II

103D CONGRESS

1ST SESSION S. 1282

To increase the number of primary health care providers, help assure access

to health care in rural and other underserved areas, and increase retention rates among primary health care providers in rural and underserved

areas.

IN THE SENATE OF THE UNITED STATES

JULY 23 (legislative day, JUNE 30), 1993

Mr. BINGAMAN introduced the following bill; which was read twice and

referred to the Committee on Labor and Human Resources

A BILL

To increase the number of primary health care providers,

help assure access to health care in rural and other

underserved areas, and increase retention rates among

primary health care providers in rural and underserved

areas.

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.

4 This Act may be cited as the ‘‘Graduate Reform

5 Opportunities and Work Force Training in Health Act’’

6 (GROWTH).
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1 SEC. 2. FINDINGS.

2 Congress finds that—

3 (1) of the approximately 600,000 practicing

4 physicians in the United States, only one-third are

5 in primary health care and, of recent United States

6 medical school graduates, only one-sixth are choos7 ing primary health care careers;

8 (2) every year, more United States medical

9 school graduates enter specialty fields, turning away

10 from the practice of primary health care;

11 (3) although the Nation’s physician-to-popu12 lation ratio has increased significantly in recent

13 years and the total United States physician supply

14 has doubled over the past 3 decades, rural areas

15 throughout the country face growing access-to-care

16 problems;

17 (4) the number of physicians entering rural

18 practice is declining and many rural areas are expe19 riencing shortages of primary health care providers;

20 (5) because almost 20 percent of physicians

21 practicing in rural counties are over the age of 65,

22 physician shortages in such counties are expected to

23 become worse over the next few years as these pro24 viders retire;

25 (6) one-quarter of the United States population

26 lives in rural areas;
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1 (7) rural communities have unique characteris2 tics and special needs which challenge the health

3 care delivery system;

4 (8) in addition to training too few primary

5 health care providers and providers willing to prac6 tice in rural areas, the United States trains too few

7 minority providers;

8 (9) the growing number of highly compensated

9 specialists contributes to the difficulty the United

10 States faces in containing health care costs and in11 creasing access to basic health care services;

12 (10) there is no national plan or set of appro13 priate incentives in medical education financing sys14 tems to achieve the desired physician specialty mix,

15 racial and ethnic composition, and geographic dis16 tribution; and

17 (11) it is in the best interest of the United

18 States to establish such a national plan and such in19 centives in Federal medical education financing

20 systems.

21 SEC. 3. HEALTH WORK FORCE INTERAGENCY TASK FORCE.

22 Part F of title VII of the Public Health Service Act

23 (42 U.S.C. 295 et seq.) is amended by adding at the end

24 the following new section:
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1 ‘‘SEC. 783. HEALTH WORK FORCE INTERAGENCY TASK

2 FORCE.

3 ‘‘(a) ESTABLISHMENT.—Not later than 90 days after

4 the date of enactment of this section, the Secretary shall

5 establish a Health Work Force Interagency Task Force.

6 The Task Force shall be composed of representatives of

7 Federal agencies and departments that have responsibility

8 for the training, monitoring, funding, or supporting of

9 health care professions.

10 ‘‘(b) CO-CHAIRPERSONS.—The Assistant Secretary

11 for Health and the Assistant Secretary for Post-secondary

12 Education shall serve as the co-chairpersons of the Task

13 Force established under subsection (a).

14 ‘‘(c) FUNCTIONS AND ACTIVITIES.—The Task Force

15 established under subsection (a) shall—

16 ‘‘(1) review and coordinate all health work force

17 development and training efforts supported by the

18 Federal Government;

19 ‘‘(2) make recommendations to the Secretary of

20 Health and Human Services and the Secretary of

21 Education for coordinating Federal vocational edu22 cation policy with national health work force needs

23 and goals;

24 ‘‘(3) develop standards for programs on voca25 tional education in the health care professions and

26 procedures for program accountability; and
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1 ‘‘(4) carry out any other activity determined ap2 propriate by the Secretary of Health and Human

3 Services and the Secretary of Education.

4 ‘‘(d) REPORT.—Not later than 13 months after the

5 establishment of the Task Force under subsection (a), and

6 annually thereafter, the Task Force shall prepare and sub7 mit to the appropriate committees of Congress a report

8 concerning the types and funding levels of vocational edu9 cation in the health care professions for which the Federal

10 Government provides support and detailing the activities

11 of the Task Force over the preceding 12-month period.’’.

12 SEC. 4. PROGRAMS FOR PRIMARY HEALTH CARE IN RURAL

13 AREAS.

14 Section 778(b)(1) of the Public Health Service Act

15 (42 U.S.C. 294p(b)(1)) is amended—

16 (1) in subparagraph (D), by striking ‘‘and’’ at

17 the end;

18 (2) in subparagraph (E), by striking the period

19 and inserting a semicolon; and

20 (3) by adding at the end the following new sub21 paragraphs:

22 ‘‘(F) establish training programs in medi23 cal schools that recruit students from rural un24 derserved areas who have demonstrated a com-
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1 mitment to careers in primary care medicine

2 and service in rural underserved areas;

3 ‘‘(G) give preference under the National

4 Health Service Corps and other Federal schol5 arship programs to candidates from and likely

6 to practice in rural underserved areas;

7 ‘‘(H) develop training programs for health

8 care practitioners that provide curricula and

9 faculty role models appropriate to a rural

10 health setting;

11 ‘‘(I) develop training programs for

12 underrepresented minorities in rural health set13 tings;

14 ‘‘(J) develop demonstration programs for

15 infrastructure development in rural health set16 tings, including the development of state-of-the17 art telecommunications and network systems

18 that link health care providers in rural areas

19 with other rural and urban health care provid20 ers and academic health centers;

21 ‘‘(K) establish State and regional locum

22 tenens programs in rural health settings so that

23 substitute health care providers are available

24 when permanent staff is absent from the health

25 care setting; and
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1 ‘‘(L) implement programs using inter2 disciplinary team approaches to health care

3 training and practice.’’.

4 SEC. 5. TERTIARY CARE CENTER TRAINING FOR NURSE

5 PRACTITIONERS, CLINICAL NURSE

6 SPECIALISTS AND PHYSICIAN ASSISTANTS.

7 Part C of title VII of the Public Health Service Act

8 (42 U.S.C. 293j et seq.) is amended by adding at the end

9 the following new section:

10 ‘‘SEC. 753. TERTIARY CARE CENTER TRAINING FOR NURSE

11 PRACTITIONERS, CLINICAL NURSE

12 SPECIALISTS AND PHYSICIAN ASSISTANTS.

13 ‘‘The Secretary shall develop training programs for

14 nurse practitioners, clinical nurse specialists and physician

15 assistants designed to prepare trainees in such programs

16 to staff tertiary care centers in a manner that addresses

17 the current and projected needs of such centers.’’.

18 SEC. 6. LIFE-TIME LEARNING.

19 Subtitle C of title VII of the Public Health Service

20 Act (42 U.S.C. 293j et seq.), as amended by section 5,

21 is further amended by adding at the end the following new

22 section:
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1 ‘‘SEC. 754. LIFE-TIME LEARNING DEMONSTRATION PRO2 GRAM.

3 ‘‘(a) IN GENERAL.—The Secretary, through grants,

4 contracts or cooperative agreements, shall support the es5 tablishment of demonstration projects in 10 States con6 cerning the retraining of certain physicians.

7 ‘‘(b) APPLICATIONS.—To be eligible to receive assist8 ance under subsection (a), an entity shall—

9 ‘‘(1) be a State or other public or nonprofit pri10 vate entity; and

11 ‘‘(2) prepare and submit to the Secretary an

12 application, at such time, in such manner and con13 taining such information as the Secretary may re14 quire.

15 ‘‘(c) USE.—An entity receiving assistance under sub16 section (a) shall conduct a program to—

17 ‘‘(1) evaluate the cost-effectiveness of retraining

18 physicians who are trained and practicing in

19 oversubscribed specialties to—

20 ‘‘(A) serve in medically underserved areas

21 in or outside of the United States; or

22 ‘‘(B) retrain for practice in primary health

23 care; and

24 ‘‘(2) conduct outcomes research targeted at im25 proving the scientific basis of medical practice.
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1 ‘‘(d) AUTHORIZATION OF APPROPRIATIONS.—There

2 are authorized to be appropriated to carry out this section,

3 $20,000,000 for each of the fiscal years 1994 through

4 1998.’’.

5 SEC. 7. HEALTH WORK FORCE NEEDS STUDY.

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

7 Human Services shall enter into a contract with a public

8 or nonprofit private entity to conduct a study for the pur9 pose of assessing current and projected health work force

10 needs in order to promote cost-effective, quality patient

11 care.

12 (b) NATIONAL ACADEMY OF SCIENCES.—The Sec13 retary shall request the National Academy of Sciences to

14 enter into the contract described in subsection (a). If the

15 Institute declines to conduct the study under such con16 tract, the Secretary of Health and Human Services shall

17 carry out such subsection through another public or non18 profit private entity.

19 (c) REPORT.—The Secretary shall ensure that, not

20 later than October 1, 1995, the study required in sub21 section (a) is completed and a report describing the find22 ings made as a result of such study is submitted to the

23 Committee on Energy and Commerce of the House of

24 Representatives, and to the Committee on Labor and

25 Human Resources of the Senate.’’.
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1 SEC. 8. PAYMENTS FOR DIRECT GRADUATE MEDICAL EDU2 CATION COSTS.

3 (a) IN GENERAL.—Section 1886(h) of the Social Se4 curity Act (42 U.S.C. 1395ww(h)) is amended—

5 (1) in paragraph (1), by striking ‘‘hospitals’’

6 each place it appears and inserting ‘‘GME consor7 tia’’;

8 (2) by amending paragraph (2) to read as

9 follows:

10 ‘‘(2) DETERMINATION OF AVERAGE PER RESI11 DENT AMOUNT.—The Secretary shall determine for

12 all GME consortia with approved medical residency

13 training programs, an average per resident amount

14 for cost reporting periods beginning on or after July

15 1, 1995 as follows:

16 ‘‘(A) BASE AMOUNT.—The Secretary shall

17 determine the national mean of all hospital spe18 cific FTE resident amounts for cost reporting

19 periods beginning on or after July 1, 1994, and

20 ending on or before June 30, 1995, under this

21 subsection as in effect on the day before the

22 date of the enactment of the Graduate Reform

23 Opportunities and Work Force Training in

24 Health Act.

25 ‘‘(B) INFLATION ADJUSTMENT TO BASE

26 AMOUNT.—
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1 ‘‘(i) AMOUNT FOR THE FIRST RE2 PORTING PERIOD.—For the first cost re3 porting period of the GME consortium be4 ginning on or after July 1, 1995, the aver5 age per resident amount for the GME con6 sortium is the amount determined under

7 subparagraph (A) updated by the esti8 mated percentage increase in the

9 Consumer Price Index during the 12-

10 month period described in subparagraph

11 (A).

12 ‘‘(ii) SUBSEQUENT COST REPORTING

13 PERIODS.—For each subsequent cost re14 porting period, the per average resident

15 amount for the GME consortium is equal

16 to the amount determined under this para17 graph for the previous cost reporting pe18 riod updated, through the midpoint of the

19 period, by projecting the estimated per20 centage change in the Consumer Price

21 Index during the 12-month period ending

22 at that midpoint, with appropriate adjust23 ments to reflect previous underestimations

24 or overestimations under this clause in the
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1 projected percentage change in the

2 Consumer Price Index.’’.

3 (3) by amending paragraph (3) to read as

4 follows:

5 ‘‘(3) GME CONSORTIUM PAYMENT AMOUNT PER

6 RESIDENT.—

7 ‘‘(A) IN GENERAL.—The payment amount,

8 for a GME consortium cost reporting period be9 ginning on and after July 1, 1995, is equal to

10 the product of—

11 ‘‘(i) the aggregate approved amount

12 (as defined in subparagraph (B)) for that

13 period, and

14 ‘‘(ii) the GME consortium’s medicare

15 patient load (as defined in subparagraph

16 (C)) for that period.

17 ‘‘(B) AGGREGATE APPROVED AMOUNT.—

18 As used in subparagraph (A), the term ‘aggre19 gate approved amount’ means, for a GME con20 sortium cost reporting period, the product of—

21 ‘‘(i) the average per resident amount

22 determined under paragraph (2) for that

23 period, and

24 ‘‘(ii) the weighted average number of

25 full-time-equivalent residents (as deter-
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1 mined under paragraph (4)) in the GME

2 consortium’s approved medical residency

3 training programs in that period.

4 ‘‘(C) MEDICARE PATIENT LOAD.—As used

5 in subparagraph (A), the term ‘medicare pa6 tient load’ means with respect to a GME con7 sortium’s cost reporting period the sum of—

8 ‘‘(i) the fraction of the total number

9 of inpatient-bed-days (as established by the

10 Secretary) during the period which is at11 tributable to patients with respect to whom

12 payment may be made under part A; and

13 ‘‘(ii) in the case of a member entity of

14 a GME consortium that does not furnish

15 inpatient services but does furnish services

16 for which payment may be made under

17 part B, the fraction of the total number of

18 all services provided by such member dur19 ing the period attributable to services for

20 which payment may be made under part

21 B.’’;

22 (4) in paragraph (4)—

23 (A) by amending subparagraph (A) to read

24 as follows:

25 ‘‘(A) IN GENERAL.—
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1 ‘‘(i) AGGREGATE NUMBER OF FIRST-YEAR

2 RESIDENTS.—For the 12 month period begin3 ning on July 1, 1995, and for each succeeding

4 12 month period, the aggregate number of first5 year residency positions for which payment may

6 be made under this subsection shall be equal to

7 110 percent of the total number of graduates of

8 United States medical schools in calendar year

9 1994.’’.

10 ‘‘(ii) PROPORTION OF SPECIALTY POSI11 TIONS.—The total number of first-year spe12 cialty residency positions for which payment

13 under this section may be made shall be equal

14 to—

15 ‘‘(I) 65 percent of the aggregate num16 ber of residency positions determined

17 under clause (i) for the period July 1,

18 1995, through June 30, 1996,

19 ‘‘(II) 60 percent of the aggregate

20 number of residency positions determined

21 under clause (i) for the period July 1,

22 1996, through June 30, 1997,

23 ‘‘(III) 50 percent of the aggregate

24 number of residency positions determined

25 under clause (i) for the 12 month period
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1 beginning July 1, 1997, and for each suc2 ceeding 12 month period.

3 ‘‘(iii) ALLOCATION TO GME CONSORTIA.—

4 ‘‘(I) IN GENERAL.—For the 12 month

5 period beginning on July 1, 1995, and for

6 each succeeding 12 month period, the Sec7 retary shall allocate the first year residency

8 positions permitted under clause (i) to

9 GME consortia after considering the rec10 ommendations of the National Health Care

11 Work Force Board established in section 9

12 of the Graduate Reform Opportunities and

13 Work Force Training in Health Act. Each

14 residency position allocated to a GME con15 sortium under this subclause shall remain

16 allocated to such consortium until the indi17 vidual who fills such position completes

18 such individual’s residency training.

19 ‘‘(II) NOTICE.—The Secretary shall

20 notify each GME consortium of such con21 sortium’s allocation of first-year residency

22 positions at least 1 year before the begin23 ning of the residency year for which such

24 allocation applies.
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1 ‘‘(III) FUNDING ELIGIBILITY CRI2 TERIA.—The Secretary shall provide that a

3 GME consortium receiving funds under

4 this subsection maintains an approved

5 medical residency program.’’.

6 (B) by amending subparagraph (B) to read

7 as follows—

8 ‘‘(B) RULES FOR DETERMINING FULL9 TIME EQUIVALENT RESIDENTS.—The Secretary

10 shall establish rules consistent with this para11 graph for the computation of the number of

12 full-time-equivalent residents in an approved

13 medical residency training program. Such rules

14 shall take into account individuals who serve

15 United States residents for only a portion of a

16 period with a GME consortium or simulta17 neously with more than 1 GME consortium.’’;

18 and

19 (C) by amending subparagraph (C) to read

20 as follows:

21 ‘‘(C) WEIGHTING FACTORS FOR CERTAIN

22 RESIDENTS.—Subject to subparagraph (D),

23 such rules shall provide, in calculating the num24 ber of full-time-equivalent residents in an ap25 proved medical residency training program—
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1 ‘‘(i) for a resident who is in the resi2 dent’s initial residency period, the

3 weighting factor is 0.80 (1.50, in the case

4 of a resident who is in a residency in a

5 rural area as defined in section

6 1886(d)(2)(D)), and

7 ‘‘(ii) for a resident who is not in the

8 resident’s initial residency period, the

9 weighting factor is 0.50 (1.50, in the case

10 of a resident who is in a residency in a

11 rural area as defined in section

12 1886(d)(2)(D)).’’; and

13 (D) in subparagraph (E), by striking ‘‘hos14 pital’’ and inserting ‘‘GME consortium’’; and

15 (7) in paragraph (5)—

16 (A) in subparagraph (A), by inserting ‘‘of17 fered by a consortium’’ after ‘‘postgraduate

18 medical training program’’; and

19 (B) by adding at the end the following new

20 subparagraphs:

21 ‘‘(I) GME CONSORTIUM.—

22 ‘‘(i) IN GENERAL.—The term ‘GME

23 consortium’ means a group composed of at

24 least 1 medical school, 1 teaching hospital,

25 and 1 community-based ambulatory train-
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1 ing site (including a physician’s office, a

2 community health center, or a rural health

3 clinic) that is organized and overseen by a

4 member medical school.

5 ‘‘(ii) COST REPORTING PERIOD.—For

6 purposes of this subsection, a consortium’s

7 cost reporting period shall be the cost re8 porting period of a member hospital, as de9 termined by the Secretary.

10 ‘‘(iii) REPORTS.—Each GME consor11 tium shall submit an annual report to the

12 National Health Care Work Force Board

13 describing—

14 ‘‘(I) the organization of the GME

15 consortium’s approved medical resi16 dency training programs, and

17 ‘‘(II) the location and profes18 sional activities of each individual that

19 completed the GME consortium’s ap20 proved medical residency training pro21 gram in the prior 3 years.

22 ‘‘(J) PRIMARY CARE RESIDENCY.—The

23 term ‘primary care residency’ means a resi24 dency in family medicine, general internal medi25 cine, or general pediatric medicine.
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1 ‘‘(K) SPECIALTY RESIDENCY.—The term

2 ‘specialty residency’ means a residency that is

3 not a primary care residency.’’.

4 (b) EFFECTIVE DATE.—The amendments made by

5 this section shall be effective for cost reporting periods

6 beginning on or after July 1, 1995.

7 SEC. 9. NATIONAL HEALTH CARE WORK FORCE BOARD.

8 (a) ESTABLISHMENT.—There is established a Board

9 to be known as the National Health Care Work Force

10 Board (hereafter in this section referred to as the

11 ‘‘Board’’).

12 (1) MEMBERSHIP.—

13 (A) COMPOSITION.—The Board shall be

14 composed of—

15 (i) 11 voting members to be appointed

16 by the President no later than January 1,

17 1994, and

18 (ii) 3 non-voting members consisting

19 of—

20 (I) the Secretary of Health and

21 Human Services (hereafter in this sec22 tion referred to as the ‘‘Secretary’’),

23 (II) the Director of the Health

24 Care Financing Administration, and
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1 (III) the Director of the Health

2 Resources and Services Administra3 tion,

4 or the designees of such individuals.

5 (B) QUALIFICATIONS.—The members of

6 the Board appointed under subparagraph (A)(i)

7 shall include individuals who—

8 (i) have national recognition for ex9 pertise in the health professions, hospital

10 and community-based care, biomedicine,

11 health services and health economics re12 search, licensing, accreditation, certifi13 cation, and related fields, and

14 (ii) are and represent consumers of

15 health services.

16 (C) PROHIBITION.—A member of the

17 Board appointed under subparagraph (A)(i)

18 may not be an employee or officer of the

19 Federal Government.

20 (2) PERIOD OF APPOINTMENT; VACANCIES.—

21 (A) TERMS.—The members of the Board

22 appointed under paragraph (1)(A)(i) shall be

23 appointed to serve for terms of 4 years, except

24 that the terms of the members first appointed
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1 may be staggered to ensure that the terms of

2 no more than 3 members expire in any 1 year.

3 (B) VACANCIES.—

4 (i) IN GENERAL.—The President shall

5 make an appointment to fill a vacancy on

6 the Board not later than 90 days from the

7 date that the vacancy occurred.

8 (ii) FILLING UNEXPIRED TERM.—An

9 individual chosen to fill a vacancy shall be

10 appointed for the unexpired term of the

11 member replaced.

12 (iii) EXPIRATION OF TERMS.—The

13 term of any member shall not expire before

14 the date on which the member’s successor

15 takes office.

16 (3) CHAIRPERSON.—The Board shall annually

17 select a Chairperson from among its members.

18 (4) MEETINGS.—

19 (A) IN GENERAL.—The Board shall meet

20 not less than twice a year at the call of the

21 Chairperson, or on a written request of one22 third of the members of the Board.

23 (B) INITIAL MEETING.—The Board shall

24 hold its first meeting not later than March 31,

25 1994.
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1 (C) QUORUM.—A majority of the members

2 of the Board shall constitute a quorum, but a

3 lesser number of members may hold hearings.

4 (b) FUNCTIONS.—

5 (1) ALLOCATION RECOMMENDATION.—

6 (A) INFORMATION COLLECTION AND RE7 CEIPT OF REQUESTS.—The Board shall—

8 (i) seek the recommendations of pri9 vate accrediting bodies concerning the

10 ranking of medical residency programs ac11 cording to program quality;

12 (ii) collect data from the Department

13 of Health and Human Services and State

14 health departments on national, State, and

15 regional health work force needs; and

16 (iii) solicit and receive requests from

17 GME consortia (as defined in section

18 1886(h)(5)(I) of the Social Security Act)

19 concerning the number and types of resi20 dency positions for which graduate medical

21 education funds under section 1886(h) of

22 the Social Security Act are sought;

23 (B) RECOMMENDATIONS.—The Board

24 shall develop and submit to the Secretary on an

25 annual basis recommendations on the number
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1 and types of first-year residency training posi2 tions for which each GME consortium should

3 receive graduate medical education funds under

4 section 1886(h) of the Social Security Act

5 based on quality of the medical residency pro6 gram operated by the GME consortium and

7 evaluation of national, State, and regional

8 needs.

9 (2) STUDY.—

10 (A) IN GENERAL.—The Board shall con11 duct a thorough study of—

12 (i) current and projected health care

13 work force needs and the extent to which

14 the work force represents the areas and

15 populations to be served;

16 (ii) State licensing, accreditation and

17 certification policies, reimbursement prac18 tices, and medical liability practices that

19 may discourage health care providers from

20 entering or practicing primary care medi21 cine or create disincentives to the practice

22 of medicine in rural areas; and

23 (iii) the need to limit non-federally

24 supported specialty residency positions.
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1 (B) RECOMMENDATIONS.—The Board

2 shall develop recommendations on each of the

3 matters studied under subparagraph (A).

4 (C) REPORT.—The Board shall submit a

5 report to the Congress which shall contain a de6 tailed statement of the findings and conclusions

7 of the Board, together with its recommenda8 tions for such legislation and administrative ac9 tions as it considers appropriate—

10 (i) not later than September 30,

11 1998, for the matter studied in subpara12 graph (A)(iii), and

13 (ii) not later than September 30,

14 1996, for the matter studied in clauses (i)

15 and (ii) of subparagraph (A).

16 (3) LEGISLATIVE PROPOSALS.—

17 (A) NUMBER OF RESIDENTS.—

18 (i) INITIAL PROPOSAL.—Not later

19 than 3 years after the date of the enact20 ment of this Act, the Board shall develop

21 and submit to Congress a legislative pro22 posal that adjusts the aggregate number of

23 federally-funded residency positions under

24 section 1886(h)(4)(A)(i) of the Social Se25 curity Act for the 3-year period beginning
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1 on July 1, 1998, and ending on June 30,

2 2001, based on the Board’s evaluation of

3 national, State, and regional needs.

4 (ii) SUBSEQUENT PROPOSALS.—Not

5 later than 3 years after the date the last

6 legislative proposal was submitted under

7 this subparagraph, the Board shall develop

8 and submit to Congress a legislative pro9 posal described in clause (i) for the follow10 ing 3-year period.

11 (B) PROPORTION OF FUNDED SPECIALTY

12 RESIDENCIES.—

13 (i) INITIAL PROPOSAL.—Not later

14 than 3 years after the date of the enact15 ment of this Act, the Board shall develop

16 and submit to Congress a legislative pro17 posal that adjusts the proportion of spe18 cialty residency positions under section

19 1886(h)(4)(A)(ii) of the Social Security

20 Act for the 3-year period beginning on

21 July 1, 1998, and ending on June 30,

22 2001, based on the Board’s evaluation of

23 national, State, and regional needs.

24 (ii) SUBSEQUENT PROPOSALS.—Not

25 later than 3 years after the date the last
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1 legislative proposal was submitted under

2 this subparagraph, the Board shall develop

3 and submit to Congress a legislative pro4 posal described in clause (i) for the follow5 ing 3-year period.

6 (C) APPROVAL RESOLUTION.—The legisla7 tive proposals described in subparagraphs (A)

8 and (B) shall be considered by Congress under

9 the procedures for consideration of an ‘‘ap10 proval resolution’’ as described in subsection

11 (c).

12 (c) CONGRESSIONAL CONSIDERATION OF APPROVAL

13 RESOLUTION.—

14 (1) RULES OF HOUSE OF REPRESENTATIVES

15 AND SENATE.—This paragraph is enacted by Con16 gress—

17 (A) as an exercise of the rulemaking power

18 of the House of Representatives and the Sen19 ate, respectively, and as such is deemed a part

20 of the rules of each House, respectively, but ap21 plicable only with respect to the procedure to be

22 followed in that House in the case of approval

23 resolutions described in paragraph (2), and su24 persedes other rules only to the extent that

25 such rules are inconsistent therewith; and
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1 (B) with full recognition of the constitu2 tional right of either House to change the rules

3 (so far as relating to the procedure of that

4 House) at any time, in the same manner and

5 to the same extent as in the case of any other

6 rule of that House.

7 (2) TERMS OF THE RESOLUTION.—For pur8 poses of paragraph (1), the term ‘‘approval resolu9 tion’’ means only a joint resolution of the 2 Houses

10 of Congress, providing in—

11 (A) the matter after the resolving clause of

12 which is as follows: ‘‘That Congress approves

13 the legislative proposal of the National Health

14 Care Work Force Board as submitted by the

15 Board on llllllllllllll’’,

16 the blank space being filled in with the appro17 priate date; and

18 (B) the title of which is as follows: ‘‘Joint

19 Resolution approving the legislative proposal of

20 the National Health Care Work Force Board.’’.

21 (3) INTRODUCTION AND REFERRAL.—On the

22 day on which the legislative proposal of the Commis23 sion is transmitted to the House of Representatives

24 and the Senate, an approval resolution with respect

25 to such proposal shall be introduced (by request) in
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1 the House of Representatives by the majority leader

2 of the House, for himself and the minority leader of

3 the House, or by Members of the House designated

4 by the majority leader of the House, for himself and

5 the minority leader of the House, or by Members of

6 the House designated by the majority leader and mi7 nority leader of the House; and shall be introduced

8 (by request) in the Senate by the majority leader of

9 the Senate, for himself and the minority leader of

10 the Senate, or by Members of the Senate designated

11 by the majority leader and minority leader of the

12 Senate. If either House is not in session on the day

13 on which such proposal is transmitted, the approval

14 resolution with respect to such proposal shall be in15 troduced in the House, as provided in the preceding

16 sentence, on the first day thereafter on which the

17 House is in session. The approval resolution intro18 duced in the House of Representatives and the Sen19 ate shall be referred to the appropriate committees

20 of each House.

21 (4) AMENDMENTS PROHIBITED.—No amend22 ment to an approval resolution shall be in order in

23 either the House of Representatives or the Senate

24 and no motion to suspend the application of this

25 paragraph shall be in order in either House, nor
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1 shall it be in order in either House for the Presiding

2 Officer to entertain a request to suspend the appli3 cation of this paragraph by unanimous consent.

4 (5) PERIOD FOR COMMITTEE AND FLOOR CON5 SIDERATION.—

6 (A) IN GENERAL.—Except as provided in

7 clause (ii), if the committee or committees of ei8 ther House to which an approval resolution has

9 been referred have not reported it at the close

10 of the 45th day after its introduction, such

11 committee or committees shall be automatically

12 discharged from further consideration of the

13 approval resolution and it shall be placed on the

14 appropriation calendar. A vote on final passage

15 of the approval resolution shall be taken in each

16 House on or before the close of the 45th day

17 after the approval resolution is reported by the

18 committees or committee of that House to

19 which it was referred, or after such committee

20 or committees have been discharged from fur21 ther consideration of the approval resolution. If

22 prior to the passage by 1 House of an approval

23 resolution of that House, that House receives

24 the same approval resolution from the other

25 House then—
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1 (i) the procedure in that House shall

2 be the same as if no approval resolution

3 had been received from the other House;

4 but

5 (ii) the vote on final passage shall be

6 on the approval resolution of the other

7 House.

8 (B) COMPUTATION OF DAYS.—For pur9 poses of clause (i), in computing a number of

10 days in either House, there shall be excluded

11 any day on which the House is not in session.

12 (6) FLOOR CONSIDERATION IN THE HOUSE OF

13 REPRESENTATIVES.—

14 (A) MOTION TO PROCEED.—A motion in

15 the House of Representatives to proceed to the

16 consideration of an approval resolution shall be

17 highly privileged and not debatable. An amend18 ment to the motion shall not be in order, nor

19 shall it be in order to move to reconsider the

20 vote by which the motion is agreed to or dis21 agreed to.

22 (B) DEBATE.—Debate in the House of

23 Representatives on an approval resolution shall

24 be limited to not more than 20 hours, which

25 shall be divided equally between those favoring
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1 and those opposing the bill or resolution. A mo2 tion further to limit debate shall not be debat3 able. It shall not be in order to move to recom4 mit an approval resolution or to move to recon5 sider the vote by which an approval resolution

6 is agreed to or disagreed to.

7 (C) MOTION TO POSTPONE.—Motions to

8 postpone, made in the House of Representatives

9 with respect to the consideration of an approval

10 resolution, and motions to proceed to the con11 sideration of other business, shall be decided

12 without debate.

13 (D) APPEALS.—All appeals from the deci14 sions of the Chair relating to the application of

15 the Rules of the House of Representatives to

16 the procedure relating to an approval resolution

17 shall be decided without debate.

18 (E) GENERAL RULES APPLY.—Except to

19 the extent specifically provided in the preceding

20 provisions of this subsection, consideration of

21 an approval resolution shall be governed by the

22 Rules of the House of Representatives applica23 ble to other bills and resolutions in similar cir24 cumstances.

25 (7) FLOOR CONSIDERATION IN THE SENATE.—
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1 (A) MOTION TO PROCEED.—A motion in

2 the Senate to proceed to the consideration of an

3 approval resolution shall be privileged and not

4 debatable. An amendment to the motion shall

5 not be in order, nor shall it be in order to move

6 to reconsider the vote by which the motion is

7 agreed to or disagreed to.

8 (B) GENERAL DEBATE.—Debate in the

9 Senate on an approval resolution, and all debat10 able motions and appeals in connection there11 with, shall be limited to not more than 20

12 hours. The time shall be equally divided be13 tween, and controlled by, the majority leader

14 and the minority leader or their designees.

15 (C) DEBATE OF MOTIONS AND APPEALS.—

16 Debate in the Senate on any debatable motion

17 or appeal in connection with an approval resolu18 tion shall be limited to not more than 1 hour,

19 to be equally divided between, and controlled

20 by, the mover and the manager of the approval

21 resolution, except that in the event the manager

22 of the approval resolution is in favor of any

23 such motion or appeal, the time in opposition

24 thereto, shall be controlled by the minority lead25 er or his designee. Such leaders, or either of
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1 them, may, from time under their control on

2 the passage of an approval resolution, allot ad3 ditional time to any Senator during the consid4 eration of any debatable motion or appeal.

5 (D) OTHER MOTIONS.—A motion in the

6 Senate to further limit debate is not debatable.

7 A motion to recommit an approval resolution is

8 not in order.

9 (8) POINT OF ORDER REQUIRING

10 SUPERMAJORITY FOR MODIFICATIONS TO PROPOSAL

11 ONCE APPROVED.—

12 (A) IN GENERAL.—It shall not be in order

13 in the House of Representatives or the Senate

14 to consider any amendment to the provisions of

15 the Graduate Reform Opportunities and Work

16 Force Training in Health Act except as pro17 vided in subparagraph (B).

18 (B) WAIVER.—The point of order de19 scribed in subparagraph (A) may be waived or

20 suspended in the House of Representatives or

21 the Senate only, by the affirmative vote of

22 three-fifths of the Members duly chosen and

23 sworn.

24 (d) RESUBMISSIONS.—If a legislative proposal of the

25 Board submitted under subparagraph (A) or (B) of sub-
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1 section (b)(3) is not approved by Congress within 90 days

2 of the submission of such proposal to Congress, or is ap3 proved by Congress and vetoed by the President (and such

4 veto is not overridden by the Congress), the Board shall

5 submit a new legislative proposal not later than 90 days

6 after Congress failed to approve the proposal or the Presi7 dent failed to override the President’s veto, and such new

8 legislative proposal shall be subject to congressional con9 sideration as provided in subsection (c).

10 (e) POWERS OF THE BOARD.—

11 (1) HEARINGS.—The Board may hold such

12 hearings, sit and act at such times and places, take

13 such testimony, and receive such evidence as the

14 Board considers advisable to carry out the purposes

15 of this section.

16 (2) INFORMATION FROM FEDERAL AGENCIES.—

17 The Board may secure directly from any Federal de18 partment or agency such information as the Board

19 considers necessary to carry out the provisions of

20 this section. Upon request of the Chairperson of the

21 Board, the head of such department or agency shall

22 furnish such information to the Board.

23 (3) POSTAL SERVICES.—The Board may use

24 the United States mails in the same manner and
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1 under the same conditions as other departments and

2 agencies of the Federal Government.

3 (4) GIFTS.—The Board may accept, use, and

4 dispose of gifts or donations of services or property.

5 (g) BOARD PERSONNEL MATTERS.—

6 (1) COMPENSATION OF MEMBERS.—Each mem7 ber of the Board who is not an officer or employee

8 of the Federal Government shall be compensated at

9 a rate equal to the daily equivalent of the annual

10 rate of basic pay prescribed for level V of the Execu11 tive Schedule under section 5315 of title 5, United

12 States Code, for each day (including travel time)

13 during which such member is engaged in the per14 formance of the duties of the Board. All members of

15 the Board who are officers or employees of the

16 United States shall serve without compensation in

17 addition to that received for their services as officers

18 or employees of the United States.

19 (2) TRAVEL EXPENSES.—The members of the

20 Board shall be allowed travel expenses, including per

21 diem in lieu of subsistence, at rates authorized for

22 employees of agencies under subchapter I of chapter

23 57 of title 5, United States Code, while away from

24 their homes or regular places of business in the per25 formance of services for the Board.
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1 (3) STAFF.—

2 (A) IN GENERAL.—The Secretary shall,

3 after consultation with and consideration of the

4 recommendations of the Board, provide the

5 Board with—

6 (i) an executive director and 1 other

7 professional staff member, and

8 (ii) such additional professional staff

9 members including clerical staff, services of

10 consultants, information, and administra11 tive support services (through contracts or

12 other arrangements) as the Secretary

13 deems necessary for the Board to carry out

14 its functions.

15 (B) DETAIL OF GOVERNMENT EMPLOY16 EES.—Any Federal Government employee may

17 be detailed to the Board without reimburse18 ment, and such detail shall be without interrup19 tion or loss of civil service status or privilege.

20 (h) AUTHORIZATION OF APPROPRIATIONS.—

21 (1) IN GENERAL.—There are authorized to be

22 appropriated such sums as may be necessary for the

23 Board to carry out the purposes of this section.

24 (2) AVAILABILITY.—Any sums appropriated

25 under the authorization contained in this section
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1 shall remain available, without fiscal year limitation,

2 until expended.

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