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[Congressional Bills 103th Congress]
[From the U.S. Government Publishing Office]
[S. 1282 Introduced in Senate (IS)]

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.

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

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Graduate Reform Opportunities and 
Work Force Training in Health Act'' (GROWTH).

SEC. 2. FINDINGS.

    Congress finds that--
            (1) of the approximately 600,000 practicing physicians in 
        the United States, only one-third are in primary health care 
        and, of recent United States medical school graduates, only 
        one-sixth are choosing primary health care careers;
            (2) every year, more United States medical school graduates 
        enter specialty fields, turning away from the practice of 
        primary health care;
            (3) although the Nation's physician-to-population ratio has 
        increased significantly in recent years and the total United 
        States physician supply has doubled over the past 3 decades, 
        rural areas throughout the country face growing access-to-care 
        problems;
            (4) the number of physicians entering rural practice is 
        declining and many rural areas are experiencing shortages of 
        primary health care providers;
            (5) because almost 20 percent of physicians practicing in 
        rural counties are over the age of 65, physician shortages in 
        such counties are expected to become worse over the next few 
        years as these providers retire;
            (6) one-quarter of the United States population lives in 
        rural areas;
            (7) rural communities have unique characteristics and 
        special needs which challenge the health care delivery system;
            (8) in addition to training too few primary health care 
        providers and providers willing to practice in rural areas, the 
        United States trains too few minority providers;
            (9) the growing number of highly compensated specialists 
        contributes to the difficulty the United States faces in 
        containing health care costs and increasing access to basic 
        health care services;
            (10) there is no national plan or set of appropriate 
        incentives in medical education financing systems to achieve 
        the desired physician specialty mix, racial and ethnic 
        composition, and geographic distribution; and
            (11) it is in the best interest of the United States to 
        establish such a national plan and such incentives in Federal 
        medical education financing systems.

SEC. 3. HEALTH WORK FORCE INTERAGENCY TASK FORCE.

    Part F of title VII of the Public Health Service Act (42 U.S.C. 295 
et seq.) is amended by adding at the end the following new section:

``SEC. 783. HEALTH WORK FORCE INTERAGENCY TASK FORCE.

    ``(a) Establishment.--Not later than 90 days after the date of 
enactment of this section, the Secretary shall establish a Health Work 
Force Interagency Task Force. The Task Force shall be composed of 
representatives of Federal agencies and departments that have 
responsibility for the training, monitoring, funding, or supporting of 
health care professions.
    ``(b) Co-Chairpersons.--The Assistant Secretary for Health and the 
Assistant Secretary for Post-secondary Education shall serve as the co-
chairpersons of the Task Force established under subsection (a).
    ``(c) Functions and Activities.--The Task Force established under 
subsection (a) shall--
            ``(1) review and coordinate all health work force 
        development and training efforts supported by the Federal 
        Government;
            ``(2) make recommendations to the Secretary of Health and 
        Human Services and the Secretary of Education for coordinating 
        Federal vocational education policy with national health work 
        force needs and goals;
            ``(3) develop standards for programs on vocational 
        education in the health care professions and procedures for 
        program accountability; and
            ``(4) carry out any other activity determined appropriate 
        by the Secretary of Health and Human Services and the Secretary 
        of Education.
    ``(d) Report.--Not later than 13 months after the establishment of 
the Task Force under subsection (a), and annually thereafter, the Task 
Force shall prepare and submit to the appropriate committees of 
Congress a report concerning the types and funding levels of vocational 
education in the health care professions for which the Federal 
Government provides support and detailing the activities of the Task 
Force over the preceding 12-month period.''.

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

    Section 778(b)(1) of the Public Health Service Act (42 U.S.C. 
294p(b)(1)) is amended--
            (1) in subparagraph (D), by striking ``and'' at the end;
            (2) in subparagraph (E), by striking the period and 
        inserting a semicolon; and
            (3) by adding at the end the following new subparagraphs:
                    ``(F) establish training programs in medical 
                schools that recruit students from rural underserved 
                areas who have demonstrated a commitment to careers in 
                primary care medicine and service in rural underserved 
                areas;
                    ``(G) give preference under the National Health 
                Service Corps and other Federal scholarship programs to 
                candidates from and likely to practice in rural 
                underserved areas;
                    ``(H) develop training programs for health care 
                practitioners that provide curricula and faculty role 
                models appropriate to a rural health setting;
                    ``(I) develop training programs for 
                underrepresented minorities in rural health settings;
                    ``(J) develop demonstration programs for 
                infrastructure development in rural health settings, 
                including the development of state-of-the-art 
                telecommunications and network systems that link health 
                care providers in rural areas with other rural and 
                urban health care providers and academic health 
                centers;
                    ``(K) establish State and regional locum tenens 
                programs in rural health settings so that substitute 
                health care providers are available when permanent 
                staff is absent from the health care setting; and
                    ``(L) implement programs using interdisciplinary 
                team approaches to health care training and 
                practice.''.

SEC. 5. TERTIARY CARE CENTER TRAINING FOR NURSE PRACTITIONERS, CLINICAL 
              NURSE SPECIALISTS AND PHYSICIAN ASSISTANTS.

    Part C of title VII of the Public Health Service Act (42 U.S.C. 
293j et seq.) is amended by adding at the end the following new 
section:

``SEC. 753. TERTIARY CARE CENTER TRAINING FOR NURSE PRACTITIONERS, 
              CLINICAL NURSE SPECIALISTS AND PHYSICIAN ASSISTANTS.

    ``The Secretary shall develop training programs for nurse 
practitioners, clinical nurse specialists and physician assistants 
designed to prepare trainees in such programs to staff tertiary care 
centers in a manner that addresses the current and projected needs of 
such centers.''.

SEC. 6. LIFE-TIME LEARNING.

    Subtitle C of title VII of the Public Health Service Act (42 U.S.C. 
293j et seq.), as amended by section 5, is further amended by adding at 
the end the following new section:

``SEC. 754. LIFE-TIME LEARNING DEMONSTRATION PROGRAM.

    ``(a) In General.--The Secretary, through grants, contracts or 
cooperative agreements, shall support the establishment of 
demonstration projects in 10 States concerning the retraining of 
certain physicians.
    ``(b) Applications.--To be eligible to receive assistance under 
subsection (a), an entity shall--
            ``(1) be a State or other public or nonprofit private 
        entity; and
            ``(2) prepare and submit to the Secretary an application, 
        at such time, in such manner and containing such information as 
        the Secretary may require.
    ``(c) Use.--An entity receiving assistance under subsection (a) 
shall conduct a program to--
            ``(1) evaluate the cost-effectiveness of retraining 
        physicians who are trained and practicing in oversubscribed 
        specialties to--
                    ``(A) serve in medically underserved areas in or 
                outside of the United States; or
                    ``(B) retrain for practice in primary health care; 
                and
            ``(2) conduct outcomes research targeted at improving the 
        scientific basis of medical practice.
    ``(d) Authorization of Appropriations.--There are authorized to be 
appropriated to carry out this section, $20,000,000 for each of the 
fiscal years 1994 through 1998.''.

SEC. 7. HEALTH WORK FORCE NEEDS STUDY.

    (a) In General.--The Secretary of Health and Human Services shall 
enter into a contract with a public or nonprofit private entity to 
conduct a study for the purpose of assessing current and projected 
health work force needs in order to promote cost-effective, quality 
patient care.
    (b) National Academy of Sciences.--The Secretary shall request the 
National Academy of Sciences to enter into the contract described in 
subsection (a). If the Institute declines to conduct the study under 
such contract, the Secretary of Health and Human Services shall carry 
out such subsection through another public or nonprofit private entity.
    (c) Report.--The Secretary shall ensure that, not later than 
October 1, 1995, the study required in subsection (a) is completed and 
a report describing the findings made as a result of such study is 
submitted to the Committee on Energy and Commerce of the House of 
Representatives, and to the Committee on Labor and Human Resources of 
the Senate.''.

SEC. 8. PAYMENTS FOR DIRECT GRADUATE MEDICAL EDUCATION COSTS.

    (a) In General.--Section 1886(h) of the Social Security Act (42 
U.S.C. 1395ww(h)) is amended--
            (1) in paragraph (1), by striking ``hospitals'' each place 
        it appears and inserting ``GME consortia'';
            (2) by amending paragraph (2) to read as follows:
            ``(2) Determination of average per resident amount.--The 
        Secretary shall determine for all GME consortia with approved 
        medical residency training programs, an average per resident 
        amount for cost reporting periods beginning on or after July 1, 
        1995 as follows:
                    ``(A) Base amount.--The Secretary shall determine 
                the national mean of all hospital specific FTE resident 
                amounts for cost reporting periods beginning on or 
                after July 1, 1994, and ending on or before June 30, 
                1995, under this subsection as in effect on the day 
                before the date of the enactment of the Graduate Reform 
                Opportunities and Work Force Training in Health Act.
                    ``(B) Inflation adjustment to base amount.--
                            ``(i) Amount for the first reporting 
                        period.--For the first cost reporting period of 
                        the GME consortium beginning on or after July 
                        1, 1995, the average per resident amount for 
                        the GME consortium is the amount determined 
                        under subparagraph (A) updated by the estimated 
                        percentage increase in the Consumer Price Index 
                        during the 12-month period described in 
                        subparagraph (A).
                            ``(ii) Subsequent cost reporting periods.--
                        For each subsequent cost reporting period, the 
                        per average resident amount for the GME 
                        consortium is equal to the amount determined 
                        under this paragraph for the previous cost 
                        reporting period updated, through the midpoint 
                        of the period, by projecting the estimated 
                        percentage change in the Consumer Price Index 
                        during the 12-month period ending at that 
                        midpoint, with appropriate adjustments to 
                        reflect previous underestimations or 
                        overestimations under this clause in the 
                        projected percentage change in the Consumer 
                        Price Index.''.
            (3) by amending paragraph (3) to read as follows:
            ``(3) GME consortium payment amount per resident.--
                    ``(A) In general.--The payment amount, for a GME 
                consortium cost reporting period beginning on and after 
                July 1, 1995, is equal to the product of--
                            ``(i) the aggregate approved amount (as 
                        defined in subparagraph (B)) for that period, 
                        and
                            ``(ii) the GME consortium's medicare 
                        patient load (as defined in subparagraph (C)) 
                        for that period.
                    ``(B) Aggregate approved amount.--As used in 
                subparagraph (A), the term `aggregate approved amount' 
                means, for a GME consortium cost reporting period, the 
                product of--
                            ``(i) the average per resident amount 
                        determined under paragraph (2) for that period, 
                        and
                            ``(ii) the weighted average number of full-
                        time-equivalent residents (as determined under 
                        paragraph (4)) in the GME consortium's approved 
                        medical residency training programs in that 
                        period.
                    ``(C) Medicare patient load.--As used in 
                subparagraph (A), the term `medicare patient load' 
                means with respect to a GME consortium's cost reporting 
                period the sum of--
                            ``(i) the fraction of the total number of 
                        inpatient-bed-days (as established by the 
                        Secretary) during the period which is 
                        attributable to patients with respect to whom 
                        payment may be made under part A; and
                            ``(ii) in the case of a member entity of a 
                        GME consortium that does not furnish inpatient 
                        services but does furnish services for which 
                        payment may be made under part B, the fraction 
                        of the total number of all services provided by 
                        such member during the period attributable to 
                        services for which payment may be made under 
                        part B.'';
            (4) in paragraph (4)--
                    (A) by amending subparagraph (A) to read as 
                follows:
            ``(A) In general.--
                    ``(i) Aggregate number of first-year residents.--
                For the 12 month period beginning on July 1, 1995, and 
                for each succeeding 12 month period, the aggregate 
                number of first-year residency positions for which 
                payment may be made under this subsection shall be 
                equal to 110 percent of the total number of graduates 
                of United States medical schools in calendar year 
                1994.''.
                    ``(ii) Proportion of specialty positions.--The 
                total number of first-year specialty residency 
                positions for which payment under this section may be 
                made shall be equal to--
                            ``(I) 65 percent of the aggregate number of 
                        residency positions determined under clause (i) 
                        for the period July 1, 1995, through June 30, 
                        1996,
                            ``(II) 60 percent of the aggregate number 
                        of residency positions determined under clause 
                        (i) for the period July 1, 1996, through June 
                        30, 1997,
                            ``(III) 50 percent of the aggregate number 
                        of residency positions determined under clause 
                        (i) for the 12 month period beginning July 1, 
                        1997, and for each succeeding 12 month period.
                    ``(iii) Allocation to gme consortia.--
                            ``(I) In general.--For the 12 month period 
                        beginning on July 1, 1995, and for each 
                        succeeding 12 month period, the Secretary shall 
                        allocate the first year residency positions 
                        permitted under clause (i) to GME consortia 
                        after considering the recommendations of the 
                        National Health Care Work Force Board 
                        established in section 9 of the Graduate Reform 
                        Opportunities and Work Force Training in Health 
                        Act. Each residency position allocated to a GME 
                        consortium under this subclause shall remain 
                        allocated to such consortium until the 
                        individual who fills such position completes 
                        such individual's residency training.
                            ``(II) Notice.--The Secretary shall notify 
                        each GME consortium of such consortium's 
                        allocation of first-year residency positions at 
                        least 1 year before the beginning of the 
                        residency year for which such allocation 
                        applies.
                            ``(III) Funding eligibility criteria.--The 
                        Secretary shall provide that a GME consortium 
                        receiving funds under this subsection maintains 
                        an approved medical residency program.''.
                    (B) by amending subparagraph (B) to read as 
                follows--
                    ``(B) Rules for determining full-time equivalent 
                residents.--The Secretary shall establish rules 
                consistent with this paragraph for the computation of 
                the number of full-time-equivalent residents in an 
                approved medical residency training program. Such rules 
                shall take into account individuals who serve United 
                States residents for only a portion of a period with a 
                GME consortium or simultaneously with more than 1 GME 
                consortium.''; and
                    (C) by amending subparagraph (C) to read as 
                follows:
                    ``(C) Weighting factors for certain residents.--
                Subject to subparagraph (D), such rules shall provide, 
                in calculating the number of full-time-equivalent 
                residents in an approved medical residency training 
                program--
                            ``(i) for a resident who is in the 
                        resident's initial residency period, the 
                        weighting factor is 0.80 (1.50, in the case of 
                        a resident who is in a residency in a rural 
                        area as defined in section 1886(d)(2)(D)), and
                            ``(ii) for a resident who is not in the 
                        resident's initial residency period, the 
                        weighting factor is 0.50 (1.50, in the case of 
                        a resident who is in a residency in a rural 
                        area as defined in section 1886(d)(2)(D)).''; 
                        and
                    (D) in subparagraph (E), by striking ``hospital'' 
                and inserting ``GME consortium''; and
            (7) in paragraph (5)--
                    (A) in subparagraph (A), by inserting ``offered by 
                a consortium'' after ``postgraduate medical training 
                program''; and
                    (B) by adding at the end the following new 
                subparagraphs:
                    ``(I) GME consortium.--
                            ``(i) In general.--The term `GME 
                        consortium' means a group composed of at least 
                        1 medical school, 1 teaching hospital, and 1 
                        community-based ambulatory training site 
                        (including a physician's office, a community 
                        health center, or a rural health clinic) that 
                        is organized and overseen by a member medical 
                        school.
                            ``(ii) Cost reporting period.--For purposes 
                        of this subsection, a consortium's cost 
                        reporting period shall be the cost reporting 
                        period of a member hospital, as determined by 
                        the Secretary.
                            ``(iii) Reports.--Each GME consortium shall 
                        submit an annual report to the National Health 
                        Care Work Force Board describing--
                                    ``(I) the organization of the GME 
                                consortium's approved medical residency 
                                training programs, and
                                    ``(II) the location and 
                                professional activities of each 
                                individual that completed the GME 
                                consortium's approved medical residency 
                                training program in the prior 3 years.
                    ``(J) Primary care residency.--The term `primary 
                care residency' means a residency in family medicine, 
                general internal medicine, or general pediatric 
                medicine.
                    ``(K) Specialty residency.--The term `specialty 
                residency' means a residency that is not a primary care 
                residency.''.
    (b) Effective Date.--The amendments made by this section shall be 
effective for cost reporting periods beginning on or after July 1, 
1995.

SEC. 9. NATIONAL HEALTH CARE WORK FORCE BOARD.

    (a) Establishment.--There is established a Board to be known as the 
National Health Care Work Force Board (hereafter in this section 
referred to as the ``Board'').
            (1) Membership.--
                    (A) Composition.--The Board shall be composed of--
                            (i) 11 voting members to be appointed by 
                        the President no later than January 1, 1994, 
                        and
                            (ii) 3 non-voting members consisting of--
                                    (I) the Secretary of Health and 
                                Human Services (hereafter in this 
                                section referred to as the 
                                ``Secretary''),
                                    (II) the Director of the Health 
                                Care Financing Administration, and
                                    (III) the Director of the Health 
                                Resources and Services Administration,
                        or the designees of such individuals.
                    (B) Qualifications.--The members of the Board 
                appointed under subparagraph (A)(i) shall include 
                individuals who--
                            (i) have national recognition for expertise 
                        in the health professions, hospital and 
                        community-based care, biomedicine, health 
                        services and health economics research, 
                        licensing, accreditation, certification, and 
                        related fields, and
                            (ii) are and represent consumers of health 
                        services.
                    (C) Prohibition.--A member of the Board appointed 
                under subparagraph (A)(i) may not be an employee or 
                officer of the Federal Government.
            (2) Period of appointment; vacancies.--
                    (A) Terms.--The members of the Board appointed 
                under paragraph (1)(A)(i) shall be appointed to serve 
                for terms of 4 years, except that the terms of the 
                members first appointed may be staggered to ensure that 
                the terms of no more than 3 members expire in any 1 
                year.
                    (B) Vacancies.--
                            (i) In general.--The President shall make 
                        an appointment to fill a vacancy on the Board 
                        not later than 90 days from the date that the 
                        vacancy occurred.
                            (ii) Filling unexpired term.--An individual 
                        chosen to fill a vacancy shall be appointed for 
                        the unexpired term of the member replaced.
                            (iii) Expiration of terms.--The term of any 
                        member shall not expire before the date on 
                        which the member's successor takes office.
            (3) Chairperson.--The Board shall annually select a 
        Chairperson from among its members.
            (4) Meetings.--
                    (A) In general.--The Board shall meet not less than 
                twice a year at the call of the Chairperson, or on a 
                written request of one-third of the members of the 
                Board.
                    (B) Initial meeting.--The Board shall hold its 
                first meeting not later than March 31, 1994.
                    (C) Quorum.--A majority of the members of the Board 
                shall constitute a quorum, but a lesser number of 
                members may hold hearings.
    (b) Functions.--
            (1) Allocation recommendation.--
                    (A) Information collection and receipt of 
                requests.--The Board shall--
                            (i) seek the recommendations of private 
                        accrediting bodies concerning the ranking of 
                        medical residency programs according to program 
                        quality;
                            (ii) collect data from the Department of 
                        Health and Human Services and State health 
                        departments on national, State, and regional 
                        health work force needs; and
                            (iii) solicit and receive requests from GME 
                        consortia (as defined in section 1886(h)(5)(I) 
                        of the Social Security Act) concerning the 
                        number and types of residency positions for 
                        which graduate medical education funds under 
                        section 1886(h) of the Social Security Act are 
                        sought;
                    (B) Recommendations.--The Board shall develop and 
                submit to the Secretary on an annual basis 
                recommendations on the number and types of first-year 
                residency training positions for which each GME 
                consortium should receive graduate medical education 
                funds under section 1886(h) of the Social Security Act 
                based on quality of the medical residency program 
                operated by the GME consortium and evaluation of 
                national, State, and regional needs.
            (2)  Study.--
                    (A) In general.--The Board shall conduct a thorough 
                study of--
                            (i) current and projected health care work 
                        force needs and the extent to which the work 
                        force represents the areas and populations to 
                        be served;
                            (ii) State licensing, accreditation and 
                        certification policies, reimbursement 
                        practices, and medical liability practices that 
                        may discourage health care providers from 
                        entering or practicing primary care medicine or 
                        create disincentives to the practice of 
                        medicine in rural areas; and
                            (iii) the need to limit non-federally 
                        supported specialty residency positions.
                    (B) Recommendations.--The Board shall develop 
                recommendations on each of the matters studied under 
                subparagraph (A).
                    (C) Report.--The Board shall submit a report to the 
                Congress which shall contain a detailed statement of 
                the findings and conclusions of the Board, together 
                with its recommendations for such legislation and 
                administrative actions as it considers appropriate--
                            (i) not later than September 30, 1998, for 
                        the matter studied in subparagraph (A)(iii), 
                        and
                            (ii) not later than September 30, 1996, for 
                        the matter studied in clauses (i) and (ii) of 
                        subparagraph (A).
            (3) Legislative proposals.--
                    (A) Number of residents.--
                            (i) Initial proposal.--Not later than 3 
                        years after the date of the enactment of this 
                        Act, the Board shall develop and submit to 
                        Congress a legislative proposal that adjusts 
                        the aggregate number of federally-funded 
                        residency positions under section 
                        1886(h)(4)(A)(i) of the Social Security Act for 
                        the 3-year period beginning on July 1, 1998, 
                        and ending on June 30, 2001, based on the 
                        Board's evaluation of national, State, and 
                        regional needs.
                            (ii) Subsequent proposals.--Not later than 
                        3 years after the date the last legislative 
                        proposal was submitted under this subparagraph, 
                        the Board shall develop and submit to Congress 
                        a legislative proposal described in clause (i) 
                        for the following 3-year period.
                    (B) Proportion of funded specialty residencies.--
                            (i) Initial proposal.--Not later than 3 
                        years after the date of the enactment of this 
                        Act, the Board shall develop and submit to 
                        Congress a legislative proposal that adjusts 
                        the proportion of specialty residency positions 
                        under section 1886(h)(4)(A)(ii) of the Social 
                        Security Act for the 3-year period beginning on 
                        July 1, 1998, and ending on June 30, 2001, 
                        based on the Board's evaluation of national, 
                        State, and regional needs.
                            (ii) Subsequent proposals.--Not later than 
                        3 years after the date the last legislative 
                        proposal was submitted under this subparagraph, 
                        the Board shall develop and submit to Congress 
                        a legislative proposal described in clause (i) 
                        for the following 3-year period.
                    (C) Approval resolution.--The legislative proposals 
                described in subparagraphs (A) and (B) shall be 
                considered by Congress under the procedures for 
                consideration of an ``approval resolution'' as 
                described in subsection (c).
    (c) Congressional Consideration of Approval Resolution.--
            (1) Rules of house of representatives and senate.--This 
        paragraph is enacted by Congress--
                    (A) as an exercise of the rulemaking power of the 
                House of Representatives and the Senate, respectively, 
                and as such is deemed a part of the rules of each 
                House, respectively, but applicable only with respect 
                to the procedure to be followed in that House in the 
                case of approval resolutions described in paragraph 
                (2), and supersedes other rules only to the extent that 
                such rules are inconsistent therewith; and
                    (B) with full recognition of the constitutional 
                right of either House to change the rules (so far as 
                relating to the procedure of that House) at any time, 
                in the same manner and to the same extent as in the 
                case of any other rule of that House.
            (2) Terms of the resolution.--For purposes of paragraph 
        (1), the term ``approval resolution'' means only a joint 
        resolution of the 2 Houses of Congress, providing in--
                    (A) the matter after the resolving clause of which 
                is as follows: ``That Congress approves the legislative 
                proposal of the National Health Care Work Force Board 
                as submitted by the Board on 
                ____________________________'', the blank space being 
                filled in with the appropriate date; and
                    (B) the title of which is as follows: ``Joint 
                Resolution approving the legislative proposal of the 
                National Health Care Work Force Board.''.
            (3) Introduction and referral.--On the day on which the 
        legislative proposal of the Commission is transmitted to the 
        House of Representatives and the Senate, an approval resolution 
        with respect to such proposal shall be introduced (by request) 
        in the House of Representatives by the majority leader of the 
        House, for himself and the minority leader of the House, or by 
        Members of the House designated by the majority leader of the 
        House, for himself and the minority leader of the House, or by 
        Members of the House designated by the majority leader and 
        minority leader of the House; and shall be introduced (by 
        request) in the Senate by the majority leader of the Senate, 
        for himself and the minority leader of the Senate, or by 
        Members of the Senate designated by the majority leader and 
        minority leader of the Senate. If either House is not in 
        session on the day on which such proposal is transmitted, the 
        approval resolution with respect to such proposal shall be 
        introduced in the House, as provided in the preceding sentence, 
        on the first day thereafter on which the House is in session. 
        The approval resolution introduced in the House of 
        Representatives and the Senate shall be referred to the 
        appropriate committees of each House.
            (4) Amendments prohibited.--No amendment to an approval 
        resolution shall be in order in either the House of 
        Representatives or the Senate and no motion to suspend the 
        application of this paragraph shall be in order in either 
        House, nor shall it be in order in either House for the 
        Presiding Officer to entertain a request to suspend the 
        application of this paragraph by unanimous consent.
            (5) Period for committee and floor consideration.--
                    (A) In general.--Except as provided in clause (ii), 
                if the committee or committees of either House to which 
                an approval resolution has been referred have not 
                reported it at the close of the 45th day after its 
                introduction, such committee or committees shall be 
                automatically discharged from further consideration of 
                the approval resolution and it shall be placed on the 
                appropriation calendar. A vote on final passage of the 
                approval resolution shall be taken in each House on or 
                before the close of the 45th day after the approval 
                resolution is reported by the committees or committee 
                of that House to which it was referred, or after such 
                committee or committees have been discharged from 
                further consideration of the approval resolution. If 
                prior to the passage by 1 House of an approval 
                resolution of that House, that House receives the same 
                approval resolution from the other House then--
                            (i) the procedure in that House shall be 
                        the same as if no approval resolution had been 
                        received from the other House; but
                            (ii) the vote on final passage shall be on 
                        the approval resolution of the other House.
                    (B) Computation of days.--For purposes of clause 
                (i), in computing a number of days in either House, 
                there shall be excluded any day on which the House is 
                not in session.
            (6) Floor consideration in the house of representatives.--
                    (A) Motion to proceed.--A motion in the House of 
                Representatives to proceed to the consideration of an 
                approval resolution shall be highly privileged and not 
                debatable. An amendment to the motion shall not be in 
                order, nor shall it be in order to move to reconsider 
                the vote by which the motion is agreed to or disagreed 
                to.
                    (B) Debate.--Debate in the House of Representatives 
                on an approval resolution shall be limited to not more 
                than 20 hours, which shall be divided equally between 
                those favoring and those opposing the bill or 
                resolution. A motion further to limit debate shall not 
                be debatable. It shall not be in order to move to 
                recommit an approval resolution or to move to 
                reconsider the vote by which an approval resolution is 
                agreed to or disagreed to.
                    (C) Motion to postpone.--Motions to postpone, made 
                in the House of Representatives with respect to the 
                consideration of an approval resolution, and motions to 
                proceed to the consideration of other business, shall 
                be decided without debate.
                    (D) Appeals.--All appeals from the decisions of the 
                Chair relating to the application of the Rules of the 
                House of Representatives to the procedure relating to 
                an approval resolution shall be decided without debate.
                    (E) General rules apply.--Except to the extent 
                specifically provided in the preceding provisions of 
                this subsection, consideration of an approval 
                resolution shall be governed by the Rules of the House 
                of Representatives applicable to other bills and 
                resolutions in similar circumstances.
            (7) Floor consideration in the senate.--
                    (A) Motion to proceed.--A motion in the Senate to 
                proceed to the consideration of an approval resolution 
                shall be privileged and not debatable. An amendment to 
                the motion shall not be in order, nor shall it be in 
                order to move to reconsider the vote by which the 
                motion is agreed to or disagreed to.
                    (B) General debate.--Debate in the Senate on an 
                approval resolution, and all debatable motions and 
                appeals in connection therewith, shall be limited to 
                not more than 20 hours. The time shall be equally 
                divided between, and controlled by, the majority leader 
                and the minority leader or their designees.
                    (C) Debate of motions and appeals.--Debate in the 
                Senate on any debatable motion or appeal in connection 
                with an approval resolution shall be limited to not 
                more than 1 hour, to be equally divided between, and 
                controlled by, the mover and the manager of the 
                approval resolution, except that in the event the 
                manager of the approval resolution is in favor of any 
                such motion or appeal, the time in opposition thereto, 
                shall be controlled by the minority leader or his 
                designee. Such leaders, or either of them, may, from 
                time under their control on the passage of an approval 
                resolution, allot additional time to any Senator during 
                the consideration of any debatable motion or appeal.
                    (D) Other motions.--A motion in the Senate to 
                further limit debate is not debatable. A motion to 
                recommit an approval resolution is not in order.
            (8) Point of order requiring supermajority for 
        modifications to proposal once approved.--
                    (A) In general.--It shall not be in order in the 
                House of Representatives or the Senate to consider any 
                amendment to the provisions of the Graduate Reform 
                Opportunities and Work Force Training in Health Act 
                except as provided in subparagraph (B).
                    (B) Waiver.--The point of order described in 
                subparagraph (A) may be waived or suspended in the 
                House of Representatives or the Senate only, by the 
                affirmative vote of three-fifths of the Members duly 
                chosen and sworn.
    (d) Resubmissions.--If a legislative proposal of the Board 
submitted under subparagraph (A) or (B) of subsection (b)(3) is not 
approved by Congress within 90 days of the submission of such proposal 
to Congress, or is approved by Congress and vetoed by the President 
(and such veto is not overridden by the Congress), the Board shall 
submit a new legislative proposal not later than 90 days after Congress 
failed to approve the proposal or the President failed to override the 
President's veto, and such new legislative proposal shall be subject to 
congressional consideration as provided in subsection (c).
    (e) Powers of the Board.--
            (1) Hearings.--The Board may hold such hearings, sit and 
        act at such times and places, take such testimony, and receive 
        such evidence as the Board considers advisable to carry out the 
        purposes of this section.
            (2) Information from federal agencies.--The Board may 
        secure directly from any Federal department or agency such 
        information as the Board considers necessary to carry out the 
        provisions of this section. Upon request of the Chairperson of 
        the Board, the head of such department or agency shall furnish 
        such information to the Board.
            (3) Postal services.--The Board may use the United States 
        mails in the same manner and under the same conditions as other 
        departments and agencies of the Federal Government.
            (4) Gifts.--The Board may accept, use, and dispose of gifts 
        or donations of services or property.
    (g) Board Personnel Matters.--
            (1) Compensation of members.--Each member of the Board who 
        is not an officer or employee of the Federal Government shall 
        be compensated at a rate equal to the daily equivalent of the 
        annual rate of basic pay prescribed for level V of the 
        Executive Schedule under section 5315 of title 5, United States 
        Code, for each day (including travel time) during which such 
        member is engaged in the performance of the duties of the 
        Board. All members of the Board who are officers or employees 
        of the United States shall serve without compensation in 
        addition to that received for their services as officers or 
        employees of the United States.
            (2) Travel expenses.--The members of the Board shall be 
        allowed travel expenses, including per diem in lieu of 
        subsistence, at rates authorized for employees of agencies 
        under subchapter I of chapter 57 of title 5, United States 
        Code, while away from their homes or regular places of business 
        in the performance of services for the Board.
            (3) Staff.--
                    (A) In general.--The Secretary shall, after 
                consultation with and consideration of the 
                recommendations of the Board, provide the Board with--
                            (i) an executive director and 1 other 
                        professional staff member, and
                            (ii) such additional professional staff 
                        members including clerical staff, services of 
                        consultants, information, and administrative 
                        support services (through contracts or other 
                        arrangements) as the Secretary deems necessary 
                        for the Board to carry out its functions.
                    (B) Detail of government employees.--Any Federal 
                Government employee may be detailed to the Board 
                without reimbursement, and such detail shall be without 
                interruption or loss of civil service status or 
                privilege.
    (h) Authorization of Appropriations.--
            (1) In general.--There are authorized to be appropriated 
        such sums as may be necessary for the Board to carry out the 
        purposes of this section.
            (2) Availability.--Any sums appropriated under the 
        authorization contained in this section shall remain available, 
        without fiscal year limitation, until expended.
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