I

103D CONGRESS

1ST SESSION H. R. 1192

To provide for uniformity of quality and a substantial reduction in the

overall costs of health care in the United States through the development

of diagnostic and treatment protocols and the implementation of the

protocols in the program under title XVIII of the Social Security Act,

the imposition of limitations on the amount of damages that may be

paid in a health care liability action, and the mandatory establishment

by States of alternative dispute resolution systems to resolve health

care liability claims, and for other purposes.

IN THE HOUSE OF REPRESENTATIVES

MARCH 3, 1993

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

Committees on Ways and Means, Energy and Commerce, and the Judiciary

A BILL

To provide for uniformity of quality and a substantial reduction in the overall costs of health care in the United

States through the development of diagnostic and treatment protocols and the implementation of the protocols

in the program under title XVIII of the Social Security

Act, the imposition of limitations on the amount of damages that may be paid in a health care liability action,

and the mandatory establishment by States of alternative

dispute resolution systems to resolve health care liability

claims, and for other purposes.
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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 ‘‘Savings Through

5 Health Protocols and Malpractice Reform Act of 1993’’.

6 TITLE I—DEVELOPMENT AND

7 IMPLEMENTATION OF DIAG8 NOSTIC AND TREATMENT

9 PROTOCOLS

10 SEC. 101. SUBSTANTIAL REDUCTION IN COSTS OF HEALTH

11 CARE THROUGH IMPLEMENTATION IN MEDI12 CARE PROGRAM OF DIAGNOSTIC AND TREAT13 MENT PROTOCOLS.

14 (a) CENTERS FOR DEVELOPMENT OF PROTOCOLS

15 AND MODEL TRAINING PROGRAMS.—Subject to sub16 section (b), the Secretary of Health and Human Services,

17 after consultation with the advisory council established

18 under section 103, shall make grants to or enter into con19 tracts with public or nonprofit private entities for the op20 eration of not less than 4 and not more than 6 centers—

21 (1) to develop diagnostic and treatment proto22 cols for various health conditions; and

23 (2) to develop model programs for training

24 health care providers with respect to such protocols.
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1 (b) UNIFORMITY OF QUALITY AND SUBSTANTIAL RE2 DUCTION IN COSTS OF HEALTH CARE AS PRINCIPAL

3 GOALS OF PROTOCOLS.—The Secretary shall ensure that,

4 in the development of protocols under subsection (a), the

5 principal goals are achieving uniformity of quality in, and

6 the substantial reduction of the overall costs of, health

7 care in the United States.

8 (c) APPROVAL OF PROTOCOLS AND PROGRAMS; PLAN

9 FOR IMPLEMENTATION IN MEDICARE PROGRAM.—

10 (1) IN GENERAL.—The Secretary shall require

11 that all protocols and programs developed under

12 subsection (a) be submitted to the Secretary. Sub13 ject to subsection (d), in the case of each such proto14 col or program so submitted, the Secretary shall—

15 (A) evaluate the protocol or program (as

16 the case may be) on the basis of the extent to

17 which the protocol or program facilitates the

18 goal described in subsection (b); and

19 (B) on such basis approve or disapprove

20 the protocol or program not later than 45 days

21 after the protocol or program is submitted to

22 the Secretary.

23 (2) PLAN FOR IMPLEMENTATION.—In the case

24 of each protocol and program approved under para25 graph (1), the Secretary, not later than 90 days
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1 after the protocol or program (as the case may be)

2 is so approved, shall submit to the appropriate com3 mittees of the Congress a plan for the implementa4 tion of the protocol or program in the program

5 under title XVIII of the Social Security Act. The

6 plan shall include proposed legislation for accom7 plishing such implementation.

8 (d) COLLABORATION AMONG CENTERS.—The Sec9 retary may not approve a protocol or program for pur10 poses of subsection (c) unless the protocol or program (as

11 the case may be) has been approved by each of the heads

12 of the centers operated pursuant to subsection (a).

13 SEC. 102. REQUIREMENTS FOR CENTERS.

14 The Secretary may provide a grant or contract under

15 section 101(a) only if—

16 (1) the applicant for the grant operates a medi17 cal facility;

18 (2) such facility has a large patient population;

19 and

20 (3) the administrators and medical staff of the

21 facility have demonstrated expertise in developing

22 and implementing successful programs for the reduc23 tion of health care costs.
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1 SEC. 103. ADVISORY COUNCIL.

2 The Secretary shall establish an advisory council to

3 provide recommendations to the Secretary with respect to

4 carrying out this title, including recommendations on ap5 proving applications for grants and contracts under sec6 tion 101(a). The Secretary shall make appointments to

7 such council from among health care providers and admin8 istrators of medical facilities who are not employees or

9 officers of the Federal Government.

10 SEC. 104. GENERAL PROVISIONS.

11 (a) APPLICATION FOR GRANT OR CONTRACT.—The

12 Secretary may provide a grant or contract under section

13 101(a) only if an application for the grant or contract is

14 submitted to the Secretary and the application is in such

15 form, is made in such manner, and contains such agree16 ments, assurances, and information as the Secretary

17 determines to be necessary to carry out this title.

18 (b) SOURCE OF FUNDING.—The Secretary shall

19 make grants and contracts under section 101(a) using

20 only funds appropriated to carry out activities of the

21 Administrator for Health Care Policy and Research.

22 (c) LIMITATION ON AMOUNT PROVIDED TO RECIPI23 ENT.—The total amount provided to any entity under any

24 grant or contract made under section 101(a) may not

25 exceed $5,000,000.
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1 (d) DEFINITION.—For purposes of this title, the term

2 ‘‘Secretary’’ means the Secretary of Health and Human

3 Services.

4 TITLE II—MEDICAL MAL5 PRACTICE LIABILITY RE6 FORM

7 SEC. 201. DEFINITIONS.

8 In this title, the following definitions shall apply:

9 (1) ECONOMIC DAMAGES.—The term ‘‘economic

10 damages’’ means damages paid to compensate an in11 dividual for medical expenses, lost wages or other in12 come, lost employment, burial expenses, and other

13 pecuniary losses.

14 (2) HEALTH CARE LIABILITY ACTION.—The

15 term ‘‘health care liability action’’ means a civil ac16 tion brought against a health care provider (regard17 less of the theory of liability on which the action is

18 based) in which a plaintiff alleges an injury caused

19 by the provision of (or the failure to provide) health

20 care services, except that such term does not in21 clude—

22 (A) any action in which a plaintiff alleges

23 an intentional tort; or
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1 (B) any action in which the plaintiff’s sole

2 allegation is an allegation of an injury arising

3 from the use of a medical product.

4 (3) HEALTH CARE PROVIDER.—The term

5 ‘‘health care provider’’ means any individual or en6 tity that is engaged in the delivery of health care

7 services and is required under Federal or State law

8 to be licensed, certified, or accredited in order to

9 deliver such services.

10 (4) INJURY.—The term ‘‘injury’’ means any ill11 ness, disease, or other harm that is the subject of

12 a health care liability action.

13 (5) NON-ECONOMIC DAMAGES.—The term

14 ‘‘non-economic damages’’ means any damages paid

15 to compensate an individual for subjective, non-mon16 etary losses, including pain, suffering, inconvenience,

17 mental suffering, emotional distress, loss of society

18 and companionship, loss of consortium, injury to

19 reputation, and humiliation, but does not include

20 punitive damages.

21 (6) SECRETARY.—The term ‘‘Secretary’’ means

22 the Secretary of Health and Human Services.

23 (7) STATE.—The term ‘‘State’’ means each of

24 the several States, the District of Columbia, the

25 Commonwealth of Puerto Rico, the Virgin Islands,
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1 Guam, American Samoa, and the Northern Mariana

2 Islands.

3 SEC. 202. MALPRACTICE LIABILITY REFORM REQUIRE4 MENTS DESCRIBED.

5 (a) IN GENERAL.—Subject to section 203, a State

6 meets the requirements of this section if it has enacted

7 laws, rules, or regulations relating to the treatment of

8 health care liability actions that meet the requirements of

9 subsections (b) through (d), and relating to alternative

10 dispute resolution mechanisms that meet the requirements

11 of subsection (e).

12 (b) LIABILITY SEVERAL AND NOT JOINT FOR NON13 ECONOMIC DAMAGES.—

14 (1) IN GENERAL.—With respect to non-eco15 nomic damages, the liability of each defendant in a

16 health care liability action shall be several only and

17 shall not be joint. Each defendant shall be liable

18 only for the amount of non-economic losses incurred

19 by the plaintiff that is in direct proportion to the de20 fendant’s percentage of responsibility for the injury

21 suffered by the plaintiff (as determined by the trier

22 of fact pursuant to paragraph (2)).

23 (2) DETERMINATION OF PERCENTAGE OF RE24 SPONSIBILITY.—The trier of fact shall determine the

25 extent of each defendant’s responsibility for the non-
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1 economic injury suffered by the plaintiff, and shall

2 assign a percentage of responsibility for such injury

3 to each defendant.

4 (c) LIMITATION ON NONECONOMIC DAMAGES.—

5 (1) IN GENERAL.—The total amount of non6 economic damages that may be awarded to an indi7 vidual and the family members of such individual for

8 losses resulting from an injury which is the subject

9 of a health care liability action may not exceed

10 $250,000, regardless of the number of health care

11 providers against whom the action is brought or the

12 number of actions brought with respect to the

13 injury.

14 (2) ADJUSTMENT FOR INFLATION.—The

15 amount referred to in paragraph (1) shall be in16 creased every 3rd year (beginning with the 3rd year

17 that begins after the date of the enactment of this

18 Act) in the same manner as amounts are increased

19 under section 215(i) of the Social Security Act for

20 base quarters or cost-of-living computation quarters

21 in such a year.

22 (d) MANDATORY OFFSETS FOR DAMAGES PAID BY

23 A COLLATERAL SOURCE.—

24 (1) IN GENERAL.—The total amount of dam25 ages received by an individual under a health care
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1 liability action shall be reduced (in accordance with

2 paragraph (2)) by any other payment that has been

3 or will be made to the individual to compensate the

4 individual for the injury that was the subject of the

5 health care liability action, including payment

6 under—

7 (A) Federal or State disability or sickness

8 programs;

9 (B) Federal, State, or private health insur10 ance programs;

11 (C) private disability insurance programs;

12 (D) employer wage continuation programs;

13 and

14 (E) any other source of payment intended

15 to compensate such individual for such injury.

16 (2) AMOUNT OF REDUCTION.—The amount by

17 which an award of damages to an individual shall be

18 reduced under paragraph (1) shall be the total

19 amount of any payments (other than such award)

20 that have been made or that will be made to the in21 dividual to compensate the individual for the injury

22 that was the subject of the action.

23 (e) ESTABLISHMENT OF ALTERNATIVE DISPUTE

24 RESOLUTION MECHANISMS.—
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1 (1) IN GENERAL.—Each State shall have in ef2 fect at least one mediation or pretrial screening

3 panel that meets requirements specified in regula4 tions issued by the Secretary, or shall have in effect

5 another alternative dispute resolution mechanism

6 which the Secretary, in consultation with the Attor7 ney General, finds to be equally effective in deterring

8 the filing of frivolous health care liability actions and

9 providing fair and expeditious compensation for mer10 itorious health care liability claims.

11 (2) PROMULGATION OF REGULATIONS.—Sub12 ject to paragraph (3), the Secretary, in consultation

13 with the Administrative Conference of the United

14 States and the Attorney General, shall promulgate

15 regulations that specify the Secretary’s criteria for

16 mediation and pretrial screening panels and for eval17 uating the effectiveness of other alternative dispute

18 resolution mechanisms under paragraph (1).

19 (3) TOLLING OF STATUTE OF LIMITATIONS

20 DURING ALTERNATIVE PROCEDURES.—Any regula21 tions promulgated by the Secretary pursuant to

22 paragraph (2) shall include a requirement that a

23 State may not include any time occurring after a

24 claim is filed with a mediation or pretrial screening

25 panel or under any other alternative dispute resolu-
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1 tion mechanism under paragraph (1) for purposes of

2 determining the applicability of any statute of limi3 tations to a health care liability action arising from

4 the injury that is the subject of the claim.

5 SEC. 203. WAIVER OF REQUIREMENTS FOR GOOD CAUSE OR

6 FOR CARRYING OUT DEMONSTRATION

7 PROJECTS.

8 The Secretary may waive any of the requirements of

9 subsections (b) through (e) of section 202 for good cause

10 or to the extent necessary to enable a State to carry out

11 an experimental, demonstration, or pilot project if, in the

12 judgment of the Secretary, the project is likely to promote

13 the objectives of this title.

14 SEC. 204. CERTIFICATION OF STATE COMPLIANCE.

15 (a) NOTIFICATION.—

16 (1) IN GENERAL.—Not later than 6 months be17 fore the beginning of each year (beginning with the

18 first year that begins after the expiration of the 3-

19 year period beginning on the date of the enactment

20 of this Act), each State shall submit a notification

21 to the Secretary, with a certification by the Chief

22 Executive Officer of the State that, on the date the

23 notification is submitted, the State has enacted,

24 adopted, or otherwise has in effect laws, rules, or
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1 regulations that meet the requirements of section

2 202.

3 (2) CONTENTS OF NOTIFICATION.—The notifi4 cation shall be accompanied by documentation to

5 support the certification required by this subsection,

6 including copies of relevant State statutes, rules,

7 procedures, regulations, judicial decisions, State con8 stitutional provisions, and opinions of the State At9 torney General, and shall contain such other infor10 mation, be in such form, and be submitted in such

11 manner, as the Secretary may require.

12 (b) REVIEW OF NOTIFICATION.—

13 (1) IN GENERAL.— Within 90 days after receiv14 ing a notification under subsection (a), the Secretary

15 shall review the notification and determine whether

16 the notification demonstrates that the State has en17 acted, adopted, or otherwise has in effect laws, rules,

18 or regulations that meet the requirements of section

19 202.

20 (2) APPROVAL OF NOTIFICATION.—If the Sec21 retary determines that the notification makes such

22 demonstration, the Secretary shall approve the

23 notification.

24 (3) NOTICE OF DISAPPROVAL.—If, after review25 ing a State’s notification under subsection (a), the
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1 Secretary determines that the notification does not

2 make the demonstration required, the Secretary

3 shall, not later than 15 days after making such de4 termination, provide the State with a written notice

5 specifying such determination and containing rec6 ommendations for revisions which would cause the

7 notification of the State to be approved.

8 (4) REVIEW OF REVISED NOTIFICATIONS.—Not

9 later than 30 days after receiving a revised notifica10 tion, the Secretary shall review the revised notifica11 tion and determine whether the notification dem12 onstrates that the State has enacted, adopted, or

13 otherwise has in effect laws, rules, or regulations

14 that meet the requirements of section 202. If the

15 Secretary determines that the revised notification

16 makes such a demonstration, the Secretary shall

17 approve the revised notification.

18 (c) NON-COMPLIANCE.—

19 (1) FAILURE TO SUBMIT NOTIFICATION.—If a

20 State fails to submit to the Secretary a notification

21 or revised notification pursuant to this section, the

22 Secretary shall, not later than 15 days after the pe23 riod provided for submitting notification under this

24 section, send the State written notice of determina25 tion of non-compliance.
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1 (2) FAILURE TO MEET REQUIREMENTS.—If the

2 Secretary determines that a revised notification sub3 mitted under subsection (b) does not demonstrate

4 that the State has enacted, adopted, or otherwise

5 has in effect laws, rules, or regulations that meet the

6 requirements of section 202, and disapproves the

7 State’s revised notification, the Secretary shall, not

8 later than 15 days after making such determination,

9 provide the State with written notice of non-compli10 ance, including the determination of the Secretary

11 and the reasons therefore.

12 (3) FAILURE TO MEET REQUIREMENTS AFTER

13 INITIAL APPROVAL.—If, during any time period after

14 a notification is approved under this section, the

15 Secretary determines that the State does not have

16 currently in effect or has ceased enforcing the laws,

17 rules, or regulations upon which the notification was

18 approved, the Secretary shall, not later than 30 days

19 of making such determination provide the State with

20 written notice of such determination and withdraw

21 the approval of the notification. Such notice shall

22 specify the determination of the Secretary and the

23 reasons therefore.

24 (d) CONSULTATION WITH ATTORNEY GENERAL.—In

25 making determinations of compliance or non-compliance
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1 pursuant to this section, the Secretary shall consult with

2 the Attorney General.

3 SEC. 205. INCENTIVES THROUGH MEDICARE AND MEDIC4 AID.

5 (a) MEDICARE INCENTIVES.—

6 (1) IN GENERAL.—Section 1886 of the Social

7 Security Act (42 U.S.C. 1395ww) is amended by

8 adding at the end the following new subsection:

9 ‘‘(j) PAYMENT INCENTIVES TO ENCOURAGE MEDI10 CAL MALPRACTICE LIABILITY REFORM.—

11 ‘‘(1) REDUCTION IN PAYMENTS FOR HOSPITALS

12 LOCATED IN CERTAIN STATES.—Notwithstanding

13 any other provision of this title, the Secretary shall

14 reduce each payment amount otherwise determined

15 under this section by 1 percent for discharges during

16 a cost reporting period with respect to hospitals that

17 are not located in a State which the Secretary cer18 tifies (pursuant to section 204 of the Savings

19 Through Health Protocols and Malpractice Reform

20 Act of 1993) meets the requirements of section 202

21 of the Savings Through Health Protocols and Mal22 practice Reform Act of 1993 for the cost reporting

23 period.

24 ‘‘(2) ADDITIONAL PAYMENT FOR HOSPITALS

25 LOCATED IN STATES ENACTING REFORMS.—With re-
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1 spect to hospitals that are not subject to a reduction

2 in payment under paragraph (1), the Secretary shall

3 make an additional payment for discharges during a

4 cost reporting period equal to the product of—

5 ‘‘(A) an amount equal to the total of all

6 amounts that were not paid to hospitals during

7 the cost reporting period as a result of the re8 ductions made under such paragraph; and

9 ‘‘(B) a percentage equal to the percentage

10 of all payments under this section during the

11 year to all hospitals that are not subject to the

12 reduction described in such paragraph that is

13 attributable to payments to that hospital.’’.

14 (2) EFFECTIVE DATE.—The amendment made

15 by paragraph (1) shall apply with respect to dis16 charges for cost reporting periods beginning on or

17 after the first day of the first fiscal year that begins

18 after the expiration of the 3-year period beginning

19 on the date of the enactment of this Act.

20 (b) MEDICAID INCENTIVES.—

21 (1) IN GENERAL.—Section 1903 of the Social

22 Security Act (42 U.S.C. 1396b) is amended by in23 serting after subsection (r) the following new sub24 section:
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1 ‘‘(s)(1)(A) In order for a State to receive payments

2 under paragraph (7) of subsection (a) for quarters in a

3 year without being subject to the reduction described in

4 subparagraph (B), the Secretary must certify (pursuant

5 to section 204 of the Savings Through Health Protocols

6 and Malpractice Reform Act of 1993) that the State meets

7 the requirements of section 202 of the Savings Through

8 Health Protocols and Malpractice Reform Act of 1993 for

9 the year.

10 ‘‘(B) If a State is not certified for a year by the Sec11 retary under subparagraph (A), the per centum specified

12 in paragraph (7) of subsection (a) with respect to the

13 State shall be reduced by 2 percentage points for quarters

14 during the year.

15 ‘‘(2) In the case of a State that is not subject to the

16 reduction described in paragraph (1)(B) for quarters dur17 ing a year, the Secretary shall make an additional pay18 ment to the State equal to the product of—

19 ‘‘(A) an amount equal to the total of all

20 amounts that were not paid to States during the

21 year as a result of the reductions made under such

22 paragraph; and

23 ‘‘(B) a percentage equal to the percentage of all

24 payments under this section during the year to all

25 States that are not subject to the reduction de-
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1 scribed in such paragraph that is attributable to

2 payments to that State.’’.

3 (2) EFFECTIVE DATE.—The amendment made

4 by paragraph (1) shall apply to calendar quarters

5 beginning on or after the first January 1 that begins

6 after the expiration of the 3-year period beginning

7 on the date of the enactment of this Act.

8 SEC. 206. APPLICABILITY OF CERTAIN PROVISIONS TO FED9 ERAL TORT CLAIMS ACT.

10 (a) IN GENERAL.—Chapter 171 of title 28, United

11 States Code, is amended by adding at the end the follow12 ing new section:

13 ‘‘§2681. Special rules for health care liability actions

14 ‘‘(a) Notwithstanding any other provision of this

15 chapter, any action brought against the United States

16 under this chapter that is a health care liability action

17 shall be subject to the following:

18 ‘‘(1)(A) With respect to non-economic damages,

19 the liability of the United States shall be several

20 only and shall not be joint. The United States shall

21 be liable only for the amount of non-economic losses

22 incurred by the plaintiff that is in direct proportion

23 to the United States’ percentage of responsibility for

24 the injury suffered by the plaintiff (as determined by

25 the court pursuant to subparagraph (B)).
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1 ‘‘(B) The court shall determine the extent of

2 each defendant’s responsibility for the non-economic

3 injury suffered by the plaintiff, and shall assign a

4 percentage of responsibility for such injury to each

5 defendant.

6 ‘‘(2)(A) The total amount of noneconomic dam7 ages that may be awarded to an individual and the

8 family members of such individual for losses result9 ing from an injury which is the subject of the action

10 may not exceed $250,000, regardless of the number

11 of defendants against whom the action is brought or

12 the number of actions brought with respect to the

13 injury.

14 ‘‘(B) The amount referred to in subparagraph

15 (A) shall be increased every 3rd year (beginning

16 with the 3rd year that begins after the date of the

17 enactment of this section) in the same manner as

18 amounts are increased under section 215(i) of the

19 Social Security Act for base quarters or cost-of-liv20 ing computation quarters in such a year.

21 ‘‘(3)(A) The total amount of damages received

22 by an individual shall be reduced (in accordance with

23 subparagraph (B)) by any other payment that has

24 been or will be made to the individual to compensate
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1 the individual for the injury that was the subject of

2 the action, including payment under—

3 ‘‘(i) Federal or State disability or sickness

4 programs;

5 ‘‘(ii) Federal, State, or private health in6 surance programs;

7 ‘‘(iii) private disability insurance programs;

8 ‘‘(iv) employer wage continuation pro9 grams; and

10 ‘‘(v) any other source of payment intended

11 to compensate such individual for such injury.

12 ‘‘(B) The amount by which an award of dam13 ages to an individual shall be reduced under sub14 paragraph (A) shall be the total amount of any pay15 ments (other than such award) that have been made

16 or that will be made to the individual to compensate

17 the individual for the injury that was the subject of

18 the action.

19 ‘‘(b) In this section, the following definitions shall

20 apply:

21 ‘‘(1) The term ‘economic damages’ means dam22 ages paid to compensate an individual for medical

23 expenses, lost wages or other income, lost employ24 ment, burial expenses, and other pecuniary losses.
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1 ‘‘(2) The term ‘health care liability action’

2 means a civil action brought against the United

3 States (regardless of the theory of liability on which

4 the action is based) in which a plaintiff alleges an

5 injury caused by the provision of (or the failure to

6 provide) health care services, except that such term

7 does not include—

8 ‘‘(A) any action in which a plaintiff alleges

9 an intentional tort; or

10 ‘‘(B) any action in which the plaintiff’s

11 sole allegation is an allegation of an injury aris12 ing from the use of a medical product.

13 ‘‘(3) The term ‘injury’ means any illness, dis14 ease, or other harm that is the subject of a health

15 care liability action.

16 ‘‘(4) The term ‘non-economic damages’ means

17 any damages paid to compensate an individual for

18 subjective, non-monetary losses, including pain, suf19 fering, inconvenience, mental suffering, emotional

20 distress, loss of society and companionship, loss of

21 consortium, injury to reputation, and humiliation,

22 but does not include punitive damages.’’.

23 (b) CLERICAL AMENDMENT.—The table of sections

24 at the beginning of chapter 171 of title 28, United States
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1 Code, is amended by adding at the end the following new

2 item:

‘‘2681. Special rules for health care liability actions.’’.

3 (c) EFFECTIVE DATE.—The amendments made by

4 subsections (a) and (b) shall apply to actions brought

5 against the United States on or after the date of the en6 actment of this Act.

7 SEC. 207. RULES OF CONSTRUCTION.

8 Nothing in this title may be construed to—

9 (1) waive or affect any defense of sovereign im10 munity asserted by any State under any law or by

11 the United States;

12 (2) preempt State choice-of-law rules with re13 spect to claims brought by a foreign nation or a citi14 zen of a foreign nation;

15 (3) affect the right of any court to transfer

16 venue, to apply the law of a foreign nation, or to dis17 miss a claim of a foreign nation or of a citizen of

18 a foreign nation on the ground of inconvenient

19 forum;

20 (4) create or vest jurisdiction in the district

21 courts of the United States over any health care li22 ability action subject to this Act (which is not other23 wise properly in Federal district court); or

24 (5) prevent any State from enacting, adopting,

25 or otherwise having in effect more comprehensive or
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1 additional health care liability reforms than those set

2 forth in this title.

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