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[Senate Report 107-97]
[From the U.S. Government Publishing Office]

                                                       Calendar No. 222
107th Congress                                                   Report
                                 SENATE
 1st Session                                                     107-97

======================================================================

 
        STROKE TREATMENT AND ONGOING PREVENTION ACT OF 2001

                                _______
                                

              November 9, 2001.--Ordered to be printed

                                _______
                                

   Mr. Kennedy, from the Committee on Health, Education, Labor, and 
                   Pensions, submitted the following

                              R E P O R T

                             together with

                            ADDITIONAL VIEWS

                         [To accompany S. 1274]

    The Committee on Health, Education, Labor, and Pensions, to 
which was referred the bill (S. 1274) to amend the Public 
Health Service Act to provide programs for the prevention, 
treatment, and rehabilitation of stroke, having considered the 
same, reports favorably thereon and recommends that the bill do 
pass.

                                CONTENTS

                                                                   Page
  I. Purpose and summary..............................................1
 II. Background and need for the legislation..........................2
III. History of the legislation.......................................5
 IV. Explanation of bill and committee views..........................5
  V. Cost estimate....................................................7
 VI. Regulatory impact statement.....................................10
VII. Application of law to the legislative branch....................10
VIII.Section-by-section analysis.....................................10

 IX. Additional views................................................13
  X. Changes in existing law.........................................14

                         I. Purpose and Summary

    The Stroke Treatment and Ongoing Prevention Act of 2001 
authorizes initiatives at the State and Federal levels to 
improve and enhance the Nation's capacity to provide effective 
treatment for stroke.

                II. Background and Need for Legislation

    Stroke is a loss of brain function resulting from an 
interruption of the blood supply to the brain, due either to 
ischemia or hemorrhage. Stroke often causes disability and 
frequently results in death, due to the tissue damage to the 
brain that results from an interrupted blood supply. The 
effects of a vascular accident in the brain are particularly 
severe, since neural tissue has an extremely limited capacity 
to regenerate. Even a brief interruption to the blood flow can 
cause severe neurological deficits.
    There are two different types of stroke or Brain Attack--
ischemic stroke and hemorrhagic stroke. An ischemic stroke is 
caused when a blood clot blocks or ``plugs'' a blood vessel in 
the brain. There are two ways that a blood-clot stroke can 
occur. An embolic stroke occurs when a blood clot travels from 
other parts of the body (for example, the heart) to the neck or 
brain and blocks a blood vessel. In a thrombotic stroke, a 
blood clot (thrombus) forms inside one of the brain's arteries 
and blocks blood flow. This usually happens inside an artery 
that has already been narrowed by atherosclerosis, a condition 
where fatty deposits (plaques) build up along the walls of 
blood vessels. Ischemic stroke is the most common type of 
stroke (80 percent-85 percent of strokes are ischemic).
    A hemorrhagic stroke is caused when a blood vessel in the 
brain breaks or ruptures. There are two types of hemorrhagic 
stroke: a subarachnoid hemorrhage and a intracerebral 
hemorrhage. With a subarachnoid hemorrhage, bleeding occurs in 
the space around the brain. Often this is due to an aneurysm--a 
weak or thin spot on a blood vessel wall. An intracerebral 
hemorrhage involves bleeding within the brain tissue itself, 
and this is the more common form. Hemorrhagic stroke occurs in 
10 percent of stroke sufferers. While there are mild to severe 
strokes, the outcomes of a hemorrhagic stroke are usually 
severe.
    The consequences of a stroke very depending on the region 
of the brain that is deprived of blood supply. Symptoms of 
stroke can include blurred or lost vision, difficulties in 
forming or comprehending speech, muscle weakness or paralysis, 
disorientation, loss of sensation in a part of the body, loss 
of consciousness or death. If the blood flow is interrupted for 
longer than a few seconds, neurons in the ischemic area die, 
causing permanent losses in brain function.
    Stroke has a profound impact on the health of the people of 
the United States. It is the third leading cause of death in 
the United States. There are roughly 700,000-750,000 strokes in 
the United States each year, and almost 160,000 Americans die 
each year from stroke. Every minute in the United States, an 
individual experiences a stroke. Every 3.3 minutes an 
individual dies from one.
    Over the course of a lifetime, four out of every five 
families in the United States will be touched by stroke. 
Currently, there are four million Americans living with the 
effects of stroke. 15 percent to 30 percent of stroke survivors 
are permanently disabled. 55 percent of stroke survivors have 
some level of disability. 40 percent of these patients feel 
they can no longer visit people; almost 70 percent report that 
they cannot read; 50 percent need day-hospital services; 40 
percent need home help; 40 percent have a visiting nurse; and 
14 percent need Meals on Wheels.
    The economic impact of stroke is similarly profound. Stroke 
costs the United States $30 billion each year. The average cost 
per patient for the first 90 days following a stroke is 
$15,000. The lifetime costs of stroke exceed $90,000 per 
patient for ischemic stroke and over $225,000 per patient for 
subarachnoid hemorrhage.
    Improving the quality of treatment provided to stroke 
patients and enhancing stroke prevention would save lives and 
reduce the economic toll taken by this disorder. However, there 
is strong evidence that stroke care and prevention is not 
adequate.
    Recent developments in the treatment of persons with stroke 
could save lives and reduce disability if properly and promptly 
administered. Thrombolytic medications can improve stroke 
outcomes if administered rapidly after the onset of a stroke, 
yet few patients receive these therapies. Nationally, only 2 
percent to 3 percent of patients with stroke are being treated 
with the appropriate thrombolytic agent. Interventional stroke 
therapies, such as stenting or endovascular treatment of 
aneurysms, may also be effective for some patients.
    Research into new treatments for stroke is ongoing, and 
promising advances are being made continuously. Advances in 
imaging, interventional radiology, pharmacology and many other 
disciplines provide new hope that more effective stroke 
treatments will be found.
    While research promises new treatments for the future, 
existing treatments are not being administered in the most 
effective manner even now. For example, in a study of North 
Carolina's stroke treatment facilities, 66 percent of hospitals 
did not have stroke protocols and 82 percent did not have rapid 
identification for patients experiencing acute stroke. A 1995 
study found that almost half of all stroke patients who went 
through the Reading, Ohio Emergency Medical Services System 
were dispatched as having something other than stroke and a 
quarter of all patients identified as having stroke by 
paramedics were later discovered to have another cause for 
their illness. A 1993 study of patients who had a stroke while 
they were inpatient found a median delay between stroke 
recognition and neurological evaluation of 2.5 hours. Improving 
the delivery of existing therapy can thus have a marked effect 
on the morbidity and mortality caused by stroke.
    Prompt recognition of the symptoms of a stroke is a key to 
effective treatment, yet public awareness of the symptoms of 
stroke is poor. Since few Americans recognize the symptoms of 
stroke, crucial hours are often lost before patients receive 
medical care. For example, in a 1989 survey of 500 San 
Francisco residents, 65 percent of those surveyed were unable 
to correctly identify any of the early stroke warning signs 
when given a list of symptoms. In a national survey, 29 percent 
of respondents could not name the brain as the site of a stroke 
and only 44 percent identified weakness or loss of feeling in 
an arm or leg as a symptom of stroke. The International Stroke 
Trial found that only 4 percent of the 19,000 patients studied 
presented within 3 hours of symptom onset and only 16 percent 
presented within 6 hours. The average time between the onset of 
symptoms and medical treatment is a shocking 13 hours.
    Recent research provided the committee with important 
insight into ways to improve outcomes for patients experiencing 
stroke. This research (detailed below) showed that an 
integrated and comprehensive system of stroke care can save 
lives and reduce disability associated with stroke. Two strands 
of research were particularly important in demonstrating the 
likely benefits of integrated stroke care systems. The first 
shows that patients treated for stroke at stroke centers 
experience significantly better outcomes than those treated in 
other hospital settings. The second shows that implementing 
statewide systems of care for trauma significantly reduced 
death rates among trauma victims.
    Several comprehensive studies indicate that patients 
experience improved clinical outcomes if treated at designated 
stroke centers. A series of 19 clinical trials that included 
3,249 patients in European hospitals demonstrated significantly 
reduced rates of death, disability and institutionalization for 
patients treated in stroke centers compared to those treated in 
other hospital settings (meta-analyses reported in Stroke 
(1997) 28:2139; British Medical Journal (1997) 314: 1151). 
Based on this data, the number needed to treat in order to 
prevent one death was 22. Extrapolating from this data, 
treating all stroke victims in the appropriate hospital setting 
might be expected to save approximately 30,000 lives in the 
United States.
    To be most effective, stroke centers should form part of an 
integrated system of stroke care to ensure that a patient 
receives the optimal therapy at the time when it is most 
effective. Stroke care systems should include initiatives to 
prevent stroke through reduction in risk factors, pre-hospital 
and emergency care, hospital care, rehabilitation, 
reintegration into the community, surveillance and research.
    The experience of several states that have implemented 
comprehensive trauma care systems, consisting of most or all of 
the elements identified above, is instructive in showing the 
potential benefits of similar systems of care for stroke. These 
trauma care systems have been shown to significantly improve 
outcomes for patients. For example, the trauma care system 
implemented in Nebraska reduced pre-hospital death rates by 28 
percent and hospital deaths by 17 percent (data reported in 
Journal of Trauma (1985) 25: 575).
    The odds of survival from trauma in Oregon increased by 20 
percent in the years following implementation of the state's 
trauma care system (data reported in Journal of Trauma: Injury, 
Infection and Critical Care (1996) 40: 536). Comparing patient 
outcomes in states that have implemented trauma care systems to 
similar states that have not is a particularly important 
measure of these systems' effectiveness. Comparing patient 
outcomes in Oregon to those in neighboring Washington (where a 
trauma system had not been implemented) revealed that patients 
had a significantly better chance of surviving trauma if 
treated in Oregon rather than Washington (data reported in 
Journal of Trauma: Injury, Infection, and Critical Care (1997) 
43:122; ; Journal of Trauma: Injury, Infection, and Critical 
Care (1998) 44:609). The beneficial effects of a statewide 
trauma care system were confirmed by a similar study showing 
that trauma survival rates for pediatric patients were also 
significantly better in Oregon than in Washington (data 
reported in the Journal of Trauma: Injury, Infection, and 
Critical Care (1997) 42:514).
    While trauma care and stroke care present somewhat 
different health care challenges, it is the committee's belief 
that instituting statewide systems of stroke care can provide 
benefits to patients analogous to those demonstrated to occur 
after implementation of statewide trauma care systems.
    To save lives, reduce disability and improve the quality of 
stroke care, the Stroke Treatment and Ongoing Prevention (STOP 
Stroke) Act authorizes important public health initiatives to 
help patients with symptoms of stroke receive timely and 
effective care.

                    III. History of the Legislation

    The Stroke Treatment and Ongoing Prevention (STOP Stroke) 
Act of 2001 was introduced on July 31, 2001, by Senator 
Kennedy, for himself and Senator Frist, Senator Dodd, Senator 
Hutchinson, Senator Jeffords, Senator Collins, Senator 
Bingaman, Senator Edwards, Senator Murray, and Senator 
Sessions. The bill was referred to the Senate Committee on 
Health, Education, Labor, and Pensions. On August 1, 2001, the 
Senate Committee on Health, Education, Labor, and Pensions held 
an executive session to consider S. 1274. S. 1274 was ordered 
reported favorably by a unanimous voice vote.

            IV. Explanation of the Bill and Committee Views

    The committee seeks to improve systems for the treatment of 
stroke throughout the United States by reporting favorably the 
Stroke Treatment and Ongoing Prevention (STOP Stroke) Act of 
2001. The Act establishes a grant program for States to 
implement systems ofstroke care that will give health 
professionals the equipment and training they need to treat this 
disorder. The initial point of contact between a stroke patient and 
medical care is usually an emergency medical technician. Grants 
authorized by the Act may be used to train emergency medical personnel 
to provide more effective care to stroke patients in the crucial first 
few hours after an attack.
    The Act provides important new resources for States to 
improve the standard of care given to stroke patients in 
hospitals. The legislation will assist States in increasing the 
quality of stroke care available in rural hospitals through 
improvements in telemedicine and other communications 
technology.
    The Act directs the Secretary of Health and Human Services 
to conduct a national media campaign to inform the public about 
the symptoms of stroke, so that patients receive prompt medical 
care. The legislation also creates the Paul Coverdell Stroke 
Registry and Clearinghouse, which will collect data about the 
care of stroke patients and assist in the development of more 
effective treatments
    Finally, the STOP Stroke Act establishes continuing 
education programs for medical professionals in the use of new 
techniques for the prevention and treatment of stroke.
    Increased public information on the symptoms of stroke will 
help stroke patients and their families know to seek medical 
care promptly. Better training of emergency medical personnel 
will help ensure that stroke patients receive lifesaving 
medications when they are most effective. Improved systems of 
stroke care will help patients receive the quality treatment 
needed to save lives and reduce disability.
    The committee particularly wishes to stress that it views 
stroke as a national problem and intends for the initiatives in 
the Act to be national in scope. While particular areas of the 
nation may have differing needs with regard to stroke treatment 
or prevention, the committee intends for the Act to provide for 
improvements in stroke prevention, treatment and care 
throughout the nation.
    In addition, the committee wishes to clarify its views 
regarding the following sections of the Act.

Section 2801. Stroke prevention and education campaign

    Section 2801 instructs the Secretary of Health and Human 
Services to carry out a national education and information 
campaign to promote stroke prevention and increase the number 
of stroke patients who seek immediate treatment. The committee 
believes that broad consultation will be important as the 
Secretary carries out the duties described in this section. 
Thus, the list of entities with whom the Secretary may consult 
that is provided in subsection 9(a) of this Section is intended 
to be illustrative, rather than restrictive.
    The committee believes that evaluation of the success of 
the program authorized in this section is highly important. 
Thus, the committee expects that the Department of Health and 
Human Services will design and implement a rigorous program (as 
described in subsection (b)(7)) to evaluate the effectiveness 
of the program authorized under this section.

Section 2812. Paul Coverdell National Acute Stroke Registry and 
        Clearinghouse

    In approving subsection (b) of this section, the committee 
recognizes that a wealth of research has already been conducted 
regarding the activities described in paragraphs (1) through 
(5). It is not the committee's intention that the Secretary 
should duplicate existing data in these areas, but rather that 
the Secretary should conduct new research where necessary to 
supplement gaps in existing data. Where data exist, it is the 
committee's intention that the Secretary disseminate that data 
widely within the health care community so that stroke care can 
be made more effective. In doing so, it is the committee's 
intention that the Secretary ensure effective coordination 
among the agencies within the Department of Health and Human 
Services.

Section 2821. Establishment of program for improving stroke care

    This section authorizes the Secretary to award grants for 
the establishment of statewide stroke prevention, treatment and 
rehabilitation systems. Such systems should include prevention, 
pre-hospital and emergency care, hospital care, rehabilitation, 
reintegration into the community, surveillance and research.
    An important component of stroke care systems is a stroke 
care center or network of centers, where patients experiencing 
stroke can receive treatment of the highest caliber from health 
professionals with special training and experience in stroke 
care. Such centers use multidisciplinary teams of health care 
professionals to provide the most advanced approaches and 
techniques in prevention, treatment and rehabilitation of 
stroke. Such centers may also provide improved services for 
recognizing the symptoms of transient ischemic episodes, so 
that patients may receive care designed to prevent the onset of 
a major stroke. A further component of a stroke care center may 
be to provide high quality rehabilitative care, consistent with 
the standards established by the Secretary under section 2823.
    While the balance between providing care at stroke centers 
or at other hospital facilities must be struck by each State 
according to its own needs, the committee takes note of 
scientific findings showing that patients receiving stroke care 
at stroke care centers experience better outcomes than patients 
treated at facilities with less specialized expertise, 
facilities or training. The committee recognizes, however, that 
many patients experiencing stroke may not be treated at a 
stroke center. These health care facilities should be supported 
to ensure that they can provide an appropriate standard of care 
before possible transport to a center. Linkages between stroke 
care centers and other health care facilities will be crucial 
in ensuring that patients in rural or otherwise medically 
underserved communities have access to quality stroke care. 
Telemedicine and other communication technologies that allow 
for consultation between widely dispersed sites will likely 
play an essential role in these linkages. Telemedicine is a 
broad term describing the delivery of health care or sharing of 
medical knowledge over a distance using telecommunication 
systems. As such, it includes, but is not limited to, 
techniques such as telephone consultation, interactive 
televideo and digital clinical image transmission.

Sec. 2831. Medical professional development in advanced stroke 
        treatment and prevention

    Section 2831 authorizes the Secretary to make grants for 
the development and implementation of educational programs on 
the prevention and treatment of stroke. The language of the 
Section lists several health care specialties that may benefit 
from such educational programs. It is the committee's view that 
this list is illustrative rather than restrictive of the types 
of health care professionals who may participate in the 
activities authorized under this section. The exclusion of a 
particular health care specialty from the illustrative list 
provided in this section should not in any way be taken to 
imply that the specialty in question should be excluded from 
the activities authorized in the section.

                            V. Cost Estimate

               congressional budget office cost estimate

S. 1274--Stroke Treatment and Ongoing Prevention Act of 2001

    Summary: S. 1274 would amend the Public Health Service Act 
to authorize the Secretary of Health and Human Services (HHS) 
to engage in a number of new activities to inform the public 
about the symptons of stroke, and to improve systems of stroke 
care in order to give health professionals the equipment and 
training they need to treat this disorder.
    S. 1274 would authorize specific sums for fiscal years 2002 
through 2006 for grant programs to states to implement systems 
of stroke care. In addition, the bill would authorize $40 
million in fiscal year 2002 and such sums as may be necessary 
in 2003 through 2006 for a national stroke education and 
prevention campaign. Finally, S. 1274 would authorize such sums 
as may be necessary for the establishment of a national acute 
stroke registry and clearinghouse and for medical professional 
development in advanced stroke treatment and prevention in 
fiscal years 2002 through 2006.
    Assuming the appropriation of the necessary amounts, and 
including adjustments for anticipated inflation, CBO estimates 
that implementing S. 1274 would cost $47 million in 2002 and 
$594 million over the 2002-2006 period. Without inflation 
adjustments, the five-year total would be $584 million. 
Enacting S. 1274 would not affect direct spending or receipts; 
therefore, pay-as-you-go procedures would not apply.
    S. 1274 contains no intergovernmental or private-sector 
mandates as defined in the Unfunded Mandates Reform Act (UMRA). 
However the bill would provide funding to public and nonprofit 
private entities for programs related to stroke care.
    Estimated Cost to the Federal Government: The estimated 
budgetary impact of S. 1274 is shown in Table 1. For this 
estimate, CBO assumes that the bill will be enacted this fall 
and that the authorized and estimated amounts will be 
appropriated each year. Table 1 summarizes the budgetary impact 
of the legislation under two different sets of assumptions. The 
first set of assumptions provides the estimated levels of 
authorizations with annual adjustments for anticipated 
inflation. The second set does not include any such inflation 
adjustments. The costs of this legislation fall within budget 
function 550 (health).

                                 TABLE 1.--SUMMARY OF ESTIMATED COSTS OF S. 1274
----------------------------------------------------------------------------------------------------------------
                                                                        By fiscal year, in millions of dollars--

                                                                    --------------------------------------------
                                                                       2002     2003     2004     2005     2006
----------------------------------------------------------------------------------------------------------------
                                  CHANGES IN SPENDING SUBJECT TO APPROPRIATION

                                         With Adjustments for Inflation

Estimated authorization level......................................      112      138      140      166      192
Estimated outlays..................................................       47      104      124      147      171
                                        Without Adjustments for Inflation

Estimated authorization level......................................      112      137      137      162      187
Estimated outlays..................................................       47      103      123      144      167
----------------------------------------------------------------------------------------------------------------

    Basis of estimate: S. 1274 would direct the Secretary of 
HHS to engage in a number of activities related to the 
treatment and prevention of stroke. Table 2 details estimated 
authorization levels (adjusted for inflation) for the four 
programs authorized under the bill.
    The bill would direct the Secretary to conduct a national 
media campaign to promote stroke prevention and increase the 
number of stroke patients who seek immediate treatment. The 
bill would authorize $40 million in fiscal year 2002 and such 
sums as may be necessary in fiscal years 2003 through 2006 for 
such purposes. If the necessary sums are appropriated, CBO 
estimates that this provision would cost $172 million over the 
2002-2006 period.

        TABLE 2.--ESTIMATED AUTHORIZATION LEVELS FOR S. 1274 (ASSUMING ANNUAL ADJUSTMENTS FOR INFLATION)
----------------------------------------------------------------------------------------------------------------
                                                                        By fiscal year, in millions of dollars--

                                                                    --------------------------------------------
                                                                       2002     2003     2004     2005     2006
----------------------------------------------------------------------------------------------------------------
                                          ESTIMATED AUTHORIZATION LEVEL

Stroke Prevention and Education Campaign...........................       40       41       42       43       43
Paul Coverdell National Acute Stroke Registry and Clearinghouse....       12       12       13       13       13
Grants to States...................................................       50       75       75      100      125
Medical professional development in advanced stroke treatment and         10       10       10       11       11
 prevention........................................................
                                                                    --------------------------------------------
      Total........................................................      112      138      140      166      192
----------------------------------------------------------------------------------------------------------------

    The bill also would direct the Secretary to establish and 
maintain the Paul Coverdell National Acute Stroke Registry and 
Clearinghouse, which would collect data on the care of stroke 
patients and assist in the development of more effective 
treatments. The bill would authorize such sums as may be 
necessary for fiscal years 2002 through 2006 for this 
provision. If the necessary sums are appropriated, CBO 
estimates that establishment of the registry and clearinghouse 
would cost $52 million over the 2002-2006 period.
    The bill also would establish a grant program for states to 
implement systems of stroke care and train health care 
professionals in the prevention and treatment of stroke. The 
bill specifies the sums to be appropriated in each of fiscal 
years 2002 though 2006, for a five-year total of $425 million. 
CBO estimates that outlays from those grants would total $328 
million over the 2002-2006 period.
    The bill also would direct the Secretary to make grants to 
public and nonprofit private entities for the development and 
implementation of continuing education programs for medical 
professionals in the use of newly developed approaches for the 
prevention and treatment of stroke. The bill would authorize 
such sums as may be necessary for fiscal years 2002 through 
2006 for this provision. If the necessary sums are 
appropriated, CBO estimates that such programs would cost $43 
million over the 2002-2006 period.
    CBO estimates the necessary amounts for these programs 
would total $112 million in 2002 and $748 million over the 
2002-2006 period. Based on spending patterns for 
similarprograms, CBO estimates that outlays for these programs would 
total $47 million in 2002 and $594 million over the 2002-2006 period.
    Pay-as-you-go considerations: None.
    Estimated impact on State, local, and tribal governments: 
S. 1274 contains no intergovernmental mandates as defined in 
UMRA. The bill would authorize $425 million in State grants for 
stroke prevention, treatment, and rehabilitation systems over 
the 2002-2006 period. To be eligible for the grants, States 
would have to develop a statewide stroke care system that 
provides stroke treatment in accordance with federally 
established standards. After the first year of the grants, 
States would have to provide matching support for the program, 
either as in-kind contributions or as cash funding: one-quarter 
of the program's funding in years two and three; one-third in 
year four; and one-half in subsequent years. States also would 
be eligible for planning grants that would not have matching 
requirements.
    Estimated impact on the private sector: S. 1274 contains no 
private-sector mandates as defined in UMRA.
    Estimate prepared by: Federal costs: Niall Brennan; impact 
on State, local, and tribal governments: Leo Lex; impact on the 
private sector: Kate Bloniarz.
    Estimate approved by: Peter H. Fontaine, Deputy Assistant 
Director for Budget Analysis.

                    VI. Regulatory Impact Statement

    The committee has determined that there will be no 
increases in the regulatory burden of paperwork as a result of 
this bill.

           VII. Application of Law to the Legislative Branch

    Section 102(b)(3) of Public Law 104-1, the Congressional 
Accountability Act (CAA), requires a description of the 
application of the bill to the legislative branch. S. 2731 
amends the Public Health Service Act to enhance the treatment 
and prevention of stroke throughout the nation. This bill does 
not apply to the legislative branch.

                   VIII. Section-by-Section Analysis

Section 1. Short title

    This Act may be cited as the ``Stroke Treatment and Ongoing 
Prevention Act of 2001''.

Section 2. Findings and goal

    This section describes the findings of Congress that stroke 
has a significant impact on the health of thousands of 
Americans, and that stroke treatment is in need of improvement 
throughout the United States. The section also states that the 
goal of the Act is to improve the provision of stroke care in 
every State and territory and in the District of Columbia, and 
to increase public awareness about the prevention, detection, 
and treatment of stroke.

Section 3. Systems for stroke prevention, treatment, and rehabilitation

    The Act adds a new Title XXVIII to the Public Health 
Service Act. Within the new Title, the Act creates the 
following Sections.
    Section 2801 authorizes the Secretary to carry out a 
national education and information campaign to promote stroke 
prevention and increase the number of stroke patients who seek 
immediate treatment.
    Section 2811 requires the Secretary, with respect to stroke 
care, to (1) support and evaluate a grant program to enable a 
State to develop statewide stroke care systems; (2) foster the 
development of appropriate, modern systems of stroke care; and 
(3) provide to State and local agencies technical assistance.
    Sec 2812 requires the Secretary to maintain the Paul 
Coverdell National Acute Stroke Registry and Clearinghouse. The 
section further requires the Secretary to ensure the 
availability of published research on stroke or, where 
necessary, conduct research concerning stroke in areas 
specified in the Section
    Section 2821 requires the Secretary to award grants to 
States for the purpose of establishing statewide stroke 
prevention, treatment, and rehabilitation systems. The 
committee's views on this section are provided in more detail 
above. In general, the section requires that stroke care 
systems proposed or implemented with funds granted under this 
section be consistent with standards adopted by the recipient 
State and further requires that those State standards take into 
account national standards. In fiscal year 2004 and beyond, the 
State standards must take into account national standards for 
stroke care developed by the Secretary under section 2823.
    The section further authorizes the Secretary to award 
grants to assist States in formulating a plan to develop a 
statewide stroke care system or for other specified purposes. 
The section stipulates that a State may receive no more than 
one such planning grant. The section calls upon the Secretary 
to develop a model curriculum for training emergency medical 
services personnel, in the identification, assessment, 
stabilization, and prehospital treatment of stroke patients. 
This model curriculum may, at the discretion of the State, be 
adopted by a State for training emergency medical services 
personnel.
    Section 2822 requires provides that the Secretary may not 
award a grant to a State unless the State agrees to make 
available for each year during which the State receives funding 
under such section, non-Federal contributions (in cash or in 
kind) toward such costs in an amount equal to (A) for the 
second and third fiscal years of such payments to the State, 
not less than $1 for each $3 of Federal funds provided; (B) for 
the fourth fiscal year of such payments to the State, not less 
than $1 for each $2 of Federal funds; and (C) for any 
subsequent fiscal year of such payments to the State, not less 
than $1 for each $1 of Federal funds provided in such payments 
for such fiscal year.
    Section 2823 provides for an application process for States 
wishing to receive grants authorized by section 2821. The 
section further specifies that, to be eligible to receive 
grants under section 2821, a State must adopt standards of care 
for stroke patients in the acute, post-acute, and 
rehabilitation phases of stroke. These standards must take into 
account national standards, as determined by the Secretary.
    The section further requires the Secretary to develop 
standards of care for stroke patients in all phases of stroke 
that may be adopted for guidance by the State and a model plan 
for the establishment of statewide stroke care systems. In 
fiscal year 2004 and beyond, the State standards must take into 
account these national standards for stroke care developed by 
the Secretary.
    Section 2825 prohibits the Secretary from using grants 
authorized under Section 2821 of the Act to (1) to make cash 
payments to intended recipients of services provided pursuant 
to such section; (2) to satisfy any requirement for the 
expenditure of non-Federal funds as a condition for the receipt 
of Federal funds; or (3) to provide financial assistance to any 
entity other than a public or nonprofit private entity. The 
prohibition may be waived if the Secretary finds that the 
purpose described in section 2821(b) cannot otherwise be 
carried out.
    Section 2826 allows the Secretary to seek repayment of 
funds granted under section 2821 if the recipient State expends 
those funds in a manner inconsistent with the agreements made 
by that State as a condition of receipt of funds.
    Section 2827 directs the Secretary, in awarding grants 
under section 2821, to give special consideration to any State 
(1) in geographic areas in which there is a substantial rate of 
disability resulting from stroke or a substantial incidence of 
stroke; or (2) that demonstrates a significant need for 
assistance in establishing a comprehensive stroke care system. 
States with a significant need for assistance may be different 
than those in which there is a substantial rate of disability 
resulting from stroke or a substantial incidence of stroke, so 
that grants under section 2821 may be awarded in geographic 
areas other than those experiencing the highest rate of stroke.
    Section 2828 requires the Secretary to provide to the State 
(or to any public or nonprofit entity designated by the State) 
any reasonable technical assistance with respect to the 
planning, development, and operation of any program carried out 
pursuant to section 2821. The Secretary may, upon the request 
of the State, provide supplies and services in lieu of cash 
payments.
    Section 2829 requires the Secretary report to the 
appropriate committees of Congress on the activities of the 
States carried out pursuant to section 2821.
    Section 2829 authorizes there to be appropriated to carry 
out this part, $50 million for fiscal year 2002, $75 million 
for fiscal year 2003, $75 million for fiscal year 2004, $100 
million for fiscal year 2005, and $125 million for fiscal year 
2006.
    Section 2831 allows the Secretary to make grants to public 
and non-profit private entities for the development and 
implementation of education programs for appropriate health 
professionals and students in the use of newly developed 
diagnostic approaches, technologies, and therapies for the 
prevention and treatment of stroke.
    Section 2841 defines the following terms in the following 
manner. (1) The term ``State'' means each of the several 
States, the District of Columbia, the Commonwealth of Puerto 
Rico, the Indian tribes, the Virgin Islands, Guam, American 
Samoa, and the Commonwealth of the Northern Mariana Islands. 
(2) The term ``stroke care system'' means a statewide system to 
provide for the diagnosis, prehospital care, hospital 
definitive care, and rehabilitation of stroke patients. (3) The 
term ``stroke'' means a ``brain attack'' in which blood flow to 
the brain is interrupted or in which a blood vessel or aneurysm 
in the brain breaks or ruptures.
    Section 2842 requires the Secretary to consult widely in 
implementing the provisions of the Act.

                   IX. ADDITIONAL VIEWS OF MR. FRIST

    As the lead Republican cosponsor of the S. 1274, the Stroke 
Treatment and Ongoing Prevention Act of 2001, I am concerned 
about some of the wording of the current report. Although I 
fully support the overall goal of this Act to improve the 
provision of stroke care across the nation and to increase 
public awareness about the prevention, detection, and treatment 
of stroke, I believe that the grants established in section 
2831 should target those areas defined as having special 
consideration (section 2827). All of the other programs 
outlined within the Act--the medical professional development 
grants, the stroke prevention and education campaign, and the 
Paul Coverdell National Acute Stroke Registry and 
Clearinghouse--will assist with the improvement of stroke care 
nationwide.
    The areas considered to have special consideration under 
the Act are those geographic areas in which there is a 
substantial incidence of stroke or a substantial rate of 
disability resulting from stroke or areas that demonstrate a 
significant need for assistance in developing a comprehensive 
stroke care system. As we are all aware, twelve contiguous 
states--Alabama, Arkansas, Florida, Georgia, Indiana, Kentucky, 
Louisiana, Mississippi, North Carolina, South Carolina, 
Tennessee, Virginia, and Washington, DC--form the ``Stroke 
Belt'', an area with stroke death rates that are consistently 
more than ten percent higher than the rest of the country. 
Those areas with the greatest need should be our focus as we 
work to increase stroke prevention and treatment programs 
nationwide. Without this targeted intervention, we will not be 
able to assist those areas in greatest need.

                                                        Bill Frist.

                       X. Changes in Existing Law

    In compliance with rule XXVI paragraph 12 of the Standing 
Rules of the Senate, the following provides a print of the 
statute or the part or section thereof to be amended or 
replaced (existing law proposed to be omitted is enclosed in 
black brackets, new matter is printed in italic, existing law 
in which no change is proposed is shown in roman):

PUBLIC HEALTH SERVICE ACT

           *       *       *       *       *       *       *

    TITLE XXVII--REQUIREMENTS RELATING TO HEALTH INSURANCE COVERAGE

                      PART A--GROUP MARKET REFORMS

     Subpart 1--Portability, Access, and Renewability Requirements

SEC. 2701. [300GG] INCREASED PORTABILITY THROUGH LIMITATION ON 
                    PREEXISTING CONDITION EXCLUSIONS.

           *       *       *       *       *       *       *

      TITLE XXVIII--SYSTEMS FOR STROKE PREVENTION, TREATMENT, AND 
                             REHABILITATION

            PART A--STROKE PREVENTION AND EDUCATION CAMPAIGN

SEC. 2801. STROKE PREVENTION AND EDUCATION CAMPAIGN.

    (a) In General.--The Secretary shall carry out a national 
education and information campaign to promote stroke prevention 
and increase the number of stroke patients who seek immediate 
treatment. In implementing such education and information 
campaign, the Secretary shall avoid duplicating existing stroke 
education efforts by other Federal Government agencies and may 
consult with national and local associations that are dedicated 
to increasing the public awareness of stroke, consumers of 
stroke awareness products, and providers of stroke care.
    (b) Use of Funds.--The Secretary may use amounts 
appropriated to carry out the campaign described in subsection 
(a)--
          (1) to make public service announcements about the 
        warning signs of stroke and the importance of treating 
        stroke as a medical emergency;
          (2) to provide education regarding ways to prevent 
        stroke and the effectiveness of stroke treatment;
          (3) to purchase media time and space;
          (4) to pay for out-of-pocket advertising production 
        costs;
          (5) to test and evaluate advertising and educational 
        materials for effectiveness, especially among groups at 
        high risk for stroke, including women, older adults, 
        and African-Americans;
          (6) to develop alternative campaigns that are 
        targeted to unique communities, including rural and 
        urban communities, and communities in the ``Stroke 
        Belt'';
          (7) to measure public awareness prior to the start of 
        the campaign on a national level and in targeted 
        communities to provide baseline data that will be used 
        to evaluate the effectiveness of the public awareness 
        efforts; and
          (8) to carry out other activities that the Secretary 
        determines will promote prevention practices among the 
        general public and increase the number of stroke 
        patients who seek immediate care.
    (c) Authorization of Appropriations.--There is authorized 
to be appropriated to carry out subsection (b), $40,000,000 for 
fiscal year 2002, and such sums as may be necessary for each of 
fiscal years 2003 through 2006.

        PART B--GENERAL AUTHORITIES AND DUTIES OF THE SECRETARY

SEC. 2811. ESTABLISHMENT.

    (a) In General.--The Secretary shall, with respect to 
stroke care--
          (1) make available, support, and evaluate a grant 
        program to enable a State to develop statewide stroke 
        care systems;
          (2) foster the development of appropriate, modern 
        systems of stroke care through the sharing of 
        information among agencies and individuals involved in 
        the study and provision of such care; and
          (3) provide to State and local agencies technical 
        assistance.
    (b) Grants, Cooperative Agreements, and Contracts.--The 
Secretary may make grants, and enter into cooperative 
agreements and contracts, for the purpose of carrying out 
subsection (a).

SEC. 2812. PAUL COVERDELL NATIONAL ACUTE STROKE REGISTRY AND 
                    CLEARINGHOUSE.

    (a) In General.--The Secretary shall maintain the Paul 
Coverdell National Acute Stroke Registry and Clearinghouse by--
          (1) continuing to develop and collect specific data 
        points as well as appropriate benchmarks for analyzing 
        care of acute stroke patients;
          (2) continuing to design and pilot test prototypes 
        that will measure the delivery of care to patients with 
        acute stroke in order to provide real-time data and 
        analysis to reduce death and disability from stroke and 
        improve the quality of life for acute stroke survivors;
          (3) fostering the development of effective, modern 
        stroke care systems (including the development of 
        policies related to emergency services systems) through 
        the sharing of information among agencies and 
        individuals involved in planning, furnishing, and 
        studying such systems;
          (4) collecting, compiling, and disseminating 
        information on the achievements of, and problems 
        experienced by, State and local agencies and private 
        entities in developing and implementing stroke care 
        systems and, in carrying out this paragraph, giving 
        special consideration to the unique needs of 
ruralfacilities and those facilities with inadequate resources for 
providing quality prevention, acute treatment, post-acute treatment, 
and rehabilitation services for stroke patients;
          (5) providing technical assistance relating to stroke 
        care systems to State and local agencies; and
          (6) carrying out any other activities the Secretary 
        determines to be useful to fulfill the purposes of the 
        Paul Coverdell National Acute Stroke Registry and 
        Clearinghouse.
  (b) Research on Stroke.--The Secretary shall, not earlier 
than 1 year after the date of enactment of the Stroke Treatment 
and Ongoing Prevention Act of 2001, ensure the availability of 
published research on stroke or, where necessary, conduct 
research concerning--
          (1) best practices in the prevention, diagnosis, 
        treatment, and rehabilitation of stroke;
          (2) barriers to access to currently approved stroke 
        prevention, treatment, and rehabilitation services;
          (3) barriers to access to newly developed diagnostic 
        approaches, technologies, and therapies for stroke 
        patients;
          (4) the effectiveness of existing public awareness 
        campaigns regarding stroke; and
          (5) disparities in the prevention, diagnosis, 
        treatment, and rehabilitation of stroke among different 
        populations.
  (c) Certain Research Activities.--In carrying out the 
activities described in subsection (b), the Secretary may 
conduct--
          (1) studies with respect to all phases of stroke 
        care, including prehospital, acute, post-acute and 
        rehabilitation care;
          (2) studies with respect to patient access to 
        currently approved and newly developed stroke 
        prevention and treatment services, including a review 
        of the effect of coverage, coding, and reimbursement 
        practices on access;
          (3) studies with respect to the effect of existing 
        public awareness campaigns on stroke; and
          (4) any other studies that the Secretary determines 
        are necessary or useful to conduct a thorough and 
        effective research program regarding stroke.
  (d) Mechanisms of Support.--In carrying out the activities 
described in subsection (b), the Secretary may make grants to 
public and private non-profit entities.
  (e) Coordination of Effort.--The Secretary shall ensure the 
adequate coordination of the activities carried out under this 
section.
  (f) Authorization of Appropriations.--There is authorized to 
be appropriated such sums as may be necessary for each of 
fiscal years 2002 through 2006 to carry out this section.

        PART C--GRANTS WITH RESPECT TO STATE STROKE CARE SYSTEMS

SEC. 2821. ESTABLISHMENT OF PROGRAM FOR IMPROVING STROKE CARE.

  (a) Grants.--The Secretary shall award grants to States for 
the purpose of establishing statewide stroke prevention, 
treatment, and rehabilitation systems.
  (b) Use of Funds.--
          (1) In general.--The Secretary shall make available 
        grants under subsection (a) for the development and 
        implementation of statewide stroke care systems that 
        provide stroke prevention services and quality acute, 
        post-acute, and rehabilitation care for stroke patients 
        through the development of sufficient resources and 
        infrastructure, including personnel with appropriate 
        training, acute stroke teams, equipment, and procedures 
        necessary to prevent stroke and to treat and 
        rehabilitate stroke patients. In developing and 
        implementing statewide stroke care systems, each State 
        that is awarded such a grant shall--
                  (A) oversee the design and implementation of 
                the statewide stroke care system;
                  (B) enhance, develop, and implement model 
                curricula for training emergency medical 
                services personnel, including dispatchers, 
                first responders, emergency medical 
                technicians, and paramedics in the 
                identification, assessment, stabilization, and 
                prehospital treatment of stroke patients;
                  (C) ensure that stroke patients in the State 
                have access to quality care that is consistent 
                with the standards established by the Secretary 
                under section 2823(c);
                  (D) establish a support network to provide 
                assistance to facilities with smaller 
                populations of stroke patients or less advanced 
                on-site stroke treatment resources; and
                  (E) carry out any other activities that the 
                State-designated agency determines are useful 
                or necessary for the implementation of the 
                statewide stroke care system.
          (2) Access to care.--A State may meet the requirement 
        of paragraph (1)(C) by--
                  (A) identifying acute stroke centers with 
                personnel, equipment, and procedures adequateto 
provide quality treatment to patients in the acute phase of stroke 
consistent with the standards established by the Secretary under 
section 2823(c);
                  (B) identifying comprehensive stroke centers 
                with advanced personnel, equipment, and 
                procedures to prevent stroke and to treat 
                stroke patients in the acute and post-acute 
                phases of stroke and to provide assistance to 
                area facilities with less advanced stroke 
                treatment resources;
                  (C) identifying stroke rehabilitation centers 
                with personnel, equipment, and procedures to 
                provide quality rehabilitative care to stroke 
                patients consistent with the standards 
                established by the Secretary under section 
                2823(c); or
                  (D) carrying out any other activities that 
                the designated State agency determines are 
                necessary or useful.
          (3) Support network.--A facility that provides care 
        to stroke patients and that receives support through a 
        support network established under paragraph (1)(D) 
        shall meet the standards and requirements outlined by 
        the State application under paragraph (2) of section 
        2823(b). The support network may include--
                  (A) the use of telehealth technology 
                connecting facilities described in such 
                paragraph to more advanced stroke care 
                facilities;
                  (B) the provision of neuroimaging, lab, and 
                any other equipment necessary to facilitate the 
                establishment of a telehealth network;
                  (C) the use of phone consultation, where 
                useful;
                  (D) the use of referral links when a patient 
                needs more advanced care than is available at 
                the facility providing initial care; and
                  (E) any other assistance determined 
                appropriate by the State.
    (c) Planning Grants.--
          (1) In general.--The Secretary may award a grant to a 
        State to assist such State in formulating a plan to 
        develop a statewide stroke care system or in otherwise 
        meeting the conditions described in subsection (b) with 
        respect to a grant under this section.
          (2) Submission to secretary.--The governor of a State 
        that receives a grant under paragraph (1) shall submit 
        to the Secretary a copy of the plan developed using the 
        amounts provided under such grant. Such plan shall be 
        submitted to the Secretary as soon as practicable after 
        the plan has been developed.
          (3) Single grant limitation.--To be eligible to 
        receive a grant under paragraph (1), a State shall not 
        have previously received a grant under such paragraph.
    (d) Model Curriculum.--
          (1) Development.--The Secretary shall develop a model 
        curriculum for training emergency medical services 
        personnel, including dispatchers, first responders, 
        emergency medical technicians, and paramedics in the 
        identification, assessment, stabilization, and 
        prehospital treatment of stroke patients.
          (2) Implementation.--The model curriculum developed 
        under paragraph (1) may be implemented by a State to 
        fulfill the requirements of subsection (b)(1)(B).

SEC. 2822. REQUIREMENT OF MATCHING FUNDS FOR FISCAL YEARS SUBSEQUENT TO 
                    FIRST FISCAL YEAR OF PAYMENTS.

    (a) Non-Federal Contributions.--
          (1) In general.--The Secretary may not award grants 
        under section 2821(a) unless the State involved agrees, 
        with respect to the costs described in paragraph (2), 
        to make available for each year during which the State 
        receives funding under such section, non-Federal 
        contributions (in cash or in kind under subsection 
        (b)(1)) toward such costs in an amount equal to--
                  (A) for the second and third fiscal years of 
                such payments to the State, not less than $1 
                for each $3 of Federal funds provided in such 
                payments for each such fiscal year;
                  (B) for the fourth fiscal year of such 
                payments to the State, not less than $1 for 
                each $2 of Federal funds provided in such 
                payments for such fiscal year; and
                  (C) for any subsequent fiscal year of such 
                payments to the State, not less than $1 for 
                each $1 of Federal funds provided in such 
                payments for such fiscal year.
          (2) Program costs.--The costs referred to in 
        paragraph (1) are the costs to be incurred by the State 
        in carrying out the purpose described in section 
        2821(b).
          (3) Initial year of payments.--The Secretary may not 
        require a State to make non-Federal contributions as a 
        condition of receiving payments under section 2821(a) 
        for the first fiscal year of such payments to the 
        State.
  (b) Determination of Amount of Non-Federal Contributions.--
With respect to compliance under subsection (a) as a condition 
of receiving payments under section 2811(a)--
          (1) a State may make the non-Federal contributions 
        required in such subsection in cash or in kind, fairly 
        evaluated, including plant, equipment, or services; and
          (2) the Secretary may not, in making a determination 
        of the amount of non-Federal contributions, include 
        amounts provided by the Federal Government or services 
        assisted or subsidized by a significant extent by the 
        Federal Government.

SEC. 2823. APPLICATION REQUIREMENTS.

  (a) Requirement of Application.--The Secretary may not award 
a grant to a State under section 2821(b) unless an application 
for the grant is submitted by the State to the Secretary.
  (b) Application Process and Guidelines.--The Secretary shall 
provide for an application process and develop guidelines to 
assist States in submitting an application under this section 
that--
          (1) outlines the stroke care system and explains how 
        such system will ensure that stroke patients throughout 
        the State have access to quality care in all phases of 
        stroke, consistent with the standards established by 
        the Secretary under subsection (c);
          (2) contains standards and requirements for 
        facilities in the State that provide basic preventive 
        services, advanced preventive services, acute stroke 
        care, post-acute stroke care, and rehabilitation 
        services to stroke patients; and
          (3) provides for the establishment of a central data 
        reporting and analysis system and for the collection of 
        data from each facility that will provide direct care 
        to stroke patients in the State--
                  (A) to identify the number of stroke patients 
                treated in the State;
                  (B) to monitor patient care in the State for 
                stroke patients at all phases of stroke for the 
                purpose of evaluating the diagnosis, treatment, 
                and treatment outcome of such stroke patients;
                  (C) to identify the total amount of 
                uncompensated and under-compensated stroke care 
                expenditures for each fiscal year by each 
                stroke care facility in the State;
                  (D) to identify the number of acute stroke 
                patients who receive advanced drug therapy;
                  (E) to identify patients transferred within 
                the statewide stroke care system, including 
                reasons for such transfer; and
                  (F) to communicate to the greatest extent 
                practicable with the Paul Coverdell National 
                Acute Stroke Registry and Clearinghouse.
  (c) Certain Standards With Respect to Statewide Stroke Care 
System.--
          (1) In general.--The Secretary may not award a grant 
        to a State under section 2821(a) for a fiscal year 
        unless the State agrees that, in carrying out 
        paragraphs (2) and (3), the State will--
                  (A) adopt standards of care for stroke 
                patients in the acute, post-acute, and 
                rehabilitation phases of stroke; and
                  (B) in adopting the standards described in 
                subparagraph (A)--
                          (i) consult with medical, surgical, 
                        and nursing specialty groups, hospital 
                        associations, voluntary health 
                        organizations, State offices of rural 
                        health, emergency medical services 
                        State and local directors, experts in 
                        the use of telecommunications 
                        technology to provide stroke care, 
                        concerned advocates, and other 
                        interested parties;
                          (ii) conduct hearings on the proposed 
                        standards providing adequate notice to 
                        the public concerning such hearing; and
                          (iii) beginning in fiscal year 2004, 
                        take into account the national 
                        standards of care.
          (2) Quality of stroke care.--The highest quality of 
        stroke care shall be the primary goal of the State 
        standards adopted under this subsection.
          (3) Approval by secretary.--The Secretary may not 
        make payments to a State under section 2821(a) if the 
        Secretary determines that--
                  (A) the State has not taken into account 
                national standards in adopting standards under 
                this subsection;
                  (B) in the case of payments for fiscal year 
                2004 and subsequent fiscal years, the State has 
                not, in adopting such standards, taken into 
                account the national standards of care and the 
                model system plan developed under subsection 
                (c); or
                  (C) in the case of payments for fiscal year 
                2004 and subsequent fiscal years, the State has 
                not provided to the Secretary the information 
                received by the State pursuant to paragraphs 
                (9) and (10) of subsection (a).
    (d) Model Stroke Care System Plan.--Not later than 1 year 
after the date of enactment of the Stroke Treatment and Ongoing 
Prevention Act of 2001, the Secretary shall develop standards 
of care for stroke patients in all phases of stroke that may be 
adopted for guidance by the State and a model plan for the 
establishment of statewide stroke care systems. Such plan 
shall--
          (1) take into account national standards;
          (2) take into account existing State systems and 
        plans; and
          (3) take into account the unique needs of urban and 
        rural communities, different regions of the Nation, and 
        States with varying degrees of established stroke care 
        infrastructures;

SEC. 2824. REQUIREMENT OF SUBMISSION OF APPLICATION CONTAINING CERTAIN 
                    AGREEMENTS AND ASSURANCES.

    The Secretary may not award grants under section 2821(a) to 
a State for a fiscal year unless--
          (1) the State submits an application for the payments 
        containing agreements in accordance with this part;
          (2) the agreements are made through certification 
        from the chief executive officer of the State;
          (3) with respect to such agreements, the application 
        provides assurances of compliance satisfactory to the 
        Secretary;
          (4) the application contains the plan provisions and 
        the information required to be submitted to the 
        Secretary pursuant to section 2823; and
          (5) the application otherwise 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 part.

SEC. 2825. RESTRICTIONS ON USE OF PAYMENTS.

    (a) In General.--The Secretary may not, except as provided 
in subsection (b), make payments to a State under section 
2821(a) for a fiscal year unless the State involved agrees that 
the payments will not be expended--
          (1) to make cash payments to intended recipients of 
        services provided pursuant to such section;
          (2) to satisfy any requirement for the expenditure of 
        non-Federal funds as a condition for the receipt of 
        Federal funds; or
          (3) to provide financial assistance to any entity 
        other than a public or nonprofit private entity.
    (b) Exception.--If the Secretary finds that the purpose 
described in section 2821(b) cannot otherwise be carried out, 
the Secretary may, with respect to an otherwise qualified 
State, waive the restriction established in subsection (a)(3).

SEC. 2826. FAILURE TO COMPLY WITH AGREEMENTS.

    (a) Repayment of Payments.--
          (1) Requirement.--The Secretary may, in accordance 
        with subsection (b), require a State to repay any 
        payments received by the State pursuant to section 
        2821(a) that the Secretary determines were not expended 
        by the State in accordance with the agreements required 
        to be made by the State as a condition of the receipt 
        of payments under such section.
          (2) Offset of amounts.--If a State fails to make a 
        repayment required in paragraph (1), the Secretary may 
        offset the amount of the repayment against any amount 
        due to be paid to the State under section 2821(a).
    (b) Opportunity for a Hearing.--Before requiring repayment 
of payments under subsection (a)(1), the Secretary shall 
provide to the State an opportunity for a hearing.

SEC. 2827. SPECIAL CONSIDERATION.

    In awarding grants under this part, the Secretary shall 
give special consideration to any State that has submitted an 
application for carrying out programs under such a grant--
          (1) in geographic areas in which there is--
                  (A) a substantial rate of disability 
                resulting from stroke; or
                  (B) a substantial incidence of stroke; or
          (2) that demonstrates a significant need for 
        assistance in establishing a comprehensive stroke care 
        system.

SEC. 2828. TECHNICAL ASSISTANCE AND PROVISION BY SECRETARY OF SUPPLIES 
                    AND SERVICES IN LIEU OF GRANT FUNDS.

    (a) Technical Assistance.--The Secretary shall, without 
charge to a State receiving payments under section 2821(a), 
provide to the State (or to any public or nonprofit entity 
designated by the State) technical assistancewith respect to 
the planning, development, and operation of any program carried out 
pursuant to section 2821(b). The Secretary may provide such technical 
assistance directly, through contract, or through grants.
    (b) Provisions by Secretary of Supplies and Services in 
Lieu of Grant Funds.--
          (1) In General.--Upon the request of a State 
        receiving payments under section 2821(a), the Secretary 
        may, subject to paragraph (2), provide supplies, 
        equipment, and services for the purpose of aiding the 
        State in carrying out section 2821(b) and, for such 
        purpose, may detail to the State any officer or 
        employee of the Department of Health and Human 
        Services.
          (2) Reduction in Payments.--With respect to a request 
        described in paragraph (1), the Secretary shall reduce 
        the amount of payments to the State under section 
        2821(a) by an amount equal to the costs of detailing 
        personnel and the fair market value of any supplies, 
        equipment, or services provided by the Secretary. The 
        Secretary shall, for the payment of expenses incurred 
        in complying with such request, expend the amounts 
        withheld.

SEC. 2829. REPORT BY SECRETARY.

    Not later than 3 years after the date of enactment of the 
Stroke Treatment and Ongoing Prevention Act of 2001, the 
Secretary shall report to the appropriate committees of 
Congress on the activities of the States carried out pursuant 
to section 2821. Such report shall include an assessment of the 
extent to which Federal and State efforts to develop stroke 
care systems, including the establishment of support networks 
and the identification of acute, comprehensive, and 
rehabilitation stroke centers, where applicable, have increased 
the number of stroke patients who have received acute stroke 
consultation or therapy within the appropriate timeframe and 
reduced the level of disability due to stroke. Such report may 
include any recommendations of the Secretary for appropriate 
administrative and legislative initiatives with respect to 
stroke care.

SEC. 2830. FUNDING.

    (a) Authorization of Appropriations.--There is authorized 
to be appropriated to carry out this part, $50,000,000 for 
fiscal year 2002, $75,000,000 for fiscal year 2003, $75,000,000 
for fiscal year 2004, $100,000,000 for fiscal year 2005, and 
$125,000,000 for fiscal year 2006.
    (b) Limitation on Administrative Expenses.--A State may use 
not to exceed 10 percent of amounts received under a grant 
awarded under section 2821(a) for administrative expenses.

                     PART D--MISCELLANEOUS PROGRAMS

SEC. 2831. MEDICAL PROFESSIONAL DEVELOPMENT IN ADVANCED STROKE 
                    TREATMENT AND PREVENTION.

    (a) In General.--The Secretary may make grants to public 
and non-profit private entities for the development and 
implementation of education programs for appropriate medical 
personnel including medical students, emergency physicians, 
primary care providers, neurologists, neurosurgeons, and 
physical therapists in the use of newly developed diagnostic 
approaches, technologies, and therapies for the prevention and 
treatment of stroke.
    (b) Distribution of Grants.--In awarding grants under 
subsection (a), the Secretary shall ensure that such grants are 
equitably distributed among the geographical regions of the 
United States and between urban and rural populations.
    (c) Application.--A public or non-profit private entity 
desiring a grant under subsection (a) 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 a plan for the rigorous evaluation of activities 
carried out with amounts received under such a grant.
    (d) Use of Funds.--A public or non-profit private entity 
shall use amounts received under a grant under this section for 
the continuing education of appropriate medical personnel in 
the use of newly developed diagnostic approaches, technologies, 
and therapies for the prevention and treatment of stroke.
    (e) Authorization of Appropriations.--There is authorized 
to be appropriated to carry out this section, such sums as may 
be necessary for each of fiscal years 2002 through 2006.

       PART E--GENERAL PROVISIONS REGARDING PARTS A, B, C, and D

SEC. 2841. DEFINITIONS.

In this title:
          (1) State.--The term ``State'' means each of the 
        several States, the District of Columbia, the 
        Commonwealth of Puerto Rico, the Indian tribes, the 
        Virgin Islands, Guam, American Samoa, and the 
        Commonwealth of the Northern Mariana Islands.
          (2) Stroke Care System.--The term ``stroke care 
        system'' means a statewide system to provide for the 
        diagnosis, prehospital care, hospital definitive care, 
        and rehabilitation of stroke patients.
          (3) Stroke.--The term ``stroke'' means a ``brain 
        attack'' in which blood flow to the brain is 
        interrupted or in which a blood vessel or aneurysm in 
        the brain breaks or ruptures.

SEC. 2842. CONSULTATIONS.

    In carrying out this title, the Secretary shall consult 
with medical, surgical, rehabilitation, and nursing specialty 
groups, hospital associations, voluntary health organizations, 
emergency medical services, State directors, and associations, 
experts in the use of telecommunication technology to provide 
stroke care, national disability and consumer organizations 
representing individuals with disabilities and chronic 
illnesses, concerned advocates, and other interested parties.

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