiduciary, trust, or public funds, may at any time sell any of the obligations of the Service acquired under this section;

be exempt both as to principal and interest from all taxation now or hereafter imposed by any State or local taxing authority except estate, inheritance, and gift taxes; and

not be obligations of, nor shall payment of the principal thereof or interest thereon be guaranteed by, the Government of the United States, except as provided in subsection (g).

the National Health Board requests the Secretary of the Treasury to pledge the full faith and credit of the Government of the United States for the payment of principal and interest thereon; and

the Secretary, in his discretion, determines that it would be in the public interest to do so.