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[House Report 106-851]
[From the U.S. Government Publishing Office]

106th Congress                                                   Report
                        HOUSE OF REPRESENTATIVES
 2d Session                                                     106-851

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

 
           FEDERAL PRISONER HEALTH CARE COPAYMENT ACT OF 2000

                                _______
                                

 September 14, 2000.--Committed to the Committee of the Whole House on 
            the State of the Union and ordered to be printed

                                _______
                                

   Mr. McCollum, from the Committee on the Judiciary, submitted the 
                               following

                              R E P O R T

                             together with

                            DISSENTING VIEWS

                        [To accompany H.R. 1349]

      [Including cost estimate of the Congressional Budget Office]

    The Committee on the Judiciary, to whom was referred the 
bill (H.R. 1349) to amend title 18, United States Code, to 
combat the overutilization of prison health care services and 
control rising prisoner health care costs, having considered 
the same, reports favorably thereon with an amendment and 
recommends that the bill as amended do pass.

                           TABLE OF CONTENTS

                                                                  

                                                                 Page
The Amendment..............................................           2
Purpose and Summary........................................           4
Background and Need for the Legislation....................           5
Hearings...................................................           6
Committee Consideration....................................           6
Vote of the Committee......................................           6
Committee Oversight Findings...............................           8
Committee on Government Reform Findings....................           8
New Budget Authority and Tax Expenditures..................           9
Congressional Budget Office Cost Estimate..................           9
Constitutional Authority Statement.........................          12
Section-by-Section Analysis and Discussion.................          12
Agency Views...............................................          15
Changes in Existing Law Made by the Bill, as Reported......          15
Dissenting Views...........................................          21
Additional Dissenting Views................................          23

    The amendment is as follows:
    Strike all after the enacting clause and insert the 
following:

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Federal Prisoner Health Care 
Copayment Act of 2000''.

SEC. 2. HEALTH CARE FEES FOR PRISONERS IN FEDERAL INSTITUTIONS.

    (a) In General.--Chapter 303 of title 18, United States Code, is 
amended by adding at the end the following:

``Sec. 4048. Fees for health care services for prisoners

    ``(a) Definitions.--In this section--
            ``(1) the term `account' means the trust fund account (or 
        institutional equivalent) of a prisoner;
            ``(2) the term `Director' means the Director of the Bureau 
        of Prisons;
            ``(3) the term `health care provider' means any person who 
        is--
                    ``(A) authorized by the Director to provide health 
                care services; and
                    ``(B) operating within the scope of such 
                authorization;
            ``(4) the term `health care visit'--
                    ``(A) means a visit, as determined by the Director, 
                by a prisoner to an institutional or noninstitutional 
                health care provider; and
                    ``(B) does not include a visit initiated by a 
                prisoner--
                            ``(i) pursuant to a staff referral; or
                            ``(ii) to obtain staff-approved follow-up 
                        treatment for a chronic condition; and
            ``(5) the term `prisoner' means--
                    ``(A) any individual who is incarcerated in an 
                institution under the jurisdiction of the Bureau of 
                Prisons; or
                    ``(B) any other individual, as designated by the 
                Director, who has been charged with or convicted of an 
                offense against the United States.
    ``(b) Fees for Health Care Services.--
            ``(1) In general.--The Director, in accordance with this 
        section and with such regulations as the Director shall 
        promulgate to carry out this section, may assess and collect a 
        fee for health care services provided in connection with each 
        health care visit requested by a prisoner.
            ``(2) Exclusion.--The Director may not assess or collect a 
        fee under this section for preventative health care services, 
        emergency services, prenatal care, diagnosis or treatment of 
        chronic infectious diseases, mental health care, or substance 
        abuse treatment, as determined by the Director.
    ``(c) Persons Subject to Fee.--Each fee assessed under this section 
shall be collected by the Director from the account of--
            ``(1) the prisoner receiving health care services in 
        connection with a health care visit described in subsection 
        (b)(1); or
            ``(2) in the case of health care services provided in 
        connection with a health care visit described in subsection 
        (b)(1) that results from an injury inflicted on a prisoner by 
        another prisoner, the prisoner who inflicted the injury, as 
        determined by the Director.
    ``(d) Amount of Fee.--Any fee assessed and collected under this 
section shall be in an amount of not less than $1.
    ``(e) No Consent Required.--Notwithstanding any other provision of 
law, the consent of a prisoner shall not be required for the collection 
of a fee from the account of the prisoner under this section. However, 
each such prisoner shall be given a reasonable opportunity to dispute 
the amount of the fee or whether the prisoner qualifies under an 
exclusion under this section.
    ``(f) No Refusal of Treatment For Financial Reasons.--Nothing in 
this section may be construed to permit any refusal of treatment to a 
prisoner on the basis that--
            ``(1) the account of the prisoner is insolvent; or
            ``(2) the prisoner is otherwise unable to pay a fee 
        assessed under this section.
    ``(g) Use of Amounts.--
            ``(1) Restitution of specific victims.--Amounts collected 
        by the Director under this section from a prisoner subject to 
        an order of restitution issued pursuant to section 3663 or 
        3663A shall be paid to victims in accordance with the order of 
        restitution.
            ``(2) Allocation of other amounts.--Of amounts collected by 
        the Director under this section from prisoners not subject to 
        an order of restitution issued pursuant to section 3663 or 
        3663A--
                    ``(A) 75 percent shall be deposited in the Crime 
                Victims Fund established under section 1402 of the 
                Victims of Crime Act of 1984 (42 U.S.C. 10601); and
                    ``(B) 25 percent shall be available to the Attorney 
                General for administrative expenses incurred in 
                carrying out this section.
    ``(h) Notice to Prisoners of Law.--Each person who is or becomes a 
prisoner shall be provided with written and oral notices of the 
provisions of this section and the applicability of this section to the 
prisoner. Notwithstanding any other provision of this section, a fee 
under this section may not be assessed against, or collected from, such 
person--
            ``(1) until the expiration of the 30-day period beginning 
        on the date on which each prisoner in the prison system is 
        provided with such notices; and
            ``(2) for services provided before the expiration of such 
        period.
    ``(i) Notice to Prisoners of Regulations.--The regulations 
promulgated by the Director under subsection (b)(1), and any amendments 
to those regulations, shall not take effect until the expiration of the 
30-day period beginning on the date on which each prisoner in the 
prison system is provided with written and oral notices of the 
provisions of those regulations (or amendments, as the case may be). A 
fee under this section may not be assessed against, or collected from, 
a prisoner pursuant to such regulations (or amendments, as the case may 
be) for services provided before the expiration of such period.
    ``(j) Notice Before Public Comment Period.--Before the beginning of 
any period a proposed regulation under this section is open to public 
comment, the Director shall provide written and oral notice of the 
provisions of that proposed regulation to groups that advocate on 
behalf of Federal prisoners and to each prisoner subject to such 
proposed regulation.
    ``(k) Reports to Congress.--Not later than 1 year after the date of 
the enactment of the Federal Prisoner Health Care Copayment Act of 
2000, and annually thereafter, the Director shall transmit to Congress 
a report, which shall include--
            ``(1) a description of the amounts collected under this 
        section during the preceding 12-month period;
            ``(2) an analysis of the effects of the implementation of 
        this section, if any, on the nature and extent of heath care 
        visits by prisoners;
            ``(3) an itemization of the cost of implementing and 
        administering the program;
            ``(4) a description of current inmate health status 
        indicators as compared to the year prior to enactment; and
            ``(5) a description of the quality of health care services 
        provided to inmates during the preceding 12-month period, as 
        compared with the quality of those services provided during the 
        12-month period ending on the date of the enactment of such 
        Act.''.
    (b) Clerical Amendment.--The analysis for chapter 303 of title 18, 
United States Code, is amended by adding at the end the following:

``4048. Fees for health care services for prisoners.''.

SEC. 3. HEALTH CARE FEES FOR FEDERAL PRISONERS IN NON-FEDERAL 
                    INSTITUTIONS.

    Section 4013 of title 18, United States Code, is amended by adding 
at the end the following:
    ``(c) Health Care Fees For Federal Prisoners in Non-Federal 
Institutions.--
            ``(1) In general.--Notwithstanding amounts paid under 
        subsection (a)(3), a State or local government may assess and 
        collect a reasonable fee from the trust fund account (or 
        institutional equivalent) of a Federal prisoner for health care 
        services, if--
                    ``(A) the prisoner is confined in a non-Federal 
                institution pursuant to an agreement between the 
                Federal Government and the State or local government;
                    ``(B) the fee--
                            ``(i) is authorized under State law; and
                            ``(ii) does not exceed the amount collected 
                        from State or local prisoners for the same 
                        services; and
                    ``(C) the services--
                            ``(i) are provided within or outside of the 
                        institution by a person who is licensed or 
                        certified under State law to provide health 
                        care services and who is operating within the 
                        scope of such license;
                            ``(ii) constitute a health care visit 
                        within the meaning of section 4048(a)(4) of 
                        this title; and
                            ``(iii) are not preventative health care 
                        services, emergency services, prenatal care, 
                        diagnosis or treatment of chronic infectious 
                        diseases, mental health care, or substance 
                        abuse treatment.
            ``(2) No refusal of treatment for financial reasons.--
        Nothing in this subsection may be construed to permit any 
        refusal of treatment to a prisoner on the basis that--
                    ``(A) the account of the prisoner is insolvent; or
                    ``(B) the prisoner is otherwise unable to pay a fee 
                assessed under this subsection.
            ``(3) Notice to prisoners of law.--Each person who is or 
        becomes a prisoner shall be provided with written and oral 
        notices of the provisions of this subsection and the 
        applicability of this subsection to the prisoner. 
        Notwithstanding any other provision of this subsection, a fee 
        under this section may not be assessed against, or collected 
        from, such person--
                    ``(A) until the expiration of the 30-day period 
                beginning on the date on which each prisoner in the 
                prison system is provided with such notices; and
                    ``(B) for services provided before the expiration 
                of such period.
            ``(4) Notice to prisoners of state or local 
        implementation.--The implementation of this subsection by the 
        State or local government, and any amendment to that 
        implementation, shall not take effect until the expiration of 
        the 30-day period beginning on the date on which each prisoner 
        in the prison system is provided with written and oral notices 
        of the provisions of that implementation (or amendment, as the 
        case may be). A fee under this subsection may not be assessed 
        against, or collected from, a prisoner pursuant to such 
        implementation (or amendments, as the case may be) for services 
        provided before the expiration of such period.
            ``(5) Notice before public comment period.--Before the 
        beginning of any period a proposed implementation under this 
        subsection is open to public comment, written and oral notice 
        of the provisions of that proposed implementation shall be 
        provided to groups that advocate on behalf of Federal prisoners 
        and to each prisoner subject to such proposed 
        implementation.''.

SEC. 4. COMPREHENSIVE HIV/AIDS SERVICES REQUIRED TO BE INCLUDED IN 
                    HEALTH CARE SERVICES FOR WHICH HEALTH CARE FEES MAY 
                    BE ASSESSED.

    Any health care services for which a person may be assessed a fee 
under section 4048 of title 18, United States Code (as added by section 
2) or section 4013(c) of such title (as added by section 3) shall 
include comprehensive coverage for services relating to human 
immunodeficiency virus (HIV) and acquired immune deficiency syndrome 
(AIDS).

                          Purpose and Summary

    H.R. 1349, the ``Federal Prisoner Health Care Copayment Act 
of 2000,'' authorizes the Federal Bureau of Prisons to collect 
a fee from any person who has been charged with or convicted of 
a Federal crime each time that person visits a health care 
professional at his or her request and receives health care 
services. The amount of the fee is to be determined by the 
Director of the Bureau of Prisons through regulation, but would 
be at least $1 per visit. The fee would be assessed and 
deducted from any account maintained on behalf of the prisoner 
receiving the services. The fee would not be assessed or 
collected for preventative health care services, emergency 
services, prenatal care, diagnosis or treatment for chronic 
infectious diseases, mental health care, or substance abuse 
treatment. The bill further provides that when a Federal 
prisoner is housed in a non-Federal facility (e.g., pursuant to 
an agreement between the Federal Government and a State or 
local government) the State or local facility may assess a fee 
for health care services, provided that such a fee is 
authorized under the law of the State where the Federal 
prisoner is housed and that State prisoners are charged no 
greater a fee.

                Background and Need for the Legislation

    H.R. 1349 amends title 18 of the United States Code to 
authorize the Director of the Bureau of Prisons (BOP) to assess 
and collect a fee from prisoners for health care services 
provided to them. The intent of the bill is to impose a type of 
``copayment fee'' of a nominal amount on prisoners, similar to 
the nominal fee paid by many Americans when they visit a health 
care provider under a managed health care plan.
    Currently, inmates incarcerated in the Federal prison 
system and persons who are detained pending trial receive free 
medical care from BOP employees (physicians, physician 
assistants, and nurses) and Public Health Service (PHS) 
personnel (generally physician assistants, dentists, and 
pharmacists) assigned to each institution. Additionally, the 
BOP maintains contracts with medical specialists in private 
practice who provide care that cannot be provided by the BOP 
employees and PHS personnel. For the most seriously ill 
inmates, the BOP operates seven Federal Medical Centers at 
which are located fully accredited hospitals and facilities to 
care for long-term chronically and terminally ill inmates. In 
fiscal year 1999, the BOP spent $372.1 million in health care 
costs.\1\
---------------------------------------------------------------------------
    \1\ Federal Prisons: Containing Health Care Costs for an Increasing 
Inmate Population, No. GAO/T-GGD-00-112, at 3 (April 6, 
2000)(hereinafter ``GAO Report'').
---------------------------------------------------------------------------
    All inmates \2\ in the BOP system are required to work if 
medically able, and all who work are paid for their labor.\3\ 
Persons detained while awaiting trial are not required to work. 
Wages paid to inmates are retained in an inmate account, which 
inmates can use to pay for telephone calls and purchases from 
the prison commissary. A prisoner's family may deposit money 
into his or her account for his or her use as well.
---------------------------------------------------------------------------
    \2\ In this report, the term ``inmate'' is used to describe a 
person who has been convicted of a Federal crime and has been 
incarcerated for that offense, while the term ``prisoner'' is used to 
describe both inmates as well as persons who are detained pending 
trial.
    \3\ Approximately, 75% of BOP inmates are paid between 12 cents and 
40 cents per hour, with the majority of BOP inmates making less than 17 
cents per hour. The highest paid inmates make approximately $1.15 per 
hour.
---------------------------------------------------------------------------
    At a hearing on H.R. 1349 held by the Subcommittee on 
Crime, a representative of the Bureau of Prisons testified that 
some portion of the inmates who seek medical treatment at any 
given time do so for the purpose of avoiding work or other 
rehabilitative programming which is imposed on them. Inmates 
know that while they are waiting for treatment they are excused 
from all programming. Inmates who seek treatment without a 
legitimate medical complaint waste the time of medical staff 
and force truly sick inmates to wait to receive the care they 
need. The BOP supports imposing a nominal health care co-
payment fee on all prisoners for the same reason that managed 
health care plans impose them on their customers, namely, it 
will help deter overuse of health care services (i.e., use of 
those services by people who do not really need them).
    A recent General Accounting Office report found that co-
payment fees for prison inmates have been adopted in 36 
States.\4\ Among States and localities that have imposed these 
fees, reductions in sick call visits of from 16 to 50 percent 
have been realized. In its report, the GAO concluded that use 
of a health care co-payment fee system would reduce the number 
of unnecessary medical visits in the Federal prison system, 
perhaps reducing overall visits by as much as 25 percent.\5\
---------------------------------------------------------------------------
    \4\ GAO Report, at 3.
    \5\ Id. at 12.
---------------------------------------------------------------------------

                                Hearings

    The committee's Subcommittee on Crime held 1 day of 
hearings on H.R. 1349 on September 30, 1999. Testimony was 
received from 3 witnesses, representing 2 organizations. No 
additional material was submitted.

                        Committee Consideration

    On March 16, 2000, the Subcommittee on Crime met in open 
session and ordered favorably reported the bill H.R. 1349, as 
amended, by a voice vote, a quorum being present. On July 19, 
2000, the committee met in open session and ordered favorably 
reported the bill H.R. 1349 with an amendment by voice vote, a 
quorum being present.

                         Vote of the Committee

    Rollcall No. 1 (6/27/00). Mr. Scott offered an amendment to 
prohibit the assessment and collection of a fee for health care 
services if prisoners have a ``reasonable basis'' for seeking 
health care services. By a rollcall vote of 9 yeas to 14 nays, 
the amendment was defeated.

                                                   ROLLCALL NO. 1
----------------------------------------------------------------------------------------------------------------
                                                                       Ayes            Nays           Present
----------------------------------------------------------------------------------------------------------------
Mr. Sensenbrenner...............................................  ..............              X   ..............
Mr. McCollum....................................................  ..............  ..............  ..............
Mr. Gekas.......................................................  ..............              X   ..............
Mr. Coble.......................................................  ..............              X   ..............
Mr. Smith (TX)..................................................  ..............              X   ..............
Mr. Gallegly....................................................  ..............  ..............  ..............
Mr. Canady......................................................  ..............              X   ..............
Mr. Goodlatte...................................................  ..............              X   ..............
Mr. Chabot......................................................  ..............  ..............  ..............
Mr. Barr........................................................  ..............  ..............  ..............
Mr. Jenkins.....................................................  ..............  ..............  ..............
Mr. Hutchinson..................................................  ..............              X   ..............
Mr. Pease.......................................................  ..............  ..............  ..............
Mr. Cannon......................................................  ..............  ..............  ..............
Mr. Rogan.......................................................  ..............              X   ..............
Mr. Graham......................................................  ..............  ..............  ..............
Ms. Bono........................................................  ..............              X   ..............
Mr. Bachus......................................................  ..............              X   ..............
Mr. Scarborough.................................................  ..............  ..............  ..............
Mr. Vitter......................................................  ..............              X   ..............
Mr. Conyers.....................................................              X   ..............  ..............
Mr. Frank.......................................................  ..............  ..............  ..............
Mr. Berman......................................................              X   ..............  ..............
Mr. Boucher.....................................................  ..............  ..............  ..............
Mr. Nadler......................................................              X   ..............  ..............
Mr. Scott.......................................................              X   ..............  ..............
Mr. Watt........................................................              X   ..............  ..............
Ms. Lofgren.....................................................              X   ..............  ..............
Ms. Jackson Lee.................................................              X   ..............  ..............
Ms. Waters......................................................              X   ..............  ..............
Mr. Meehan......................................................  ..............  ..............  ..............
Mr. Delahunt....................................................  ..............  ..............  ..............
Mr. Wexler......................................................  ..............  ..............  ..............
Mr. Rothman.....................................................  ..............              X   ..............
Ms. Baldwin.....................................................              X   ..............  ..............
Mr. Weiner......................................................  ..............              X   ..............
Mr. Hyde, Chairman..............................................  ..............              X   ..............
                                                                 -----------------------------------------------
    Total.......................................................              9              14   ..............
----------------------------------------------------------------------------------------------------------------

    Rollcall No. 2 (7/19/00). Mr Scott offered an amendment to 
delete the word ``chronic'' with respect to the prohibition on 
collecting a health care services fee for the treatment of 
chronic infectious diseases. By a rollcall vote of 9 yeas to 20 
nays, the amendment was defeated.

                                                   ROLLCALL NO. 2
----------------------------------------------------------------------------------------------------------------
                                                                       Ayes            Nays           Present
----------------------------------------------------------------------------------------------------------------
Mr. Sensenbrenner...............................................  ..............              X   ..............
Mr. McCollum....................................................  ..............              X   ..............
Mr. Gekas.......................................................  ..............              X   ..............
Mr. Coble.......................................................  ..............              X   ..............
Mr. Smith (TX)..................................................  ..............              X   ..............
Mr. Gallegly....................................................  ..............              X   ..............
Mr. Canady......................................................  ..............              X   ..............
Mr. Goodlatte...................................................  ..............              X   ..............
Mr. Chabot......................................................  ..............              X   ..............
Mr. Barr........................................................  ..............              X   ..............
Mr. Jenkins.....................................................  ..............              X   ..............
Mr. Hutchinson..................................................  ..............              X   ..............
Mr. Pease.......................................................  ..............  ..............  ..............
Mr. Cannon......................................................  ..............              X   ..............
Mr. Rogan.......................................................  ..............              X   ..............
Mr. Graham......................................................  ..............              X   ..............
Ms. Bono........................................................  ..............  ..............  ..............
Mr. Bachus......................................................  ..............              X   ..............
Mr. Scarborough.................................................  ..............              X   ..............
Mr. Vitter......................................................  ..............              X   ..............
Mr. Conyers.....................................................              X   ..............  ..............
Mr. Frank.......................................................              X   ..............  ..............
Mr. Berman......................................................              X   ..............  ..............
Mr. Boucher.....................................................  ..............  ..............  ..............
Mr. Nadler......................................................              X   ..............  ..............
Mr. Scott.......................................................              X   ..............  ..............
Mr. Watt........................................................  ..............  ..............  ..............
Ms. Lofgren.....................................................              X   ..............  ..............
Ms. Jackson Lee.................................................  ..............  ..............  ..............
Ms. Waters......................................................              X   ..............  ..............
Mr. Meehan......................................................  ..............  ..............  ..............
Mr. Delahunt....................................................  ..............  ..............  ..............
Mr. Wexler......................................................  ..............  ..............  ..............
Mr. Rothman.....................................................  ..............              X   ..............
Ms. Baldwin.....................................................              X   ..............  ..............
Mr. Weiner......................................................              X   ..............  ..............
Mr. Hyde, Chairman..............................................  ..............              X   ..............
                                                                 -----------------------------------------------
    Total.......................................................              9              20   ..............
----------------------------------------------------------------------------------------------------------------

    Rollcall No. 3 (7/19/00). Mr. Scott offered an amendment to 
strike that portion of the bill that authorizes State and local 
governments to assess and collect a health care services fee 
from Federal prisoners housed in non-Federal institutions in 
certain circumstances. By a rollcall vote of 7 yeas to 21 nays, 
the amendment was defeated.

                                                   ROLLCALL NO. 3
----------------------------------------------------------------------------------------------------------------
                                                                       Ayes            Nays           Present
----------------------------------------------------------------------------------------------------------------
Mr. Sensenbrenner...............................................  ..............              X   ..............
Mr. McCollum....................................................  ..............              X   ..............
Mr. Gekas.......................................................  ..............              X   ..............
Mr. Coble.......................................................  ..............              X   ..............
Mr. Smith (TX)..................................................  ..............              X   ..............
Mr. Gallegly....................................................  ..............  ..............  ..............
Mr. Canady......................................................  ..............              X   ..............
Mr. Goodlatte...................................................  ..............              X   ..............
Mr. Chabot......................................................  ..............              X   ..............
Mr. Barr........................................................  ..............              X   ..............
Mr. Jenkins.....................................................  ..............              X   ..............
Mr. Hutchinson..................................................  ..............              X   ..............
Mr. Pease.......................................................  ..............  ..............  ..............
Mr. Cannon......................................................  ..............              X   ..............
Mr. Rogan.......................................................  ..............              X   ..............
Mr. Graham......................................................  ..............              X   ..............
Ms. Bono........................................................  ..............  ..............  ..............
Mr. Bachus......................................................  ..............              X   ..............
Mr. Scarborough.................................................  ..............              X   ..............
Mr. Vitter......................................................  ..............              X   ..............
Mr. Conyers.....................................................              X   ..............  ..............
Mr. Frank.......................................................              X   ..............  ..............
Mr. Berman......................................................  ..............  ..............  ..............
Mr. Boucher.....................................................  ..............  ..............  ..............
Mr. Nadler......................................................              X   ..............  ..............
Mr. Scott.......................................................              X   ..............  ..............
Mr. Watt........................................................  ..............  ..............  ..............
Ms. Lofgren.....................................................              X   ..............  ..............
Ms. Jackson Lee.................................................  ..............  ..............  ..............
Ms. Waters......................................................              X   ..............  ..............
Mr. Meehan......................................................  ..............              X   ..............
Mr. Delahunt....................................................  ..............  ..............  ..............
Mr. Wexler......................................................  ..............  ..............  ..............
Mr. Rothman.....................................................  ..............              X   ..............
Ms. Baldwin.....................................................              X   ..............  ..............
Mr. Weiner......................................................  ..............              X   ..............
Mr. Hyde, Chairman..............................................  ..............              X   ..............
                                                                 -----------------------------------------------
    Total.......................................................              7              21   ..............
----------------------------------------------------------------------------------------------------------------

                      Committee Oversight Findings

    In compliance with clause 3(c)(1) of rule XIII of the Rules 
of the House of Representatives, the committee reports that the 
findings and recommendations of the committee, based on 
oversight activities under clause 2(b)(1) of rule X of the 
Rules of the House of Representatives, are incorporated in the 
descriptive portions of this report.

                Committee on Government Reform Findings

    No findings or recommendations of the Committee on 
Government Reform were received as referred to in clause 
3(c)(4) of rule XIII of the Rules of the House of 
Representatives.

               New Budget Authority and Tax Expenditures

    Clause 3(c)(2) of House Rule XIII is inapplicable because 
this legislation does not provide new budgetary authority or 
increased tax expenditures.

               Congressional Budget Office Cost Estimate

    In compliance with clause 3(c)(3) of rule XIII of the Rules 
of the House of Representatives, the committee sets forth, with 
respect to the bill, H.R. 1349, the following estimate and 
comparison prepared by the Director of the Congressional Budget 
Office under section 402 of the Congressional Budget Act of 
1974:

                                     U.S. Congress,
                               Congressional Budget Office,
                                    Washington, DC, August 3, 2000.
Hon. Henry J. Hyde, Chairman,
Committee on the Judiciary,
House of Representatives, Washington, DC.
    Dear Mr. Chairman: The Congressional Budget Office has 
prepared the enclosed cost estimate for H.R. 1349, the Federal 
Prisoner Health Care Copayment Act of 2000.
    If you wish further details on this estimate, we will be 
pleased to provide them. The CBO staff contacts are Lanette J. 
Keith (for federal costs), who can be reached at 226-2860, 
Shelley Finlayson (for the state and local impact), who can be 
reached at 225-3220, and John Harris (for the private-sector 
impact), who can be reached at 226-2618.
            Sincerely,
                                  Dan L. Crippen, Director.

Enclosure

cc:
        Honorable John Conyers Jr.
        Ranking Democratic Member
H.R. 1349--Federal Prisoner Health Care Copayment Act of 2000.

                                SUMMARY

    Enacting H.R. 1349 would permit the Bureau of Prisons (BOP) 
to assess and collect a copayment fee of at least $1 for each 
health care visit initiated by a prisoner (excluding those for 
preventative health care services, emergency services, prenatal 
care, treatment of chronic infectious diseases, mental health, 
or substance abuse services). Fees collected from prisoners who 
are subject to an order of restitution would be paid to 
victims. Of the remaining fees, 75 percent would be deposited 
into the Crime Victims Fund and 25 percent would be available 
to the Attorney General for spending on administrative expenses 
incurred in carrying out the copayment program.
    CBO expects that imposing such fees would reduce the demand 
for health care services from federal prisoners. We estimate 
that the reduction in demand would result in net savings of 
less than $5 million annually over the 2001-2005 period, 
assuming that future appropriations are reduced to reflect the 
lower health care costs. Also, we estimate that the proposed 
health care copayment would generate about $2 million in 
offsetting receipts (a credit against direct spending) over the 
2001-2005 period. Those collections would be available for 
spending without appropriation action. CBO expects that there 
would be a lag between the collection and the spending of such 
receipts, but we estimate that the net change in direct 
spending would be less than $500,000 a year. Because enacting 
this bill would affect direct spending, pay-as-you-go 
procedures would apply.
    H.R. 1349 contains no intergovernmental mandates as defined 
in that Unfunded Mandates Reform Act (UMRA) and would impose no 
costs on state, local, or tribal governments. H.R. 1349 would 
impose a new private sector-mandate, but CBO estimates that the 
direct cost of the mandate would fall well below the annual 
threshold established in UMRA ($109 million in 2000, adjusted 
annually for inflation).

                ESTIMATED COST TO THE FEDERAL GOVERNMENT

    Collecting and spending the copayment fees under H.R. 1349 
would constitute direct spending, but have no significant net 
budgetary impact. The reduction in demand for health care 
services that would likely stem from imposing those copayments 
would in turn reduce the need for discretionary appropriations. 
CBO estimates that potential savings would be less than $5 
million a year.
Direct Spending
    Based on information from the BOP, CBO estimates that under 
this bill, about 400,000 health care visits by prisoners in 
federal prisons would be subject to a $1 fee in fiscal year 
2001. We estimate some indigent prisoners could not pay the 
fee, and that assessing such a fee would deter some prisoners 
from initiating some visits, but we also expect that the 
overall prison population will continue to increase each year. 
Assuming that the bill would reduce nonpreventative health care 
visits by between 10 percent and 25 percent, and that the 
prison population will increase by about 10 percent annually, 
CBO estimates that about $350,000 in copayments would be 
collected each year. Most or all such amounts would be spent, 
resulting in little or no net budgetary impact.
Spending Subject to Appropriation
    Based on the results of programs in some states that 
require health care copayments from prisoners, CBO expects that 
the copayment program would reduce the number of health care 
visits initiated by prisoners. As a result, the BOP would 
realize some savings in health care costs. Savings would not be 
directly proportionate to the reduction in the number of visits 
because much of the BOP's $350 million annual spending on 
health services would not be affected by this reduction. In 
addition, CBO estimates that the BOP would spend about $170,000 
a year to administer the copayment program and only about half 
of such costs would be offset by the portion of collections 
made available to the Attorney General.
    CBO estimates that net savings of about $1 million could be 
realized in fiscal year 2001. Savings could be as high as $5 
million annually in subsequent years because some costs that 
are fixed in the near term might be eliminated in future years. 
Savings in health care services would be realized only to the 
extent that appropriations were reduced accordingly.

                      PAY-AS-YOU-GO CONSIDERATIONS

    The Balanced Budget and Emergency Deficit Control Act sets 
up pay-as-you-go procedures for legislation affecting direct 
spending and receipts. H.R. 1349 would affect direct spending, 
but CBO estimates that the net changes in direct spending 
(accounting for some lag between collections and spending) 
would be less than $500,000 a year.

        ESTIMATED IMPACT ON STATE, LOCAL, AND TRIBAL GOVERNMENTS

    H.R. 1349 contains no intergovernmental mandates as defined 
in UMRA and would impose no costs on state, local, or tribal 
governments. Under certain circumstances, the bill would allow 
state and local correctional institutions to charge federal 
prisoners in their facilities a copayment for certain health 
care services. While the fees charged by these institutions 
vary, CBO estimates that total receipts to state and local 
governments would increase by less than $400,000 per year.

                 ESTIMATED IMPACT ON THE PRIVATE SECTOR

    H.R. 1349 would create a new private-sector mandate by 
requiring federal prisoners to make copayments for some health 
care visits. Based on data from the Bureau of Prisons, CBO 
estimates that prisoners in federal facilities would pay about 
$350,000 annually in such fees. Federal prisoners housed in 
state or local institutions would also be required to pay fees 
in cases where those institutions choose to charge them; such 
fees would amount to less than $400,000 annually over the next 
five years. CBO therefore expects that the direct cost of the 
federal mandate would be well below the annual threshold 
established in UMRA ($109 million in 2000, adjusted for 
inflation) for any of the first five years that the mandate is 
in effect.

                         PREVIOUS CBO ESTIMATE

    On May 25, 1999, CBO transmitted a cost estimate for S. 
704, the Federal Prisoner Health Care Copayment Act of 1999, as 
reported by the Senate Committee on the Judiciary on April 29, 
1999. S. 704 would set the minimum copay charge for health 
services in federal prisons at $2 per visit. H.R. 1349 would 
set the minimum charge at $1 per visit, and our cost estimates 
reflect this difference.

                         ESTIMATE PREPARED BY:

Federal Costs: Lanette J. Keith (226-2860)
Impact on State, Local, and Tribal Governments: Shelley 
        Finlayson (225-3220)
Impact on the Private Sector: John Harris (226-2618)

                         ESTIMATE APPROVED BY:

Peter H. Fontaine
Deputy Assistant Director for Budget Analysis

                   Constitutional Authority Statement

    Pursuant to clause 3(d)(1) of rule XIII of the Rules of the 
House of Representatives, the committee finds the authority for 
this legislation in Article I, section 8, clause 18 of the 
Constitution.

               Section-by-Section Analysis and Discussion

    Sec. 1. Short Title. Section 1 of the bill states the short 
title of the act as the ``Federal Prisoner Health Care 
Copayment Act of 2000.''
    Section 2. Health Care Fees for Prisoners in Federal 
Institutions. Section 2 of the bill enacts new section 4048 to 
title 18 of the United States Code. New section 4048 authorizes 
the collection of a fee for health care services from persons 
in the custody of the Bureau of Prisons or who have been 
charged with or convicted of an offense against the United 
States. Thus, the fee may be assessed and collected from 
persons awaiting trial as well as from convicted offenders.
    Under new section 4048, the Director of the Bureau of 
Prisons is authorized to assess and collect a fee for health 
care services provided to a prisoner. The amount of the fee is 
to be determined by the Director pursuant to regulations 
promulgated by her, but in no event may the fee be less than 
$1. The committee understands that the Director plans to 
establish a sliding scale of fees that take into account a 
prisoner's ability to pay the fee assessed.
    The fee is to be assessed and collected with respect to 
each ``health care visit,'' which is defined in the bill to 
mean any visit to a health care provider, but not visits 
initiated by a prisoner pursuant to a staff referral or to 
obtain staff-approved follow-up treatment for a chronic 
condition. The bill also provides that no fee is to be assessed 
or collected for preventative health care services, emergency 
services, prenatal care, diagnosis or treatment for chronic 
infectious diseases, mental health care, or substance abuse 
treatment. The Director is to determine which specific health 
care treatments fall into these broad categories. In the event 
that an inmate receives health care services as a result of an 
injury inflicted on that prisoner by another prisoner, the bill 
requires that the prisoner who inflicted the injury is to be 
assessed the fee that otherwise would have been assessed 
against the prisoner receiving the health care services.
    Fees assessed under this section are to be collected by the 
Director from the account of the prisoner receiving the health 
care services. However, a prisoner may not be refused health 
care services solely on the basis that the prisoner's inmate 
account is insolvent or that the prisoner is otherwise unable 
to pay a fee assessed under this section. The committee expects 
that when medically appropriate, health care services will be 
provided to all prisoners regardless of their ability to pay 
the fee required under section 4048.
    Subsection (e) of new section 4048 requires that prisoners 
be given a reasonable opportunity to dispute the amount of the 
fee and to dispute whether the prisoner qualifies under an 
exclusion set forth in section 4048. The committee notes that 
the Bureau of Prisons has an existing administrative remedy 
process whereby prisoners may raise grievances and request 
official action. The committee expects that prisoners will use 
this procedure to raise issues under subsection (e) of section 
4048. If so, that process satisfies the requirements of 
subsection (e).
    Subsection (g) of section 4048 provides for the manner in 
which health care fees collected under that section are to be 
used. If a fee is collected from a prisoner who is subject to 
an order of restitution, the amount collected is to be paid to 
the prisoner's victim or victims in accordance with that order. 
Of the fees collected from prisoners who are not subject to 
restitution orders, 75% of those fees collected are to be 
deposited in he Federal Crime Victims Fund and 25% are to be 
made available to the Attorney General to be used to offset the 
administrative expenses incurred in carrying out the 
requirements of section 4048.
    Subsection (h) of new section 4048 requires that all 
prisoners receive written and oral notice of the provisions of 
section 4048 before any fee is collected from them under it. 
That subsection also prohibits the collection of such a fee 
from a prisoners until 30 days after date on which the prisoner 
receives the notices. This provision simply prohibits the 
assessment or collection of the fee authorized under this act 
during that 30 day period. The committee expects that medically 
appropriate health care services will continue to be provided 
during this period, notwithstanding the fact that no fee may be 
assessed.
    Subsection (i) provides that any regulations promulgated by 
the Director of the Bureau of Prisons implementing the 
provisions of section 4048 may not take effect for 30 days 
after the date on which all prisoners in the prison system are 
provided with written and oral notice of the provisions of the 
regulations, or any amendments to them, as the case may be. The 
subsection also prohibits the assessment or collection of any 
fee under section 4048 for health care services provided within 
the 30 day period after notice of the regulations (or 
amendments to them) are given to prisoners. In the case of 
amendments, this subsection should not be interpreted to mean 
that no fee may be assessed during the 30 day period, but 
rather that no increase in the fees to be collected resulting 
from the amendment may be assessed or collected for services 
performed during the 30 day period. Fees may still be assessed 
and collected during that period in accordance with the 
regulations then in effect during that period.
    Subsection (j) of new section 4048 requires that prior to 
the start of any period in which the public may comment on 
regulations implementing section 4048, or amendments to them, 
the Director of the Bureau of Prisons must give notice of the 
proposed regulation to each prisoner subject to the regulation 
and to groups that advocate on behalf of Federal prisoners. 
With respect to advocacy groups, the committee intends that 
this notice requirement be deemed satisfied if the Director 
mails a copy of the proposed regulations or amendments thereto 
to the national headquarters office of the following 
organizations: the American Civil Liberties Union, Justice 
Fellowship, and Citizens United for the Rehabilitation of 
Errants, or any successor organization to them.
    Section 4048 also requires the BOP Director to submit 
annual reports to Congress concerning the implementation of 
section 4048, including the amounts collected under that 
section, the cost of administering it, and an analysis of the 
effects of the section on the nature and extent of health care 
visits by prisoners. Section 4048 also defines certain terms 
used in the new section, including ``prisoner,'' ``health care 
visit,'' and ``health care provider.''
    Section 3. Health Care Fees for Federal Prisoners in Non-
Federal Institutions. Section 3 amends existing section 4013 of 
title 18 (relating to support of Federal prisoners in non-
Federal institutions) by adding new subsection (c) to that 
section.
    New subsection (c) of section 4013 authorizes a State or 
local government to assess and collect a reasonable fee from a 
Federal prisoner for health care services provided to that 
prisoners when the prisoner is confined in a non-Federal 
institution pursuant to an agreement between the Federal 
Government and the State or local government, such a fee is 
authorized to be collected under the law of the State in which 
the Federal prisoners is housed, and the fee does not exceed 
that collected from State or local prisoners for the same 
services. Unlike the fee to be collected under section 4048, 
the bill does not require that any minimum fee be assessed and 
collected. The fee may only be assessed and collected for 
health care services that are provided by health care providers 
who are licensed or certified under State law, that constitute 
a ``health care visit'' under new section 4048, and that are 
not the types of services described in subsection (b)(2) of new 
section 4048. As in the case of fees assessed under section 
4048, health care services may not be withheld under section 
4013(c) if the prisoner's account from which the fee would be 
deducted is insolvent, or if the prisoner is otherwise unable 
to pay the fee assessed.
    As in the case of fees to be assessed under section 4048, 
Federal prisoners in State or local facilities must also be 
provided with 30 days oral and written notice of the fee to be 
imposed under section 4013(c). The State or local government is 
not required to provide this notice to prisoners other than 
those who are Federal prisoners, and thus subject to section 
4013(c). If a State or local government promulgates regulations 
or other written guidance to implement section 4013(c), 30 days 
notice of the provisions of those regulations, and any 
amendments thereto, must be given to a prisoners before a fee 
under section 4013 may be assessed against him or her. In the 
case of amendments, the provision should not be interpreted to 
mean that no fee may be assessed during the 30 day notice 
period, but rather that no increase in the fees to be collected 
resulting from an amendment may be assessed or collected for 
services performed during the 30 day notice period. As in the 
case with section 4048, in no event may a State refuse to treat 
a Federal prisoner on the basis that the prisoner's inmate 
account is insolvent or that the prisoner is otherwise unable 
to pay the fee to be assessed under section 4013.
    Section 4. Comprehensive HIV/AIDS Services Required to be 
Included in Health Care Services for Which Health Care Fees May 
Be Assessed. Section 4 of the bill requires that as a condition 
of assessing fees under section 4048 or 4013(c), the Director 
of the Bureau of Prisons, or the State or local government, as 
the case may be, must ensure that comprehensive coverage for 
services relating to the virus known as HIV and the condition 
known as AIDS is included as part of the total program of heath 
care services provided to Federal prisoners. The committee 
notes that the Bureau of Prisons currently provides medically 
appropriate treatment for the virus and the syndrome that 
results from it and that, absent changes in the standard of 
care generally accepted by the medical community for HIV and 
AIDS, no additional treatment need be provided by the Bureau of 
Prisons to impose the fee authorized under section 4048.

                              Agency Views

                        U.S. Department of Justice,
                             Office of Legislative Affairs,
                                      Washington, DC, May 24, 1999.
Hon. Matt Salmon,
House of Representatives, Washington, DC.
    Dear Congressman Salmon: Thank you for requesting our views 
on H.R. 1349, the ``Federal Prisoner Health Care Copayment 
Act.'' The Department of Justice strongly supports allowing 
federal prisoners to pay fees for certain medical services. We 
do, however, recommend that the terminology in Section 3 of the 
bill be clarified so that it is consistent with Section 2 of 
the bill. We would recommend that language be added similar to 
that in the substitute amendment adopted by the Senate 
Judiciary Committee.
    Thank you again for the opportunity to comment on this 
important legislation. Please do not hesitate to contact us if 
we may be of further assistance. The Office of Management and 
Budget has advised that it has no objection to submission of 
this letter from the standpoint of the Administration's 
program.
            Sincerely,
        Jon P. Jennings, Acting Assistant Attorney General.

         Changes in Existing Law Made by the Bill, as Reported

    In compliance with clause 3(e) of rule XIII of the Rules of 
the House of Representatives, changes in existing law made by 
the bill, as reported, are shown as follows (existing law 
proposed to be omitted is enclosed in black brackets, new 
matter is printed in italics, existing law in which no change 
is proposed is shown in roman):

                      TITLE 18, UNITED STATES CODE

           *       *       *       *       *       *       *
                    PART III--PRISONS AND PRISONERS

           *       *       *       *       *       *       *

                    CHAPTER 301--GENERAL PROVISIONS

           *       *       *       *       *       *       *

Sec. 4013. Support of United States prisoners in non-Federal 
                    institutions

    (a) * * *

           *       *       *       *       *       *       *

    (c) Health Care Fees For Federal Prisoners in Non-Federal 
Institutions.--
            (1) In general.--Notwithstanding amounts paid under 
        subsection (a)(3), a State or local government may 
        assess and collect a reasonable fee from the trust fund 
        account (or institutional equivalent) of a Federal 
        prisoner for health care services, if--
                    (A) the prisoner is confined in a non-
                Federal institution pursuant to an agreement 
                between the Federal Government and the State or 
                local government;
                    (B) the fee--
                            (i) is authorized under State law; 
                        and
                            (ii) does not exceed the amount 
                        collected from State or local prisoners 
                        for the same services; and
                    (C) the services--
                            (i) are provided within or outside 
                        of the institution by a person who is 
                        licensed or certified under State law 
                        to provide health care services and who 
                        is operating within the scope of such 
                        license;
                            (ii) constitute a health care visit 
                        within the meaning of section 
                        4048(a)(4) of this title; and
                            (iii) are not preventative health 
                        care services, emergency services, 
                        prenatal care, diagnosis or treatment 
                        of chronic infectious diseases, mental 
                        health care, or substance abuse 
                        treatment.
            (2) No refusal of treatment for financial 
        reasons.--Nothing in this subsection may be construed 
        to permit any refusal of treatment to a prisoner on the 
        basis that--
                    (A) the account of the prisoner is 
                insolvent; or
                    (B) the prisoner is otherwise unable to pay 
                a fee assessed under this subsection.
            (3) Notice to prisoners of law.--Each person who is 
        or becomes a prisoner shall be provided with written 
        and oral notices of the provisions of this subsection 
        and the applicability of this subsection to the 
        prisoner. Notwithstanding any other provision of this 
        subsection, a fee under this section may not be 
        assessed against, or collected from, such person--
                    (A) until the expiration of the 30-day 
                period beginning on the date on which each 
                prisoner in the prison system is provided with 
                such notices; and
                    (B) for services provided before the 
                expiration of such period.
            (4) Notice to prisoners of state or local 
        implementation.--The implementation of this subsection 
        by the State or local government, and any amendment to 
        that implementation, shall not take effect until the 
        expiration of the 30-day period beginning on the date 
        on which each prisoner in the prison system is provided 
        with written and oral notices of the provisions of that 
        implementation (or amendment, as the case may be). A 
        fee under this subsection may not be assessed against, 
        or collected from, a prisoner pursuant to such 
        implementation (or amendments, as the case may be) for 
        services provided before the expiration of such period.
            (5) Notice before public comment period.--Before 
        the beginning of any period a proposed implementation 
        under this subsection is open to public comment, 
        written and oral notice of the provisions of that 
        proposed implementation shall be provided to groups 
        that advocate on behalf of Federal prisoners and to 
        each prisoner subject to such proposed implementation.

           *       *       *       *       *       *       *

                     CHAPTER 303--BUREAU OF PRISONS

Sec.
4041. Bureau of Prisons; director and employees.
     * * * * * * *
4048. Fees for health care services for prisoners.

           *       *       *       *       *       *       *

Sec. 4048. Fees for health care services for prisoners

    (a) Definitions.--In this section--
            (1) the term ``account'' means the trust fund 
        account (or institutional equivalent) of a prisoner;
            (2) the term ``Director'' means the Director of the 
        Bureau of Prisons;
            (3) the term ``health care provider'' means any 
        person who is--
                    (A) authorized by the Director to provide 
                health care services; and
                    (B) operating within the scope of such 
                authorization;
            (4) the term ``health care visit''--
                    (A) means a visit, as determined by the 
                Director, by a prisoner to an institutional or 
                noninstitutional health care provider; and
                    (B) does not include a visit initiated by a 
                prisoner--
                            (i) pursuant to a staff referral; 
                        or
                            (ii) to obtain staff-approved 
                        follow-up treatment for a chronic 
                        condition; and
            (5) the term ``prisoner'' means--
                    (A) any individual who is incarcerated in 
                an institution under the jurisdiction of the 
                Bureau of Prisons; or
                    (B) any other individual, as designated by 
                the Director, who has been charged with or 
                convicted of an offense against the United 
                States.
    (b) Fees for Health Care Services.--
            (1) In general.--The Director, in accordance with 
        this section and with such regulations as the Director 
        shall promulgate to carry out this section, may assess 
        and collect a fee for health care services provided in 
        connection with each health care visit requested by a 
        prisoner.
            (2) Exclusion.--The Director may not assess or 
        collect a fee under this section for preventative 
        health care services, emergency services, prenatal 
        care, diagnosis or treatment of chronic infectious 
        diseases, mental health care, or substance abuse 
        treatment, as determined by the Director.
    (c) Persons Subject to Fee.--Each fee assessed under this 
section shall be collected by the Director from the account 
of--
            (1) the prisoner receiving health care services in 
        connection with a health care visit described in 
        subsection (b)(1); or
            (2) in the case of health care services provided in 
        connection with a health care visit described in 
        subsection (b)(1) that results from an injury inflicted 
        on a prisoner by another prisoner, the prisoner who 
        inflicted the injury, as determined by the Director.
    (d) Amount of Fee.--Any fee assessed and collected under 
this section shall be in an amount of not less than $1.
    (e) No Consent Required.--Notwithstanding any other 
provision of law, the consent of a prisoner shall not be 
required for the collection of a fee from the account of the 
prisoner under this section. However, each such prisoner shall 
be given a reasonable opportunity to dispute the amount of the 
fee or whether the prisoner qualifies under an exclusion under 
this section.
    (f) No Refusal of Treatment For Financial Reasons.--Nothing 
in this section may be construed to permit any refusal of 
treatment to a prisoner on the basis that--
            (1) the account of the prisoner is insolvent; or
            (2) the prisoner is otherwise unable to pay a fee 
        assessed under this section.
    (g) Use of Amounts.--
            (1) Restitution of specific victims.--Amounts 
        collected by the Director under this section from a 
        prisoner subject to an order of restitution issued 
        pursuant to section 3663 or 3663A shall be paid to 
        victims in accordance with the order of restitution.
            (2) Allocation of other amounts.--Of amounts 
        collected by the Director under this section from 
        prisoners not subject to an order of restitution issued 
        pursuant to section 3663 or 3663A--
                    (A) 75 percent shall be deposited in the 
                Crime Victims Fund established under section 
                1402 of the Victims of Crime Act of 1984 (42 
                U.S.C. 10601); and
                    (B) 25 percent shall be available to the 
                Attorney General for administrative expenses 
                incurred in carrying out this section.
    (h) Notice to Prisoners of Law.--Each person who is or 
becomes a prisoner shall be provided with written and oral 
notices of the provisions of this section and the applicability 
of this section to the prisoner. Notwithstanding any other 
provision of this section, a fee under this section may not be 
assessed against, or collected from, such person--
            (1) until the expiration of the 30-day period 
        beginning on the date on which each prisoner in the 
        prison system is provided with such notices; and
            (2) for services provided before the expiration of 
        such period.
    (i) Notice to Prisoners of Regulations.--The regulations 
promulgated by the Director under subsection (b)(1), and any 
amendments to those regulations, shall not take effect until 
the expiration of the 30-day period beginning on the date on 
which each prisoner in the prison system is provided with 
written and oral notices of the provisions of those regulations 
(or amendments, as the case may be). A fee under this section 
may not be assessed against, or collected from, a prisoner 
pursuant to such regulations (or amendments, as the case may 
be) for services provided before the expiration of such period.
    (j) Notice Before Public Comment Period.--Before the 
beginning of any period a proposed regulation under this 
section is open to public comment, the Director shall provide 
written and oral notice of the provisions of that proposed 
regulation to groups that advocate on behalf of Federal 
prisoners and to each prisoner subject to such proposed 
regulation.
    (k) Reports to Congress.--Not later than 1 year after the 
date of the enactment of the Federal Prisoner Health Care 
Copayment Act of 2000, and annually thereafter, the Director 
shall transmit to Congress a report, which shall include--
            (1) a description of the amounts collected under 
        this section during the preceding 12-month period;
            (2) an analysis of the effects of the 
        implementation of this section, if any, on the nature 
        and extent of heath care visits by prisoners;
            (3) an itemization of the cost of implementing and 
        administering the program;
            (4) a description of current inmate health status 
        indicators as compared to the year prior to enactment; 
        and
            (5) a description of the quality of health care 
        services provided to inmates during the preceding 12-
        month period, as compared with the quality of those 
        services provided during the 12-month period ending on 
        the date of the enactment of such Act.

           *       *       *       *       *       *       *

                            Dissenting Views

    H.R. 1349, as amended authorizes the Bureau of Prisons 
(BOP) to assess and collect a fee from inmates for health care 
services provided to the inmate during a health care visit. The 
bill provides for the Director of the BOP to set the fee per 
visit, but further provides that it shall be in an amount not 
less than one dollar. H.R. 1349 prohibits an assessment for 
preventative health care services, staff referrals, staff 
approved follow-up treatment, emergency visits, prenatal care, 
diagnosis or treatment of chronic infectious diseases, mental 
health care, or substance abuse treatment, and further provides 
that BOP cannot refuse treatment to an inmate because of an 
inability to pay the designated fee. Funds collected under this 
bill are to be used to pay victim restitution. If there is no 
order of restitution, 75% goes to the Crime Victims Fund and 
25% is available to BOP to defer administrative expense of the 
program.
    The Supreme Court has recognized the government's 
obligation to provide health care. The U.S. Supreme Court, in 
Estelle v. Gamble \1\ enunciated the principle that the 
government has an obligation to provide medicare to prisoners 
and this principle has been upheld in subsequent cases \2\. In 
DeShaney v. Winnebago County DSS, the court stated:
---------------------------------------------------------------------------
    \1\ 429 U.S. 97 (1976)
    \2\ DeShaney v. Winnebago County DSS, 489 U.S. 189 (1989)

        When the State by affirmative exercise of its power so 
        restrains an individual's liberty that it renders him 
        unable to care for himself, and at the same time fails 
        to provide for his basic human needs--e.g., food, 
        clothing, shelter, medical care, and reasonable 
        safety--it transgresses the substantive limits on State 
        actions set by the eight amendment and the due process 
        clause.\3\
---------------------------------------------------------------------------
    \3\ Ibid at 199-200.

    Given the limited amounts of money on hand in federal 
prisoner accounts at any given time, a health care co-payment 
requirement may impede their access to needed health care, 
particularly at the early treatment and intervention stage. BOP 
acknowledges that 75% of BOP inmates are paid between 12 cents 
and 40 cents per hour, with the majority of BOP inmates making 
less than 17 cents per hour. Further, BOP reports that more 
than half of all BOP inmates have no more than $60 in their 
accounts at any time, including the day immediately after their 
monthly pay period. Thus, even a minor co-pay would constitute 
a significant burden on them. Establishing such a prerequisite 
to health care treatment not only undermines the federal 
government's obligation to provide medical care to inmates, as 
discussed in DeShaney, it constitutes bad public policy. An 
inmate's failure to get timely treatment could result in minor 
problems becoming major problems, such as the spread of 
untreated infectious diseases.
    There is also a significant question as to whether the cost 
of administering the program will be greater than any savings 
it projects. Proponents of the legislation point to States 
which have instituted inmate health care co-payments to suggest 
that co-pays work to discourage unnecessary use of health care 
services and save the States money without jeopardizing the 
health of inmates. However, this information appears anecdotal 
at best. The only study of the issue anyone has been able to 
identify is a study by the California State Auditor. This study 
found that the California Department of Corrections' annual co-
pay program collections amounted to less than \1/3\ ($654,000) 
of the estimated annual collections ($1.7 million) and that the 
estimated annual cost of administering the program ($3.2 
million) amounted to almost five times the annual collections.
    In addition, the proponents' argument that a co-pay will 
deter inmate abuse of health care services lacks merit. 
Obviously, inmates with substantial amounts of money on account 
will not be deterred by a dollar or so co-pay from seeking 
unnecessary health care and inmates have to pay a co-pay even 
if they are sick. Therefore, the more likely effect of H.R. 
1349 is that ability to pay will be the determining factor as 
to whether inmates seek health care, not whether the prisoner 
truly needs medical attention. Thus, it was not surprising when 
the BOP witness acknowledged at the hearing on H.R. 1349 that 
there is no way to know how many truly sick inmates would be 
deterred because of the cost, as opposed to those abusing the 
system. Furthermore, since even those that are determined to be 
truly sick must pay, it appears that the real purpose of the 
bill is to simply deter inmates from seeking health care, 
regardless of whether they need it or not. Consistent with this 
goal, the majority opposed amendments which would require a co-
payment only if the inmate is found to have had no reasonable 
basis for seeking health care services.
    In conclusion, this bill will likely result in inmates 
having to choose between needed health care services and other 
crucial needs, and in more, as opposed to less, cost to 
taxpayers.

                                   John Conyers, Jr.
                                   Barney Frank.
                                   Howard L. Berman.
                                   Robert C. Scott.
                                   Melvin L. Watt.
                                   Zoe Lofgren.
                                   Maxine Waters.
                      Additional Dissenting Views

    In addition to the concerns raised in our dissenting views, 
we would also like to note that the sponsors of this bill have 
argued that, if prisoners can pay for their health care, they 
should. They argue that taxpayers should not be subsidizing 
prisoners health care. Our concern is this sets up a double 
standard. If we are concerned about wasteful, taxpayer-
supported health care subsidies, we should be asking: What 
about Members of Congress?
    One floor down from the committee offices, we have a nurse 
on call whenever the House is in session. We receive medical 
attention, treatment and medicine for a small yearly fee, the 
rest of the expense is paid by the taxpayers.
    Because of this discrepancy, at the committee markup, we 
offered an amendment requiring that Members of Congress pay a 
health care copay, in keeping with the Congressional 
Accountability Act that made Congress live by the laws it 
passes. The majority raised a point of order against the 
amendment and refused to even debate it. This was unfortunate. 
Why should a Member of Congress get medical evaluation 
compensated by taxpayers? Why should a Member of Congress get 
Tylenol without paying the same amount as working American 
families? Why should the taxpayer be any less concerned about 
subsidizing the health care of Members of Congress, who earn 
more than $100,000 a year, than they are about prisoners, who 
earn less than 50 cents an hour?
    This double standard is yet another reason why we have 
expressed concerns about the underlying legislation.

                                   John Conyers, Jr.
                                   Maxine Waters.

                                  
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