I

103D CONGRESS

2D SESSION H. R. 5119

To increase access to, control the costs associated with, and improve the

quality of health care in States through health insurance reform, State

innovation, public health and medical research, and for other purposes.

IN THE HOUSE OF REPRESENTATIVES

SEPTEMBER 28, 1994

Mr. DEFAZIO introduced the following bill; which was referred jointly to the

Committees on Energy and Commerce, Ways and Means, and Education

and Labor

A BILL

To increase access to, control the costs associated with, and

improve the quality of health care in States through

health insurance reform, State innovation, public health

and medical research, and for other purposes.

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled,

3 SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

4 (a) SHORT TITLE.—This Act may be cited as the

5 ‘‘Health Innovation Partnership Act of 1994’’.

6 (b) TABLE OF CONTENTS.—The table of contents of

7 this Act is as follows:

Sec. 1. Short title.

Sec. 2. Findings.
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TITLE I—HEALTH INSURANCE REFORM

Sec. 1001. Establishment of standards.

Sec. 1002. Medicare select.

TITLE II—STATE INNOVATION

SUBTITLE A—STATE WAIVER AUTHORITY

Sec. 2001. State health reform projects.

SUBTITLE B—EXISTING STATE LAWS

Sec. 2101. Continuance of existing Federal law waivers.

Sec. 2102. Hawaii Prepaid Health Care Act.

Sec. 2103. Alternative State provider payment systems.

Sec. 2104. Alternative State hospital services payment systems.

Sec. 2105. Exemption from erisa preemption of certain provisions of the law of

the State of Oregon relating to health plans.

TITLE III—PUBLIC HEALTH AND RURAL AND UNDERSERVED

ACCESS IMPROVEMENT

Sec. 3001. Short title.

Sec. 3002. Establishment of new title XXVII regarding public health programs.

‘‘TITLE XXVII—PUBLIC HEALTH PROGRAMS IMPROVEMENT

‘‘SUBTITLE A—CORE FUNCTIONS OF PUBLIC HEALTH PROGRAMS

‘‘PART 1—FORMULA GRANTS TO STATES

‘‘Sec. 2711. Authorizations of appropriations from Fund.

‘‘Sec. 2712. Formula grants to States for core health functions.

‘‘Sec. 2713. Number of functions; planning.

‘‘Sec. 2714. Submission of information; reports.

‘‘Sec. 2715. Application for grant.

‘‘Sec. 2716. Determination of amount of allotment.

‘‘Sec. 2717. Allocations for certain activities.

‘‘PART 2—COMPREHENSIVE EVALUATION OF DISEASE

PREVENTION AND HEALTH PROMOTION PROGRAMS

‘‘Sec. 2718. Authorizations of appropriations from Fund.

‘‘Sec. 2719. Evaluation of programs.

‘‘SUBTITLE B—OPPORTUNITIES FOR EDUCATION AND TRAINING IN PUBLIC

HEALTH

‘‘PART 1—SCHOLARSHIP AND LOAN REPAYMENT PROGRAMS

REGARDING SERVICE IN PUBLIC HEALTH POSITIONS

‘‘Sec. 2721. Authorizations of appropriations from Fund.

‘‘Sec. 2722. Scholarship program.

‘‘Sec. 2723. Loan repayment program.

‘‘Sec. 2724. Approved public health positions.

‘‘Sec. 2725. Allocation of funds; special considerations.
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‘‘PART 2—EDUCATIONAL INSTITUTIONS REGARDING PUBLIC

HEALTH

‘‘Sec. 2731. Authorizations of appropriations from Fund.

‘‘Sec. 2732. Grants for expanding capacity of institutions.

‘‘Sec. 2733. Coordination of grant activities with national priorities.

‘‘Sec. 2734. Certain requirements for grants.

‘‘PART 3—EXPANSION OF COMPETENCY IN PUBLIC HEALTH

‘‘Sec. 2736. Authorizations of appropriations from Fund.

‘‘Sec. 2737. Grants to States.

‘‘PART 4—AREA HEALTH EDUCATION CENTERS

‘‘Sec. 2738. Authorizations of appropriations from Fund.

‘‘PART 5—HEALTH EDUCATION TRAINING CENTERS

‘‘Sec. 2739. Authorizations of appropriations from Fund.

‘‘SUBTITLE C—REGIONAL POISON CONTROL CENTERS

‘‘Sec. 2741. Authorizations of appropriations from Fund.

‘‘Sec. 2742. Grants for regional centers.

‘‘Sec. 2743. Requirements regarding certification.

‘‘Sec. 2744. General provisions.

‘‘SUBTITLE D—SCHOOL-RELATED HEALTH SERVICES

‘‘PART 1—PROJECTS FOR PROVISION OF SERVICES

‘‘Sec. 2746. Authorization of appropriations from Fund.

‘‘Sec. 2747. Eligibility for grants.

‘‘Sec. 2748. Preferences.

‘‘Sec. 2749. Planning and development grants.

‘‘Sec. 2750. Grants for operation of school health services.

‘‘PART 2—SCHOLARSHIP AND LOAN REPAYMENT PROGRAMS

REGARDING SCHOOL NURSES

‘‘Sec. 2751. Authorizations of appropriations from Fund.

‘‘Sec. 2752. Scholarship program regarding upgrade in skills.

‘‘Sec. 2753. Loan repayment program.

‘‘Sec. 2754. School-nurse positions.

‘‘SUBTITLE E—EXPANSION OF RURAL AND UNDERSERVED AREAS ACCESS

TO HEALTH SERVICES

‘‘PART 1—COMMUNITY AND MIGRANT HEALTH CENTERS

‘‘Sec. 2756. Authorizations of appropriations from Fund.

‘‘Sec. 2757. Grants to community and migrant health centers.

‘‘PART 2—NATIONAL HEALTH SERVICE CORPS

‘‘Sec. 2781. Authorizations of appropriations from Fund.

‘‘PART 3—SATELLITE CLINICS REGARDING PRIMARY HEALTH

CARE
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‘‘Sec. 2783. Authorization of appropriations from Fund.

‘‘Sec. 2783A. Grants to States for development and operation of satellite clinics.

‘‘PART 4—COMMUNITY HEALTH ADVISORS

‘‘Sec. 2784. Authorization of appropriations from Fund.

‘‘Sec. 2785. Formula grants regarding community health advisor programs.

‘‘Sec. 2786. Requirements regarding community health advisor programs.

‘‘Sec. 2787. Additional agreements.

‘‘Sec. 2788. Application for assistance; State plan.

‘‘Sec. 2789. Determination of amount of allotment.

‘‘Sec. 2790. Quality assurance; cost-effectiveness.

‘‘Sec. 2791. Evaluations; technical assistance.

‘‘Sec. 2792. Rule of construction regarding programs of Indian Health Service.

‘‘Sec. 2793. Definitions.

‘‘Sec. 2794. Effect of insufficient appropriations for minimum allotments.

‘‘SUBTITLE F—GENERAL PROVISIONS

‘‘Sec. 2798. Requirement regarding accreditation of schools, departments, and

programs.

‘‘Sec. 2799. Relation to other funds.

‘‘Sec. 2799A. Definitions.’’

TITLE IV—MEDICAL RESEARCH

Sec. 4001. Findings.

Sec. 4002. National Fund for Health Research.

TITLE V—REVENUE PROVISIONS

Sec. 5000. Amendment of 1986 code.

SUBTITLE A—FINANCING PROVISIONS

Sec. 5001. Increase in excise taxes on tobacco products.

Sec. 5002. Modifications of certain tobacco tax provisions.

Sec. 5003. Imposition of excise tax on manufacture or importation of roll-yourown tobacco.

SUBTITLE B—HEALTH CARE REFORM TRUST FUND

Sec. 5101. Establishment of Health Care Reform Trust Fund.

1 SEC. 2. FINDINGS.

2 The Congress finds the following:

3 (1) Americans support universal coverage. The

4 people of this country agree that all Americans, rich

5 and poor, should be guaranteed access to affordable,

6 high-quality health care.
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1 (2) Although there is common agreement on the

2 goal of universal coverage, there are many different

3 ways to achieve this goal. The States can play an

4 important role in achieving universal coverage for

5 our population, demonstrating additional health re6 forms that may be needed on a national level to en7 hance access to affordable, high-quality health care.

8 The States also can serve as testing grounds to iden9 tify effective alternatives for making the transition

10 to universal coverage, while maintaining the

11 strengths of the current health care system.

12 (3) Maintaining the high quality of health care

13 Americans expect and controlling costs are also im14 portant goals of health care reform. As payers of

15 health care, the States have a strong incentive to en16 sure that such States purchase high-quality, cost-ef17 fective services for the residents of such States. The

18 States can develop and test alternative payment and

19 delivery systems to ensure that these goals are

20 achieved.

21 (4) There are many health-related issues that

22 should be addressed at the State level before their

23 implementation on the national level. As with social

24 security and child labor protections, States can lead

25 the way in testing ideas for national application.
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1 (5) The States should have the flexibility to test

2 alternative health reforms with the objectives of in3 creasing access to care, controlling health care costs,

4 and maintaining or improving the quality of health

5 care.

6 TITLE I—HEALTH INSURANCE

7 REFORM

8 SEC. 1001. ESTABLISHMENT OF STANDARDS.

9 (a) IN GENERAL.—The Secretary of Health and

10 Human Services (hereafter referred to in this Act as the

11 ‘‘Secretary’’) shall request that the National Association

12 of Insurance Commissioners (hereafter referred to in this

13 title as the ‘‘Association’’) develop, not later than 6

14 months after the date of the enactment of this Act, stand15 ards for health insurance plans with respect to—

16 (1) the renewability of coverage under such

17 plans;

18 (2) the portability of coverage under such plans,

19 including—

20 (A) limitations on the use of pre-existing

21 conditions;

22 (B) the concept of an ‘‘amnesty period’’

23 during which limitations on pre-existing condi24 tions would be suspended; and
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1 (C) the advisability of open enrollment pe2 riods;

3 (3) guaranteed issue with respect to all health

4 insurance coverage products;

5 (4) the establishment of an adjusted community

6 rating system with adjustment factors limited to age

7 (with no more than a 2:1 variation in premiums

8 based on age) and geography;

9 (5) solvency standards for health insurance

10 plans regulated under Federal and State law, includ11 ing the development of risk-based capital standards

12 for health plans, solvency standards for health plans,

13 self-funded employer-sponsored health plans, and

14 multiple employer welfare arrangements and associa15 tion plans;

16 (6) stop-loss standards for self-funded health

17 insurance plans and multi-employer welfare arrange18 ments and association plans;

19 (7) the identification of minimum employer size

20 for self-funding and the interrelationship between

21 self-funding and the community-rated pool of enroll22 ees; and

23 (8) any other areas determined appropriate by

24 the Secretary (including enforcement of standards

25 under this section).
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1 (b) REVIEW.—Not later than 30 days after receipt

2 of the standards developed by the Association under sub3 section (a), the Secretary shall complete a review of such

4 standards. If the Secretary, based on such review, ap5 proves such standards, such standards shall apply with re6 spect to all health insurance plans offered or operating

7 in a State on and after the effective date specified in sub8 section (d).

9 (c) FAILURE TO DEVELOP STANDARDS OR FAILURE

10 TO APPROVE.—If the Association fails to develop stand11 ards within the 6-month period referred to in subsection

12 (a), or the Secretary fails to approve any standards devel13 oped under such subsection, the Secretary shall develop,

14 not later than 15 months after the date of the enactment

15 of this Act, standards applicable to health insurance plans,

16 including standards related to the matters described in

17 paragraphs (1) through (8) of subsection (a) and such

18 standards shall apply with respect to all health insurance

19 plans offered or operating in a State on and after the ef20 fective date specified in subsection (d).

21 (d) EFFECTIVE DATE.—

22 (1) IN GENERAL.—Subject to paragraph (2),

23 the effective date specified in this subsection for a

24 State is the date the State adopts standards devel-
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1 oped under this section or 1 year after the date the

2 Secretary first approves such standards.

3 (2) DELAY FOR LEGISLATION.—In the case of

4 a State which the Secretary identifies, in consulta5 tion with the Association, as (A) requiring State leg6 islation (other than legislation appropriating funds)

7 in order for health insurance policies to meet the

8 standards developed and approved under this sec9 tion, but (B) having a legislature which is not sched10 uled to meet in 1996 in a legislative session in which

11 such legislation may be considered, the date speci12 fied in this subsection is the first day of the first

13 calendar quarter beginning after the close of the

14 first legislative session of the State legislature that

15 begins on or after January 1, 1996. For purposes of

16 the previous sentence, in the case of a State that has

17 a 2-year legislative session, each year of such session

18 shall be deemed to be a separate regular session of

19 the State legislature.

20 (e) WORKING GROUP.—In developing standards

21 under this section, the Association or Secretary shall con22 sult with a working group composed of representatives of

23 issuers of health insurance policies, consumer groups,

24 health insurance beneficiaries, and other qualified individ25 uals. Such representatives shall be selected in a manner
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1 so as to assure balanced representation among the inter2 ested groups.

3 (f) AFFECT ON STATE LAW.—Nothing in this section

4 shall be construed to preempt any State law to the extent

5 that such State law implements more progressive reforms

6 than those implemented under the standards developed

7 under this section, as determined by the Secretary.

8 SEC. 1002. MEDICARE SELECT.

9 (a) AMENDMENTS TO PROVISIONS RELATING TO

10 MEDICARE SELECT POLICIES.—

11 (1) PERMITTING MEDICARE SELECT POLICIES

12 IN ALL STATES.—Subsection (c) of section 4358 of

13 the Omnibus Budget Reconciliation Act of 1990 is

14 hereby repealed.

15 (2) REQUIREMENTS OF MEDICARE SELECT

16 POLICIES.—Section 1882(t)(1) of the Social Security

17 Act (42 U.S.C. 1395ss(t)(1)) is amended to read as

18 follows:

19 ‘‘(1)(A) If a medicare supplemental policy meets the

20 requirements of the 1991 NAIC Model Regulation or 1991

21 Federal Regulation and otherwise complies with the re22 quirements of this section except that—

23 ‘‘(i) the benefits under such policy are re24 stricted to items and services furnished by certain
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1 entities (or reduced benefits are provided when items

2 or services are furnished by other entities), and

3 ‘‘(ii) in the case of a policy described in sub4 paragraph (C)(i)—

5 ‘‘(I) the benefits under such policy are not

6 one of the groups or packages of benefits de7 scribed in subsection (p)(2)(A),

8 ‘‘(II) except for nominal copayments im9 posed for services covered under part B of this

10 title, such benefits include at least the core

11 group of basic benefits described in subsection

12 (p)(2)(B), and

13 ‘‘(III) an enrollee’s liability under such pol14 icy for physician’s services covered under part

15 B of this title is limited to the nominal

16 copayments described in subclause (II),

17 the policy shall nevertheless be treated as meeting

18 those requirements if the policy meets the require19 ments of subparagraph (B).

20 ‘‘(B) A policy meets the requirements of this sub21 paragraph if—

22 ‘‘(i) full benefits are provided for items and

23 services furnished through a network of entities

24 which have entered into contracts or agreements

25 with the issuer of the policy,
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1 ‘‘(ii) full benefits are provided for items and

2 services furnished by other entities if the services are

3 medically necessary and immediately required be4 cause of an unforeseen illness, injury, or condition

5 and it is not reasonable given the circumstances to

6 obtain the services through the network,

7 ‘‘(iii) the network offers sufficient access,

8 ‘‘(iv) the issuer of the policy has arrangements

9 for an ongoing quality assurance program for items

10 and services furnished through the network,

11 ‘‘(v)(I) the issuer of the policy provides to each

12 enrollee at the time of enrollment an explanation

13 of—

14 ‘‘(aa) the restrictions on payment under

15 the policy for services furnished other than by

16 or through the network,

17 ‘‘(bb) out of area coverage under the pol18 icy,

19 ‘‘(cc) the policy’s coverage of emergency

20 services and urgently needed care, and

21 ‘‘(dd) the availability of a policy through

22 the entity that meets the 1991 Model NAIC

23 Regulation or 1991 Federal Regulation without

24 regard to this subsection and the premium

25 charged for such policy, and
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1 ‘‘(II) each enrollee prior to enrollment acknowl2 edges receipt of the explanation provided under

3 subclause (I), and

4 ‘‘(vi) the issuer of the policy makes available to

5 individuals, in addition to the policy described in this

6 subsection, any policy (otherwise offered by the is7 suer to individuals in the State) that meets the 1991

8 Model NAIC Regulation or 1991 Federal Regulation

9 and other requirements of this section without re10 gard to this subsection.

11 ‘‘(C)(i) A policy described in this subparagraph—

12 ‘‘(I) is offered by an eligible organization (as

13 defined in section 1876(b)),

14 ‘‘(II) is not a policy or plan providing benefits

15 pursuant to a contract under section 1876 or an ap16 proved demonstration project described in section

17 603(c) of the Social Security Amendments of 1983,

18 section 2355 of the Deficit Reduction Act of 1984,

19 or section 9412(b) of the Omnibus Budget Reconcili20 ation Act of 1986, and

21 ‘‘(III) provides benefits which, when combined

22 with benefits which are available under this title, are

23 substantially similar to benefits under policies of24 fered to individuals who are not entitled to benefits

25 under this title.
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1 ‘‘(ii) In making a determination under subclause (III)

2 of clause (i) as to whether certain benefits are substan3 tially similar, there shall not be taken into account, except

4 in the case of preventive services, benefits provided under

5 policies offered to individuals who are not entitled to bene6 fits under this title which are in addition to the benefits

7 covered by this title and which are benefits an entity must

8 provide in order to meet the definition of an eligible orga9 nization under section 1876(b)(1).’’.

10 (b) RENEWABILITY OF MEDICARE SELECT POLI11 CIES.—Section 1882(q)(1) of such Act (42 U.S.C.

12 1395ss(q)(1)) is amended—

13 (1) by striking ‘‘(1) Each’’ and inserting

14 ‘‘(1)(A) Except as provided in subparagraph (B),

15 each’’;

16 (2) by redesignating subparagraphs (A) and

17 (B) as clauses (i) and (ii), respectively; and

18 (3) by adding at the end the following new sub19 paragraph:

20 ‘‘(B)(i) In the case of a policy that meets the

21 requirements of subsection (t), an issuer may cancel

22 or nonrenew such policy with respect to an individ23 ual who leaves the service area of such policy; except

24 that, if such individual moves to a geographic area

25 where such issuer, or where an affiliate of such is-
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1 suer, is issuing medicare supplemental policies, such

2 individual must be permitted to enroll in any medi3 care supplemental policy offered by such issuer or

4 affiliate that provides benefits comparable to or less

5 than the benefits provided in the policy being can6 celed or nonrenewed. An individual whose coverage

7 is canceled or nonrenewed under this subparagraph

8 shall, as part of the notice of termination or

9 nonrenewal, be notified of the right to enroll in other

10 medicare supplemental policies offered by the issuer

11 or its affiliates.

12 ‘‘(ii) For purposes of this subparagraph, the

13 term ‘affiliate’ shall have the meaning given such

14 term by the 1991 NAIC Model Regulation.’’.

15 (c) CIVIL PENALTY.—Section 1882(t)(2) of such Act

16 (42 U.S.C. 1395ss(t)(2)) is amended—

17 (1) by striking ‘‘(2)’’ and inserting ‘‘(2)(A)’’;

18 (2) by redesignating subparagraphs (A), (B),

19 (C), and (D) as clauses (i), (ii), (iii), and (iv), re20 spectively;

21 (3) in clause (iv), as redesignated—

22 (A) by striking ‘‘paragraph (1)(E)(i)’’ and

23 inserting ‘‘paragraph (1)(B)(v)(I); and

24 (B) by striking ‘‘paragraph (1)(E)(ii)’’ and

25 inserting ‘‘paragraph (1)(B)(v)(II)’’;
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1 (4) by striking ‘‘the previous sentence’’ and in2 serting ‘‘this subparagraph’’; and

3 (5) by adding at the end the following new sub4 paragraph:

5 ‘‘(B) If the Secretary determines that an issuer of

6 a policy approved under paragraph (1) has made a mis7 representation to the Secretary or has provided the Sec8 retary with false information regarding such policy, the

9 issuer is subject to a civil money penalty in an amount

10 not to exceed $100,000 for each such determination. The

11 provisions of section 1128A (other than the first sentence

12 of subsection (a) and other than subsection (b)) shall

13 apply to a civil money penalty under this subparagraph

14 in the same manner as such provisions apply to a penalty

15 or proceeding under section 1128A(a).’’.

16 (d) EFFECTIVE DATES.—

17 (1) NAIC STANDARDS.—If, within 9 months

18 after the date of the enactment of this Act, the Na19 tional Association of Insurance Commissioners

20 makes changes in the 1991 NAIC Model Regulation

21 (as defined in section 1882(p)(1)(A) of the Social

22 Security Act) to incorporate the additional require23 ments imposed by the amendments made by this sec24 tion, section 1882(g)(2)(A) of such Act shall be ap25 plied in each State, effective for policies issued to
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1 policyholders on and after the date specified in para2 graph (3), as if the reference to the Model Regula3 tion adopted on June 6, 1979, were a reference to

4 the 1991 NAIC Model Regulation (as so defined) as

5 changed under this paragraph (such changed Regu6 lation referred to in this subsection as the ‘‘1995

7 NAIC Model Regulation’’).

8 (2) SECRETARY STANDARDS.—If the Associa9 tion does not make changes in the 1991 NAIC

10 Model Regulation (as so defined) within the 9-month

11 period specified in paragraph (1), the Secretary shall

12 promulgate a regulation and section 1882(g)(2)(A)

13 of the Social Security Act shall be applied in each

14 State, effective for policies issued to policyholders on

15 and after the date specified in paragraph (3), as if

16 the reference to the Model Regulation adopted on

17 June 6, 1979, were a reference to the 1991 NAIC

18 Model Regulation (as so defined) as changed by the

19 Secretary under this paragraph (such changed Regu20 lation referred to in this subsection as the ‘‘1995

21 Federal Regulation’’).

22 (3) DATE SPECIFIED.—

23 (A) IN GENERAL.—Subject to subpara24 graph (B), the date specified in this paragraph

25 for a State is the earlier of—
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1 (i) the date the State adopts the 1995

2 NAIC Model Regulation or the 1995 Fed3 eral Regulation, or

4 (ii) 1 year after the date the Associa5 tion or the Secretary first adopts such reg6 ulations.

7 (B) ADDITIONAL LEGISLATIVE ACTION RE8 QUIRED.—In the case of a State which the Sec9 retary identifies, in consultation with the Asso10 ciation, as—

11 (i) requiring State legislation (other

12 than legislation appropriating funds) in

13 order for medicare supplemental policies to

14 meet the 1995 NAIC Model Regulation or

15 the 1995 Federal Regulation, but

16 (ii) having a legislature which is not

17 scheduled to meet in 1995 in a legislative

18 session in which such legislation may be

19 considered,

20 the date specified in this paragraph is the first

21 day of the first calendar quarter beginning after

22 the close of the first legislative session of the

23 State legislature that begins on or after Janu24 ary 1, 1996. For purposes of the previous sen25 tence, in the case of a State that has a 2-year
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1 legislative session, each year of such session

2 shall be deemed to be a separate regular session

3 of the State legislature.

4 TITLE II—STATE INNOVATION

5 Subtitle A—State Waiver Authority

6 SEC. 2001. STATE HEALTH REFORM PROJECTS.

7 (a) OBJECTIVES.—The objectives of the waiver pro8 grams approved under this section shall include, but not

9 be limited to—

10 (1) achieving the goals of increased health cov11 erage and access;

12 (2) containing the annual rate of growth in

13 public and private health care expenditures;

14 (3) ensuring that patients receive high-quality,

15 appropriate health care; and

16 (4) testing alternative reforms, such as building

17 on the private health insurance system or creating

18 new systems, to achieve the objectives of this Act.

19 (b) STATE HEALTH REFORM APPLICATIONS.—

20 (1) IN GENERAL.—A State may apply for—

21 (A) an alternative State health program

22 waiver under paragraph (2); or

23 (B) a limited State health care waiver

24 under paragraph (3).
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1 (2) ALTERNATIVE STATE HEALTH PROGRAM

2 WAIVERS.—

3 (A) IN GENERAL.—In accordance with this

4 paragraph, each State desiring to implement an

5 alternative State health program may submit

6 an application for waiver to the Secretary for

7 approval.

8 (B) WAIVER REQUIREMENTS SPECIFIED.—

9 A State that desires to receive a program waiv10 er under this paragraph shall prepare and sub11 mit to the Secretary, as part of the application,

12 a State health care plan that shall—

13 (i) provide and describe the manner in

14 which the State will ensure that individuals

15 residing within the State have expanded

16 access to health care coverage;

17 (ii) describe the number and percent18 age of current uninsured individuals who

19 will achieve coverage under the alternative

20 State health program;

21 (iii) describe the benefits package that

22 will be provided to all classes of bene23 ficiaries under the alternative State health

24 program;
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1 (iv) identify Federal, State, or local

2 programs that currently provide health

3 care services in the State and describe how

4 such programs could be incorporated into

5 or coordinated with the alternative State

6 health program, to the extent practicable;

7 (v) provide that the State will develop

8 and implement health care cost contain9 ment procedures;

10 (vi) describe the public and private

11 sector financing to be provided for the al12 ternative State health program;

13 (vii) estimate the amount of Federal,

14 State, and local expenditures, as well as,

15 the costs to business and individuals under

16 the alternative State health program;

17 (viii) describe how the State plan will

18 ensure the financial solvency of the alter19 native State health program;

20 (ix) describe any changes in eligibility

21 for public subsidies;

22 (x) provide assurances that Federal

23 expenditures under the alternative State

24 health program shall not exceed the Fed25 eral expenditures which would otherwise be
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1 made in the aggregate for the entire pro2 gram period;

3 (xi) provide quality control assurances

4 and agreements as required by the Sec5 retary;

6 (xii) provide for the development and

7 implementation of a State health care de8 livery system that provides increased ac9 cess to care in areas of the State where

10 there is an inadequate supply of health

11 care providers;

12 (xiii) identify all Federal law waivers

13 required to implement the alternative State

14 health program, including such waivers

15 necessary to achieve the access, cost con16 tainment, and quality goals of this Act and

17 the alternative State health program; and

18 (xiv) provide that the State will pre19 pare and submit the Secretary such re20 ports as the Secretary may require to carry

21 out program evaluations.

22 (C) PROJECT WAIVERS.—

23 (i) CRITERIA FOR SELECTION.—In se24 lecting from among the applications for al25 ternative State health program waivers,
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1 the Secretary shall be satisfied that each

2 approved State alternative State health

3 program—

4 (I) will not have a negative effect

5 on quality of care;

6 (II) will increase coverage of or

7 access for the State’s population; and

8 (III) will—

9 (aa) provide quality of care

10 and premium comparisons di11 rectly to employers and individ12 uals in an easy-to-use format,

13 (bb) contract with an exter14 nal peer review organization to

15 monitor the quality of health care

16 plans, and

17 (cc) establish a mechanism

18 within the State’s grievance proc19 ess that allows members of a

20 health plan to disenroll at any

21 time if it can be shown that such

22 members were provided erroneous

23 information that biased their

24 health plan selection.
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1 (ii) WAIVER APPROVAL.—The Sec2 retary shall approve applications submitted

3 by States that meet the access, cost con4 tainment, and quality goals established in

5 this Act and shall waive to the extent nec6 essary to conduct each alternative State

7 health program any of the requirements of

8 this Act, including, but not limited to, eli9 gibility requirements; alternative data col10 lection systems and sampling designs that

11 focus on measuring health status, patient

12 treatment outcomes, and patient satisfac13 tion with health plans, rather than on the

14 collection of 100 percent of patient encoun15 ters; and benefit designs; and any provi16 sions of Federal law contained in the fol17 lowing:

18 (I) Titles V, XVIII, XIX, and

19 XX of the Social Security Act.

20 (II) The Public Health Service

21 Act.

22 (III) Any other Federal law au23 thorizing a Federal health care pro24 gram that the Secretary identifies as
25

•HR 5119 IH

1 providing health care services to quali2 fied recipients.

3 (3) LIMITED STATE HEALTH CARE WAIVERS.—

4 Each State which does not receive an approved ap5 plication under paragraph (2) may apply for a lim6 ited State health care waiver. The Secretary shall

7 award limited State health care waivers to ensure

8 State demonstrations of health reforms that could

9 address, but are not limited to addressing, the fol10 lowing issues that are likely to provide guidance for

11 the development of additional national health re12 forms:

13 (A) Integration of acute and long-term

14 care systems, including delivery and financing

15 systems.

16 (B) Establishment of methodologies that

17 limit expenditures or establish global budgets,

18 including rate setting and provider reimburse19 ments.

20 (C) Implementation of a quality manage21 ment and improvement system.

22 (D) Strategies to improve the proper spe23 ciality and geographic distribution of the health

24 care work force.
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1 (E) Initiatives to improve the population’s

2 health status.

3 (F) Development of uniform health data

4 sets that emphasize the measurement of patient

5 satisfaction, treatment outcomes, and health

6 status.

7 (G) Methods for coordinating or integrat8 ing State-funded programs that provide services

9 for low-income individuals, including programs

10 authorized by this Act.

11 (H) Programs to improve public health.

12 (I) Reforms intended to reduce health care

13 fraud and abuse.

14 (J) Reforms to reduce the incidence of de15 fensive medicine and practitioner liability costs

16 associated with medical malpractice.

17 (K) Development of a uniform billing sys18 tem.

19 (c) ADDITIONAL RULES REGARDING APPLICA20 TIONS.—

21 (1) TECHNICAL ASSISTANCE.—The Secretary

22 shall, if requested, provide technical assistance to

23 States to assist such States in developing waiver ap24 plications under this section.
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•HR 5119 IH

1 (2) INITIAL REVIEW.—The Secretary shall com2 plete an initial review of each State application for

3 a waiver under paragraph (2) or (3) of subsection

4 (b) within 40 days of the date of receipt of such ap5 plication, analyze the scope of the proposal, and de6 termine whether additional information is needed

7 from the State. The Secretary shall issue a prelimi8 nary opinion concerning the likelihood that the ap9 plication will be approved within such 40-day period

10 and shall advise the State within such period of the

11 need to submit additional information.

12 (3) FINAL DECISION.—The Secretary shall,

13 within 90 days of the later of—

14 (A) the date of receipt of a State applica15 tion for a waiver under paragraph (2) or (3) of

16 subsection (b), or

17 (B) the date on which the Secretary re18 ceives additional information requested from a

19 State under paragraph (1),

20 issue a final decision concerning such application.

21 (4) WAIVER PERIOD.—A State waiver may be

22 approved for a period of 5 years and may be ex23 tended for subsequent 5-year periods upon approval

24 by the Secretary, except that a shorter period may
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•HR 5119 IH

1 be requested by a State and granted by the Sec2 retary.

3 (d) QUALIFICATION FOR FEDERAL FUNDS.—For

4 purposes of this section, a State with an approved alter5 native health care system under subsection (b)(2) shall be

6 considered a participating State and shall maintain such

7 status if such State meets the requirements established

8 by the Secretary in the waiver approval and in this section.

9 (e) EVALUATION, MONITORING, AND COMPLIANCE.—

10 (1) STATE HEALTH REFORM ADVISORY

11 BOARD.—Within 90 days after the date of the enact12 ment of this Act, the Secretary shall establish a 7-

13 member State Health Reform Advisory Board (here14 after in this subsection referred to as the ‘‘Board’’)

15 that will be responsible for monitoring the status

16 and progress achieved under waivers granted under

17 this section and promoting information exchange be18 tween States and the Federal Government. The

19 Board shall be comprised of members representing

20 relevant participants in State programs, including

21 representatives of State government, employers, con22 sumers, providers, and insurers. The Board shall

23 also be responsible for making recommendations to

24 the Secretary, using equivalency or minimum stand25 ards, for minimizing the negative effect of State
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•HR 5119 IH

1 waivers on national employer groups, provider orga2 nizations, and insurers because of differing State re3 quirements under the waivers.

4 (2) ANNUAL REPORTS BY STATES.—Each State

5 that has received a waiver approval shall submit to

6 the Secretary an annual report based on the period

7 representing the respective State’s fiscal year, detail8 ing compliance with the requirements established by

9 the Secretary in the waiver approval and in this sec10 tion.

11 (3) CORRECTIVE ACTION PLANS.—If a State is

12 not in compliance with the requirements of this sec13 tion, the Secretary shall develop, in conjunction with

14 all the approved States, a corrective action plan.

15 (4) TERMINATION.—For good cause, the Sec16 retary may revoke any waiver of Federal law granted

17 under this section, and if necessary, may terminate

18 any alternative State health program. Such decisions

19 shall be subject to a petition for reconsideration and

20 appeal pursuant to regulations established by the

21 Secretary.

22 (5) EVALUATIONS BY SECRETARY.—The Sec23 retary shall prepare and submit to the Committee on

24 Finance and the Committee on Labor and Human

25 Resources of the Senate and the Committee on En-
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•HR 5119 IH

1 ergy and Commerce and the Committee on Ways

2 and Means of the House of Representatives annual

3 reports that shall contain—

4 (A) a description of the effects of the re5 forms undertaken in States receiving waiver ap6 provals under this section;

7 (B) an evaluation of the effectiveness of

8 such reforms in—

9 (i) expanding health care coverage for

10 State residents;

11 (ii) providing health care to State

12 residents with special needs;

13 (iii) reducing or containing health

14 care costs in the States; and

15 (iv) improving the quality of health

16 care provided in the States; and

17 (C) recommendations regarding the advis18 ability of increasing Federal financial assistance

19 for State alternative State health program ini20 tiatives, including the amount and source of

21 such assistance.

22 (f) FUNDING.—

23 (1) IN GENERAL.—The Secretary may provide a

24 grant to a State that has an application for a waiver

25 approved under this section to enable such State to
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•HR 5119 IH

1 carry out an alternative State health program in the

2 State.

3 (2) AMOUNT OF GRANT.—The amount of a

4 grant provided to a State under paragraph (1) shall

5 be determined pursuant to an allocation formula es6 tablished by the Secretary.

7 (3) PRIORITY.—In awarding grants under para8 graph (1), the Secretary shall give priority to those

9 State projects that the Secretary determines have

10 the greatest opportunity to succeed in providing ex11 panded health insurance coverage and in providing

12 children and youth with access to health care items

13 and services.

14 (4) MAINTENANCE OF EFFORT.—A State, in

15 utilizing the proceeds of a grant received under

16 paragraph (1), shall maintain the expenditures of

17 the State for health care coverage purposes at a level

18 equal to not less than the level of such expenditures

19 maintained by the State for the fiscal year preceding

20 the fiscal year for which the grant is received. The

21 requirement of this paragraph shall not apply in the

22 case of a State that desires to alter health care cov23 erage funding levels within the scope of the State’s

24 alternative health program.
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•HR 5119 IH

1 (5) REPORT.—At the end of the 5-year period

2 beginning on the date on which the Secretary

3 awards the first grant under paragraph (1), the

4 State Health Reform Advisory Board established

5 under subsection (e)(1) shall prepare and submit to

6 the appropriate committees of Congress, a report on

7 the progress made by States receiving grants under

8 paragraph (1) in achieving universal health care cov9 erage in such States during the 5-year period of the

10 grant. Such report shall contain the recommendation

11 of the Board concerning any future action that Con12 gress should take concerning health care reform, in13 cluding whether or not to extend the program estab14 lished under this subsection.

15 (g) AVAILABILITY OF FUNDS.—With respect to each

16 of calendar years 1996 through 2000, $10,000,000,000

17 shall be available for a calendar year to carry out this sec18 tion from the Health Care Reform Trust Fund established

19 under section 9551(a)(2)(A) of the Internal Revenue Code

20 of 1986. Amounts made available in a calendar year under

21 this paragraph and not expended may be used in subse22 quent calendar years to carry out this section.

23 (h) AMENDMENT TO CRIMINAL PENALTIES FOR

24 ACTS INVOLVING MEDICARE OR STATE HEALTH CARE

25 PROGRAMS.—Section 1128B(b) of the Social Security Act
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•HR 5119 IH

1 (42 U.S.C. 1320a-7b(b)) is amended by adding at the end

2 the following new paragraph:

3 ‘‘(4) Paragraphs (1) and (2) shall not apply to—

4 ‘‘(A) any payment to a health insurer or health

5 maintenance organization for which the premium is

6 paid in whole or in part by a State health care pro7 gram; and

8 ‘‘(B) any payment made by a health insurer or

9 a health maintenance organization to a sales rep10 resentative or a licensed insurance agent as com11 pensation for the services of the representative or

12 agent in marketing and enrolling an individual in a

13 health plan for which the premium is paid in whole

14 or in part by a State health care program.’’.

15 Subtitle B—Existing State Laws

16 SEC. 2101. CONTINUANCE OF EXISTING FEDERAL LAW

17 WAIVERS.

18 Nothing in this Act shall preempt any feature of a

19 State health care system operating under a waiver granted

20 before the date of the enactment of this Act under title

21 XVIII or XIX of the Social Security Act (42 U.S.C. 1395

22 et seq. or 1396 et seq.) or under an exemption from pre23 emption under section 514(b) of the Employee Retirement

24 Income Security Act of 1974 (29 U.S.C. 1001 et seq.).
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•HR 5119 IH

1 SEC. 2102. HAWAII PREPAID HEALTH CARE ACT.

2 (a) ERISA WAIVER.—Section 514(b)(5) of the Em3 ployee Retirement Income Security Act of 1974 (29

4 U.S.C. 1144(b)(5)) is amended to read as follows:

5 ‘‘(5)(A) Except as provided in subparagraphs

6 (B) and (C), subsection (a) shall not apply to the

7 Hawaii Prepaid Health Care Act (Haw. Rev. Stat.

8 393–1 through 393–51).

9 ‘‘(B) Nothing in subparagraph (A) shall be con10 strued to exempt from subsection (a) any State tax

11 law relating to employee benefits plans.

12 ‘‘(C) If the Secretary of Labor notifies the Gov13 ernor of the State of Hawaii that as the result of

14 an amendment to the Hawaii Prepaid Health Care

15 Act enacted after the date of the enactment of the

16 Health Innovation Partnership Act of 1994—

17 ‘‘(i) the proportion of the population with

18 health care coverage under such Act is less than

19 such proportion on such date, or

20 ‘‘(ii) the level of benefit coverage provided

21 under such Act is less than the actuarial equiv22 alent of such level of coverage on such date,

23 subparagraph (A) shall not apply with respect to the

24 application of such amendment to such Act after the

25 date of such notification.’’.
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•HR 5119 IH

1 (b) EFFECTIVE DATE.—The amendment made by

2 subsection (a) shall take effect on the date of the enact3 ment of this Act and shall apply with respect to notifica4 tions made on or after such date.

5 SEC. 2103. ALTERNATIVE STATE PROVIDER PAYMENT SYS6 TEMS.

7 Notwithstanding any other provision of law, if a hos8 pital reimbursement system operated by a State meets the

9 requirements of section 1814(b) of the Social Security Act

10 (42 U.S.C. 1395f(b)) and has been approved by the Sec11 retary and in continuous operation since July 1, 1977, the

12 payment rates and methodologies required under the sys13 tem for services provided in the State shall apply to all

14 purchasers and payers, including those under employee

15 welfare benefit plans covered under the Employee Retire16 ment Income Security Act of 1974 (29 U.S.C. 1001 et

17 seq.), workers’ compensation programs under State law,

18 the Federal Employees’ Compensation Act under chapter

19 81 of title 5, United States Code, and Federal employee

20 health benefit plans under chapter 89 of title 5, United

21 States Code.

22 SEC. 2104. ALTERNATIVE STATE HOSPITAL SERVICES PAY23 MENT SYSTEMS.

24 (a) IN GENERAL.—No State shall be prevented from

25 enforcing—
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•HR 5119 IH

1 (1) a State system described in subsection (b),

2 or

3 (2) a State system described in subsection (c),

4 by any provision of the Employee Retirement Income Se5 curity Act of 1974 (29 U.S.C. 1001 et seq.) or chapter

6 81 or 89 of title 5, United States Code.

7 (b) REIMBURSEMENT CONTROL SYSTEM.—A State

8 system is described in this subsection if it is a State reim9 bursement control system in operation before the date of

10 the enactment of this Act which—

11 (1) applies to substantially all non-Federal

12 acute care hospitals in the State, and

13 (2) regulates substantially all rates of payment

14 (including maximum charges) in the State for inpa15 tient hospital services, except payments made under

16 title XVIII of the Social Security Act (42 U.S.C.

17 1395 et seq.).

18 (c) HEALTH INSURANCE REFORM SYSTEM.—A State

19 system is described in this subsection if it is a State health

20 insurance reform system in operation before the date of

21 the enactment of this Act which requires any insurer (in22 cluding a health maintenance organization) to comply with

23 requirements governing open enrollment and community

24 rating, including premium adjustments or other health

25 care assessments for the purpose of risk adjustment.
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•HR 5119 IH

1 (d) EFFECTIVE DATE.—In the case of a State system

2 described in subsection (b) or (c), the provisions of this

3 section shall apply before, on, and after the date of the

4 enactment of this Act.

5 SEC. 2105. EXEMPTION FROM ERISA PREEMPTION OF CER6 TAIN PROVISIONS OF THE LAW OF THE

7 STATE OF OREGON RELATING TO HEALTH

8 PLANS.

9 (a) IN GENERAL.—Section 514(b) of the Employee

10 Retirement Income Security Act of 1974 (29 U.S.C.

11 1144(b)) is amended by adding at the end the following

12 new paragraph:

13 ‘‘(9)(A) Subject to subparagraph (B), subsection (a)

14 shall not apply to the following provisions of the law of

15 the State of Oregon as applied to a group health plan:

16 ‘‘(i) Chapter 838, Oregon Laws 1989 (relating

17 to the creation and operation of a high-risk insur18 ance pool).

19 ‘‘(ii) Chapter 591, Oregon Laws 1987, chapter

20 381, Oregon Laws 1989, and chapter 916, Oregon

21 Laws 1991 (relating to employer-based health plan

22 coverage reforms).

23 ‘‘(iii) Chapter 470, Oregon Laws 1991 (relating

24 to health care cost containment and technology as25 sessment).
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1 ‘‘(iv) Chapter 836, Oregon Laws 1989 and

2 chapter 753, Oregon Laws 1991 (relating to

3 prioritization and medical assistance reforms).

4 ‘‘(v) Chapter 815, Oregon Laws 1993 (relating

5 to phasing in of employer coverage and other revi6 sions of the Oregon Health Plan).

7 ‘‘(vi) Any other provision of the law of the

8 State of Oregon, to the extent that such provision is

9 necessary to achieve universal coverage under the

10 Oregon Health Plan.

11 ‘‘(B) Subparagraph (A) shall apply with respect to

12 any provision of the law of the State of Oregon which pro13 vides, directly or indirectly, for taxation of employers or

14 group health plans only if under such provision the assess15 ment of the tax is under a uniform schedule, applicable

16 to all employers and group health plans, and does not dis17 criminate on the basis of the extent to which a group

18 health plan is insured.

19 ‘‘(C) For purposes of this paragraph, the term ‘group

20 health plan’ has the meaning provided in section 607(1).’’.

21 (b) APPLICABILITY OF FEDERAL HEALTH REFORM

22 LEGISLATION.—The State of Oregon shall not be treated

23 as failing to comply with applicable requirements of any

24 Federal health reform law, which is enacted on or after

25 the date of the enactment of this Act and which provides
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•HR 5119 IH

1 for coverage of individuals under a comprehensive benefit

2 package, before the first day of the first calendar year fol3 lowing the calendar year in which all other States have

4 in effect plans under which individuals are eligible for cov5 erage under a comprehensive benefit package in compli6 ance with such law.

7 TITLE III—PUBLIC HEALTH AND

8 RURAL AND UNDERSERVED

9 ACCESS IMPROVEMENT

10 SEC. 3001. SHORT TITLE.

11 This title may be cited as the ‘‘Public Health and

12 Rural and Underserved Access Improvement Act of

13 1994’’.

14 SEC. 3002. ESTABLISHMENT OF NEW TITLE XXVII REGARD15 ING PUBLIC HEALTH PROGRAMS.

16 The Public Health Service Act (42 U.S.C. 201 et

17 seq.) is amended by adding at the end the following title:
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•HR 5119 IH

1 ‘‘TITLE XXVII—PUBLIC HEALTH

2 PROGRAMS IMPROVEMENT

3 ‘‘Subtitle A—Core Functions of

4 Public Health Programs

5 ‘‘PART 1—FORMULA GRANTS TO STATES

6 ‘‘SEC. 2711. AUTHORIZATIONS OF APPROPRIATIONS FROM

7 FUND.

8 ‘‘For the purpose of carrying out this subtitle, there

9 are authorized to be appropriated from the Health Care

10 Reform Trust Fund established under section

11 9551(a)(2)(A) of the Internal Revenue Code of 1986

12 (hereafter referred to in this title as the ‘‘Fund’’),

13 $200,000,000 for fiscal year 1996, $350,000,000 for fis14 cal year 1997, $500,000,000 for fiscal year 1998,

15 $650,000,000 for fiscal year 1999, and $700,000,000 for

16 fiscal year 2000.

17 ‘‘SEC. 2712. FORMULA GRANTS TO STATES FOR CORE

18 HEALTH FUNCTIONS.

19 ‘‘(a) IN GENERAL.—In the case of each State that

20 submits to the Secretary an application in accordance with

21 section 2715 for a fiscal year, the Secretary of Health and

22 Human Services, acting through the Director of the Cen23 ters for Disease Control and Prevention, shall make a

24 grant to the State for carrying out the activities described
41

•HR 5119 IH

1 in subsection (c). The award shall consist of the allotment

2 determined under section 2716 for the State.

3 ‘‘(b) GENERAL PURPOSE.—The purpose of this sub4 title is to provide for improvements in the health status

5 of the public through carrying out the activities described

6 in subsection (c) toward attaining the Healthy People

7 2000 Objectives (as defined in section 2799A). A funding

8 agreement for a grant under subsection (a) is that—

9 ‘‘(1) the grant will be expended for such activi10 ties; and

11 ‘‘(2) the activities will be carried out by the

12 State in collaboration with local public health de13 partments, health education and training centers,

14 neighborhood health centers, and other community

15 health providers.

16 ‘‘(c) CORE FUNCTIONS OF PUBLIC HEALTH PRO17 GRAMS.—Subject to the purpose described in subsection

18 (b), the activities referred to in subsection (a) are the fol19 lowing:

20 ‘‘(1) Data collection, and analytical activities,

21 related to population-based status and outcomes

22 monitoring, including the following:

23 ‘‘(A) The regular collection and analysis of

24 public health data (including the 10 leading

25 causes of death and their costs to society).
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1 ‘‘(B) Vital statistics.

2 ‘‘(C) Personal health services data.

3 ‘‘(D) The supply and distribution of health

4 professionals.

5 ‘‘(2) Activities to reduce environmental risk and

6 to assure the safety of housing, schools, workplaces,

7 day-care centers, food and water, including the fol8 lowing activities:

9 ‘‘(A) Monitoring the overall public health

10 status and safety of communities.

11 ‘‘(B) Assessing exposure to high lead levels

12 and other environmental contaminants; and ac13 tivities for abatement of toxicant hazards, in14 cluding lead-related hazards.

15 ‘‘(C) Monitoring the quality of community

16 water supplies used for consumption or for rec17 reational purposes.

18 ‘‘(D) Monitoring sewage and solid waste

19 disposal, radiation exposure, radon exposure,

20 and noise levels.

21 ‘‘(E) Monitoring indoor and ambient air

22 quality and related risks to vulnerable popu23 lations.

24 ‘‘(F) Assuring recreation, worker, and

25 school safety.
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•HR 5119 IH

1 ‘‘(G) Enforcing public health safety and

2 sanitary codes.

3 ‘‘(H) Monitoring community access to ap4 propriate health services.

5 ‘‘(I) Other activities relating to promoting

6 and protecting the public health of commu7 nities.

8 ‘‘(3) Investigation, control, and public-aware9 ness activities regarding adverse health conditions

10 (such as emergency treatment preparedness, commu11 nity efforts to reduce violence, outbreaks of commu12 nicable diseases within communities, chronic disease

13 and dysfunction exposure-related conditions, toxic

14 environmental pollutants, occupational and rec15 reational hazards, motor vehicle accidents, and other

16 threats to the health status of individuals).

17 ‘‘(4) Public information and education pro18 grams to reduce risks to health (such as use of to19 bacco; alcohol and other drugs; unintentional injury

20 from accidents, including motor vehicle accidents;

21 sexual activities that increase the risk of HIV trans22 mission and sexually transmitted diseases; poor diet;

23 physical inactivity; stress-related illness; mental

24 health problems; genetic disorders; and low child25 hood immunization levels).
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1 ‘‘(5) Provision of public health laboratory serv2 ices that complement private clinical laboratory serv3 ices and that screen for diseases and conditions

4 (such as metabolic diseases in newborns, provide as5 sessments of blood lead levels and other environ6 mental toxicants, diagnose and contact tracing of

7 sexually transmitted diseases, tuberculosis and other

8 diseases requiring partner notification, test for infec9 tious and food-borne diseases, and monitor the safe10 ty of water and food supplies).

11 ‘‘(6) Training and education of new and exist12 ing health professionals in the field of public health,

13 with special emphasis on epidemiology, biostatistics,

14 health education, public health administration, pub15 lic health nursing and dentistry, environmental and

16 occupational health sciences, public health nutrition,

17 social and behavioral health sciences, operations re18 search, and laboratory technology.

19 ‘‘(7) Leadership, policy development and admin20 istration activities, including assessing needs and the

21 supply and distribution of health professionals; the

22 setting of public health standards; the development

23 of community public health policies; and the develop24 ment of community public health coalitions.

25 ‘‘(d) RESTRICTIONS ON USE OF GRANT.—
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1 ‘‘(1) IN GENERAL.—A funding agreement for a

2 grant under subsection (a) for a State is that the

3 grant will not be expended—

4 ‘‘(A) to provide inpatient services;

5 ‘‘(B) to make cash payments to intended

6 recipients of health services;

7 ‘‘(C) to purchase or improve land, pur8 chase, construct, or permanently improve (other

9 than minor remodeling) any building or other

10 facility, or purchase major medical equipment;

11 ‘‘(D) to satisfy any requirement for the ex12 penditure of non-Federal funds as a condition

13 for the receipt of Federal funds; or

14 ‘‘(E) to provide financial assistance to any

15 entity other than a public or nonprofit private

16 entity.

17 ‘‘(2) LIMITATION ON ADMINISTRATIVE EX18 PENSES.—A funding agreement for a grant under

19 subsection (a) is that the State involved will not ex20 pend more than 20 percent of the grant for adminis21 trative expenses with respect to the grant.

22 ‘‘(e) MAINTENANCE OF EFFORT.—A funding agree23 ment for a grant under subsection (a) is that the State

24 involved will maintain expenditures of non-Federal

25 amounts for core health functions at a level that is not
46

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1 less than the level of such expenditures maintained by the

2 State for the fiscal year preceding the first fiscal year for

3 which the State receives such a grant.

4 ‘‘SEC. 2713. NUMBER OF FUNCTIONS; PLANNING.

5 ‘‘(a) NUMBER OF FUNCTIONS.—Subject to sub6 section (b), a funding agreement for a grant under section

7 2712 is that the State involved will carry out each of the

8 activities described in subsection (c) of such section.

9 ‘‘(b) PLANNING.—In making grants under section

10 2712, the Secretary shall for each State designate a period

11 during which the State is to engage in planning to meet

12 the responsibilities of the State under subsection (a). The

13 period so designated may not exceed 18 months. With re14 spect to such period for a State, a funding agreement for

15 a grant under section 2712 for any fiscal year containing

16 any portion of the period is that, during the period, the

17 State will expend the grant only for such planning.

18 ‘‘SEC. 2714. SUBMISSION OF INFORMATION; REPORTS.

19 ‘‘(a) SUBMISSION OF INFORMATION.—The Secretary

20 may make a grant under section 2712 only if the State

21 involved submits to the Secretary the following informa22 tion:

23 ‘‘(1) A description of the relationship between

24 community health providers, public and private
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•HR 5119 IH

1 health plans, and the public health system of the

2 State.

3 ‘‘(2) A description of existing deficiencies in the

4 public health system at the State level and the local

5 level, using standards under the Healthy People

6 2000 Objectives.

7 ‘‘(3) A description of public health priorities

8 identified at the State level and local levels, includ9 ing the 10 leading causes of death and their respec10 tive direct and indirect costs to the State and the

11 Federal Government.

12 ‘‘(4) Measurable outcomes and process objec13 tives (using criteria under the Healthy People 2000

14 Objectives) which indicate improvements in health

15 status as a result of the activities carried out under

16 section 2712(c).

17 ‘‘(5) Information regarding each such activity,

18 which—

19 ‘‘(A) identifies the amount of State and

20 local funding expended on each such activity for

21 the fiscal year preceding the fiscal year for

22 which the grant is sought; and

23 ‘‘(B) provides a detailed description of how

24 additional Federal funding will improve each
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1 such activity by both the State and local public

2 health agencies.

3 ‘‘(6) A description of activities under section

4 2712(c) to be carried out at the local level, and a

5 specification for each such activity of—

6 ‘‘(A) the communities in which the activity

7 will be carried out and any collaborating agen8 cies; and

9 ‘‘(B) the amount of the grant to be ex10 pended for the activity in each community so

11 specified.

12 ‘‘(7) A description of how such activities have

13 been coordinated with activities supported under

14 title V of the Social Security Act (relating to mater15 nal and child health).

16 ‘‘(b) REPORTS.—A funding agreement for a grant

17 under section 2712 is that the States involved will, not

18 later than the date specified by the Secretary, submit to

19 the Secretary a report describing—

20 ‘‘(1) the purposes for which the grant was ex21 pended;

22 ‘‘(2) the health status of the population of the

23 State, as measured by criteria under the Healthy

24 People 2000 Objectives; and
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1 ‘‘(3) the progress achieved and obstacles en2 countered in using uniform data sets under such Ob3 jectives.

4 ‘‘SEC. 2715. APPLICATION FOR GRANT.

5 ‘‘The Secretary may make a grant under section

6 2712 only if an application for the grant is submitted to

7 the Secretary, the application contains each agreement de8 scribed in this part, the application contains the informa9 tion required in section 2712(c), and the application is in

10 such form, is made in such manner, and contains such

11 agreements, assurances, and information as the Secretary

12 determines to be necessary to carry out this part.

13 ‘‘SEC. 2716. DETERMINATION OF AMOUNT OF ALLOTMENT.

14 ‘‘For purposes of section 2712, the allotment under

15 this section for a State for a fiscal year shall be deter16 mined through a formula established by the Secretary on

17 the basis of the population, economic indicators, and

18 health status of each State. Such allotment shall be the

19 product of—

20 ‘‘(1) a percentage determined under the for21 mula; and

22 ‘‘(2) the amount appropriated under section

23 2711 for the fiscal year, less any amounts reserved

24 under section 2717.
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1 ‘‘SEC. 2717. ALLOCATIONS FOR CERTAIN ACTIVITIES.

2 ‘‘Of the amounts made available under section 2711

3 for a fiscal year for carrying out this part, the Secretary

4 may reserve not more than 15 percent for carrying out

5 the following activities:

6 ‘‘(1) Technical assistance with respect to plan7 ning, development, and operation of activities under

8 section 2712(b), including provision of biostatistical

9 and epidemiological expertise, provision of laboratory

10 expertise, and the development of uniform data sets

11 under the Health People 2000 Objectives.

12 ‘‘(2) Development and operation of a national

13 information network among State and local health

14 agencies for utilizing such uniform data sets.

15 ‘‘(3) Program monitoring and evaluation of ac16 tivities carried out under section 2712(b).

17 ‘‘(4) Development of a unified electronic report18 ing mechanism to improve the efficiency of adminis19 trative management requirements regarding the pro20 vision of Federal grants to State public health agen21 cies.
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1 ‘‘PART 2—COMPREHENSIVE EVALUATION OF DIS2 EASE PREVENTION AND HEALTH PRO3 MOTION PROGRAMS

4 ‘‘SEC. 2718. AUTHORIZATIONS OF APPROPRIATIONS FROM

5 FUND.

6 ‘‘For the purpose of carrying out this part, there are

7 authorized to be appropriated from the Fund,

8 $100,000,000 for fiscal year 1996, and $150,000,000 for

9 each of the fiscal years 1997 through 2000.

10 ‘‘SEC. 2719. EVALUATION OF PROGRAMS.

11 ‘‘(a) GRANTS.—The Secretary may make grants to,

12 or enter into cooperative agreements or contracts with, eli13 gible entities for the purpose of enabling such entities to

14 carry out evaluations of the type described in subsection

15 (c). The Secretary shall carry out this section acting

16 through the Director of the Centers for Disease Control

17 and Prevention, subject to subsection (g).

18 ‘‘(b) REQUIREMENTS.—

19 ‘‘(1) ELIGIBLE ENTITIES.—To be eligible to re20 ceive an award of a grant, cooperative agreement, or

21 contract under subsection (a), an entity must—

22 ‘‘(A) be a public, nonprofit, or private en23 tity or a university;

24 ‘‘(B) prepare and submit to the Secretary

25 an application at such time, in such form, and

26 containing such information as the Secretary
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1 may require, including a plan for the conduct of

2 the evaluation under the grant;

3 ‘‘(C) provide assurances that any informa4 tion collected while conducting evaluations

5 under this section will be maintained in a con6 fidential manner with respect to the identities

7 of the individuals from which such information

8 is obtained; and

9 ‘‘(D) meet any other requirements that the

10 Secretary determines to be appropriate.

11 ‘‘(2) TYPES OF ENTITIES.—In making awards

12 under subsection (a), the Secretary shall consider

13 applications from entities proposing to conduct eval14 uations using community programs, managed care

15 programs, State and county health departments,

16 public education campaigns, school programs, and

17 other appropriate programs. The Secretary shall en18 sure that not less than 25 percent of the amounts

19 appropriated under section 2718 for a fiscal year are

20 used for making such awards to entities that will use

21 the amounts to conduct evaluations in the work22 place.

23 ‘‘(c) USE OF FUNDS.—

24 ‘‘(1) EVALUATIONS.—An award under sub25 section (a) shall be used to—
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•HR 5119 IH

1 ‘‘(A) conduct evaluations to determine the

2 extent to which clinical preventive services,

3 health promotion and unintentional injury pre4 vention activities, and interpersonal and com5 munity violence prevention activities, achieve

6 short-term and long-term health care cost re7 ductions and health status improvement with

8 respect to the Healthy People 2000 Objectives;

9 and

10 ‘‘(B) evaluate other areas determined ap11 propriate by the Secretary.

12 ‘‘(2) INCLUSION OF CERTAIN POPULATION

13 GROUPS.—In carrying out this section, the Secretary

14 shall ensure that data concerning women, children,

15 minorities, older individuals with different income

16 levels, retirees, and individuals from diverse geo17 graphical backgrounds, are obtained.

18 ‘‘(3) MINIMUM SERVICES.—The evaluations

19 that the Secretary may provide for under this sec20 tion include (but are not limited to) evaluations of

21 programs that provide one or more of the following

22 services:

23 ‘‘(A) Blood pressure screening and control

24 (to detect and control hypertension and coro25 nary health disease).
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•HR 5119 IH

1 ‘‘(B) Early cancer screening.

2 ‘‘(C) Blood cholesterol screening and con3 trol.

4 ‘‘(D) Smoking cessation programs.

5 ‘‘(E) Substance abuse programs.

6 ‘‘(F) Dietary and nutrition counseling, in7 cluding nutrition.

8 ‘‘(G) Physical fitness counseling.

9 ‘‘(H) Stress management.

10 ‘‘(I) Diabetes education and screening.

11 ‘‘(J) Intraocular pressure screening.

12 ‘‘(K) Monitoring of prescription drug use.

13 ‘‘(L) Violence and injury prevention pro14 grams.

15 ‘‘(M) Health education.

16 ‘‘(N) Immunization rates.

17 ‘‘(4) ENVIRONMENTAL DATA.—Evaluations con18 ducted under this section may consider the health ef19 fects and cost-effectiveness of certain environmental

20 programs, including fluoridation programs, traffic

21 safety programs, pollution control programs, acci22 dent prevention programs, and antismoking pro23 grams.

24 ‘‘(5) PUBLIC POLICIES.—Evaluations conducted

25 under this section may consider the effects of pre-
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•HR 5119 IH

1 vention-oriented social and economic policies on im2 provement of health status and their long-term cost

3 effectiveness.

4 ‘‘(6) USE OF EXISTING DATA.—In conducting

5 evaluations under this section, entities shall use ex6 isting data and health promotion and screening pro7 grams where practicable.

8 ‘‘(7) COOPERATION.—In providing for an eval9 uation under this section, the Secretary shall encour10 age the recipient of the award and public and pri11 vate entities with relevant expertise (including State

12 and local agencies) to collaborate for purposes of

13 conducting the evaluation.

14 ‘‘(d) SITES.—Recipients of awards under subsection

15 (a) shall select evaluation sites under the award that

16 present the greatest potential for new and relevant knowl17 edge. Such recipients, in selecting such sites, shall ensure

18 that—

19 ‘‘(1) the sites provide evidence of pilot testing,

20 process evaluation, formative evaluation, availability

21 assessment strategies and results;

22 ‘‘(2) the sites provide evidence of a clear defini23 tion of the program and protocols for the implemen24 tation of the evaluation; and
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•HR 5119 IH

1 ‘‘(3) the sites provide evidence of valid, appro2 priate and feasible assessment methods and tools

3 and a willingness to use common data items and in4 struments across such sites.

5 ‘‘(e) REPORTING REQUIREMENTS.—Not later than 1

6 year after an entity first receives an award under sub7 section (a), and not less than once during each 1-year pe8 riod thereafter for which such an award is made to the

9 entity, the entity shall prepare and submit to the Sec10 retary a report containing a description of the activities

11 under this section conducted during the period for which

12 the report is prepared, and the findings derived as a result

13 of such activities.

14 ‘‘(f) TERM OF EVALUATIONS.—Evaluations con15 ducted under this section shall be for a period of not less

16 than 3 years and may continue as necessary to permit the

17 grantee to adequately measure the full benefit of the eval18 uations.

19 ‘‘(g) DISSEMINATION AND GUIDELINES.—

20 ‘‘(1) CONSULTATION.—The Secretary shall

21 carry out this subsection acting through the Director

22 of the Centers for Disease Control and Prevention

23 and the Administrator for Health Care Policy and

24 Research.
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1 ‘‘(2) GUIDELINES.—The Secretary shall, where

2 feasible and practical, develop and issue practice

3 guidelines that are based on the results of evalua4 tions conducted under this section. The practice

5 guidelines shall be developed by the Secretary utiliz6 ing expert practitioners to assist in the development

7 and implementation of these guidelines.

8 ‘‘(3) DATA.—

9 ‘‘(A) IN GENERAL.—The Secretary shall

10 collect, store, analyze, and make available data

11 related to the formulation of the guidelines that

12 is provided to the Centers for Disease Control

13 and Prevention by entities conducting evalua14 tions under this section.

15 ‘‘(B) USE OF DATA.—The Secretary

16 shall—

17 ‘‘(i) identify activities that prevent

18 disease, illness, injury and disability, and

19 promote good health practices; ascertain

20 their cost-effectiveness; and identify their

21 potential to overall health status with re22 spect to Healthy People 2000 Objectives;

23 ‘‘(ii) disseminate practice guidelines to

24 State and county health departments,

25 State insurance departments, insurance
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•HR 5119 IH

1 companies, employers, professional medical

2 organizations, and others determined ap3 propriate by the Secretary; and

4 ‘‘(iii) provide information with respect

5 to recidivism rates of participation in the

6 evaluations.

7 ‘‘(4) DISSEMINATION.—The Secretary may dis8 seminate information collected from evaluations

9 under this section.

10 ‘‘(h) LIMITATION.—Amounts appropriated for carry11 ing out this section shall not be utilized to provide services.

12 ‘‘Subtitle B—Opportunities for

13 Education and Training in Pub14 lic Health

15 ‘‘PART 1—SCHOLARSHIP AND LOAN REPAYMENT

16 PROGRAMS REGARDING SERVICE IN PUBLIC

17 HEALTH POSITIONS

18 ‘‘SEC. 2721. AUTHORIZATIONS OF APPROPRIATIONS FROM

19 FUND.

20 ‘‘For the purpose of carrying out this part, there are

21 authorized to be appropriated from the Fund,

22 $50,000,000 for each of the fiscal years 1996 through

23 2000.
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1 ‘‘SEC. 2722. SCHOLARSHIP PROGRAM.

2 ‘‘(a) IN GENERAL.—The Secretary, acting through

3 the Administrator of the Health Resources and Services

4 Administration and in consultation with the Director of

5 the Centers for Disease Control and Prevention, shall

6 carry out a program under which the Secretary awards

7 scholarships to individuals described in subsection (b) for

8 the purpose of assisting the individuals with the costs of

9 attending public and nonprofit private schools of public

10 health (or other public or nonprofit private institutions

11 providing graduate or specialized training in public

12 health).

13 ‘‘(b) ELIGIBLE INDIVIDUALS.—An individual re14 ferred to in subsection (a) is any individual meeting the

15 following conditions:

16 ‘‘(1) The individual is enrolled (or accepted for

17 enrollment) at a school or other institution referred

18 to in subsection (a) as a full-time or part-time stu19 dent in a program providing training in a health

20 profession in a field of public health (including the

21 fields of epidemiology, biostatistics, environmental

22 health, health administration and planning, behav23 ioral sciences, maternal and child health, occupa24 tional safety, public health nursing, nutrition, and

25 toxicology).
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1 ‘‘(2) The individual enters into the contract re2 quired pursuant to subsection (d) as a condition of

3 receiving the scholarship (relating to an agreement

4 to provide services in approved public health posi5 tions, as defined in section 2724).

6 ‘‘(c) ELIGIBLE SCHOOLS.—For fiscal year 1996 and

7 subsequent fiscal years, the Secretary may make an award

8 of a scholarship under subsection (a) only if the Secretary

9 determines that—

10 ‘‘(1) the school or other institution with respect

11 to which the award is to be provided has coordinated

12 the activities of the school or institution with rel13 evant activities of the Health Resources and Services

14 Administration and the Centers for Disease Control

15 and Prevention; and

16 ‘‘(2) not fewer than 60 percent of the graduates

17 of the school or institution are in public health posi18 tions determined by the Secretary to be consistent

19 with the needs of the United States regarding such

20 professionals.

21 ‘‘(d) APPLICABILITY OF CERTAIN PROVISIONS.—Ex22 cept as inconsistent with this section or section 2724, the

23 provisions of subpart III of part D of title III (relating

24 to the Scholarship and Loan Repayment Programs of the

25 National Health Service Corps) apply to an award of a
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1 scholarship under subsection (a) to the same extent and

2 in the same manner as such provisions apply to an award

3 of a scholarship under section 338A.

4 ‘‘SEC. 2723. LOAN REPAYMENT PROGRAM.

5 ‘‘(a) IN GENERAL.—The Secretary, acting through

6 the Administrator of the Health Resources and Services

7 Administration and in consultation with the Director of

8 the Centers for Disease Control and Prevention, shall

9 carry out a program under which the Federal Government

10 enters into agreements to repay all or part of the edu11 cational loans of individuals meeting the following condi12 tions:

13 ‘‘(1) The individual involved is a graduate of a

14 school or other institution described in section

15 2722(a).

16 ‘‘(2) The individual meets the applicable legal

17 requirements to provide services as a public health

18 professional (including a professional in any of the

19 fields specified in section 2722(b)(1)).

20 ‘‘(3) The individual enters into the contract re21 quired pursuant to subsection (b) as a condition of

22 the Federal Government repaying such loans (relat23 ing to an agreement to provide services in approved

24 public health positions, as defined in section 2724).
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1 ‘‘(b) APPLICABILITY OF CERTAIN PROVISIONS.—Ex2 cept as inconsistent with this section or section 2724, the

3 provisions of subpart III of part D of title III (relating

4 to the Scholarship and Loan Repayment Programs of the

5 National Health Service Corps) apply to an agreement re6 garding repayment under subsection (a) to the same ex7 tent and in the same manner as such provisions apply to

8 an agreement regarding repayment under section 338B.

9 ‘‘(c) AMOUNT OF REPAYMENTS.—For each year for

10 which an individual contracts to serve in an approved pub11 lic health position pursuant to subsection (b), the Sec12 retary may repay not more than $20,000 of the principal

13 and interest of the educational loans of the individual.

14 ‘‘SEC. 2724. APPROVED PUBLIC HEALTH POSITIONS.

15 ‘‘(a) POSITION REGARDING POPULATIONS WITH SIG16 NIFICANT NEED FOR SERVICES.—

17 ‘‘(1) IN GENERAL.—With respect to the pro18 grams under this part, the obligated service of a

19 program participant pursuant to sections 2722(d)

20 and 2723(b) shall be provided through an assign21 ment, to an entity described in subsection (b), for a

22 position in which the participant provides services as

23 a public health professional to a population deter24 mined by the Secretary to have a significant unmet

25 need for the services of such a professional.
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1 ‘‘(2) PERIOD OF SERVICE.—For purposes of

2 sections 2722(d) and 2723(d), the period of obli3 gated service is the following, as applicable to the

4 program participant involved:

5 ‘‘(A) In the case of scholarships under sec6 tion 2722 for full-time students, the greater

7 of—

8 ‘‘(i) 1 year for each year for which

9 such a scholarship is provided; or

10 ‘‘(ii) 2 years.

11 ‘‘(B) In the case of scholarships under sec12 tion 2722 for part-time students, a period de13 termined by the Secretary on the basis of the

14 number of hours of education or training re15 ceived under the scholarship, considering the

16 percentage constituted by the ratio of such

17 number to the number of hours for a full-time

18 student in the program involved.

19 ‘‘(C) In the case of the loan repayments

20 under section 2723, such period as the Sec21 retary and the participant may agree, except

22 that the period may not be less than 2 years.

23 ‘‘(b) APPROVAL OF ENTITIES FOR ASSIGNMENT OF

24 PROGRAM PARTICIPANTS.—The entities referred to in

25 subsection (a) are public and nonprofit private entities ap-
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•HR 5119 IH

1 proved by the Secretary as meeting such requirements for

2 the assignment of a program participant as the Secretary

3 may establish. The entities that the Secretary may so ap4 prove include State and local departments of health, public

5 hospitals, community and neighborhood health clinics, mi6 grant health clinics, community-based health-related orga7 nizations, certified regional poison control centers, pur8 chasing cooperatives regarding health insurance, and any

9 other public or nonprofit private entity.

10 ‘‘(c) DEFINITIONS.—For purposes of this part:

11 ‘‘(1) The term ‘approved public health position’,

12 with respect to a program participant, means a posi13 tion to which the participant is assigned pursuant to

14 subsection (a).

15 ‘‘(2) The term ‘program participant’ means an

16 individual who enters into a contract pursuant to

17 section 2722(b)(2) or 2723(a)(3).

18 ‘‘SEC. 2725. ALLOCATION OF FUNDS; SPECIAL CONSIDER19 ATIONS.

20 ‘‘(a) ALLOCATIONS REGARDING NEW PARTICIPANTS

21 IN SCHOLARSHIP PROGRAM.—Of the amounts appro22 priated under section 2721 for a fiscal year, the Secretary

23 shall obligate not less than 30 percent for the purpose of

24 providing awards for scholarships under section 2722 to
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1 individuals who have not previously received such scholar2 ships.

3 ‘‘(b) SPECIAL CONSIDERATION FOR CERTAIN INDI4 VIDUALS.—In making awards of scholarships under sec5 tion 2722 and making repayments under section 2723, the

6 Secretary shall give special consideration to individuals

7 who are in the armed forces of the United States or who

8 are veterans of the armed forces.

9 ‘‘PART 2—EDUCATIONAL INSTITUTIONS

10 REGARDING PUBLIC HEALTH

11 ‘‘SEC. 2731. AUTHORIZATIONS OF APPROPRIATIONS FROM

12 FUND.

13 ‘‘For the purpose of carrying out this part from the

14 Fund, there are authorized to be appropriated from the

15 Fund, $100,000,000 for each of the fiscal years 1996

16 through 2000.

17 ‘‘SEC. 2732. GRANTS FOR EXPANDING CAPACITY OF INSTI18 TUTIONS.

19 ‘‘(a) IN GENERAL.—The Secretary may make grants

20 to institutions described in subsection (b) for the purpose

21 of expanding the educational capacities of the institutions

22 through recruiting and retaining faculty, curriculum devel23 opment, and coordinating the activities of the institutions

24 regarding education, training, and field placements.
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•HR 5119 IH

1 ‘‘(b) RELEVANT INSTITUTIONS.—The institutions re2 ferred to in subsection (a) are public and nonprofit pri3 vate—

4 ‘‘(1) schools of public health;

5 ‘‘(2) departments of community and preventive

6 medicine that—

7 ‘‘(A) are within schools of medicine and

8 schools of osteopathic medicine; and

9 ‘‘(B) have established formal arrangements

10 with schools of public health in order to award

11 joint degrees in public health and another

12 health profession; and

13 ‘‘(3) schools of nursing or dentistry that have

14 established formal arrangements with schools of

15 public health in order to carry out educational pro16 grams in public health at the schools of nursing or

17 dentistry, respectively.

18 ‘‘(c) REQUIREMENTS REGARDING CURRICULUM DE19 VELOPMENT.—A funding agreement for a grant under

20 subsection (a) for an institution is that, to the extent de21 termined to be appropriate by the Secretary, the curricu22 lum of institution will include the following:

23 ‘‘(1) Subject to subsection (d)(1), part-time

24 nondegree programs for public health professionals

25 who need further training in fields of public health.
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1 ‘‘(2) With respect to the program of community

2 health advisors established in part 5 of subtitle E,

3 a program to train individuals to serve as super4 visors under such part (including training and evalu5 ating the community health advisors), which pro6 gram is carried out in collaboration with local public

7 health departments and health education and train8 ing centers.

9 ‘‘(3) A program under which the institution col10 laborates with health departments and elementary

11 and secondary schools to develop a health education

12 curriculum for use in the program established under

13 subtitle B of the Public Health Improvement Act of

14 1994.

15 ‘‘(d) ADDITIONAL REQUIREMENTS.—Funding agree16 ments for a grant under subsection (a) for an institution

17 are as follows:

18 ‘‘(1) In developing the curriculum under the

19 grant, the institution will consult with the health de20 partments in the State involved, and will follow the

21 relevant priorities of such departments.

22 ‘‘(2) The institution will, as appropriate in the

23 determination of the Secretary, coordinate the activi24 ties of the institution under the grant with relevant

25 activities of the Health Resources and Services Ad-
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1 ministration and the Centers for Disease Control

2 and Prevention.

3 ‘‘SEC. 2733. COORDINATION OF GRANT ACTIVITIES WITH

4 NATIONAL PRIORITIES.

5 ‘‘The Secretary shall—

6 ‘‘(1) determine the needs of the United States

7 regarding the education and geographic distribution

8 of public health professionals;

9 ‘‘(2) determine priorities among such needs;

10 and

11 ‘‘(3) in making grants under section 2732, en12 sure that the curricula developed under such section,

13 and the expertise of the faculty recruited and re14 tained under such section, are consistent with such

15 priorities.

16 ‘‘SEC. 2734. CERTAIN REQUIREMENTS FOR GRANTS.

17 ‘‘For fiscal year 1997 and subsequent fiscal years,

18 the Secretary may make a grant under section 2732 only

19 if the institution involved is in compliance with the follow20 ing:

21 ‘‘(1) The institution has coordinated the activi22 ties of the school or institution with relevant activi23 ties of the Health Resources and Services Adminis24 tration and the Centers for Disease Control and

25 Prevention.
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1 ‘‘(2) A significant number of the faculty of the

2 institution has served as practitioners in public

3 health.

4 ‘‘(3) The institution has consulted with public

5 health departments and public hospital systems in

6 the State involved in order to develop a curriculum

7 that reflects the needs and priorities of the State re8 garding the public health.

9 ‘‘(4) The institution has coordinated the activi10 ties of the institution with the activities of the health

11 departments and of community groups.

12 ‘‘(5) The institution carries out a program for

13 part-time students to receive training in fields of

14 public health.

15 ‘‘(6) Not less than 60 percent of the graduates

16 of the school or institution are in public health posi17 tions determined by the Secretary to be consistent

18 with the needs of the United States regarding such

19 professionals.

20 ‘‘PART 3—EXPANSION OF COMPETENCY IN

21 PUBLIC HEALTH

22 ‘‘SEC. 2736. AUTHORIZATIONS OF APPROPRIATIONS FROM

23 FUND.

24 ‘‘For the purpose of carrying out this section, there

25 is authorized to be appropriated from the Fund,
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1 $60,000,000 for each of the fiscal years 1996 through

2 2000.

3 ‘‘SEC. 2737. GRANTS TO STATES.

4 ‘‘(a) STATES LACKING ADEQUATE TRAINING PRO5 GRAMS.—

6 ‘‘(1) IN GENERAL.—The Secretary may make

7 grants to States in which there is either no program

8 of training in a field of public health, or only one

9 such program, but in which there are 1 or more

10 schools of medicine, osteopathic medicine, nursing,

11 dentistry, social work, pharmacy, or health adminis12 tration. A funding agreement for such a grant is

13 that the purpose of the grant is for the State in14 volved to assist 1 or more of such schools in develop15 ing and integrating public health curricula for the

16 schools.

17 ‘‘(2) SPECIAL CONSIDERATIONS IN MAKING

18 GRANTS.—In making grants under paragraph (1),

19 the Secretary shall give special consideration to

20 States that agree to consult with 1 or more schools

21 of public health in carrying out the purpose de22 scribed in such subsection.

23 ‘‘(b) STATES WITH NONACCREDITED SCHOOLS.—

24 The Secretary may make grants to States in which there

25 are 1 or more nonaccredited schools of public health. A
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1 funding agreement for such a grant is that the purpose

2 of the grant is for the State involved to assist 1 or more

3 of such schools in improving the schools.

4 ‘‘(c) AMOUNT OF GRANT; LIMITATION REGARDING

5 INDIVIDUAL EDUCATIONAL ENTITIES.—

6 ‘‘(1) AMOUNT.—The amount of a grant under

7 this section to a State may not exceed $6,000,000.

8 ‘‘(2) LIMITATION.—A funding agreement for a

9 grant under this section for a State is that, with re10 spect to the school involved, the State will not pro11 vide more than 2 years of assistance to the school

12 from grants under this section.

13 ‘‘PART 4—AREA HEALTH EDUCATION CENTERS

14 ‘‘SEC. 2738. AUTHORIZATIONS OF APPROPRIATIONS FROM

15 FUND.

16 ‘‘(a) ADDITIONAL FUNDING.—For the purpose of

17 carrying out section 746 with respect to area health edu18 cation center programs, there are authorized to be appro19 priated from the Fund, $35,000,000 for each of the fiscal

20 years 1996 through 2000.

21 ‘‘(b) RELATION TO OTHER FUNDS.—The authoriza22 tions of appropriations established in subsection (a) are

23 in addition to any other authorizations of appropriations

24 that are available for the purpose described in such sub25 section.
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1 ‘‘PART 5—HEALTH EDUCATION TRAINING

2 CENTERS

3 ‘‘SEC. 2739. AUTHORIZATIONS OF APPROPRIATIONS FROM

4 FUND.

5 ‘‘(a) ADDITIONAL FUNDING.—For the purpose of

6 carrying out section 746 with respect to health education

7 and training centers, there are authorized to be appro8 priated from the Fund, $20,000,000 for each of the fiscal

9 years 1996 through 2000.

10 ‘‘(b) RELATION TO OTHER FUNDS.—The authoriza11 tions of appropriations established in subsection (a) are

12 in addition to any other authorizations of appropriations

13 that are available for the purpose described in such sub14 section.

15 ‘‘Subtitle C—Regional Poison

16 Control Centers

17 ‘‘SEC. 2741. AUTHORIZATIONS OF APPROPRIATIONS FROM

18 FUND.

19 ‘‘For the purpose of carrying out this subtitle, there

20 is authorized to be appropriated from the Fund,

21 $50,000,000 for each of the fiscal years 1996 through

22 2000.

23 ‘‘SEC. 2742. GRANTS FOR REGIONAL CENTERS.

24 ‘‘(a) IN GENERAL.—The Secretary may make grants

25 to public and nonprofit private entities for centers to carry

26 out activities regarding—
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1 ‘‘(1) the prevention and treatment of poisoning;

2 and

3 ‘‘(2) such other activities regarding the control

4 of poisons as the Secretary determines to be appro5 priate.

6 ‘‘(b) REGIONAL CONSIDERATIONS.—In making

7 grants under subsection (a), the Secretary shall determine

8 the need in each of the principal geographic regions of

9 the United States for a center under such subsection, and

10 shall make the grants according to priorities established

11 by the Secretary on the basis of the extent of such need

12 in each of the regions. In carrying out the preceding sen13 tence, the Secretary shall ensure that no two centers re14 ceive grants for the same geographic service area.

15 ‘‘(c) MATCHING FUNDS.—

16 ‘‘(1) IN GENERAL.—With respect to the costs of

17 an entity in providing for centers under subsection

18 (a), the Secretary may make a grant under such

19 subsection only if the State in which the center is to

20 operate, or other public entities in the State, agree

21 to make available (directly or through donations

22 from public or private entities) non-Federal con23 tributions toward such costs in an amount deter24 mined by the Secretary.
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1 ‘‘(2) DETERMINATION OF AMOUNT CONTRIB2 UTED.—Non-Federal contributions required under

3 paragraph (1) may be in cash or in kind, fairly eval4 uated, including plant, equipment, or services.

5 Amounts provided by the Federal Government, or

6 services assisted or subsidized to any significant ex7 tent by the Federal Government, may not be in8 cluded in determining the amount of such non-Fed9 eral contributions.

10 ‘‘SEC. 2743. REQUIREMENTS REGARDING CERTIFICATION.

11 ‘‘(a) IN GENERAL.—Subject to subsection (b), the

12 Secretary may make a grant under section 2742 only if

13 the center involved has been certified by a professional or14 ganization in the field of poison control, and the Secretary

15 has approved the organization as having in effect stand16 ards for certification that reasonably provide for the pro17 tection of the public health with respect to poisoning. In

18 carrying out the preceding sentence, the Secretary shall

19 consider the standards established by the American Asso20 ciation of Poison Control Centers.

21 ‘‘(b) TEMPORARY WAIVER.—The Secretary may

22 waive the requirement of subsection (a) for a center for

23 a period not exceeding 1 year.
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1 ‘‘SEC. 2744. GENERAL PROVISIONS.

2 ‘‘(a) DURATION OF GRANT.—The period during

3 which payments are made under a grant under section

4 2742 may not exceed 3 years. The provision of such pay5 ments is subject to annual approval by the Secretary of

6 the payments and subject to the availability of appropria7 tions for the fiscal year involved to make the payments.

8 The preceding sentence may not be construed as establish9 ing a limitation on the number of such grants that may

10 be made to an entity.

11 ‘‘(b) STUDY REGARDING NEED FOR CENTERS.—

12 ‘‘(1) IN GENERAL.—The Secretary shall con13 duct a study of each of the centers for which a grant

14 under section 2742 has been provided. The purpose

15 of the study shall be to determine the effectiveness

16 of the centers in carrying out the activities described

17 in such section and the extent to which the activities

18 have been carried out in a cost-effective manner.

19 ‘‘(2) ALTERNATIVES TO CENTERS.—In carrying

20 out the study under paragraph (1), the Secretary

21 shall determine the extent to which the activities de22 scribed in section 2742 can be effectively carried out

23 through means other than centers under such sec24 tion. The alternative means considered by the Sec25 retary under the preceding sentence shall include the
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1 alternative of requiring public and private health

2 plans to carry out such activities.

3 ‘‘(3) DATE CERTAIN FOR COMPLETION.—Not

4 later than November 1, 1996, the Secretary shall

5 submit to the Congress a report describing the find6 ings made in the study under paragraph (1).

7 ‘‘(4) NOTICE TO CENTERS.—Not later than

8 February 1, 1997, the Secretary shall notify each

9 grantee under section 2742 whether the Secretary

10 considers the continued operation of the center in11 volved to be necessary in meeting the needs of the

12 geographic region involved for the activities de13 scribed in such section.

14 ‘‘Subtitle D—School-Related Health

15 Services

16 ‘‘PART 1—PROJECTS FOR PROVISION OF

17 SERVICES

18 ‘‘SEC. 2746. AUTHORIZATION OF APPROPRIATIONS FROM

19 FUND.

20 ‘‘(a) FUNDING FOR SCHOOL-RELATED HEALTH

21 SERVICES.—For the purpose of carrying out this part,

22 there are authorized to be appropriated from the Fund,

23 $100,000,000 for fiscal year 1996, $200,000,000 for fis24 cal year 1997, $300,000,000 for fiscal year 1998,
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1 $400,000,000 for fiscal year 1999, and $500,000,000 for

2 fiscal year 2000.

3 ‘‘(b) FUNDING FOR PLANNING AND DEVELOPMENT

4 GRANTS.—Of amounts made available under this section,

5 not to exceed $10,000,000 for each of fiscal years 1996

6 and 1997 may be utilized to carry out section 2749.

7 ‘‘SEC. 2747. ELIGIBILITY FOR GRANTS.

8 ‘‘(a) IN GENERAL.—

9 ‘‘(1) PLANNING AND DEVELOPMENT GRANTS.—

10 Entities eligible to apply for and receive grants

11 under section 2749 are—

12 ‘‘(A) State health agencies that apply on

13 behalf of local community partnerships; or

14 ‘‘(B) local community partnerships in

15 States in which health agencies have not suc16 cessfully applied.

17 ‘‘(2) OPERATIONAL GRANTS.—Entities eligible

18 to apply for and receive grants under section 2750

19 are—

20 ‘‘(A) a qualified State as designated under

21 subsection (c) that apply on behalf of local com22 munity partnerships; or

23 ‘‘(B) local community partnerships in

24 States that are not designated under subpara25 graph (A).
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1 ‘‘(b) LOCAL COMMUNITY PARTNERSHIPS.—

2 ‘‘(1) IN GENERAL.—A local community partner3 ship under subsection (a)(1)(B) and (a)(2)(B) is an

4 entity that, at a minimum includes—

5 ‘‘(A) a local health care provider, which

6 may be a local public health department, with

7 experience in delivering services to children and

8 youth or medically underserved populations;

9 ‘‘(B) local educational agency on behalf of

10 one or more public schools; and

11 ‘‘(C) one community based organization lo12 cated in the community to be served that has

13 a history of providing services to at-risk chil14 dren and youth.

15 ‘‘(2) RURAL COMMUNITIES.—In rural commu16 nities, local partnerships should seek to include, to

17 the fullest extent practicable, providers and commu18 nity based organizations with experience in serving

19 the target population.

20 ‘‘(3) PARENT AND COMMUNITY PARTICIPA21 TION.—An applicant described in subsection (a)

22 shall, to the maximum extent feasible, involve broad23 based community participation (including parents of

24 the youth to be served).
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1 ‘‘(c) QUALIFIED STATE.—A qualified State under

2 subsection (a)(2)(A) is a State that, at a minimum—

3 ‘‘(1) demonstrates an organizational commit4 ment (including a strategic plan) to providing a

5 broad range of health, health education and support

6 services to at-risk youth; and

7 ‘‘(2) has a memorandum of understanding or

8 cooperative agreement jointly entered into by the

9 State agencies responsible for health and education

10 regarding the planned delivery of health and support

11 services in school-based or school-linked centers.

12 ‘‘SEC. 2748. PREFERENCES.

13 ‘‘In making grants under sections 2749 and 2750,

14 the Secretary shall give priority to applicants whose-com15 munities to be served show the most substantial level of

16 need for health services among children and youth.

17 ‘‘SEC. 2749. PLANNING AND DEVELOPMENT GRANTS.

18 ‘‘(a) IN GENERAL.—The Secretary may make grants

19 during fiscal years 1996 and 1997 to entities eligible

20 under section 2747 to develop school-based or school21 linked health service sites.

22 ‘‘(b) USE OF FUNDS.—Amounts provided under a

23 grant under this section may be used for the following:

24 ‘‘(1) Planning for the provision of school health

25 services, including—
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1 ‘‘(A) an assessment of the need for health

2 services among youth in the communities to be

3 served;

4 ‘‘(B) the health services to be provided and

5 how new services will be integrated with exist6 ing services;

7 ‘‘(C) assessing and planning for the mod8 ernization and expansion of existing facilities

9 and equipment to accommodate such services;

10 and

11 ‘‘(D) an affiliation with relevant health

12 plans.

13 ‘‘(2) Recruitment and training of staff for the

14 administration and delivery of school health services.

15 ‘‘(3) The establishment of local community

16 partnerships as described in section 2747(b).

17 ‘‘(4) In the case of States, the development of

18 memorandums of understanding or cooperative

19 agreements for the coordinated delivery of health

20 and support services through school health service

21 sites.

22 ‘‘(5) Other activities necessary to assume oper23 ational status.

24 ‘‘(c) APPLICATION FOR GRANTS.—To be eligible to

25 receive a grant under this section an entity described in
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1 section 2747(a) shall submit an application in a form and

2 manner prescribed by the Secretary.

3 ‘‘(d) NUMBER OF GRANTS.—Not more than one plan4 ning grant may be made to a single applicant. A planning

5 grant may not exceed 2 years in duration.

6 ‘‘(e) AMOUNT AVAILABLE FOR DEVELOPMENT

7 GRANT.—The Secretary may award not to exceed—

8 ‘‘(1) $150,000 to entities under section

9 2747(a)(1)(A) and to localities planning for a city10 wide or countywide school health services delivery

11 system; and

12 ‘‘(2) $50,000 to entities under section

13 2747(a)(1)(B).

14 ‘‘SEC. 2750. GRANTS FOR OPERATION OF SCHOOL HEALTH

15 SERVICES.

16 ‘‘(a) IN GENERAL.—The Secretary may make grants

17 to eligible entities described in section 2747(a)(2) that

18 submit applications consistent with the requirements of

19 this section, to pay the cost of operating school-based or

20 school-linked health service sites.

21 ‘‘(b) USE OF GRANT.—Amounts provided under a

22 grant under this section may be used for the following—

23 ‘‘(1) health services, including diagnosis and

24 treatment of simple illnesses and minor injuries;
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1 ‘‘(2) preventive health services, including health

2 screenings follow-up health care, mental health, and

3 preventive health education;

4 ‘‘(3) enabling services and other necessary sup5 port services;

6 ‘‘(4) training, recruitment, and compensation of

7 health professionals and other staff necessary for the

8 administration and delivery of school health services;

9 and

10 ‘‘(5) referral services, including the linkage of

11 individuals to health plans, and community-based

12 health and social service providers.

13 ‘‘(c) APPLICATION FOR GRANT.—To be eligible to re14 ceive a grant under this section an entity described in sec15 tion 2747(a)(2) shall submit an application in a form and

16 manner prescribed by the Secretary. In order to receive

17 a grant under this section, an applicant must include in

18 the application the following information—

19 ‘‘(1) a description of the services to be fur20 nished by the applicant;

21 ‘‘(2) the amounts and sources of funding that

22 the applicant will expend, including estimates of the

23 amount of payments the applicant will receive from

24 health plans and other sources;
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1 ‘‘(3) a description of local community partner2 ships, including parent and community participation;

3 ‘‘(4) a description of the linkages with other

4 health and social service providers; and

5 ‘‘(5) such other information as the Secretary

6 determines to be appropriate.

7 ‘‘(d) ASSURANCES.—In order to receive a grant

8 under this section, an applicant must meet the following

9 conditions—

10 ‘‘(1) school health service sites will, directly or

11 indirectly, provide a broad range of health services,

12 in accordance with the determinations of the local

13 community partnership, that may include—

14 ‘‘(A) diagnosis and treatment of simple ill15 nesses and minor injuries;

16 ‘‘(B) preventive health services, including

17 health screenings and follow-up health care,

18 mental health and preventive health education;

19 ‘‘(C) enabling services; and

20 ‘‘(D) referrals (including referrals regard21 ing mental health and substance abuse) with

22 follow-up to ensure that needed services are re23 ceived;

24 ‘‘(2) the applicant provides services rec25 ommended by the health provider, in consultation
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1 with the local community partnership, and with the

2 approval of the local education agency;

3 ‘‘(3) the applicant provides the services under

4 this subsection to adolescents, and other school age

5 children and their families as deemed appropriate by

6 the local partnership;

7 ‘‘(4) the applicant maintains agreements with

8 community-based health care providers with a his9 tory of providing services to such populations for the

10 provision of health care services not otherwise pro11 vided directly or during the hours when school

12 health services are unavailable;

13 ‘‘(5) the applicant establishes an affiliation with

14 relevant health plans and will establish reimburse15 ment procedures and will make every reasonable ef16 fort to collect appropriate reimbursement for serv17 ices provided;

18 ‘‘(6) the applicant agrees to supplement and

19 not supplant the level of State or local funds under

20 the direct control of the applying State or participat21 ing local education or health authority expended for

22 school health services as defined by this part;

23 ‘‘(7) services funded under this Act will be co24 ordinated with existing school health services pro25 vided at a participating school; and
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1 ‘‘(8) for applicants in rural areas, the assur2 ances required under paragraph (4) shall be fulfilled

3 to the maximum extent possible.

4 ‘‘(e) STATE LAWS.—Notwithstanding any other pro5 vision in this part, no school based health clinic may pro6 vide services, to any minor, when to do so is a violation

7 of State laws or regulations pertaining to informed con8 sent for medical services to minors.

9 ‘‘(f) LIMITATION ON ADMINISTRATIVE FUNDS.—In

10 the case of a State applying on behalf of local educational

11 partnerships, the applicant may retain not more than 5

12 percent of grants awarded under this subpart for adminis13 trative costs.

14 ‘‘(g) DURATION OF GRANT.—A grant under this sec15 tion shall be for a period determined appropriate by the

16 Secretary.

17 ‘‘(h) AMOUNT OF GRANT.—The annual amount of a

18 grant awarded under this section shall not be more than

19 $200,000 per school-based or school-linked health service

20 site.

21 ‘‘(i) FEDERAL SHARE.—

22 ‘‘(1) IN GENERAL.—Subject to paragraph (3), a

23 grant for services awarded under this section may

24 not exceed—
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1 ‘‘(A) 90 percent of the non-reimbursed cost

2 of the activities to be funded under the program

3 for the first 2 fiscal years for which the pro4 gram receives assistance under this section; and

5 ‘‘(B) 75 percent of the non-reimbursed

6 cost of such activities for subsequent years for

7 which the program receives assistance under

8 this section.

9 The remainder of such costs shall be made available

10 as provided in paragraph (2).

11 ‘‘(2) FORM OF NON-FEDERAL SHARE.—The

12 non-Federal share required by paragraph (1) may be

13 in cash or in-kind, fairly evaluated, including facili14 ties, equipment, personnel, or services, but may not

15 include amounts provided by the Federal Govern16 ment. In-kind contributions may include space with17 in a school facilities, school personnel, program use

18 of school transportation systems, outposted health

19 personnel, and extension of health provider medical

20 liability insurance.

21 ‘‘(3) WAIVER.—The Secretary may waive the

22 requirements of paragraph (1) for any year in ac23 cordance with criteria established by regulation.

24 Such criteria shall include a documented need for

25 the services provided under this section and an in-
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1 ability of the grantee to meet the requirements of

2 paragraph (1) despite a good faith effort.

3 ‘‘(j) TRAINING AND TECHNICAL ASSISTANCE.—Enti4 ties that receive assistance under this section may use not

5 to exceed 10 percent of the amount of such assistance to

6 provide staff training and to secure necessary technical as7 sistance. To the maximum extent feasible, technical assist8 ance should be sought through local community-based en9 tities. The limitation contained in this subsection shall

10 apply to individuals employed to assist in obtaining funds

11 under this part. Staff training should include the training

12 of teachers and other school personnel necessary to ensure

13 appropriate referral and utilization of services, and appro14 priate linkages between class-room activities and services

15 offered.

16 ‘‘(k) REPORT AND MONITORING.—The Secretary will

17 submit to the Committee on Labor and Human Resources

18 in the Senate and the Committee on Energy and Com19 merce in the House of Representatives a biennial report

20 on the activities funded under this Act, consistent with

21 the ongoing monitoring activities of the Department. Such

22 reports are intended to advise the relevant Committees of

23 the availability and utilization of services, and other rel24 evant information about program activities.
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1 ‘‘PART 2—SCHOLARSHIP AND LOAN REPAYMENT

2 PROGRAMS REGARDING SCHOOL NURSES

3 ‘‘SEC. 2751. AUTHORIZATIONS OF APPROPRIATIONS FROM

4 FUND.

5 ‘‘For the purpose of carrying out this part, there is

6 authorized to be appropriated from the Fund,

7 $10,000,000 for each of the fiscal years 1996 through

8 2000.

9 ‘‘SEC. 2752. SCHOLARSHIP PROGRAM REGARDING UP10 GRADE IN SKILLS.

11 ‘‘(a) IN GENERAL.—The Secretary, acting through

12 the Administrator of the Health Resources and Services

13 Administration and in consultation with the Director of

14 the Centers for Disease Control and Prevention, shall

15 carry out a program under which the Secretary awards

16 scholarships to individuals described in subsection (b) for

17 the purpose of assisting the individuals with the costs of

18 attending programs of education in professional nursing

19 (exclusive of graduate programs in nursing).

20 ‘‘(b) ELIGIBLE INDIVIDUALS.—An individual re21 ferred to in subsection (a) is any individual meeting the

22 following conditions:

23 ‘‘(1) The individual is serving or has served as

24 a school nurse in public or nonprofit private elemen25 tary or secondary school, and the individual is not

26 a professional nurse.
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1 ‘‘(2) The individual is enrolled (or accepted for

2 enrollment) at a program referred to in subsection

3 (a) as a full-time or part-time student.

4 ‘‘(3) The individual enters into the contract re5 quired pursuant to subsection (d) as a condition of

6 receiving the scholarship (relating to an agreement

7 to provide services as a school nurse).

8 ‘‘(c) APPLICABILITY OF CERTAIN PROVISIONS.—Ex9 cept as inconsistent with this section or section 2754, the

10 provisions of subpart III of part D of title III (relating

11 to the Scholarship and Loan Repayment Programs of the

12 National Health Service Corps) apply to an award of a

13 scholarship under subsection (a) to the same extent and

14 in the same manner as such provisions apply to an award

15 of a scholarship under section 338A.

16 ‘‘SEC. 2753. LOAN REPAYMENT PROGRAM.

17 ‘‘(a) IN GENERAL.—The Secretary, acting through

18 the Administrator of the Health Resources and Services

19 Administration and in consultation with the Director of

20 the Centers for Disease Control and Prevention, shall

21 carry out a program under which the Federal Government

22 enters into agreements to repay all or part of the edu23 cational loans of individuals meeting the following condi24 tions:
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1 ‘‘(1) The individual is a professional nurse and

2 meets the applicable legal requirements to serve as

3 a school nurse.

4 ‘‘(2) The individual enters into the contract re5 quired pursuant to subsection (b) as a condition of

6 the Federal Government repaying such loans (relat7 ing to an agreement to provide services as a school

8 nurse).

9 ‘‘(b) APPLICABILITY OF CERTAIN PROVISIONS.—Ex10 cept as inconsistent with this section or section 2754, the

11 provisions of subpart III of part D of title III (relating

12 to the Scholarship and Loan Repayment Programs of the

13 National Health Service Corps) apply to an agreement re14 garding repayment under subsection (a) to the same ex15 tent and in the same manner as such provisions apply to

16 an agreement regarding repayment under section 338B.

17 ‘‘(c) AMOUNT OF REPAYMENTS.—For each year for

18 which an individual contracts to serve as school nurse pur19 suant to subsection (b), the Secretary may repay not more

20 than $20,000 of the principal and interest of the edu21 cational loans of the individual.

22 ‘‘SEC. 2754. SCHOOL-NURSE POSITIONS.

23 ‘‘(a) POSITION REGARDING STUDENTS WITH SIG24 NIFICANT NEED FOR SERVICES.—
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1 ‘‘(1) IN GENERAL.—With respect to the pro2 grams under this part, the obligated service of a

3 program participant pursuant to sections 2752(d)

4 and 2753(b) shall be provided through an assign5 ment to a school described in subsection (b) for a

6 position as a school nurse.

7 ‘‘(2) PERIOD OF SERVICE.—For purposes of

8 sections 2752(d) and 2753(d), the period of obli9 gated service is the following, as applicable to the

10 program participant involved:

11 ‘‘(A) In the case of scholarships under sec12 tion 2752 for full-time students, the greater

13 of—

14 ‘‘(i) 1 year for each year for which

15 such a scholarship is provided; or

16 ‘‘(ii) 2 years.

17 ‘‘(B) In the case of scholarships under sec18 tion 2752 for part-time students, a period de19 termined by the Secretary on the basis of the

20 number of hours of education or training re21 ceived under the scholarship, considering the

22 percentage constituted by the ratio of such

23 number to the number of hours for a full-time

24 student in the program involved.
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1 ‘‘(C) In the case of the loan repayments

2 under section 2753, such period as the Sec3 retary and the participant may agree, except

4 that the period may not be less than 2 years.

5 ‘‘(b) APPROVAL OF SCHOOLS FOR ASSIGNMENT OF

6 PROGRAM PARTICIPANTS.—The schools referred to in

7 subsection (a) are public or nonprofit private elementary

8 or secondary schools whose students include a significant

9 number of students with an unmet need for health services

10 that are provided by school nurses.

11 ‘‘(c) DEFINITIONS.—For purposes of this subpart:

12 ‘‘(1) The term ‘professional nurse’ has the

13 meaning given such term under title VIII.

14 ‘‘(2) The term ‘program participant’ means an

15 individual who enters into a contract pursuant to

16 section 2752(b)(3) or 2753(a)(2).

17 ‘‘(3) The term ‘school nurse’ means a nurse

18 who provides health services on the premises of an

19 elementary or secondary school and meets such cri20 teria as the Secretary may establish.
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1 ‘‘Subtitle E—Expansion of Rural

2 and Underserved Areas Access

3 to Health Services

4 ‘‘PART 1—COMMUNITY AND MIGRANT HEALTH

5 CENTERS

6 ‘‘SEC. 2756. AUTHORIZATIONS OF APPROPRIATIONS FROM

7 FUND.

8 ‘‘(a) IN GENERAL.—For the purpose of carrying out

9 this part, there is authorized to be appropriated from the

10 Fund, $100,000,000 for each of the fiscal years 1996

11 through 2000.

12 ‘‘(b) RELATION TO OTHER FUNDS.—The authoriza13 tions of appropriations established in subsection (a) for

14 the purpose described in such subsection are in addition

15 to any other authorizations of appropriations that are

16 available for such purpose.

17 ‘‘SEC. 2757. GRANTS TO COMMUNITY AND MIGRANT

18 HEALTH CENTERS.

19 ‘‘(a) IN GENERAL.—The Secretary shall make grants

20 in accordance with this section to migrant health centers

21 and community health centers.

22 ‘‘(b) USE OF FUNDS.—

23 ‘‘(1) DEVELOPMENT, OPERATION, AND OTHER

24 PURPOSES REGARDING CENTERS.—Subject to para25 graph (2), grants under subsection (a) to migrant
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1 health centers and community health centers may be

2 made only in accordance with the conditions upon

3 which grants are made under sections 329 and 330,

4 respectively.

5 ‘‘(2) REQUIRED FINANCIAL RESERVES.—The

6 Secretary may authorize migrant health centers and

7 community health centers to expend a grant under

8 subsection (a) to establish and maintain financial re9 serves required for purposes of health plans.

10 ‘‘(c) DEFINITIONS.—For purposes of this subtitle,

11 the terms ‘migrant health center’ and ‘community health

12 center’ have the meanings given such terms in sections

13 329(a)(1) and 330(a), respectively.

14 ‘‘PART 2—NATIONAL HEALTH SERVICE CORPS

15 ‘‘SEC. 2781. AUTHORIZATIONS OF APPROPRIATIONS FROM

16 FUND.

17 ‘‘(a) ADDITIONAL FUNDING; GENERAL CORPS PRO18 GRAM; ALLOCATIONS REGARDING NURSES.—For the pur19 pose of carrying out subpart II of part D of title III, and

20 for the purpose of carrying out subsection (c), there are

21 authorized to be appropriated from the Fund,

22 $100,000,000 for each of the fiscal years 1996 through

23 2000.

24 ‘‘(b) RELATION TO OTHER FUNDS.—The authoriza25 tions of appropriations established in subsection (a) are
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1 in addition to any other authorizations of appropriations

2 that are available for the purpose described in such sub3 section.

4 ‘‘(c) ALLOCATION FOR PARTICIPATION OF NURSES

5 IN SCHOLARSHIP AND LOAN REPAYMENT PROGRAMS.—

6 Of the amounts appropriated under subsection (a), the

7 Secretary shall reserve such amounts as may be necessary

8 to ensure that, of the aggregate number of individuals who

9 are participants in the Scholarship Program under section

10 338A, or in the Loan Repayment Program under section

11 338B, the total number who are being educated as nurses

12 or are serving as nurses, respectively, is increased to 30

13 percent.

14 ‘‘(d) AVAILABILITY OF FUNDS.—An appropriation

15 under this section for any fiscal year may be made at any

16 time before that fiscal year and may be included in an

17 Act making an appropriation under an authorization

18 under subsection (a) for another fiscal year; but no funds

19 may be made available from any appropriation under this

20 section for obligation under sections 331 through 335, sec21 tion 336A, and section 337 before the fiscal year involved.
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1 ‘‘PART 3—SATELLITE CLINICS REGARDING

2 PRIMARY HEALTH CARE

3 ‘‘SEC. 2783. AUTHORIZATION OF APPROPRIATIONS FROM

4 FUND.

5 ‘‘For the purpose of carrying out this part, there is

6 authorized to be appropriated from the Fund,

7 $50,000,000 for each of the fiscal years 1996 through

8 2000.

9 ‘‘SEC. 2783A. GRANTS TO STATES FOR DEVELOPMENT AND

10 OPERATION OF SATELLITE CLINICS.

11 ‘‘(a) IN GENERAL.—With respect to outpatient

12 health centers that are providers of comprehensive health

13 services, the Secretary may make grants to States for the

14 purpose of assisting such centers in developing or operat15 ing facilities that—

16 ‘‘(1) provide clinical preventive services, treat17 ment of minor illnesses and injuries, family planning

18 services, and referrals for health services, mental

19 health services, and health-related social services;

20 and

21 ‘‘(2) are located at a distance from the center

22 sufficient to increase the extent to which individuals

23 in the geographic area involved have access to the

24 services specified in paragraph (1).

25 ‘‘(b) CERTAIN REQUIREMENTS.—The Secretary may

26 make a grant under subsection (a) only if the State agrees
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1 that the health facility for which the grant is made, once

2 in operation, will meet the following conditions:

3 ‘‘(1) The clinical preventive services provided by

4 the facility will include routine preventive services,

5 including family planning services, for pregnant and

6 postpartum women and for children, including

7 health screenings and immunizations.

8 ‘‘(2) The principal providers of health services

9 at the facility, and the principal managers of the fa10 cility, will be nurse practitioners, physician assist11 ants, or nurse clinicians, subject to applicable law.

12 ‘‘(3) The outpatient health center operating the

13 facility will serve as a referral center for physician

14 services and will provide for the ongoing monitoring

15 of the activities of the facility.

16 ‘‘(c) MATCHING FUNDS.—The Secretary may make

17 a grant under subsection (a) only if the State involved

18 agrees to make non-Federal contributions toward the costs

19 of developing and operating the health facilities involved.

20 ‘‘(d) APPLICATION FOR GRANT.—The Secretary may

21 make a grant under subsection (a) only if an application

22 for the grant is submitted to the Secretary and the appli23 cation is in such form, is made in such manner, and con24 tains such agreements, assurances, and information as the
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1 Secretary determines to be necessary to carry out this

2 part.

3 ‘‘(e) LIMITATION ON AMOUNT OF ASSISTANCE PER

4 FACILITY.—With respect to a health facility for which one

5 or more grants under subsection (a) are made, the Sec6 retary may not provide more than an aggregate $250,000

7 for the development and operation of the facility.

8 ‘‘PART 4—COMMUNITY HEALTH ADVISORS

9 ‘‘SEC. 2784. AUTHORIZATION OF APPROPRIATIONS FROM

10 FUND.

11 ‘‘For the purpose of carrying out this part, there is

12 authorized to be appropriated from the Fund,

13 $100,000,000 for each of the fiscal years 1996 through

14 2000.

15 ‘‘SEC. 2785. FORMULA GRANTS REGARDING COMMUNITY

16 HEALTH ADVISOR PROGRAMS.

17 ‘‘(a) FORMULA GRANTS.—

18 ‘‘(1) IN GENERAL.—In the case of each State

19 (or entity designated by a State under subsection

20 (b)) that submits to the Secretary an application in

21 accordance with section 2788 for a fiscal year, the

22 Secretary, acting through the Director of the Cen23 ters for Disease Control and Prevention and in co24 ordination with the heads of the agencies specified

25 in paragraph (2), shall make an award of financial
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1 assistance to the State or entity for the development

2 and operation of community health advisor programs

3 under section 2786(b). The award shall consist of

4 the allotment determined under section 2789 with

5 respect to the State, subject to section 2794.

6 ‘‘(2) COORDINATION WITH OTHER AGENCIES.—

7 The agencies referred to in paragraph (1) regarding

8 coordination are the Health Resources and Services

9 Administration, the National Institutes of Health,

10 the Substance Abuse and Mental Health Services

11 Administration, and the Health Education and

12 Training Center.

13 ‘‘(b) DESIGNATED ENTITIES.—With respect to the

14 State involved, an entity other than the State may receive

15 an award under subsection (a) only if the entity—

16 ‘‘(1) is a public or nonprofit private academic

17 organization (or other public or nonprofit private en18 tity); and

19 ‘‘(2) has been designated by the State to carry

20 out the purpose described in such subsection in the

21 State and to receive amounts under such subsection

22 in lieu of the State.

23 ‘‘(c) ROLE OF STATE AGENCY FOR PUBLIC

24 HEALTH.—A funding agreement for an award under sub25 section (a) is that—
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1 ‘‘(1) if the applicant is a State, the award will

2 be administered by the State agency with the prin3 cipal responsibility for carrying out public health

4 programs; and

5 ‘‘(2) if the applicant is an entity designated

6 under subsection (b), the award will be administered

7 in consultation with such State agency.

8 ‘‘(d) STATEWIDE RESPONSIBILITIES; LIMITATION ON

9 EXPENDITURES.—

10 ‘‘(1) STATEWIDE RESPONSIBILITIES.—A fund11 ing agreement for an award under subsection (a) is

12 that the applicant involved will—

13 ‘‘(A) operate a clearinghouse to maintain

14 and disseminate information on community

15 health advisor programs (and similar programs)

16 in the State, including information on develop17 ing and operating such programs, on training

18 individuals to participate in the programs, and

19 on evaluation of the programs;

20 ‘‘(B) collaborate with schools of public

21 health to provide to community health advisor

22 programs in the State technical assistance in

23 training and supervising community health ad24 visors under section 2787(g)(1); and
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1 ‘‘(C) coordinate the activities carried out in

2 the State under the award, including coordina3 tion between the various community health ad4 visor programs and coordination between such

5 programs and related activities of the State and

6 of other public or private entities.

7 ‘‘(2) LIMITATION.—A funding agreement for an

8 award under subsection (a) is that the applicant in9 volved will not expend more than 15 percent of the

10 award in the aggregate for carrying out paragraph

11 (1) and for the expenses of administering the award

12 with respect to the State involved, including the

13 process of receiving payments from the Secretary

14 under the award, allocating the payments among the

15 entities that are to develop and operate the commu16 nity health advisor programs involved, and monitor17 ing compliance with the funding agreements made

18 under this subtitle by the applicant.

19 ‘‘SEC. 2786. REQUIREMENTS REGARDING COMMUNITY

20 HEALTH ADVISOR PROGRAMS.

21 ‘‘(a) PURPOSE OF AWARD; HEALTHY PEOPLE 2000

22 OBJECTIVES.—

23 ‘‘(1) IN GENERAL.—Subject to paragraph (2), a

24 funding agreement for an award under section 2785

25 for an applicant is that the purpose of the award is,
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1 through community health advisor programs under

2 subsection (b), to assist the State involved in attain3 ing the Healthy People 2000 Objectives.

4 ‘‘(2) AUTHORITY REGARDING SELECTION OF

5 PRIORITY OBJECTIVES.—With respect to compliance

6 with the agreement made under paragraph (1), an

7 applicant receiving an award under section 2785

8 may, from among the various Healthy People 2000

9 Objectives, select one or more Objectives to be given

10 priority in the operation of a community health advi11 sor program of the applicant, subject to the appli12 cant selecting such priorities in consultation with the

13 entity that is to carry out the program and the local

14 health department involved.

15 ‘‘(b) REQUIREMENTS FOR PROGRAMS.—

16 ‘‘(1) IN GENERAL.—A funding agreement for

17 an award under section 2785 for an applicant is

18 that, in expending the award, the purpose described

19 in subsection (a)(1) will be carried out in accordance

20 with the following:

21 ‘‘(A) For each community for which the

22 purpose is to be carried out, the applicant will

23 establish a program in accordance with this

24 subsection.
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1 ‘‘(B) The program will be carried out in a

2 community only if the applicant has, under sec3 tion 2787(a), identified the community as hav4 ing a significant need for the program.

5 ‘‘(C) The program will be operated by a

6 public or nonprofit private entity with experi7 ence in providing health or health-related social

8 services to individuals who are underserved with

9 respect to such services.

10 ‘‘(D) The services of the program, as spec11 ified in paragraph (2), will be provided prin12 cipally by community health advisors (as de13 fined in subsection (d)).

14 ‘‘(2) AUTHORIZED PROGRAM SERVICES.—For

15 purposes of paragraph (1)(D), the services specified

16 in this paragraph for a program are as follows:

17 ‘‘(A) The program will collaborate with

18 health care providers and related entities in

19 order to facilitate the provision of health serv20 ices and health-related social services (including

21 collaborating with local health departments,

22 community health centers, public hospital sys23 tems, migrant health centers, rural health clin24 ics, hospitals, physicians and nurses, providers

25 of health education, pre-school facilities for chil-
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1 dren, elementary and secondary schools, and

2 providers of social services).

3 ‘‘(B) The program will provide public edu4 cation on health promotion and on the preven5 tion of diseases, illnesses, injuries, and disabil6 ities, and will facilitate the appropriate use of

7 available health services and health-related so8 cial services.

9 ‘‘(C) The program will provide health-re10 lated counseling.

11 ‘‘(D) The program will provide referrals

12 for available health services and health-related

13 social services.

14 ‘‘(E) For the purpose of increasing the ca15 pacity of individuals to utilize health services

16 and health-related social services under Federal,

17 State, and local programs, the following condi18 tions will be met:

19 ‘‘(i) The program will assist individ20 uals in establishing eligibility under the

21 programs and in receiving the services or

22 other benefits of the programs.

23 ‘‘(ii) The program will provide such

24 other services as the Secretary determines

25 to be appropriate, which services may in-
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1 clude (but are not limited to) transpor2 tation and translation services.

3 ‘‘(F) The program will provide outreach

4 services to inform the community of the avail5 ability of the services of the program.

6 ‘‘(c) PRIORITY FOR MEDICALLY UNDERSERVED COM7 MUNITIES.—A funding agreement for an award under sec8 tion 2785 is that the applicant involved will give priority

9 to developing and operating community health advisor

10 programs for medically underserved communities.

11 ‘‘(d) DEFINITION OF COMMUNITY HEALTH ADVI12 SOR.—For purposes of this part, the term ‘community

13 health advisor’ means an individual—

14 ‘‘(1) who has demonstrated the capacity to

15 carry out one or more of the authorized program

16 services;

17 ‘‘(2) who, for not less than 1 year, has been a

18 resident of the community in which the community

19 health advisor program involved is to be operated;

20 and

21 ‘‘(3) is a member of a socioeconomic group to

22 be served by the program.
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1 ‘‘SEC. 2787. ADDITIONAL AGREEMENTS.

2 ‘‘(a) IDENTIFICATION OF COMMUNITY NEEDS.—A

3 funding agreement for an award under section 2785 is

4 that the applicant involved will—

5 ‘‘(1) identify the needs of the community in6 volved for the authorized program services, including

7 the identifying the resources of the community that

8 are available for carrying out the program;

9 ‘‘(2) in identifying such needs, consult with

10 members of the community, with individuals and

11 programs that provide health services in the commu12 nity, and with individuals and programs that provide

13 health-related social services in the community; and

14 ‘‘(3) consider such needs in carrying out a com15 munity health advisor program for the community.

16 ‘‘(b) MATCHING FUNDS.—

17 ‘‘(1) IN GENERAL.—With respect to the cost of

18 carrying out a community health advisor program, a

19 funding agreement for an award under section 2785

20 is that the applicant involved will make available (di21 rectly or through donations from public or private

22 entities) non-Federal contributions toward such cost

23 in an amount that is not less than 25 percent of

24 such cost.

25 ‘‘(2) DETERMINATION OF AMOUNT CONTRIB26 UTED.—
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1 ‘‘(A) Non-Federal contributions required in

2 paragraph (1) may be in cash or in kind, fairly

3 evaluated, including plant, equipment, or serv4 ices. Amounts provided by the Federal Govern5 ment, or services assisted or subsidized to any

6 significant extent by the Federal Government,

7 may not be included in determining the amount

8 of such non-Federal contributions.

9 ‘‘(B) With respect to the State in which

10 the community health advisor program involved

11 is to be carried out, amounts provided by the

12 State in compliance with subsection (c) shall be

13 included in determining the amount of non-Fed14 eral contributions under paragraph (1).

15 ‘‘(c) MAINTENANCE OF EFFORT.—With respect to

16 the purposes for which an award under section 2785 is

17 authorized in this subtitle to be expended, the Secretary

18 may make such an award only if the State involved agrees

19 to maintain expenditures of non-Federal amounts for such

20 purposes at a level that is not less than the level of such

21 expenditures maintained by the State for the fiscal year

22 preceding the first fiscal year for which such an award

23 is made with respect to the State.

24 ‘‘(d) CULTURAL CONTEXT OF SERVICES.—A funding

25 agreement for an award under section 2785 for an appli-
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1 cant is that the services of the community health advisor

2 program involved will be provided in the language and cul3 tural context most appropriate for the individuals served

4 by the program, and that for such purpose the community

5 health advisors of the program will include an appropriate

6 number of advisors who are fluent in both English and

7 not less than one of the other relevant languages.

8 ‘‘(e) NUMBER OF PROGRAMS PER AWARD; PRO9 GRAMS FOR URBAN AND RURAL AREAS.—A funding

10 agreement for an award under section 2785 for an appli11 cant is that the number of community health advisor pro12 grams operated in the State with the award will be deter13 mined by the Secretary, except that (subject to section

14 2786(b)(1)(B)) such a program will be carried out in not

15 less than one urban area of the State, and in not less than

16 one rural area of the State.

17 ‘‘(f) ONGOING SUPERVISION OF ADVISORS.—A fund18 ing agreement for an award under section 2785 is that

19 the applicant involved will ensure that each community

20 health advisor program operated with the award provides

21 for the ongoing supervision of the community health advi22 sors of the program, and that the individuals serving as

23 supervisors in the program will include 1 or more public

24 health nurses with field experience and managerial experi25 ence.
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1 ‘‘(g) CERTAIN EXPENDITURES.—

2 ‘‘(1) TRAINING; CONTINUING EDUCATION.—

3 Funding agreements for an award under section

4 2785 include the following:

5 ‘‘(A) The applicant involved will ensure

6 that, for each community health advisor pro7 gram operated with the award, a program is

8 carried out to train community health advisors

9 to provide the authorized program services, in10 cluding practical experiences in providing serv11 ices for health promotion and disease preven12 tion.

13 ‘‘(B) The program of training will provide

14 for the continuing education of the community

15 health advisors.

16 ‘‘(C) Not more than 15 percent of the

17 award will be expended for the program of

18 training.

19 ‘‘(2) COMPENSATION.—With respect to compli20 ance with the agreements made under this subtitle,

21 the purposes for which an award under section 2785

22 may be expended include providing compensation for

23 the services of community health advisors.
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1 ‘‘(h) REPORTS TO SECRETARY; ASSESSMENT OF EF2 FECTIVENESS.—Funding agreements for an award under

3 section 2785 for an applicant include the following:

4 ‘‘(1) The applicant will ensure that, for each

5 fiscal year for which a community health advisor

6 program receives amounts from the award, the pro7 gram will prepare a report describing the activities

8 of the program for such year, including—

9 ‘‘(A) a specification of the number of indi10 viduals served by the program;

11 ‘‘(B) a specification of the entities with

12 which the program has collaborated in carrying

13 out the purpose described in section 2786(a)(1);

14 and

15 ‘‘(C) an assessment of the extent of the ef16 fectiveness of the program in carrying out such

17 purpose.

18 ‘‘(2) Such reports will include such additional

19 information regarding the applicant and the pro20 grams as the Secretary may require.

21 ‘‘(3) The applicant will prepare the reports as

22 a single document and will submit the document to

23 the Secretary not later than February 1 of the fiscal

24 year following the fiscal year for which the reports

25 were prepared.
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1 ‘‘SEC. 2788. APPLICATION FOR ASSISTANCE; STATE PLAN.

2 ‘‘For purposes of section 2785, an application is in

3 accordance with this section if—

4 ‘‘(1) the application is submitted not later than

5 the date specified by the Secretary;

6 ‘‘(2) the application contains each funding

7 agreement described in this subtitle;

8 ‘‘(3) the application contains a State plan de9 scribing the purposes for which the award is to be

10 expended in the State, including a description of the

11 manner in which the applicant will comply with each

12 such funding agreement; and

13 ‘‘(4) the application is in such form, is made in

14 such manner, and contains such agreements, assur15 ances, and information as the Secretary determines

16 to be necessary to carry out this subtitle.

17 ‘‘SEC. 2789. DETERMINATION OF AMOUNT OF ALLOTMENT.

18 ‘‘(a) IN GENERAL.—For purposes of section 2785,

19 the allotment under this section with respect to a State

20 for a fiscal year is the sum of the respective amounts de21 termined for the State under subsection (b) and sub22 section (c).

23 ‘‘(b) AMOUNT RELATING TO POPULATION.—For pur24 poses of subsection (a), the amount determined under this

25 subsection is the product of—
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1 ‘‘(1) an amount equal to 50 percent of the

2 amount appropriated under section 2784 for the fis3 cal year and available for awards under section

4 2785; and

5 ‘‘(2) the percentage constituted by the ratio

6 of—

7 ‘‘(A) the number of individuals residing in

8 the State involved; to

9 ‘‘(B) the sum of the respective numbers

10 determined for each State under subparagraph

11 (A).

12 ‘‘(c) AMOUNT RELATING TO POVERTY LEVEL.—For

13 purposes of subsection (a), the amount determined under

14 this subsection is the product of—

15 ‘‘(1) the amount determined under subsection

16 (b)(1); and

17 ‘‘(2) the percentage constituted by the ratio

18 of—

19 ‘‘(A) the number of individuals residing in

20 the State whose income is at or below an

21 amount equal to 200 percent of the official pov22 erty line; to

23 ‘‘(B) the sum of the respective numbers

24 determined for each State under subparagraph

25 (A).
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1 ‘‘SEC. 2790. QUALITY ASSURANCE; COST-EFFECTIVENESS.

2 ‘‘The Secretary shall establish guidelines for assuring

3 the quality of community health advisor programs (includ4 ing quality in the training of community health advisors)

5 and for assuring the cost-effectiveness of the programs.

6 A funding agreement for an award under section 2785 is

7 that the applicant involved will carry out such programs

8 in accordance with the guidelines.

9 ‘‘SEC. 2791. EVALUATIONS; TECHNICAL ASSISTANCE.

10 ‘‘(a) EVALUATIONS.—The Secretary shall conduct

11 evaluations of community health advisor programs and

12 disseminate information developed as result of the evalua13 tions to the States. In conducting such evaluations, the

14 Secretary shall determine whether the programs are in

15 compliance with the guidelines established under section

16 2790.

17 ‘‘(b) TECHNICAL ASSISTANCE.—The Secretary may

18 provide technical assistance to recipients of awards under

19 section 2785 with respect to the planning, development,

20 and operation of community health advisor programs.

21 ‘‘(c) GRANTS AND CONTRACTS.—The Secretary may

22 carry out this section directly or through grants, coopera23 tive agreements, or contracts.

24 ‘‘(d) LIMITATION ON EXPENDITURES.—Of the

25 amounts appropriated under section 2784 for a fiscal year,
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1 the Secretary may reserve not more than 10 percent for

2 carrying out this section.

3 ‘‘SEC. 2792. RULE OF CONSTRUCTION REGARDING PRO4 GRAMS OF INDIAN HEALTH SERVICE.

5 ‘‘This subtitle may not be construed as requiring the

6 Secretary to modify or terminate the program carried out

7 by the Director of the Indian Health Service and des8 ignated by such Director as the Community Health Rep9 resentative Program. The Secretary shall ensure that sup10 port for such Program is not supplanted by awards under

11 section 2785. In communities in which both such Program

12 and a community health advisor program are being carried

13 out, the Secretary shall ensure that the community health

14 advisor program works in cooperation with, and as a com15 plement to, the Community Health Representative Pro16 gram.

17 ‘‘SEC. 2793. DEFINITIONS.

18 ‘‘For purposes of this subtitle:

19 ‘‘(1) The term ‘authorized program services’,

20 with respect to a community health advisor program,

21 means the services specified in section 2786(b)(2).

22 ‘‘(2) The term ‘community health advisor’ has

23 the meaning given such term in section 2786(d).
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1 ‘‘(3) The term ‘community health advisor pro2 gram’ means a program carried out under section

3 2786(b).

4 ‘‘(4) The term ‘financial assistance’, with re5 spect to an award under section 2785, means a

6 grant, cooperative agreement, or a contract.

7 ‘‘(5) The term ‘funding agreement’ means an

8 agreement required as a condition of receiving an

9 award under section 2785.

10 ‘‘(6) The term ‘official poverty line’ means the

11 official poverty line established by the Director of

12 the Office of Management and Budget and revised

13 by the Secretary in accordance with section 673(2)

14 of the Omnibus Budget Reconciliation Act of 1981,

15 which poverty line is applicable to the size of the

16 family involved.

17 ‘‘(7) The term ‘State involved’, with respect to

18 an applicant for an award under section 2785,

19 means the State in which the applicant is to carry

20 out a community health advisor program.

21 ‘‘SEC. 2794. EFFECT OF INSUFFICIENT APPROPRIATIONS

22 FOR MINIMUM ALLOTMENTS.

23 ‘‘(a) IN GENERAL.—If the amounts made available

24 under section 2784 for a fiscal year are insufficient for

25 providing each State (or entity designated by the State
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1 pursuant to section 2785, as the case may be) with an

2 award under section 2785 in an amount equal to or great3 er than the amount specified in section 2789(a)(2), the

4 Secretary shall, from such amounts as are made available

5 under subsection (a), make such awards on a discretionary

6 basis.

7 ‘‘(b) RULE OF CONSTRUCTION.—For purposes of

8 subsection (a), awards under section 2785 are made on

9 a discretionary basis if the Secretary determines which

10 States (or entities designated by States pursuant to such

11 section, as the case may be) are to receive such awards,

12 subject to meeting the requirements of this subtitle for

13 such an award, and the Secretary determines the amount

14 of such awards.

15 ‘‘Subtitle F—General Provisions

16 ‘‘SEC. 2798. REQUIREMENT REGARDING ACCREDITATION

17 OF SCHOOLS, DEPARTMENTS, AND PRO18 GRAMS.

19 ‘‘Except as indicated otherwise in this title:

20 ‘‘(1) A reference in this title to a school of pub21 lic health, a school of nursing, or any other entity

22 providing education or training in a health profes23 sion (whether a school, department, program, or

24 other entity) is a reference to the entity as defined

25 under section 799 or 853.
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1 ‘‘(2) If an entity is not defined in either of such

2 sections, the reference in this title to the entity has

3 the meaning provided by the Secretary, except that

4 the Secretary shall require for purposes of this title

5 that the entity be accredited for the provision of the

6 education or training involved.

7 ‘‘SEC. 2799. RELATION TO OTHER FUNDS.

8 ‘‘Notwithstanding any other provision of law, the au9 thorizations of appropriations established in this title are

10 in addition to any other authorizations of appropriations

11 that are available for the purposes described with respect

12 to such appropriations in this title.

13 ‘‘SEC. 2799A. DEFINITIONS.

14 ‘‘(a) IN GENERAL.—For purposes of this title:

15 ‘‘(1) The term ‘Healthy People 2000 Objectives’

16 means the objectives established by the Secretary to17 ward the goals of increasing the span of healthy life,

18 reducing health disparities among various popu19 lations, and providing access to preventive services,

20 which objectives apply to the health status of the

21 population of the United States for the year 2000.

22 ‘‘(2) The term ‘medically underserved commu23 nity’ means—

24 ‘‘(A) a community that has a substantial

25 number of individuals who are members of a
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1 medically underserved population, as defined in

2 section 330; or

3 ‘‘(B) a community a significant portion of

4 which is a health professional shortage area

5 designated under section 332.’’.

6 TITLE IV—MEDICAL RESEARCH

7 SEC. 4001. FINDINGS.

8 The Congress finds the following:

9 (1) Nearly 4 of 5 peer reviewed research

10 projects deemed worthy of funding by the National

11 Institutes of Health are not funded.

12 (2) Less than 2 percent of the nearly one tril13 lion dollars our Nation spends on health care is de14 voted to health research, while the defense industry

15 spends 15 percent of its budget on research.

16 (3) Public opinion surveys have shown that

17 Americans want more Federal resources put into

18 health research and support by having a portion of

19 their health insurance premiums set aside for this

20 purpose.

21 (4) Ample evidence exists to demonstrate that

22 health research has improved the quality of health

23 care in the United States. Advances such as the de24 velopment of vaccines, the cure of many childhood

25 cancers, drugs that effectively treat a host of dis-
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1 eases and disorders, a process to protect our Na2 tion’s blood supply from the HIV virus, progress

3 against cardiovascular disease including heart attack

4 and stroke, and new strategies for the early detec5 tion and treatment of diseases such as colon, breast,

6 and prostate cancer clearly demonstrates the bene7 fits of health research.

8 (5) Among the most effective methods to con9 trol health care costs are prevention and cure of dis10 ease and disability, thus, health research which holds

11 the promise of cure and prevention of disease and

12 disability is a critical component of any comprehen13 sive health care reform plan.

14 (6) The state of our Nation’s research facilities

15 at the National Institutes of Health and at univer16 sities is deteriorating significantly. Renovation and

17 repair of these facilities are badly needed to main18 tain and improve the quality of research.

19 (7) Because the Omnibus Budget Reconciliation

20 Act of 1993 freezes discretionary spending for the

21 next 5 years, the Nation’s investment in health re22 search through the National Institutes of Health is

23 likely to decline in real terms unless corrective legis24 lative action is taken.
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1 (8) A health research fund is needed to main2 tain our Nation’s commitment to health research

3 and to increase the percentage of approved projects

4 which receive funding at the National Institutes of

5 Health to at least 33 percent.

6 SEC. 4002. NATIONAL FUND FOR HEALTH RESEARCH.

7 (a) ESTABLISHMENT.—There is established in the

8 Treasury of the United States an account, to be known

9 as the ‘‘National Fund for Health Research’’ (hereafter

10 referred to in this section as the ‘‘Fund’’), consisting of

11 such amounts as are transferred to the Fund under sub12 section (b) and any interest earned on investment of

13 amounts in the Fund.

14 (b) TRANSFERS TO FUND.—

15 (1) IN GENERAL.—With respect to each of the

16 5 full calendar years beginning after the date of en17 actment of this Act, the Secretary of the Treasury

18 shall transfer to the Fund an amount equal to the

19 applicable amount under paragraph (2).

20 (2) APPLICABLE AMOUNT.—The applicable

21 amount under this paragraph is—

22 (A) with respect to amounts in the Health

23 Care Reform Trust Fund established under sec24 tion 9551(a)(2)(A) of the Internal Revenue
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1 Code of 1986, $1,200,000,000 for each cal2 endar year described in paragraph (1); and

3 (B) with respect to amounts received in

4 the Treasury under section 6097 of the Internal

5 Revenue Code of 1986, 100 percent of the

6 amounts received under such section in each

7 calendar year described in paragraph (1).

8 (3) DESIGNATION OF OVERPAYMENTS AND CON9 TRIBUTIONS.—

10 (A) IN GENERAL.—Subchapter A of chap11 ter 61 of the Internal Revenue Code of 1986

12 (relating to returns and records) is amended by

13 adding at the end the following new part:

14 ‘‘PART IX—DESIGNATION OF OVERPAYMENTS

15 AND CONTRIBUTIONS FOR THE NATIONAL

16 FUND FOR HEALTH RESEARCH

‘‘Sec. 6097. Amounts for the National Fund for Health Research.

17 ‘‘SEC. 6097. AMOUNTS FOR THE NATIONAL FUND FOR

18 HEALTH RESEARCH.

19 ‘‘(a) IN GENERAL.—Every individual (other than a

20 nonresident alien) may designate that—

21 ‘‘(1) a portion (not less than $1) of any over22 payment of the tax imposed by chapter 1 for the

23 taxable year, and

24 ‘‘(2) a cash contribution (not less than $1),
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1 be paid over to the National Fund for Health Research

2 established under section 4002 of the Health Innovation

3 Partnership Act of 1994. In the case of a joint return of

4 a husband and wife, each spouse may designate one-half

5 of any such overpayment of tax (not less than $2).

6 ‘‘(b) MANNER AND TIME OF DESIGNATION.—Any

7 designation under subsection (a) may be made with re8 spect to any taxable year only at the time of filing the

9 original return of the tax imposed by chapter 1 for such

10 taxable year. Such designation shall be made either on the

11 1st page of the return or on the page bearing the tax12 payer’s signature.

13 ‘‘(c) OVERPAYMENTS TREATED AS REFUNDED.—For

14 purposes of this section, any overpayment of tax des15 ignated under subsection (a) shall be treated as being re16 funded to the taxpayer as of the last day prescribed for

17 filing the return of tax imposed by chapter 1 (determined

18 with regard to extensions) or, if later, the date the return

19 is filed.

20 ‘‘(d) DESIGNATED AMOUNTS NOT DEDUCTIBLE.—

21 No amount designated pursuant to subsection (a) shall be

22 allowed as a deduction under section 170 or any other sec23 tion for any taxable year.

24 ‘‘(e) TERMINATION.—This section shall not apply to

25 taxable years beginning in a calendar year after a deter-
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1 mination by the Secretary that the sum of all designations

2 under subsection (a) for taxable years beginning in the

3 second and third calendar years preceding the calendar

4 year is less than $5,000,000.’’.

5 (B) CLERICAL AMENDMENT.—The table of

6 parts for subchapter A of chapter 61 of such

7 Code is amended by adding at the end the fol8 lowing new item:

‘‘Part IX. Designation of overpayments and contributions for the

National Fund for Health Research.’’.

9 (C) EFFECTIVE DATE.—The amendments

10 made by this paragraph shall apply to taxable

11 years beginning after December 31, 1994.

12 (c) EXPENDITURES FROM FUND.—

13 (1) IN GENERAL.—The Secretary of the Treas14 ury shall pay annually, within 30 days after the

15 President signs an appropriations Act for the De16 partments of Labor, Health and Human Services,

17 and Education and related agencies, or by the end

18 of the first quarter of the fiscal year, to the Sec19 retary of Health and Human Services on behalf of

20 the National Institutes of Health, an amount equal

21 to the amount in the National Fund for Health Re22 search at the time of such payment, to enable the

23 Secretary to carry out the purpose of section 404F

24 of the Public Health Service Act, less any adminis-
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1 trative expenses which may be paid under paragraph

2 (3).

3 (2) PURPOSES FOR EXPENDITURES FROM

4 FUND.—Part A of title IV of the Public Health

5 Service Act (42 U.S.C. 281 et seq.) is amended by

6 adding at the end the following new section:

7 ‘‘SEC. 404F. EXPENDITURES FROM THE NATIONAL FUND

8 FOR HEALTH RESEARCH.

9 ‘‘(a) IN GENERAL.—From amounts received for any

10 fiscal year from the National Fund for Health Research,

11 the Secretary shall distribute—

12 ‘‘(1) 2 percent of such amounts during any fis13 cal year to the Office of the Director of the National

14 Institutes of Health to be allocated at the Director’s

15 discretion for the following activities:

16 ‘‘(A) for carrying out the responsibilities of

17 the Office of the Director, National Institutes

18 of Health, including the Office of Research on

19 Women’s Health and the Office of Research on

20 Minority Health, the Office of the Alternative

21 Medicine and the Office of Rare Diseases Re22 search; and

23 ‘‘(B) for construction and acquisition of

24 equipment for or facilities of or used by the Na25 tional Institutes of Health;
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1 ‘‘(2) 2 percent of such amounts for transfer to

2 the National Center for Research Resources to carry

3 out section 1502 of the National Institutes of

4 Health Revitalization Act of 1993 concerning Bio5 medical and Behavioral Research Facilities;

6 ‘‘(3) 1 percent of such amounts during any fis7 cal year for carrying out section 301 and part D of

8 title IV with respect to health information commu9 nications; and

10 ‘‘(4) the remainder of such amounts during any

11 fiscal year to member institutes of the National In12 stitutes of Health and centers in the same propor13 tion to the total amount received under this section,

14 as the amount of annual appropriations under ap15 propriations Acts for each member institute and cen16 ter for the fiscal year bears to the total amount of

17 appropriations under appropriations Acts for all

18 member institutes and centers of the National Insti19 tutes of Health for the fiscal year.

20 ‘‘(b) PLANS OF ALLOCATION.—The amounts trans21 ferred under subsection (a) shall be allocated by the Direc22 tor of NIH or the various directors of the institutes and

23 centers, as the case may be, pursuant to allocation plans

24 developed by the various advisory councils to such direc25 tors, after consultation with such directors.’’.
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1 (3) ADMINISTRATIVE EXPENSES.—Amounts in

2 the National Fund for Health Research shall be

3 available to pay the administrative expenses of the

4 Department of the Treasury directly allocable to—

5 (A) modifying the individual income tax re6 turn forms to carry out section 6097 of the In7 ternal Revenue Code of 1986;

8 (B) carrying out this section with respect

9 to such Fund; and

10 (C) processing amounts received under this

11 section and transferring such amounts to such

12 Fund.

13 (4) TRIGGER AND RELEASE OF FUND MON14 IES.—No expenditures shall be made pursuant to

15 section 4002(c) during any fiscal year in which the

16 annual amount appropriated for the National Insti17 tutes of Health is less than the amount so appro18 priated for the prior fiscal year.

19 (d) BUDGET ENFORCEMENT.—Amounts contained in

20 the National Fund for Health Research shall be excluded

21 from, and shall not be taken into account for purposes

22 of, any budget enforcement procedures under the Congres23 sional Budget Act of 1974 or the Balanced Budget Emer24 gency Deficit Control Act of 1985.
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1 TITLE V—REVENUE PROVISIONS

2 SEC. 5000. AMENDMENT OF 1986 CODE.

3 Except as otherwise expressly provided, whenever in

4 this title an amendment or repeal is expressed in terms

5 of an amendment to, or repeal of, a section or other provi6 sion, the reference shall be considered to be made to a

7 section or other provision of the Internal Revenue Code

8 of 1986.

9 Subtitle A—Financing Provisions

10 SEC. 5001. INCREASE IN EXCISE TAXES ON TOBACCO

11 PRODUCTS.

12 (a) CIGARETTES.—Subsection (b) of section 5701 is

13 amended—

14 (1) by striking ‘‘$12 per thousand ($10 per

15 thousand on cigarettes removed during 1991 or

16 1992)’’ in paragraph (1) and inserting ‘‘$62 per

17 thousand’’, and

18 (2) by striking ‘‘$25.20 per thousand ($21 per

19 thousand on cigarettes removed during 1991 or

20 1992)’’ in paragraph (2) and inserting ‘‘$130.20 per

21 thousand’’.

22 (b) CIGARS.—Subsection (a) of section 5701 is

23 amended—

24 (1) by striking ‘‘$1.125 cents per thousand

25 (93.75 cents per thousand on cigars removed during
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1 1991 or 1992)’’ in paragraph (1) and inserting

2 ‘‘$51.13 per thousand’’, and

3 (2) by striking ‘‘equal to’’ and all that follows

4 in paragraph (2) and inserting ‘‘equal to 66 percent

5 of the price for which sold but not more than $155

6 per thousand.’’

7 (c) CIGARETTE PAPERS.—Subsection (c) of section

8 5701 is amended by striking ‘‘0.75 cent (0.625 cent on

9 cigarette papers removed during 1991 or 1992)’’ and in10 serting ‘‘3.88 cents’’.

11 (d) CIGARETTE TUBES.—Subsection (d) of section

12 5701 is amended by striking ‘‘1.5 cents (1.25 cents on

13 cigarette tubes removed during 1991 or 1992)’’ and in14 serting ‘‘7.76 cents’’.

15 (e) SMOKELESS TOBACCO.—Subsection (e) of section

16 5701 is amended—

17 (1) by striking ‘‘36 cents (30 cents on snuff re18 moved during 1991 or 1992)’’ in paragraph (1) and

19 inserting ‘‘$13.69’’, and

20 (2) by striking ‘‘12 cents (10 cents on chewing

21 tobacco removed during 1991 or 1992)’’ in para22 graph (2) and inserting ‘‘$5.45’’.

23 (f) PIPE TOBACCO.—Subsection (f) of section 5701

24 is amended by striking ‘‘67.5 cents (56.25 cents on pipe
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1 tobacco removed during 1991 or 1992)’’ and inserting

2 ‘‘$17.35’’.

3 (g) APPLICATION OF TAX INCREASE TO PUERTO

4 RICO.—Section 5701 is amended by adding at the end the

5 following new subsection:

6 ‘‘(h) APPLICATION TO TAXES TO PUERTO RICO.—

7 Notwithstanding subsections (b) and (c) of section 7653

8 and any other provision of law:

9 ‘‘(1) IN GENERAL.—On tobacco products and

10 cigarette papers and tubes, manufactured or im11 ported into the Commonwealth of Puerto Rico, there

12 is hereby imposed a tax at the rate equal to the ex13 cess of—

14 ‘‘(A) the rate of tax applicable under this

15 section to like articles manufactured in the

16 United States, over

17 ‘‘(B) the rate referred to in subparagraph

18 (A) as in effect on the day before the date of

19 the enactment of the Health Innovation Part20 nership Act of 1994.

21 ‘‘(2) SHIPMENTS TO PUERTO RICO FROM THE

22 UNITED STATES.—Only the rates of tax in effect on

23 the day before the date of the enactment of this sub24 section shall be taken into account in determining

25 the amount of any exemption from, or credit or
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1 drawback of, any tax imposed by this section on any

2 article shipped to the Commonwealth of Puerto Rico

3 from the United States.

4 ‘‘(3) SHIPMENTS FROM PUERTO RICO TO THE

5 UNITED STATES.—The rates of tax taken into ac6 count under section 7652(a) with respect to tobacco

7 products and cigarette papers and tubes coming into

8 the United States from the Commonwealth of Puer9 to Rico shall be the rates of tax in effect on the day

10 before the date of the enactment of the Health Inno11 vation Partnership Act of 1994.

12 ‘‘(4) DISPOSITION OF REVENUES.—The provi13 sions of section 7652(a)(3) shall not apply to any

14 tax imposed by reason of this subsection.’’.

15 (h) EFFECTIVE DATE.—The amendments made by

16 this section shall apply to articles removed (as defined in

17 section 5702(k) of the Internal Revenue Code of 1986,

18 as amended by this Act) after December 31, 1994.

19 (i) FLOOR STOCKS TAXES.—

20 (1) IMPOSITION OF TAX.—On tobacco products

21 and cigarette papers and tubes manufactured in or

22 imported into the United States or the Common23 wealth of Puerto Rico which are removed before any

24 tax-increase date, and held on such date for sale by
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1 any person, there is hereby imposed a tax in an

2 amount equal to the excess of—

3 (A) the tax which would be imposed under

4 section 5701 of the Internal Revenue Code of

5 1986 on the article if the article had been re6 moved on such date, over

7 (B) the prior tax (if any) imposed under

8 section 5701 or 7652 of such Code on such ar9 ticle.

10 (2) AUTHORITY TO EXEMPT CIGARETTES HELD

11 IN VENDING MACHINES.—To the extent provided in

12 regulations prescribed by the Secretary, no tax shall

13 be imposed by paragraph (1) on cigarettes held for

14 retail sale on any tax-increase date, by any person

15 in any vending machine. If the Secretary provides

16 such a benefit with respect to any person, the Sec17 retary may reduce the $500 amount in paragraph

18 (3) with respect to such person.

19 (3) CREDIT AGAINST TAX.—Each person shall

20 be allowed as a credit against the taxes imposed by

21 paragraph (1) an amount equal to $500. Such credit

22 shall not exceed the amount of taxes imposed by

23 paragraph (1) on each tax-increase date for which

24 such person is liable.
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1 (4) LIABILITY FOR TAX AND METHOD OF PAY2 MENT.—

3 (A) LIABILITY FOR TAX.—A person hold4 ing cigarettes on any tax-increase date, to

5 which any tax imposed by paragraph (1) applies

6 shall be liable for such tax.

7 (B) METHOD OF PAYMENT.—The tax im8 posed by paragraph (1) shall be paid in such

9 manner as the Secretary shall prescribe by reg10 ulations.

11 (C) TIME FOR PAYMENT.—The tax im12 posed by paragraph (1) shall be paid on or be13 fore the date which is 3 months after the tax14 increase date.

15 (5) ARTICLES IN FOREIGN TRADE ZONES.—

16 Notwithstanding the Act of June 18, 1934 (48 Stat.

17 998, 19 U.S.C. 81a) and any other provision of law,

18 any article which is located in a foreign trade zone

19 on any tax-increase date shall be subject to the tax

20 imposed by paragraph (1) if—

21 (A) internal revenue taxes have been deter22 mined, or customs duties liquidated, with re23 spect to such article before such date pursuant

24 to a request made under the 1st proviso of sec25 tion 3(a) of such Act, or
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1 (B) such article is held on such date under

2 the supervision of a customs officer pursuant to

3 the 2d proviso of such section 3(a).

4 (6) DEFINITIONS.—For purposes of this sub5 section:

6 (A) IN GENERAL.—Terms used in this sub7 section which are also used in section 5702 of

8 the Internal Revenue Code of 1986 shall have

9 the respective meanings such terms have in

10 such section, as amended by this Act.

11 (B) SECRETARY.—The term ‘‘Secretary’’

12 means the Secretary of the Treasury or his del13 egate.

14 (C) TAX-INCREASE DATE.—The term ‘‘tax15 increase date’’ means January 1, 1995, and

16 July 1, 1996.

17 (7) CONTROLLED GROUPS.—Rules similar to

18 the rules of section 5061(e)(3) of such Code shall

19 apply for purposes of this subsection.

20 (8) OTHER LAWS APPLICABLE.—All provisions

21 of law, including penalties, applicable with respect to

22 the taxes imposed by section 5701 of such Code

23 shall, insofar as applicable and not inconsistent with

24 the provisions of this subsection, apply to the floor

25 stocks taxes imposed by paragraph (1), to the same
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1 extent as if such taxes were imposed by such section

2 5701. The Secretary may treat any person who bore

3 the ultimate burden of the tax imposed by para4 graph (1) as the person to whom a credit or refund

5 under such provisions may be allowed or made.

6 SEC. 5002. MODIFICATIONS OF CERTAIN TOBACCO TAX

7 PROVISIONS.

8 (a) EXEMPTION FOR EXPORTED TOBACCO PROD9 UCTS AND CIGARETTE PAPERS AND TUBES TO APPLY

10 ONLY TO ARTICLES MARKED FOR EXPORT.—

11 (1) Subsection (b) of section 5704 is amended

12 by adding at the end the following new sentence:

13 ‘‘Tobacco products and cigarette papers and tubes

14 may not be transferred or removed under this sub15 section unless such products or papers and tubes

16 bear such marks, labels, or notices as the Secretary

17 shall by regulations prescribe.’’

18 (2) Section 5761 is amended by redesignating

19 subsections (c) and (d) as subsections (d) and (e),

20 respectively, and by inserting after subsection (b)

21 the following new subsection:

22 ‘‘(c) SALE OF TOBACCO PRODUCTS AND CIGARETTE

23 PAPERS AND TUBES FOR EXPORT.—Except as provided

24 in subsections (b) and (d) of section 5704—
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1 ‘‘(1) every person who sells, relands, or receives

2 within the jurisdiction of the United States any to3 bacco products or cigarette papers or tubes which

4 have been labeled or shipped for exportation under

5 this chapter,

6 ‘‘(2) every person who sells or receives such

7 relanded tobacco products or cigarette papers or

8 tubes, and

9 ‘‘(3) every person who aids or abets in such

10 selling, relanding, or receiving,

11 shall, in addition to the tax and any other penalty provided

12 in this title, be liable for a penalty equal to the greater

13 of $1,000 or 5 times the amount of the tax imposed by

14 this chapter. All tobacco products and cigarette papers

15 and tubes relanded within the jurisdiction of the United

16 States, and all vessels, vehicles, and aircraft used in such

17 relanding or in removing such products, papers, and tubes

18 from the place where relanded, shall be forfeited to the

19 United States.’’.

20 (3) Subsection (a) of section 5761 is amended

21 by striking ‘‘subsection (b)’’ and inserting ‘‘sub22 section (b) or (c)’’.

23 (4) Subsection (d) of section 5761, as redesig24 nated by paragraph (2), is amended by striking

25 ‘‘The penalty imposed by subsection (b)’’ and insert-
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1 ing ‘‘The penalties imposed by subsections (b) and

2 (c)’’.

3 (5)(A) Subpart F of chapter 52 is amended by

4 adding at the end the following new section:

5 ‘‘SEC. 5754. RESTRICTION ON IMPORTATION OF PRE6 VIOUSLY EXPORTED TOBACCO PRODUCTS.

7 ‘‘(a) IN GENERAL.—Tobacco products and cigarette

8 papers and tubes previously exported from the United

9 States may be imported or brought into the United States

10 only as provided in section 5704(d). For purposes of this

11 section, section 5704(d), section 5761, and such other pro12 visions as the Secretary may specify by regulations, ref13 erences to exportation shall be treated as including a ref14 erence to shipment to the Commonwealth of Puerto Rico.

15 ‘‘(b) CROSS REFERENCE.—

‘‘For penalty for the sale of tobacco products and

cigarette papers and tubes in the United States

which are labeled for export, see section 5761(c).’’.

16 (B) The table of sections for subpart F of chap17 ter 52 is amended by adding at the end the following

18 new item:

‘‘Sec. 5754. Restriction on importation of previously exported tobacco products.’’.

19 (b) IMPORTERS REQUIRED TO BE QUALIFIED.—

20 (1) Sections 5712, 5713(a), 5721, 5722,

21 5762(a)(1), and 5763(b) and (c) are each amended

22 by inserting ‘‘or importer’’ after ‘‘manufacturer’’.
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1 (2) The heading of subsection (b) of section

2 5763 is amended by inserting ‘‘QUALIFIED IMPORT3 ERS,’’ after ‘‘MANUFACTURERS,’’.

4 (3) The heading for subchapter B of chapter 52

5 is amended by inserting ‘‘and Importers’’ after

6 ‘‘Manufacturers’’.

7 (4) The item relating to subchapter B in the

8 table of subchapters for chapter 52 is amended by

9 inserting ‘‘and importers’’ after ‘‘manufacturers’’.

10 (c) REPEAL OF TAX-EXEMPT SALES TO EMPLOYEES

11 OF CIGARETTE MANUFACTURERS.—

12 (1) Subsection (a) of section 5704 is amend13 ed—

14 (A) by striking ‘‘EMPLOYEE USE OR’’ in

15 the heading, and

16 (B) by striking ‘‘for use or consumption by

17 employees or’’ in the text.

18 (2) Subsection (e) of section 5723 is amended

19 by striking ‘‘for use or consumption by their employ20 ees, or for experimental purposes’’ and inserting

21 ‘‘for experimental purposes’’.

22 (d) REPEAL OF TAX-EXEMPT SALES TO UNITED

23 STATES.—Subsection (b) of section 5704 is amended by

24 striking ‘‘and manufacturers may similarly remove such

25 articles for use of the United States;’’.
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1 (e) BOOKS OF 25 OR FEWER CIGARETTE PAPERS

2 SUBJECT TO TAX.—Subsection (c) of section 5701 is

3 amended by striking ‘‘On each book or set of cigarette

4 papers containing more than 25 papers,’’ and inserting

5 ‘‘On cigarette papers,’’.

6 (f) STORAGE OF TOBACCO PRODUCTS.—Subsection

7 (k) of section 5702 is amended by inserting ‘‘under section

8 5704’’ after ‘‘internal revenue bond’’.

9 (g) AUTHORITY TO PRESCRIBE MINIMUM MANUFAC10 TURING ACTIVITY REQUIREMENTS.—Section 5712 is

11 amended by striking ‘‘or’’ at the end of paragraph (1),

12 by redesignating paragraph (2) as paragraph (3), and by

13 inserting after paragraph (1) the following new paragraph:

14 ‘‘(2) the activity proposed to be carried out at

15 such premises does not meet such minimum capacity

16 or activity requirements as the Secretary may pre17 scribe, or’’.

18 (h) SPECIAL RULES RELATING TO PUERTO RICO

19 AND THE VIRGIN ISLANDS.—Section 7652 is amended by

20 adding at the end the following new subsection:

21 ‘‘(h) LIMITATION ON COVER OVER OF TAX ON TO22 BACCO PRODUCTS.—For purposes of this section, with re23 spect to taxes imposed under section 5701 or this section

24 on any tobacco product or cigarette paper or tube, the

25 amount covered into the treasuries of Puerto Rico and the
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1 Virgin Islands shall not exceed the rate of tax under sec2 tion 5701 in effect on the article on the day before the

3 date of the enactment of the Health Innovation Partner4 ship Act of 1994.’’

5 (i) EFFECTIVE DATE.—The amendments made by

6 this section shall apply to articles removed (as defined in

7 section 5702(k) of the Internal Revenue Code of 1986,

8 as amended by this Act) after December 31, 1994.

9 SEC. 5003. IMPOSITION OF EXCISE TAX ON MANUFACTURE

10 OR IMPORTATION OF ROLL-YOUR-OWN TO11 BACCO.

12 (a) IN GENERAL.—Section 5701 (relating to rate of

13 tax), as amended by section 5001, is amended by redesig14 nating subsections (g) and (h) as subsections (h) and (i)

15 and by inserting after subsection (f) the following new

16 subsection:

17 ‘‘(g) ROLL-YOUR-OWN TOBACCO.—On roll-your-own

18 tobacco, manufactured in or imported into the United

19 States, there shall be imposed a tax of $17.35 per pound

20 (and a proportionate tax at the like rate on all fractional

21 parts of a pound).’’.

22 (b) ROLL-YOUR-OWN TOBACCO.—Section 5702 (re23 lating to definitions) is amended by adding at the end the

24 following new subsection:
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1 ‘‘(p) ROLL-YOUR-OWN TOBACCO.—The term ‘roll2 your-own tobacco’ means any tobacco which, because of

3 its appearance, type, packaging, or labeling, is suitable for

4 use and likely to be offered to, or purchased by, consumers

5 as tobacco for making cigarettes.’’.

6 (c) TECHNICAL AMENDMENTS.—

7 (1) Subsection (c) of section 5702 is amended

8 by striking ‘‘and pipe tobacco’’ and inserting ‘‘pipe

9 tobacco, and roll-your-own tobacco’’.

10 (2) Subsection (d) of section 5702 is amend11 ed—

12 (A) in the material preceding paragraph

13 (1), by striking ‘‘or pipe tobacco’’ and inserting

14 ‘‘pipe tobacco, or roll-your-own tobacco’’, and

15 (B) by striking paragraph (1) and insert16 ing the following new paragraph:

17 ‘‘(1) a person who produces cigars, cigarettes,

18 smokeless tobacco, pipe tobacco, or roll-your-own to19 bacco solely for the person’s own personal consump20 tion or use, and’’.

21 (3) The chapter heading for chapter 52 is

22 amended to read as follows:
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1 ‘‘CHAPTER 52—TOBACCO PRODUCTS AND

2 CIGARETTE PAPERS AND TUBES’’.

3 (4) The table of chapters for subtitle E is

4 amended by striking the item relating to chapter 52

5 and inserting the following new item:

‘‘CHAPTER 52. TOBACCO PRODUCTS AND CIGARETTE PAPERS AND

TUBES.’’

6 (d) EFFECTIVE DATE.—

7 (1) IN GENERAL.—The amendments made by

8 this section shall apply to roll-your-own tobacco re9 moved (as defined in section 5702(k) of the Internal

10 Revenue Code of 1986, as amended by this Act)

11 after December 31, 1994.

12 (2) TRANSITIONAL RULE.—Any person who—

13 (A) on the date of the enactment of this

14 Act is engaged in business as a manufacturer of

15 roll-your-own tobacco or as an importer of to16 bacco products or cigarette papers and tubes,

17 and

18 (B) before January 1, 1995, submits an

19 application under subchapter B of chapter 52

20 of such Code to engage in such business,

21 may, notwithstanding such subchapter B, continue

22 to engage in such business pending final action on

23 such application. Pending such final action, all pro24 visions of such chapter 52 shall apply to such appli-
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1 cant in the same manner and to the same extent as

2 if such applicant were a holder of a permit under

3 such chapter 52 to engage in such business.

4 Subtitle B—Health Care Reform

5 Trust Fund

6 SEC. 5101. ESTABLISHMENT OF HEALTH CARE REFORM

7 TRUST FUND.

8 (a) IN GENERAL.—Subchapter A of chapter 98 (re9 lating to establishment of trust funds) is amended by add10 ing at the end the following new part:

11 ‘‘PART II—HEALTH CARE TRUST FUND

‘‘Sec. 9551. Health Care Reform Trust Fund

12 ‘‘SEC. 9551. HEALTH CARE REFORM TRUST FUND.

13 ‘‘(a) CREATION OF TRUST FUND.—There is estab14 lished in the Treasury of the United States a trust fund

15 to be known as the ‘Health Care Reform Trust Fund’,

16 consisting of such amounts as may be appropriated or

17 credited to the Health Care Reform Trust Fund as pro18 vided in this section.

19 ‘‘(b) TRANSFERS TO THE TRUST FUND.—There are

20 hereby appropriated to the Health Care Reform Trust

21 Fund amounts received in the Treasury under section

22 5701 (relating to taxes on tobacco products) to the extent

23 attributable to the increases in such taxes as the result
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1 of the enactment of subtitle A of title V of the Health

2 Innovation Partnership Act of 1994.

3 ‘‘(c) EXPENDITURES.—Amounts in the Health Care

4 Reform Trust Fund are appropriated as provided for in

5 sections 2001 and 4002 of the Health Innovation Partner6 ship Act of 1994, and title XXVII of the Public Health

7 Service Act, and to the extent any such amount is not

8 expended during any fiscal year, such amount shall be

9 available for such purpose for subsequent fiscal years.

10 ‘‘(d) OTHER RULES.—

11 ‘‘(1) INSUFFICIENT FUNDS.—If, for any fiscal

12 year, the sum of the amounts required to be allo13 cated under subsection (c) exceeds the amounts re14 ceived in the Health Care Reform Trust Fund, then

15 each of such amounts required to be so allocated

16 shall be reduced to an amount which bears the same

17 ratio to such amount as the amounts received in the

18 trust fund bear to the amounts required to be so al19 located (without regard to this paragraph).

20 ‘‘(2) ALLOCATION OF EXCESS FUNDS AND IN21 TEREST.—Amounts received in the Health Care Re22 form Trust Fund in excess of the amounts required

23 to be allocated under subsection (c), for any fiscal

24 year shall be allocated ratably on the basis of the
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1 amounts allocated for the fiscal year (without regard

2 to this paragraph).’’.

3 (b) CONFORMING AMENDMENT.—Subchapter A of

4 chapter 98 is amended by inserting after the subchapter

5 heading the following new items:

‘‘Part I. General trust funds.

‘‘Part II. Health care trust fund.

6 ‘‘PART I—GENERAL TRUST FUNDS’’.

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