I

103D CONGRESS

2D SESSION H. R. 4024

To establish a national program of trained community health advisors to

assist the States in attaining the Healthy People 2000 Objectives.

IN THE HOUSE OF REPRESENTATIVES

MARCH 11, 1994

Mr. SANDERS (for himself, Mr. DELLUMS, Ms. EDDIE BERNICE JOHNSON of

Texas, Ms. PELOSI, Mr. PETERSON of Minnesota, Ms. VELA ́ZQUEZ, Mr.

BEILENSON, Mr. OWENS, Mr. HOCHBRUECKNER, Mr. SCOTT, Mr. PASTOR, and Mr. MCHALE) introduced the following bill; which was referred

to the Committee on Energy and Commerce

A BILL

To establish a national program of trained community health

advisors to assist the States in attaining the Healthy

People 2000 Objectives.

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 ‘‘National Community

5 Health Advisor Act’’.

6 SEC. 2. FINDINGS.

7 The Congress finds the following:
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1 (1) Poverty, geographic isolation, cultural dif2 ferences, lack of transportation, low literacy, lack of

3 access to services and further difficulties resulting

4 from a lack of continuity of care, are barriers for

5 millions of low-income and underserved Americans in

6 the current health care delivery system.

7 (2) The Public Health Service has determined

8 that many health problems are rooted in poverty and

9 hit hardest at those least able to protect themselves.

10 (3) The Public Health Service has established

11 goals and objectives regarding improvements in the

12 health of the public by the year 2000. An evaluation

13 by the Service, entitled ‘‘Health United States 1992

14 and Healthy People 2000 Review’’, illustrates the

15 acute access problem faced by rural areas and the

16 inner cities. The evaluation cites the fact that sub17 urbs have the lowest death rates, while death rates

18 in rural counties are 12 percent higher and in large

19 core metropolitan counties, 19 percent higher.

20 (4) Discussions of health care reform focus al21 most exclusively on questions of how to extend

22 health insurance to the Nation’s 35–40 million unin23 sured and make services available while simulta24 neously bringing medical cost under control; how25 ever, it is imperative to correct the fundamental and
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1 deep-rooted obstacles that low-income urban and

2 rural Americans confront when trying to access med3 ical care and preventive health services. For exam4 ple, in 1991, 19 million American women qualified

5 for mammography screening benefits through Medi6 care; however, only 670,000 (or less than 3 percent)

7 took advantage of this benefit.

8 (5) People who are local, indigenous members

9 and residents of underserved communities are

10 uniquely knowledgeable about their populations’

11 needs; where such individuals are already serving as

12 community health advisors, they communicate to

13 health and social service providers the needs of com14 munity members, provide quality health promotion

15 and disease prevention information to the commu16 nity and serve as the crucial link between their com17 munities and providers to increase utilization of

18 available preventive health services and to reach out

19 to communities to increase the effectiveness of the

20 health care delivery system, reduce preventable mor21 bidity and mortality, and improve the quality of life.

22 SEC. 3. FORMULA GRANTS REGARDING COMMUNITY

23 HEALTH ADVISOR PROGRAMS.

24 (a) IN GENERAL.—In the case of each State (or en25 tity designated by a State under subsection (b)) that sub-
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1 mits to the Secretary an application in accordance with

2 section 6 for a fiscal year, the Secretary of Health and

3 Human Services, acting through the Director of the Cen4 ters for Disease Control and Prevention, shall make an

5 award of financial assistance to the State or entity for the

6 development and operation of community health advisor

7 programs under section 4(b). The award shall consist of

8 the allotment determined under section 7 with respect to

9 the State, subject to section 12(b).

10 (b) DESIGNATED ENTITIES.—With respect to the

11 State involved, an entity other than the State may receive

12 an award under paragraph (1) only if the entity—

13 (1) is a public or nonprofit private academic or14 ganization (or other public or nonprofit private en15 tity); and

16 (2) has been designated by the State to carry

17 out the purpose described in such paragraph in the

18 State and to receive amounts under such paragraph

19 in lieu of the State.

20 (c) ROLE OF STATE AGENCY FOR PUBLIC

21 HEALTH.—A funding agreement for an award under sub22 section (a) is that—

23 (1) if the applicant is a State, the award will

24 be administered by the State agency with the prin-
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1 cipal responsibility for carrying out public health

2 programs; and

3 (2) if the applicant is an entity designated

4 under subsection (b), the award will be administered

5 in consultation with such State agency.

6 (d) STATEWIDE RESPONSIBILITIES; LIMITATION ON

7 EXPENDITURES.—

8 (1) STATEWIDE RESPONSIBILITIES.—A funding

9 agreement for an award under subsection (a) is that

10 the applicant involved will—

11 (A) operate a clearinghouse to maintain

12 and disseminate information on community

13 health advisor programs (and similar programs)

14 in the State, including information on develop15 ing and operating such programs, on training

16 individuals to participate in the programs, and

17 on evaluation of the programs;

18 (B) provide to community health advisor

19 programs in the State technical assistance in

20 training community health advisors under sec21 tion 5(g)(1); and

22 (C) coordinate the activities carried out in

23 the State under the award, including coordina24 tion between the various community health ad25 visor programs and coordination between such
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1 programs and related activities of the State and

2 of other public or private entities.

3 (2) LIMITATION.—A funding agreement for an

4 award under subsection (a) is that the applicant in5 volved will not expend more than 15 percent of the

6 award in the aggregate for carrying out paragraph

7 (1) and for the expenses of administering the award

8 with respect to the State involved, including the

9 process of receiving payments from the Secretary

10 under the award, allocating the payments among the

11 entities that are to develop and operate the commu12 nity health advisor programs involved, and monitor13 ing compliance with the funding agreements made

14 under this Act by the applicant.

15 SEC. 4. REQUIREMENTS REGARDING COMMUNITY HEALTH

16 ADVISOR PROGRAMS.

17 (a) PURPOSE OF AWARD; HEALTHY PEOPLE 2000

18 OBJECTIVES.—

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

20 funding agreement for an award under section 3 for

21 an applicant is that the purpose of the award is,

22 through community health advisor programs under

23 subsection (b), to assist the State involved in attain24 ing the Healthy People 2000 Objectives (as defined

25 in subsection (d).
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1 (2) AUTHORITY REGARDING SELECTION OF PRI2 ORITY OBJECTIVES.—With respect to compliance

3 with the agreement made under paragraph (1), an

4 applicant receiving an award under section 3 may,

5 from among the various Healthy People 2000 Objec6 tives, select one or more Objectives to be given prior7 ity in the operation of a community health advisor

8 program of the applicant, subject to the applicant

9 selecting such priorities in consultation with the en10 tity that is to carry out the program.

11 (b) REQUIREMENTS FOR PROGRAMS.—

12 (1) IN GENERAL.—A funding agreement for an

13 award under section 3 for an applicant is that, in

14 expending the award, the purpose described in sub15 section (a)(1) will be carried out in accordance with

16 the following:

17 (A) For each community for which the

18 purpose is to be carried out, the applicant will

19 establish a program in accordance with this

20 subsection.

21 (B) The program will be carried out in a

22 community only if the applicant has, under sec23 tion 5(a), identified the community as having a

24 significant need for the program.
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1 (C) The program will be operated by a

2 public or nonprofit private entity with experi3 ence in providing health or health-related social

4 services to individuals who are underserved with

5 respect to such services.

6 (D) The services of the program, as speci7 fied in paragraph (2), will be provided prin8 cipally by community health advisors (as de9 fined in subsection (d)).

10 (2) AUTHORIZED PROGRAM SERVICES.—For

11 purposes of paragraph (1)(D), the services specified

12 in this paragraph for a program are as follows:

13 (A) The program will collaborate with

14 health care providers and related entities in

15 order to facilitate the provision of health serv16 ices and health-related social services (including

17 collaborating with local health departments,

18 community health centers, migrant health cen19 ters, rural health clinics, hospitals, physicians

20 and nurses, providers of health education, and

21 providers of social services).

22 (B) The program will provide public edu23 cation on health promotion and disease preven24 tion and facilitate the use of available health

25 services and health-related social services.
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1 (C) The program will provide health-relat2 ed counseling.

3 (D) The program will provide referrals for

4 available health services and health-related so5 cial services.

6 (E) For the purpose of increasing the ca7 pacity of individuals to utilize health services

8 and health-related social services under Federal,

9 State, and local programs, the following condi10 tions will be met:

11 (i) The program will assist individuals

12 in establishing eligibility under the pro13 grams and in receiving the services or

14 other benefits of the programs.

15 (ii) The program will provide such

16 other services as the Secretary determines

17 to be appropriate, which services may in18 clude (but are not limited to) transpor19 tation and translation services.

20 (F) The program will provide outreach

21 services to inform the community of the avail22 ability of the services of the program.

23 (c) PRIORITY FOR MEDICALLY UNDERSERVED COM24 MUNITIES.—A funding agreement for an award under sec25 tion 3 is that the applicant involved will give priority to
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1 developing and operating community health advisor pro2 grams for medically underserved communities.

3 (d) CERTAIN DEFINITIONS.—

4 (1) COMMUNITY HEALTH ADVISOR.—For pur5 poses of this Act, the term ‘‘community health advi6 sor’’ means an individual—

7 (A) who has demonstrated the capacity to

8 carry out one or more of the authorized pro9 gram services;

10 (B) who, for not less than 1 year, has been

11 a resident of the community in which the com12 munity health advisor program involved is to be

13 operated; and

14 (C) is a member of a socioeconomic group

15 to be served by the program.

16 (2) HEALTHY PEOPLE 2000 OBJECTIVES.—For

17 purposes of this Act, the term ‘‘Healthy People 2000

18 Objectives’’ means the objectives established by the

19 Secretary toward increasing the span of healthy life,

20 reducing health disparities among various popu21 lations, and providing access to preventive services,

22 which objectives apply to the health status of the

23 population of the United States for the year 2000.
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1 (3) MEDICALLY UNDERSERVED COMMUNITY.—

2 For purposes of this Act, the term ‘‘medically under3 served community’’ means—

4 (A) a community that has a substantial

5 number of individuals who are members of a

6 medically underserved population, as defined in

7 section 330 of the Public Health Service Act; or

8 (B) a community a significant portion of

9 which is a health professional shortage area

10 designated under section 332 of such Act.

11 SEC. 5. ADDITIONAL AGREEMENTS.

12 (a) IDENTIFICATION OF COMMUNITY NEEDS.—A

13 funding agreement for an award under section 3 that the

14 applicant involved will—

15 (1) identify the needs of the community in16 volved for the authorized program services;

17 (2) in identifying such needs, consult with

18 members of the community, with individuals and

19 programs that provide health services in the commu20 nity, and with individuals and programs that provide

21 health-related social services in the community; and

22 (3) consider such needs in carrying out a com23 munity health advisor program for the community.

24 (b) MATCHING FUNDS.—
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1 (1) IN GENERAL.—With respect to the cost of

2 carrying out a community health advisor program, a

3 funding agreement for an award under section 3 is

4 that the applicant involved will make available (di5 rectly or through donations from public or private

6 entities) non-Federal contributions toward such cost

7 in an amount that is not less than 25 percent of

8 such cost.

9 (2) DETERMINATION OF AMOUNT CONTRIB10 UTED.—

11 (A) Non-Federal contributions required in

12 paragraph (1) may be in cash or in kind, fairly

13 evaluated, including plant, equipment, or serv14 ices. Amounts provided by the Federal Govern15 ment, or services assisted or subsidized to any

16 significant extent by the Federal Government,

17 may not be included in determining the amount

18 of such non-Federal contributions.

19 (B) With respect to the State in which the

20 community health advisor program involved is

21 to be carried out, amounts provided by the

22 State in compliance with subsection (c) shall be

23 included in determining the amount of non-Fed24 eral contributions under paragraph (1).
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1 (c) MAINTENANCE OF EFFORT.—With respect to the

2 purposes for which an award under section 3 is authorized

3 in this Act to be expended, the Secretary may make such

4 an award only if the State involved agrees to maintain

5 expenditures of non-Federal amounts for such purposes

6 at a level that is not less than the level of such expendi7 tures maintained by the State for the fiscal year preceding

8 the first fiscal year for which such an award is made with

9 respect to the State.

10 (d) CULTURAL CONTEXT OF SERVICES.—A funding

11 agreement for an award under section 3 for an applicant

12 is that the services of the community health advisor pro13 gram involved will be provided in the language and cul14 tural context most appropriate for the individuals served

15 by the program.

16 (e) NUMBER OF PROGRAMS PER AWARD; PROGRAMS

17 FOR URBAN AND RURAL AREAS.—A funding agreement

18 for an award under section 3 for an applicant is that the

19 number of community health advisor programs operated

20 in the State with the award will be determined by the Sec21 retary, except that (subject to section 4(b)(1)(B)) such a

22 program will be carried out in not less than one urban

23 area of the State, and in not less than one rural area of

24 the State.
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1 (f) ONGOING SUPERVISION OF ADVISORS.—A fund2 ing agreement for an award under section 3 is that the

3 applicant involved will ensure that each community health

4 advisor program operated with the award provides for the

5 ongoing supervision of the community health advisors of

6 the program.

7 (g) CERTAIN EXPENDITURES.—

8 (1) TRAINING; CONTINUING EDUCATION.—

9 Funding agreements for an award under section 3

10 include the following:

11 (A) The applicant involved will ensure

12 that, for each community health advisor pro13 gram operated with the award, a program is

14 carried out to train community health advisors

15 to provide the authorized program services, in16 cluding practical experiences in providing serv17 ices for health promotion and disease preven18 tion.

19 (B) The program of training will provide

20 for the continuing education of the community

21 health advisors.

22 (C) Not more than 15 percent of the

23 award will be expended for the program of

24 training.
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1 (2) COMPENSATION.—With respect to compli2 ance with the agreements made under this Act, the

3 purposes for which an award under section 3 may be

4 expended include providing compensation for the

5 services of community health advisors.

6 (h) REPORTS TO SECRETARY; ASSESSMENT OF EF7 FECTIVENESS.—Funding agreements for an award under

8 section 3 for an applicant include the following:

9 (1) The applicant will ensure that, for each fis10 cal year for which a community health advisor pro11 gram receives amounts from the award, the program

12 will prepare a report describing the activities of the

13 program for such year, including—

14 (A) a specification of the number of indi15 viduals served by the program;

16 (B) a specification of the entities with

17 which the program has collaborated in carrying

18 out the purpose described in section 4(a)(1);

19 and

20 (C) an assessment of the extent of the ef21 fectiveness of the program in carrying out such

22 purpose.

23 (2) Such reports will include such additional in24 formation regarding the applicant and the programs

25 as the Secretary may require.
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1 (3) The applicant will prepare the reports as a

2 single document and will submit the document to the

3 Secretary not later than February 1 of the fiscal

4 year following the fiscal year for which the reports

5 were prepared.

6 SEC. 6. APPLICATION FOR ASSISTANCE; STATE PLAN.

7 The Secretary may make an award under section 3

8 only if—

9 (1) an application for the award is submitted to

10 the Secretary;

11 (2) the application is submitted not later than

12 the date specified by the Secretary;

13 (3) the application contains each funding agree14 ment described in this Act;

15 (4) the application contains a State plan de16 scribing the purposes for which the award is to be

17 expended in the State, including a description of the

18 manner in which the applicant will comply with each

19 such funding agreement; and

20 (5) the application is in such form, is made in

21 such manner, and contains such agreements, assur22 ances, and information as the Secretary determines

23 to be necessary to carry out this Act.
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1 SEC. 7. DETERMINATION OF AMOUNT OF ALLOTMENT.

2 (a) IN GENERAL.—For purposes of section 3, the al3 lotment under this section with respect to a State for a

4 fiscal year is the greater of—

5 (1) the sum of the respective amounts deter6 mined for the State under subsection (b) and sub7 section (c); and

8 (2) $500,000.

9 (b) AMOUNT RELATING TO POPULATION.—For pur10 poses of subsection (a), the amount determined under this

11 subsection is the product of—

12 (1) an amount equal to 50 percent of the

13 amount appropriated under section 12 for the fiscal

14 year and available for awards under section 3; and

15 (2) the percentage constituted by the ratio of—

16 (A) the number of individuals residing in

17 the State involved; to

18 (B) the sum of the respective amounts de19 termined for each State under subparagraph

20 (A).

21 (c) AMOUNT RELATING TO POVERTY LEVEL.—For

22 purposes of subsection (a), the amount determined under

23 this subsection is the product of—

24 (1) the amount determined under subsection

25 (b)(1); and

26 (2) the percentage constituted by the ratio of—
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1 (A) the number of individuals residing in

2 the State whose income is at or below an

3 amount equal to 200 percent of the official pov4 erty line; to

5 (B) the sum of the respective amounts de6 termined for each State under subparagraph

7 (A).

8 SEC. 8. QUALITY ASSURANCE; COST-EFFECTIVENESS.

9 The Secretary shall establish guidelines for assuring

10 the quality of community health advisor programs (includ11 ing quality in the training of community health advisors)

12 and for assuring the cost-effectiveness of the programs.

13 A funding agreement for an award under section 3 is that

14 the applicant involved will carry out such programs in ac15 cordance with the guidelines.

16 SEC. 9. EVALUATIONS; TECHNICAL ASSISTANCE.

17 (a) EVALUATIONS.—The Secretary shall conduct

18 evaluations of community health advisor programs, and

19 may disseminate information developed as result of the

20 evaluations. In conducting such evaluations, the Secretary

21 shall determine whether the programs are in compliance

22 with the guidelines established under section 8.

23 (b) TECHNICAL ASSISTANCE.—The Secretary may

24 provide technical assistance to recipients of awards under
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1 section 3 with respect to the planning, development, and

2 operation of community health advisor programs.

3 (c) GRANTS AND CONTRACTS.—The Secretary may

4 carry out this section directly or through grants, coopera5 tive agreements, or contracts.

6 (d) LIMITATION ON EXPENDITURES.—Of the

7 amounts appropriated under section 12 for a fiscal year,

8 the Secretary may reserve not more than 10 percent for

9 carrying out this section.

10 SEC. 10. RULE OF CONSTRUCTION REGARDING PROGRAMS

11 OF INDIAN HEALTH SERVICE.

12 This Act may not be construed as requiring the Sec13 retary to modify or terminate the program carried out by

14 the Director of the Indian Health Service and designated

15 by such Director as the Community Health Representative

16 Program. The Secretary shall ensure that support for such

17 Program is not supplanted by awards under section 3. In

18 communities in which both such Program and a commu19 nity health advisor program are being carried out, the Sec20 retary shall ensure that the community health advisor pro21 gram works in cooperation with, and as a complement to,

22 the Community Health Representative Program.

23 SEC. 11. DEFINITIONS.

24 For purposes of this Act:
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1 (1) The term ‘‘authorized program services’’,

2 with respect to a community health advisor program,

3 means the services specified in section 4(b)(2).

4 (2) The term ‘‘community health advisor’’ has

5 the meaning given such term in section 4(d).

6 (3) The term ‘‘community health advisor pro7 gram’’ means a program carried out under section

8 4(b).

9 (4) The term ‘‘financial assistance’’, with re10 spect to an award under section 3, means a grant,

11 cooperative agreement, or a contract.

12 (5) The term ‘‘funding agreement’’ means an

13 agreement required as a condition of receiving an

14 award under section 3.

15 (6) The term ‘‘Healthy People 2000 Objectives’’

16 has the meaning given such term in section 4(d).

17 (7) The term ‘‘medically underserved commu18 nity’’ has the meaning given such term in section

19 4(d).

20 (8) The term ‘‘official poverty line’’ means the

21 official poverty line established by the Director of

22 the Office of Management and Budget and revised

23 by the Secretary in accordance with section 673(2)

24 of the Omnibus Budget Reconciliation Act of 1981.
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1 (9) The term ‘‘Secretary’’ means the Secretary

2 of Health and Human Services.

3 (10) The term ‘‘State’’ means each of the sev4 eral States, the District of Columbia, and each of

5 the Commonwealth of Puerto Rico, American

6 Samoa, Guam, the Commonwealth of the Northern

7 Mariana Islands, the Virgin Islands, and the Trust

8 Territory of the Pacific Islands.

9 (11) The term ‘‘State involved’’, with respect to

10 an applicant for an award under section 3, means

11 the State in which the applicant is to carry out a

12 community health advisor program.

13 SEC. 12. FUNDING.

14 (a) AUTHORIZATION OF APPROPRIATIONS.—For the

15 purpose of carrying out this Act, there is authorized to

16 be appropriated $100,000,000 for each of the fiscal years

17 1995 through 2000.

18 (b) EFFECT OF INSUFFICIENT APPROPRIATIONS FOR

19 MINIMUM ALLOTMENTS.—

20 (1) IN GENERAL.—If the amounts made avail21 able under subsection (a) for a fiscal year are insuf22 ficient for providing each State (or entity designated

23 by the State pursuant to section 3, as the case may

24 be) with an award under section 3 in an amount

25 equal to or greater than the amount specified in sec-
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1 tion 7(a)(2), the Secretary shall, from such amounts

2 as are made available under subsection (a), make

3 such awards on a discretionary basis.

4 (2) RULE OF CONSTRUCTION.—For purposes of

5 paragraph (1), awards under section 3 are made on

6 a discretionary basis if the Secretary determines

7 which States (or entities designated by States pursu8 ant to such section, as the case may be) are to re9 ceive such awards, subject to meeting the require10 ments of this Act for such an award, and the Sec11 retary determines the amount of such awards.

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