II

103D CONGRESS

2D SESSION S. 2452

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

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

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

IN THE SENATE OF THE UNITED STATES

SEPTEMBER 22 (legislative day, SEPTEMBER 12), 1994

Mr. GRAHAM (for himself and Mr. HATFIELD) introduced the following bill;

which was read the first time

A BILL

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

improve the quality of health care in States through

health insurance reform, State innovation, public health

and medical research, and for other purposes.

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

3 SECTION 1. SHORT TITLE.

4 This Act may be cited as the ‘‘Health Innovation

5 Partnership Act of 1994’’.

6 SEC. 2. FINDINGS.

7 The Congress finds the following:
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1 (1) Americans support universal coverage. The

2 people of this country agree that all Americans, rich

3 and poor, should be guaranteed access to affordable,

4 high-quality health care.

5 (2) Although there is common agreement on the

6 goal of universal coverage, there are many different

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

8 important role in achieving universal coverage for

9 our population, demonstrating additional health re10 forms that may be needed on a national level to en11 hance access to affordable, high-quality health care.

12 The States can also serve as testing grounds to iden13 tify effective alternatives for making the transition

14 to universal coverage, while maintaining the

15 strengths of the current health care system.

16 (3) Maintaining the high quality of health care

17 Americans expect and controlling costs are also im18 portant goals of health care reform. As payers of

19 health care, the States have a strong incentive to en20 sure that such States purchase high-quality, cost-ef21 fective services for the residents of such States. The

22 States can develop and test alternative payment and

23 delivery systems to ensure that these goals are

24 achieved.
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1 (4) There are many health-related issues that

2 should be addressed at the State level before their

3 implementation on the national level. As with social

4 security and child labor protections, States can lead

5 the way in testing ideas for national application.

6 (5) The States should have the flexibility to test

7 alternative health reforms with the objectives of in8 creasing access to care, controlling health care costs,

9 and maintaining or improving the quality of health

10 care.

11 TITLE I—HEALTH INSURANCE

12 REFORM

13 SEC. 1001. ESTABLISHMENT OF STANDARDS.

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

15 Human Services (hereafter referred to in this section as

16 the ‘‘Secretary’’) shall request that the National Associa17 tion of Insurance Commissioners (hereafter referred to in

18 this section as the ‘‘Association’’) develop, not later than

19 6 months after the date of enactment of this Act, stand20 ards for health insurance plans with respect to—

21 (1) the renewability of coverage under such

22 plans;

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

24 including—
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1 (A) limitations on the use of pre-existing

2 conditions;

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

4 during which limitations on pre-existing condi5 tions would be suspended; and

6 (C) the advisability of open enrollment pe7 riods;

8 (3) guaranteed issue with respect to all health

9 insurance coverage products;

10 (4) the establishment of an adjusted community

11 rating system with adjustment factors limited to age

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

13 based on age) and geography;

14 (5) solvency standards for health insurance

15 plans regulations under Federal and State law, in16 cluding the development of risk-based capital stand17 ards for health plans, solvency standards for health

18 plans, self-funded employer-sponsored health plans,

19 and multi-employer welfare arrangements and asso20 ciation plans;

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

22 insurance plans and multi-employer welfare arrange23 ments and association plans;

24 (7) the identification of minimum employer size

25 for self-funding and the interrelationship between
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1 self-funding and the community-rated pool of enroll2 ees; and

3 (8) any other areas determined appropriate by

4 the Secretary.

5 (b) REVIEW.—Not later than 30 days after receipt

6 of the standards developed by the Association under sub7 section (a), the Secretary shall complete a review of such

8 standards. If the Secretary, based on such review, ap9 proves such standards, such standards shall apply with re10 spect to all health insurance plans offered or operating

11 in a State on and after the date specified in subsection

12 (d) herein.

13 (c) FAILURE TO DEVELOP STANDARDS OR FAILURE

14 TO APPROVE.—If the Association fails to develop stand15 ards within the 6-month period referred to in subsection

16 (a), or the Secretary fails to approve any standards devel17 oped under such subsection, the Secretary shall develop,

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

19 this Act, standards applicable to health insurance plans,

20 including standards related to the matter described in

21 paragraphs (1) through (7) of subsection (a) (‘‘Federal

22 standards’’) and such standards shall apply with respect

23 to all health insurance plans offered or operating in a

24 State on and after the date specified in subsection (d)

25 herein.
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1 (d)(1) Subject to clause (ii), the date specified in this

2 subparagraph for a State is the date the State adopts the

3 NAIC standards or the Federal standards or 1 year after

4 the date the Association or the Secretary first adopts such

5 standards, whichever is earlier.

6 (2) In the case of a State which the Secretary identi7 fies, in consultation with the Association, as—

8 (A) requiring State legislation (other than legis9 lation appropriating funds) in order for health insur10 ance policies to meet the NAIC or Federal stand11 ards, but

12 (B) having a legislature which is not scheduled

13 to meet in 1992 in a legislative session in which

14 such legislation may be considered, the date speci15 fied in this subparagraph is the first day of the first

16 calendar quarter beginning after the close of the

17 first legislative session of the State legislature that

18 begins on or after January 1, 1992. For purposes of

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

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

21 shall be deemed to be a separate regular session of

22 the State legislature.

23 (e) In promulgating standards under this paragraph,

24 the Association or Secretary shall consult with a working

25 group composed or representatives of issuers of health in-
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1 surance policies, consumer groups, health insurance bene2 ficiaries, and other qualified individuals. Such representa3 tives shall be selected in a manner so as to assure balanced

4 representation among the interested groups.

5 (f) EFFECT ON STATE LAW.—Nothing in this section

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

7 that such State law implements more progressive reforms

8 than those implemented under the standards developed

9 under this section, as determined by the Secretary.

10 SEC. 1002. MEDICARE SELECT.

11 (a) AMENDMENTS TO PROVISIONS RELATING TO

12 MEDICARE SELECT POLICIES.—

13 (1) PERMITTING MEDICARE SELECT POLICIES

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

15 the Omnibus Budget Reconciliation Act of 1990 is

16 hereby repealed.

17 (2) REQUIREMENTS OF MEDICARE SELECT

18 POLICIES.—Section 1882(t)(1) (42 U.S.C.

19 1395ss(t)(1)) is amended to read as follows:

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

21 requirements of the 1991 NAIC Model Regulation or 1991

22 Federal Regulation and otherwise complies with the re23 quirements of this section except that—

24 ‘‘(i) the benefits under such policy are re25 stricted to items and services furnished by certain
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1 entities (or reduced benefits are provided when items

2 or services are furnished by other entities), and

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

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

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

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

10 title, such benefits include at least the core

11 group of basic benefits described in subsection

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

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

15 B of this title is limited to the nominal

16 copayments described in subclause (II),

17 the policy shall nevertheless be treated as meeting

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

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

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

23 services furnished through a network of entities

24 which have entered into contracts or agreements

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

2 services furnished by other entities if the services are

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

5 and it is not reasonable given the circumstances to

6 obtain the services through the network,

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

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

9 for an ongoing quality assurance program for items

10 and services furnished through the network,

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

12 enrollee at the time of enrollment an explanation

13 of—

14 ‘‘(aa) the restrictions on payment under

15 the policy for services furnished other than by

16 or through the network,

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

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

20 services and urgently needed care, and

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

22 the entity that meets the 1991 Model NAIC

23 Regulation or 1991 Federal Regulation without

24 regard to this subsection and the premium

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

3 subclause (I), and

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

5 individuals, in addition to the policy described in this

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

8 Model NAIC Regulation or 1991 Federal Regulation

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

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

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

13 defined in section 1876(b)),

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

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

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

18 section 2355 of the Deficit Reduction Act of 1984,

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

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

22 with benefits which are available under this title, are

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

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

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

4 in the case of preventive services, benefits provided under

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

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

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

10 (b) RENEWABILITY OF MEDICARE SELECT POLI11 CIES.—Section 1882(q)(1) (42 U.S.C. 1395ss(q)(1)) is

12 amended—

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

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

15 each’’;

16 (2) by redesignating subparagraphs (A) and

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

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

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

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

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

24 that, if such individual moves to a geographic area

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

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

4 affiliate that provides benefits comparable to or less

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

7 is canceled or nonrenewed under this subparagraph

8 shall, as part of the notice of termination or

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

10 medicare supplemental policies offered by the issuer

11 or its affiliates.

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

13 term ‘affiliate’ shall have the meaning given such

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

15 (c) CIVIL PENALTY.—Section 1882(t)(2) (42 U.S.C.

16 1395ss(t)(2)) is amended—

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

13 apply to a civil money penalty under this subparagraph

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

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

16 (d) EFFECTIVE DATES.—

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

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

20 (hereafter in this subsection referred to as the

21 ‘‘NAIC’’) makes changes in the 1991 NAIC Model

22 Regulation (as defined in section 1882(p)(1)(A) of

23 the Social Security Act) to incorporate the additional

24 requirements imposed by the amendments made by

25 this section, section 1882(g)(2)(A) of such Act shall
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1 be applied in each State, effective for policies issued

2 to policyholders on and after the date specified in

3 paragraph (3), as if the reference to the Model Reg4 ulation adopted on June 6, 1979, were a reference

5 to the 1991 NAIC Model Regulation (as so defined)

6 as changed under this paragraph (such changed

7 Regulation referred to in this subsection as the

8 ‘‘1995 NAIC Model Regulation’’).

9 (2) SECRETARY STANDARDS.—If the NAIC

10 does not make changes in the 1991 NAIC Model

11 Regulation (as so defined) within the 9-month period

12 specified in paragraph (1), the Secretary of Health

13 and Human Services (hereafter in this subsection re14 ferred to as the ‘‘Secretary’’) shall promulgate a reg15 ulation and section 1882(g)(2)(A) of the Social Se16 curity Act shall be applied in each State, effective

17 for policies issued to policyholders on and after the

18 date specified in paragraph (3), as if the reference

19 to the Model Regulation adopted on June 6, 1979,

20 were a reference to the 1991 NAIC Model Regula21 tion (as so defined) as changed by the Secretary

22 under this paragraph (such changed Regulation re23 ferred to in this subsection as the ‘‘1995 Federal

24 Regulation’’).

25 (3) DATE SPECIFIED.—
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1 (A) IN GENERAL.—Subject to subpara2 graph (B), the date specified in this paragraph

3 for a State is the earlier of—

4 (i) the date the State adopts the 1995

5 NAIC Model Regulation or the 1995 Fed6 eral Regulation, or

7 (ii) 1 year after the date the NAIC or

8 the Secretary first adopts such regulations.

9 (B) ADDITIONAL LEGISLATIVE ACTION RE10 QUIRED.—In the case of a State which the Sec11 retary identifies, in consultation with the NAIC,

12 as—

13 (i) requiring State legislation (other

14 than legislation appropriating funds) in

15 order for medicare supplemental policies to

16 meet the 1995 NAIC Model Regulation or

17 the 1995 Federal Regulation, but

18 (ii) having a legislature which is not

19 scheduled to meet in 1995 in a legislative

20 session in which such legislation may be

21 considered,

22 the date specified in this paragraph is the first

23 day of the first calendar quarter beginning after

24 the close of the first legislative session of the

25 State legislature that begins on or after Janu-
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1 ary 1, 1996. For purposes of the previous sen2 tence, in the case of a State that has a 2-year

3 legislative session, each year of such session

4 shall be deemed to be a separate regular session

5 of the State legislature.

6 TITLE II—STATE INNOVATION

7 Subtitle A—State Waiver Authority

8 SEC. 2001. STATE HEALTH REFORM PROJECTS.

9 (a) OBJECTIVES.—The objectives of the waiver pro10 grams approved under this section shall include, but not

11 be limited to—

12 (1) achieving the goals of increased health cov13 erage and access;

14 (2) containing the annual rate of growth in

15 public and private health care expenditures;

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

17 appropriate health care; and

18 (4) testing alternative reforms, such as building

19 on the private health insurance system or creating

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

21 (b) STATE HEALTH REFORM APPLICATIONS.—

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

23 (A) an alternative State health program

24 waiver under paragraph (2); or
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1 (B) a limited State health care waiver

2 under paragraph (3).

3 (2) ALTERNATIVE STATE HEALTH PROGRAM

4 WAIVERS.—

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

6 paragraph, each State desiring to implement an

7 alternative State health program may submit

8 an application for waiver to the Secretary for

9 approval.

10 (B) WAIVER REQUIREMENTS SPECIFIED.—

11 A State that desires to receive a program waiv12 er under this paragraph shall prepare and sub13 mit to the Secretary, as part of the application,

14 a State health care plan that shall—

15 (i) provide and describe the manner in

16 which the State will ensure that individuals

17 residing within the State have expanded

18 access to health care coverage;

19 (ii) describe the number and percent20 age of current uninsured individuals who

21 will achieve coverage under the alternative

22 State health program;

23 (iii) describe the benefits package that

24 will be provided to all classes of bene-
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1 ficiaries under the alternative State health

2 program;

3 (iv) identify Federal, State, or local

4 programs that currently provide health

5 care services in the State and describe how

6 such programs could be incorporated into

7 or coordinated with the alternative State

8 health program, to the extent practicable;

9 (v) provide that the State will develop

10 and implement health care cost contain11 ment procedures;

12 (vi) describe the public and private

13 sector financing to be provided for the al14 ternative State health program;

15 (vii) estimate the amount of Federal,

16 State, and local expenditures, as well as,

17 the costs to business and individuals under

18 the alternative State health program;

19 (viii) describe how the State plan will

20 ensure the financial solvency of the alter21 native State health program;

22 (ix) describe any changes in eligibility

23 for public subsidies;

24 (x) provide assurances that Federal

25 expenditures under the alternative State
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1 health program shall not exceed the Fed2 eral expenditures which would otherwise be

3 made in the aggregate for the entire pro4 gram period;

5 (xi) provide quality control assurances

6 and agreements as required by the Sec7 retary;

8 (xii) provide for the development and

9 implementation of a State health care de10 livery system that provides increased ac11 cess to care in areas of the State where

12 there is an inadequate supply of health

13 care providers;

14 (xiii) identify all Federal law waivers

15 required to implement the alternative State

16 health program, including such waivers

17 necessary to achieve the access, cost con18 tainment, and quality goals of this Act and

19 the alternative State health program; and

20 (xiv) provide that the State will pre21 pare and submit the Secretary such re22 ports as the Secretary may require to carry

23 out program evaluations.

24 (C) PROJECT WAIVERS.—
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1 (i) CRITERIA FOR SELECTION.—In se2 lecting from among the applications for al3 ternative State health program waivers,

4 the Secretary shall be satisfied that each

5 approved State alternative State health

6 program—

7 (I) will not have a negative effect

8 on quality of care;

9 (II) increase coverage of or ac10 cess for the State’s population; and

11 (III) will—

12 (aa) provide quality of care

13 and premium comparisons di14 rectly to employers and individ15 uals in an easy-to-use format,

16 (bb) contract with an exter17 nal peer review organization to

18 monitor the quality of health care

19 plans, and

20 (cc) establish a mechanism

21 within the State’s grievance proc22 ess that allows members of a

23 health plan to disenroll at any

24 time if it can be shown that such

25 members were provided erroneous
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1 information that biased their

2 health plan selection.

3 (ii) WAIVER APPROVAL.—The Sec4 retary shall approve applications submitted

5 by States that meet the access, cost con6 tainment, and quality goals established in

7 this Act and shall waive to the extent nec8 essary to conduct each alternative State

9 health program any of the requirements of

10 this Act, including, but not limited to, eli11 gibility requirements; alternative data col12 lection systems and sampling designs that

13 focus on measuring health status, patient

14 treatment outcomes, and patient satisfac15 tion with health plans, rather than on the

16 collection of 100 percent of patient encoun17 ters; and benefit designs; and any provi18 sions of Federal law contained in the fol19 lowing:

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

21 XX of the Social Security Act.

22 (II) The Public Health Service

23 Act.

24 (III) Any other Federal law au25 thorizing a Federal health care pro-
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1 gram that the Secretary identifies as

2 providing health care services to quali3 fied recipients.

4 (3) LIMITED STATE HEALTH CARE WAIVERS.—

5 Each State which does not receive an approved ap6 plication under paragraph (2) may apply for a lim7 ited State health care waiver. The Secretary shall

8 award limited State health care waivers to ensure

9 State demonstrations of health reforms that could

10 address, but are not limited to addressing, the fol11 lowing issues that are likely to provide guidance for

12 the development of additional national health re13 forms:

14 (A) Integration of acute and long-term

15 care systems, including delivery and financing

16 systems.

17 (B) Establishment of methodologies that

18 limit expenditures or establish global budgets,

19 including rate setting and provider reimburse20 ments.

21 (C) Implementation of a quality manage22 ment and improvement system.

23 (D) Strategies to improve the proper spe24 ciality and geographic distribution of the health

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

2 health status.

3 (F) Development of uniform health data

4 sets that emphasize the measurement of patient

5 satisfaction, treatment outcomes, and health

6 status.

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

9 for low-income individuals, including programs

10 authorized by this Act.

11 (H) Programs to improve public health.

12 (I) Reforms intended to reduce health care

13 fraud and abuse.

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

16 associated with medical malpractice.

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

19 (c) ADDITIONAL RULES REGARDING APPLICA20 TIONS.—

21 (1) TECHNICAL ASSISTANCE.—The Secretary

22 shall, if requested, provide technical assistance to

23 States to assist such States in developing waiver ap24 plications under this section.
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1 (2) INITIAL REVIEW.—The Secretary shall com2 plete an initial review of each State application for

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

4 (b) within 40 days of the receipt of such application,

5 analyze the scope of the proposal, and determine

6 whether additional information is needed from the

7 State. The Secretary shall issue a preliminary opin8 ion concerning the likelihood that the application will

9 be approved within such 40-day period and shall ad10 vise the State within such period of the need to sub11 mit additional information.

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

13 within 90 days of the later of—

14 (A) the receipt of a State application for a

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

16 (b), or

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

19 State under paragraph (1),

20 issue a final decision concerning such application.

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

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

24 by the Secretary, except that a shorter period may
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1 be requested by a State and granted by the Sec2 retary.

3 (d) QUALIFICATION FOR FEDERAL FUNDS.—For

4 purposes of this Act, a State with an approved alternative

5 health care system under subsection (b)(2) shall be consid6 ered a participating State and shall maintain such status

7 if such State meets the requirements established by the

8 Secretary in the waiver approval and in this section.

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

10 (1) STATE HEALTH REFORM ADVISORY

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

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

15 that will be responsible for monitoring the status

16 and progress achieved under waivers granted under

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

19 Board shall be comprised of members representing

20 relevant participants in State programs, including

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

23 also be responsible for making recommendations to

24 the Secretary, using equivalency or minimum stand25 ards, for minimizing the negative effect of State
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1 waivers on national employer groups, provider orga2 nizations, and insurers because of differing State re3 quirements under the waivers.

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

5 that has received a waiver approval shall submit to

6 the Secretary an annual report based on the period

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

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

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

12 not in compliance, the Secretary shall develop, in

13 conjunction with all the approved States, a correc14 tive action plan.

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

17 under this section, and if necessary, may terminate

18 any alternative State health program. Such decisions

19 shall be subject to a petition for reconsideration and

20 appeal pursuant to regulations established by the

21 Secretary.

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

24 Finance and the Committee on Labor and Human

25 Resources of the Senate and the Committee on En-
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1 ergy and Commerce and the Committee on Ways

2 and Means of the House of Representatives annual

3 reports that shall contain—

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

7 (B) an evaluation of the effectiveness of

8 such reforms in—

9 (i) expanding health care coverage for

10 State residents;

11 (ii) providing health care to State

12 residents with special needs;

13 (iii) reducing or containing health

14 care costs in the States; and

15 (iv) improving the quality of health

16 care provided in the States; and

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

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

21 such assistance.

22 (f) FUNDING.—

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

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

25 approved under this section to enable such State to
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1 carry out an alternative State health program in the

2 State.

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

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

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

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

9 State projects that the Secretary determines have

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

12 children and youth with access to health care items

13 and services.

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

15 utilizing the proceeds of a grant received under

16 paragraph (1), shall maintain the expenditures of

17 the State for health care coverage purposes at a level

18 equal to not less than the level of such expenditures

19 maintained by the State for the fiscal year preceding

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

21 requirement of this paragraph shall not apply in the

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

24 alternative health program.
29

•S 2452 IS

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

2 beginning on the date on which the Secretary

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

4 State Health Reform Advisory Board established

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

6 the appropriate committees of Congress, a report on

7 the progress made by States receiving grants under

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

10 grant. Such report shall contain the recommendation

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

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

16 of the calendar years 1996 through 2000,

17 $10,000,000,000 shall be available for a calendar year to

18 carry out this section from the Health Care Reform Trust

19 Fund established under section 9551(a)(2)(A) of the In20 ternal Revenue Code of 1986. Amounts made available in

21 a calendar year under this paragraph and not expended

22 may be used in subsequent calendar years to carry out

23 this section.

24 (h) AMENDMENT TO CRIMINAL PENALTIES FOR

25 ACTS INVOLVING MEDICARE OR STATE HEALTH CARE
30

•S 2452 IS

1 PROGRAMS.—Section 1128B(b) of the Social Security Act

2 (42 U.S.C. 1320a–7b(b)) is amended by adding at the end

3 the following new paragraph:

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

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

6 maintenance organization for which the premium is

7 paid in whole or in part by a State health care pro8 gram; and

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

10 a health maintenance organization to a sales

11 representative or a licensed insurance agent as com12 pensation for the services of the representative or

13 agent in marketing and enrolling an individual in a

14 health plan for which the premium is paid in whole

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

16 Subtitle B—Existing State Laws

17 SEC. 2101. CONTINUANCE OF EXISTING FEDERAL LAW

18 WAIVERS.

19 Nothing in this Act shall preempt any feature of a

20 State health care system operating under a waiver granted

21 before the date of the enactment of this Act under titles

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

23 et seq. or 1396 et seq.) or the Employee Retirement In24 come Security Act of 1974 (29 U.S.C. 1001 et seq.).
31

•S 2452 IS

1 SEC. 2102. HAWAII PREPAID HEALTH CARE ACT.

2 (a) ERISA WAIVER.—

3 (1) IN GENERAL.—Section 514(b)(5) of the

4 Employee Retirement Income Security Act of 1974

5 (29 U.S.C. 1144(b)(5)) is amended to read as fol6 lows:

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

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

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

10 §§ 393–1 through 393–51).

11 ‘‘(B) Nothing in subparagraph (A) shall be con12 strued to exempt from subsection (a) any State tax

13 law relating to employee benefits plans.

14 ‘‘(C) If the Secretary of Labor notifies the Gov15 ernor of the State of Hawaii that as the result of

16 an amendment to the Hawaii Prepaid Health Care

17 Act enacted after the date of the enactment of this

18 paragraph—

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

20 health care coverage under such Act is less than

21 such proportion on such date, or

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

23 under such Act is less than the actuarial equiv24 alent of such level of coverage on such date,
32

•S 2452 IS

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

2 application of such amendment to such Act after the

3 date of such notification.’’.

4 (2) EFFECTIVE DATE.—The amendment made

5 by paragraph (1) shall take effect on the date of the

6 enactment of this Act.

7 (b) HSA WAIVER.—

8 (1) IN GENERAL.—The Secretary shall, at the

9 request of the Governor of the State of Hawaii and

10 in accordance with this section, grant a waiver to

11 the State from the requirements of this Act (other

12 than the requirements specified in paragraph (3)).

13 (2) SCOPE OF WAIVER.—The waiver granted

14 under paragraph (1) shall exempt—

15 (A) the State of Hawaii;

16 (B) health plans offered within the State;

17 and

18 (C) health plan participants, including em19 ployers, employees, residents, and health plan

20 sponsors within the State,

21 from requirements otherwise applicable to the State

22 and such plans and participants.

23 (3) REQUIRED COMPLIANCE OF OTHER RE24 QUIREMENTS.—The waiver shall initially be granted

25 under paragraph (1) if the State of Hawaii dem-
33

•S 2452 IS

1 onstrates to the Secretary that the State main2 tains—

3 (A) a requirement that employers make

4 premium contributions in accordance with the

5 requirements of title I;

6 (B) a comprehensive benefit package (in7 cluding cost sharing) that is comparable with

8 the requirements of title I;

9 (C) a percentage of State population with

10 health care coverage that is not less than the

11 national average;

12 (D) a quality control mechanism and data

13 system; and

14 (E) health care cost containment consist15 ent with the provisions of title I.

16 (4) WAIVER PERIOD.—The waiver initially

17 granted under paragraph (1) shall extend for the pe18 riod during which the State of Hawaii continues to

19 comply with the requirements specified in paragraph

20 (3). The Secretary may require the State, every 5

21 years, to demonstrate to the Secretary the State’s

22 continued compliance with such requirements.

23 (5) PROCEDURE IN THE EVENT OF NON-COM24 PLIANCE.—
34

•S 2452 IS

1 (A) NOTICE.—If, at any time after grant2 ing a waiver under paragraph (1), the Secretary

3 finds that the State of Hawaii is not meeting

4 the requirements specified in paragraph (3), the

5 Secretary shall notify the State of the Sec6 retary’s findings.

7 (B) OPPORTUNITY TO CONTEST.—The

8 State may contest the Secretary’s findings.

9 (C) OPPORTUNITY FOR CORRECTION.—

10 (i) FINDINGS NOT CONTESTED.—If

11 the State does not contest the Secretary’s

12 findings within the 30-day period begin13 ning on the date of receipt of a notice of

14 such findings, the State shall have—

15 (I) a 90-day period beginning on

16 such date to show a good faith effort

17 to remedy the non-compliance, and

18 (II) an additional 12-month pe19 riod to take such actions as may be

20 required to bring the State into com21 pliance with the requirements speci22 fied in paragraph (3).

23 (ii) CONTESTED FINDINGS.—If the

24 State contests the Secretary’s findings
35

•S 2452 IS

1 within such 30-day period but such find2 ings are upheld, the State shall have—

3 (I) a 90-day period beginning on

4 the date of final adjudication to show

5 a good faith effort to remedy the non6 compliance, and

7 (II) an additional 12-month pe8 riod to take such actions as may be

9 required to bring the State into com10 pliance with the requirements speci11 fied in paragraph (3).

12 (D) TERMINATION.—If the State fails to

13 demonstrate a good faith effort under subpara14 graph (C)(i)(I) or (C)(ii)(I) or to take actions

15 under subparagraph (C)(i)(II) or (C)(ii)(II)

16 within the time period specified, the Secretary

17 may revoke the waiver granted in paragraph

18 (1).

19 (6) COOPERATIVE AGREEMENT WITH THE SEC20 RETARY.—The Secretary shall enter into cooperative

21 agreements with appropriate officials of the State of

22 Hawaii—

23 (A) to develop standards and reporting re24 quirements necessary for the issuance and
36

•S 2452 IS

1 maintenance of the State’s waiver under para2 graph (1); and

3 (B) otherwise to effectuate the provisions

4 of this subsection.

5 (7) ELIGIBILITY FOR FEDERAL FUNDS PRO6 VIDED TO PARTICIPATING STATES.—Nothing in this

7 subsection shall preclude the eligibility of the State

8 of Hawaii to participate in any public health initia9 tive, grant, or financial aid program under this Act

10 (including the medicaid program under title XIX of

11 the Social Security Act), designed to implement the

12 purpose of this Act. The Secretary shall work with

13 appropriate officials of the State of Hawaii to de14 velop comparable, alternative standards to govern

15 the State’s entitlement under title XI.

16 SEC. 2103. ALTERNATIVE STATE PROVIDER PAYMENT SYS17 TEMS.

18 Notwithstanding any other provision of law, if a hos19 pital reimbursement system operated by a State meets the

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

21 (42 U.S.C. 1395f(b)) and has been approved by the Sec22 retary and in continuous operation since July 1, 1977, the

23 payment rates and methodologies required under the sys24 tem for services provided in the State shall apply to all

25 purchasers and payers, including those under employee
37

•S 2452 IS

1 welfare benefit plans authorized under the Employee Re2 tirement Income Security Act of 1974 (29 U.S.C. 1001

3 et seq.), workers’ compensation programs under State law,

4 the Federal Employees’ Compensation Act under chapter

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

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

7 States Code.

8 SEC. 2104. ALTERNATIVE STATE HOSPITAL SERVICES PAY9 MENT SYSTEMS.

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

11 enforcing—

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

13 or

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

15 by any provision of the Employee Retirement Income Se16 curity Act of 1974 (29 U.S.C. 1001 et seq.) or chapter

17 81 or 89 of title 5, United States Code.

18 (b) REIMBURSEMENT CONTROL SYSTEM.—A State

19 system is described in this subsection if it is a State reim20 bursement control system in operation before the date of

21 the enactment of this Act which—

22 (1) applies to substantially all non-Federal

23 acute care hospitals in the State, and

24 (2) regulates substantially all rates of payment

25 (including maximum charges) in the State for inpa-
38

•S 2452 IS

1 tient hospital services, except payments made under

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

3 1395 et seq.).

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

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

6 insurance reform system in operation before the date of

7 the enactment of this Act which requires any insurer (in8 cluding a health maintenance organization) to comply with

9 requirements governing open enrollment and community

10 rating, including premium adjustments or other health

11 care assessments for the purpose of risk adjustment.

12 (d) EFFECTIVE DATES.—

13 (1) SUBSECTION (b).—In the case of a State

14 system described in subsection (b), the provisions of

15 this section shall apply before, on, and after the date

16 of the enactment of this Act.

17 (2) SUBSECTION (c).—In the case of a State

18 system described in subsection (c), the provisions of

19 this section shall apply before, on, and after the date

20 of the enactment of this Act, and before the date of

21 enactment of this Act.
39

•S 2452 IS

1 SEC. 2105. EXEMPTION FROM ERISA PREEMPTION OF CER2 TAIN PROVISIONS OF THE LAW OF THE

3 STATE OF OREGON RELATING TO HEALTH

4 PLANS.

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

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

7 1144(b)) is amended by adding at the end the following

8 new paragraph:

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

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

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

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

13 to the creation and operation of a high-risk insur14 ance pool).

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

16 381, Oregon Laws 1989, and chapter 916, Oregon

17 Laws 1991 (relating to employer-based health plan

18 coverage reforms).

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

20 to health care cost containment and technology as21 sessment).

22 ‘‘(iv) Chapter 836, Oregon Laws 1989 and

23 chapter 753, Oregon Laws 1991 (relating to

24 prioritization and medical assistance reforms).
40

•S 2452 IS

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

2 to phasing in of employer coverage and other revi3 sions of the Oregon Health Plan).

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

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

6 necessary to achieve universal coverage under the

7 Oregon Health Plan.

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

9 any provision of the law of the State of Oregon which pro10 vides, directly or indirectly, for taxation of employers or

11 group health plans only if under such provision the assess12 ment of the tax is under a uniform schedule, applicable

13 to all employers and group health plans, and does not dis14 criminate on the basis of the extent to which a group

15 health plan is insured.

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

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

18 (b) APPLICABILITY OF FEDERAL HEALTH REFORM

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

20 as failing to comply with applicable requirements of any

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

22 the date of the enactment of this Act and which provides

23 for coverage of individuals under a comprehensive benefit

24 package, before the first day of the first calendar year fol25 lowing the calendar year in which all other States have
41

•S 2452 IS

1 in effect plans under which individuals are eligible for cov2 erage under a comprehensive benefit package in compli3 ance with such law.

4 SEC. 2106. EXEMPTION FROM ERISA PREEMPTION OF CER5 TAIN PROVISIONS OF THE LAW OF THE

6 STATE OF MINNESOTA RELATING TO HEALTH

7 PLANS.

8 (a) ERISA WAIVER.—

9 (1) IN GENERAL.—Section 514(b)(5) of the

10 Employee Retirement Income Security Act of 1974

11 (29 U.S.C. 1144(b)(5)) is amended to read as fol12 lows:

13 ‘‘(5)(A)(i) Except as provided in clauses (ii) and (iii),

14 subsection (a) shall not apply to the following provisions

15 of the law of the State of Minnesota:

16 ‘‘(I) Sections 295.50 through 295.59 Minnesota

17 Statutes relating to gross revenues, hospitals and

18 health care surgical centers and pass through of

19 such tax.

20 ‘‘(II) Sections 62J.30 through 62.J.45 Min21 nesota Statutes relating to data to the extent those

22 provisions authorize or require submission of data by

23 health care providers, health insurers, health mainte24 nance organizations, or third party administrators.
42

•S 2452 IS

1 ‘‘(ii) Nothing in clause (i) shall be construed to ex2 empt from subsection (a)—

3 ‘‘(I) any State tax law relating to employee ben4 efit plans (other than a provision described in clause

5 (i)), and

6 ‘‘(II) any amendment of any provision referred

7 to in clause (i) enacted on or after May 31, 1994;

8 to the extent it provides for more than the effective

9 administration of such provision as in effect on such

10 date.

11 ‘‘(iii) Notwithstanding clause (i), parts 1 and 4 of

12 this subtitle, and the preceding sections of this part to

13 the extent they govern matters which are governed by the

14 provisions of such parts 1 and 4, shall supersede the provi15 sions described in clause (i) (as in effect on or after May

16 31, 1994), but the Secretary may enter into cooperative

17 arrangements under this subparagraph and section 506

18 with officials of the State of Minnesota to assist them in

19 effectuating the policies of such provisions which are su20 perseded by such parts 1 and 4 and the preceding sections

21 of this part.’’.
43

•S 2452 IS

1 SEC. 2107. EXEMPTION FROM ERISA PREEMPTION OF CER2 TAIN PROVISIONS OF THE LAW OF THE

3 STATE OF WASHINGTON RELATING TO

4 HEALTH PLANS.

5 Section 514(b) of the Employee Retirement Income

6 Security Act of 1974 (29 U.S.C. 1144(b)) is amended by

7 adding at the end of the following new paragraph:

8 ‘‘(9) Subsection (a) of this section shall not apply to

9 the following provisions of the law of the State of Wash10 ington—

11 ‘‘(A) section 212 of Chapter 492, Laws of 1993

12 (relating to enrollment of certain employees in the

13 Washington basic health plan);

14 ‘‘(B) sections 301 and 304 of Chapter 492,

15 Laws of 1993 (relating to taxation of premiums and

16 hospitals);

17 ‘‘(C) sections 406(7) and 454 of Chapter 492,

18 Laws of 1993 (relating to medical risk adjustment

19 mechanisms);

20 ‘‘(D) section 427 of Chapter 492, Laws of 1993

21 (relating to benefits required to be offered by reg22 istered employer health plans);

23 ‘‘(E) section 430 of Chapter 492, Laws of 1993

24 (relating to requirements applicable to registered

25 employer health plans); and
44

•S 2452 IS

1 ‘‘(F) section 464 of Chapter 492, Laws of

2 1993, as amended by section 3 of Chapter 494,

3 Laws of 1993 (relating to requirements that employ4 ers offer and pay a portion of the costs of employee

5 health care coverage).’’.

6 SEC. 2108. EXEMPTION FROM ERISA PREEMPTION OF CER7 TAIN PROVISIONS OF THE LAW OF THE

8 STATE OF CONNECTICUT RELATING TO

9 HEALTH PLANS.

10 Section 514(b) of the Employee Retirement Income

11 Security Act (29 U.S.C. 1144(b)) is amended by adding

12 at the end of the following new subsection:

13 ‘‘(9) Subsection (a) of this section shall not apply to

14 any State law enacted in the State of Connecticut in ac15 cordance with Public Law 102–234 which taxes or other16 wise assesses short-term acute care hospitals for the pur17 pose of providing funds to be used to pay for the cost of

18 uncompensated care. This subsection shall take effect Jan19 uary 1, 1992.’’.
45

•S 2452 IS

1 TITLE III—PUBLIC HEALTH AND

2 RURAL AND UNDERSERVED

3 ACCESS IMPROVEMENT

4 SEC. 3001. SHORT TITLE.

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

6 Rural and Underserved Access Improvement Act of

7 1994’’.

8 SEC. 3002. ESTABLISHMENT OF NEW TITLE XXVII REGARD9 ING PUBLIC HEALTH PROGRAMS.

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

11 seq.) is amended by adding at the end the following title:

12 ‘‘TITLE XXVII—PUBLIC HEALTH

13 PROGRAMS IMPROVEMENT

14 ‘‘Subtitle A—Core Functions of

15 Public Health Programs

16 ‘‘PART 1—FORMULA GRANTS TO STATES

17 ‘‘SEC. 2711. AUTHORIZATIONS OF APPROPRIATIONS FROM

18 FUND.

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

20 are authorized to be appropriated from the Health Care

21 Reform Trust Fund established under section

22 9551(a)(2)(A) of the Internal Revenue Code of 1986

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

24 $200,000,000 for fiscal year 1996, $350,000,000 for fis25 cal year 1997, $500,000,000 for fiscal year 1998,
46

•S 2452 IS

1 $650,000,000 for fiscal year 1999, and $700,000,000 for

2 fiscal year 2000.

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

4 HEALTH FUNCTIONS.

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

6 submits to the Secretary an application in accordance with

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

8 Human Services, acting through the Director of the Cen9 ters for Disease Control and Prevention, shall make a

10 grant to the State for carrying out the activities described

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

12 determined under section 2716 for the State.

13 ‘‘(b) GENERAL PURPOSE.—The purpose of this sub14 title is to provide for improvements in the health status

15 of the public through carrying out the activities described

16 in subsection (b) toward attaining the Healthy People

17 2000 Objectives (as defined in section 2799). A funding

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

19 ‘‘(1) the grant will be expended for such activi20 ties; and

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

22 State in collaboration with local public health de23 partments, health education and training centers,

24 neighborhood health centers, and other community

25 health providers.
47

•S 2452 IS

1 ‘‘(c) CORE FUNCTIONS OF PUBLIC HEALTH PRO2 GRAMS.—Subject to the purpose described in subsection

3 (b), the activities referred to in subsection (a) are the fol4 lowing:

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

6 related to population-based status and outcomes

7 monitoring, including the following:

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

9 public health data (including the 10 leading

10 causes of death and their costs to society).

11 ‘‘(B) Vital statistics.

12 ‘‘(C) Personal health services data.

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

14 professionals.

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

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

17 day-care centers, food and water, including the fol18 lowing activities:

19 ‘‘(A) Monitoring the overall public health

20 status and safety of communities.

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

22 and other environmental contaminants; and ac23 tivities for abatement of toxicant hazards, in24 cluding lead-related hazards.
48

•S 2452 IS

1 ‘‘(C) Monitoring the quality of community

2 water supplies used for consumption or for rec3 reational purposes.

4 ‘‘(D) Monitoring sewage and solid waste

5 disposal, radiation exposure, radon exposure,

6 and noise levels.

7 ‘‘(E) Monitoring indoor and ambient air

8 quality and related risks to vulnerable popu9 lations.

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

11 school safety.

12 ‘‘(G) Enforcing public health safety and

13 sanitary codes.

14 ‘‘(H) Monitoring community access to ap15 propriate health services.

16 ‘‘(I) Other activities relating to promoting

17 and protecting the public health of commu18 nities.

19 ‘‘(3) Investigation, control, and public-aware20 ness activities regarding adverse health conditions

21 (such as emergency treatment preparedness, commu22 nity efforts to reduce violence, outbreaks of commu23 nicable diseases within communities, chronic disease

24 and dysfunction exposure-related conditions, toxic

25 environmental pollutants, occupational and rec-
49

•S 2452 IS

1 reational hazards, motor vehicle accidents, and other

2 threats to the health status of individuals).

3 ‘‘(4) Public information and education pro4 grams to reduce risks to health (such as use of to5 bacco;, alcohol and other drugs; unintentional injury

6 from accidents, including motor vehicle accidents;

7 sexual activities that increase the risk to HIV trans8 mission and sexually transmitted diseases; poor diet;

9 physical inactivity; stress-related illness; mental

10 health problems; genetic disorders; and low child11 hood immunization levels).

12 ‘‘(5) Provision of public health laboratory serv13 ices to complement private clinical laboratory serv14 ices and that screen for diseases and conditions

15 (such as metabolic diseases in newborns, provide as16 sessments of blood lead levels and other environ17 mental toxicants, diagnose and contact tracing of

18 sexually transmitted diseases, tuberculosis and other

19 diseases requiring partner notification, test for infec20 tious and food-borne diseases, and monitor the safe21 ty of water and food supplies).

22 ‘‘(6) Training and education of new and exist23 ing health professionals in the field of public health,

24 with special emphasis on epidemiology, biostatistics,

25 health education, public health administration, pub-
50

•S 2452 IS

1 lic health nursing and dentistry, environmental and

2 occupational health sciences, public health nutrition,

3 social and behavioral health sciences, operations re4 search, and laboratory technology.

5 ‘‘(7) Leadership, policy development and admin6 istration activities, including assessing needs and the

7 supply and distribution of health professionals; the

8 setting of public health standards; the development

9 of community public health policies; and the develop10 ment of community public health coalitions.

11 ‘‘(d) RESTRICTIONS ON USE OF GRANT.—

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

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

14 grant will not be expended—

15 ‘‘(A) to provide inpatient services;

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

17 recipients of health services;

18 ‘‘(C) to purchase or improve land, pur19 chase, construct, or permanently improve (other

20 than minor remodeling) any building or other

21 facility, or purchase major medical equipment;

22 ‘‘(D) to satisfy any requirement for the ex23 penditure of non-Federal funds as a condition

24 for the receipt of Federal funds; or
51

•S 2452 IS

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

2 entity other than a public or nonprofit private

3 entity.

4 ‘‘(2) LIMITATION ON ADMINISTRATIVE EX5 PENSES.—A funding agreement for a grant under

6 subsection (a) is that the State involved will not ex7 pend more than 20 percent of the grant for adminis8 trative expenses with respect to the grant.

9 ‘‘(e) MAINTENANCE OF EFFORT.—A funding agree10 ment for a grant under subsection (a) is that the State

11 involved will maintain expenditures of non-Federal

12 amounts for core health functions at a level that is not

13 less than the level of such expenditures maintained by the

14 State for the fiscal year preceding the first fiscal year for

15 which the State receives such a grant.

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

17 ‘‘(a) NUMBER OF FUNCTIONS.—Subject to sub18 section (b), a funding agreement for a grant under section

19 2712 is that the State involved will carry out each of the

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

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

22 2712, the Secretary shall for each State designate a period

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

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

25 period so designated may not exceed 18 months. With re-
52

•S 2452 IS

1 spect to such period for a State, a funding agreement for

2 a grant under section 2712 for any fiscal year containing

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

4 State will expend the grant only for such planning.

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

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

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

8 involved submits to the Secretary the following informa9 tion:

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

11 community health providers, public and private

12 health plans, and the public health system of the

13 State.

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

15 public health system at the State level and the local

16 level, using standards under the Healthy People

17 2000 Objectives.

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

19 identified at the State level and local levels, includ20 ing the 10 leading causes of death and their respec21 tive direct and indirect costs to the State and the

22 Federal Government.

23 ‘‘(4) Measurable outcomes and process objec24 tives (using criteria under the Healthy People 2000

25 Objectives) which indicate improvements in health
53

•S 2452 IS

1 status as a result of the activities carried out under

2 section 2712(c).

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

4 which—

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

6 local funding expended on each such activity for

7 the fiscal year preceding the fiscal year for

8 which the grant is sought; and

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

10 additional Federal funding will improve each

11 such activity by both the State and local public

12 health agencies.

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

14 2712(c) to be carried out at the local level, and a

15 specification for each such activity of—

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

17 will be carried out and any collaborating agen18 cies; and

19 ‘‘(B) the amount of the grant to be ex20 pended for the activity in each community so

21 specified.

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

23 been coordinated with activities supported under

24 title V of the Social Security Act (relating to mater25 nal and child health).
54

•S 2452 IS

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

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

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

4 the Secretary a report describing—

5 ‘‘(1) the purposes for which the grant was ex6 pended;

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

8 State, as measured by criteria under the Healthy

9 People 2000 Objectives; and

10 ‘‘(3) the progress achieved and obstacles en11 countered in using uniform data sets under such Ob12 jectives.

13 ‘‘SEC. 2715. APPLICATION FOR GRANT.

14 ‘‘The Secretary may make a grant under section

15 2712 only if an application for the grant is submitted to

16 the Secretary, the application contains each agreement de17 scribed in this part, the application contains the informa18 tion required in section 2712(c), and the application is in

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

20 agreements, assurances, and information as the Secretary

21 determines to be necessary to carry out this part.

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

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

24 this section for a State for a fiscal year shall be deter25 mined through a formula established by the Secretary on
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1 the basis of the population, economic indicators, and

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

3 product of—

4 ‘‘(1) a percentage determined under the for5 mula; and

6 ‘‘(2) the amount appropriated under section

7 2711 for the fiscal year, less any amounts reserved

8 under section 2717.

9 ‘‘SEC. 2717. ALLOCATIONS FOR CERTAIN ACTIVITIES.

10 ‘‘Of the amounts made available under section 2711

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

12 may reserve not more than 15 percent for carrying out

13 the following activities:

14 ‘‘(1) Technical assistance with respect to plan15 ning, development, and operation of activities under

16 section 2712(b), including provision of biostatistical

17 and epidemiological expertise, provision of laboratory

18 expertise, and the development of uniform data sets

19 under the Health People 2000 Objectives.

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

21 information network among State and local health

22 agencies for utilizing such uniform data sets.

23 ‘‘(3) Program monitoring and evaluation of ac24 tivities carried out under section 2712(b).
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1 ‘‘(4) Development of a unified electronic report2 ing mechanism to improve the efficiency of adminis3 trative management requirements regarding the pro4 vision of Federal grants to State public health agen5 cies.

6 ‘‘PART 2—COMPREHENSIVE EVALUATION OF DIS7 EASE PREVENTION AND HEALTH PRO8 MOTION PROGRAMS

9 ‘‘SEC. 2718. AUTHORIZATIONS OF APPROPRIATIONS FROM

10 FUND.

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

12 authorized to be appropriated from the Fund,

13 $100,000,000 for fiscal year 1996, and $150,000,000 for

14 each of the fiscal years 1997 through 2000.

15 ‘‘SEC. 2719. EVALUATION OF PROGRAMS.

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

17 or enter into cooperative agreements or contracts with, eli18 gible entities for the purpose of enabling such entities to

19 carry out evaluations of the type described in subsection

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

21 through the Director of the Centers for Disease Control

22 and Prevention, subject to subsection (g).

23 ‘‘(b) REQUIREMENTS.—
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1 ‘‘(1) ELIGIBLE ENTITIES.—To be eligible to re2 ceive an award of a grant, cooperative agreement, or

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

4 ‘‘(A) be a public, nonprofit, or private en5 tity or a university;

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

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

8 containing such information as the Secretary

9 may require, including a plan for the conduct of

10 the evaluation under the grant;

11 ‘‘(C) provide assurances that any informa12 tion collected while conducting evaluations

13 under this section will be maintained in a con14 fidential manner with respect to the identities

15 of the individuals from which such information

16 is obtained; and

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

18 Secretary determines to be appropriate.

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

20 under subsection (a), the Secretary shall consider

21 applications from entities proposing to conduct eval22 uations using community programs, managed care

23 programs, State and county health departments,

24 public education campaigns, school programs, and

25 other appropriate programs. The Secretary shall en-
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1 sure that not less than 25 percent of the amounts

2 appropriated under section 2718 for a fiscal year are

3 used for making such awards to entities that will use

4 the amounts to conduct evaluations in the work5 place.

6 ‘‘(c) USE OF FUNDS.—

7 ‘‘(1) EVALUATIONS.—An award under sub8 section (a) shall be used to—

9 ‘‘(A) conduct evaluations to determine the

10 extent to which clinical preventive services,

11 health promotion and unintentional injury pre12 vention activities, and interpersonal and com13 munity violence prevention activities, achieve

14 short-term and long-term health care cost re15 ductions and health status improvement with

16 respect to the Healthy People 2000 Objectives;

17 and

18 ‘‘(B) evaluate other areas determined ap19 propriate by the Secretary.

20 ‘‘(2) INCLUSION OF CERTAIN POPULATION

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

22 shall ensure that data concerning women, children,

23 minorities, older individuals with different income

24 levels, retirees, and individuals from diverse geo25 graphical backgrounds, are obtained.
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1 ‘‘(3) MINIMUM SERVICES.—The evaluations

2 that the Secretary may provide for under this sec3 tion include (but are not limited to) evaluations of

4 programs that provide one or more of the following

5 services:

6 ‘‘(A) Blood pressure screening and control

7 (to detect and control hypertension and coro8 nary health disease).

9 ‘‘(B) Early cancer screening.

10 ‘‘(C) Blood cholesterol screening and con11 trol.

12 ‘‘(D) Smoking cessation programs.

13 ‘‘(E) Substance abuse programs.

14 ‘‘(F) Dietary and nutrition counseling, in15 cluding nutrition.

16 ‘‘(G) Physical fitness counseling.

17 ‘‘(H) Stress management.

18 ‘‘(I) Diabetes education and screening.

19 ‘‘(J) Intraocular pressure screening.

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

21 ‘‘(L) Violence and injury prevention pro22 grams.

23 ‘‘(M) Health education.

24 ‘‘(N) Immunization rates.
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1 ‘‘(4) ENVIRONMENTAL DATA.—Evaluations con2 ducted under this section may consider the health ef3 fects and cost-effectiveness of certain environmental

4 programs, including fluoridation programs, traffic

5 safety programs, pollution control programs, acci6 dent prevention programs, and antismoking pro7 grams.

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

9 under this section may consider the effects of pre10 vention-oriented social and economic policies on im11 provement of health status and their long-term cost

12 effectiveness.

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

14 evaluations under this section, entities shall use ex15 isting data and health promotion and screening pro16 grams where practicable.

17 ‘‘(7) COOPERATION.—In providing for an eval18 uation under this section, the Secretary shall encour19 age the recipient of the award and public and pri20 vate entities with relevant expertise (including State

21 and local agencies) to collaborate for purposes of

22 conducting the evaluation.

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

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

25 present the greatest potential for new and relevant knowl-
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1 edge. Such recipients, in selecting such sites, shall ensure

2 that—

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

4 process evaluation, formative evaluation, availability

5 assessment strategies and results;

6 ‘‘(2) the sites provide evidence of a clear defini7 tion of the program and protocols for the implemen8 tation of the evaluation; and

9 ‘‘(3) the sites provide evidence of valid, appro10 priate and feasible assessment methods and tools

11 and a willingness to use common data items and in12 struments across such sites.

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

14 year after an entity first receives an award under sub15 section (a), and not less than once during each 1-year pe16 riod thereafter for which such an award is made to the

17 entity, the entity shall prepare and submit to the Sec18 retary a report containing a description of the activities

19 under this section conducted during the period for which

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

21 of such activities.

22 ‘‘(f) TERM OF EVALUATIONS.—Evaluations con23 ducted under this section shall be for a period of not less

24 than 3 years and may continue as necessary to permit the
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1 grantee to adequately measure the full benefit of the eval2 uations.

3 ‘‘(g) DISSEMINATION AND GUIDELINES.—

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

5 carry out this subsection acting through the Director

6 of the Centers for Disease Control and Prevention

7 and the Administrator for Health Care Policy and

8 Research.

9 ‘‘(2) GUIDELINES.—The Secretary shall, where

10 feasible and practical, develop and issue practice

11 guidelines that are based on the results of evalua12 tions conducted under this section. The practice

13 guidelines shall be developed by the Secretary utiliz14 ing expert practitioners to assist in the development

15 and implementation of these guidelines.

16 ‘‘(3) DATA.—

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

18 collect, store, analyze, and make available data

19 related to the formulation of the guidelines that

20 is provided to the Centers for Disease Control

21 and Prevention by entities conducting evalua22 tions under this section.

23 ‘‘(B) USE OF DATA.—The Secretary

24 shall—
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1 ‘‘(i) identify activities that prevent

2 disease, illness, injury and disability, and

3 promote good health practices; ascertain

4 their cost-effectiveness; and identify their

5 potential to overall health status with re6 spect to Healthy People 2000 Objectives;

7 ‘‘(ii) disseminate practice guidelines to

8 State and county health departments,

9 State insurance departments, insurance

10 companies, employers, professional medical

11 organizations, and others determined ap12 propriate by the Secretary; and

13 ‘‘(iii) provide information with respect

14 to recidivism rates of participation in the

15 evaluations.

16 ‘‘(4) DISSEMINATION.—The Secretary may dis17 seminate information collected from evaluations

18 under this section.

19 ‘‘(h) LIMITATION.—Amounts appropriated for carry20 ing out this section shall not be utilized to provide services.
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1 ‘‘Subtitle B—Opportunities for

2 Education and Training in Pub3 lic Health

4 ‘‘PART 1—SCHOLARSHIP AND LOAN REPAYMENT

5 PROGRAMS REGARDING SERVICE IN PUBLIC

6 HEALTH POSITIONS

7 ‘‘SEC. 2721. AUTHORIZATIONS OF APPROPRIATIONS FROM

8 FUND.

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

10 authorized to be appropriated from the Fund,

11 $50,000,000 for each of the fiscal years 1996 through

12 2000.

13 ‘‘SEC. 2722. SCHOLARSHIP PROGRAM.

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

15 the Administrator of the Health Resources and Services

16 Administration and in consultation with the Director of

17 the Centers for Disease Control and Prevention, shall

18 carry out a program under which the Secretary awards

19 scholarships to individuals described in subsection (b) for

20 the purpose of assisting the individuals with the costs of

21 attending public and nonprofit private schools of public

22 health (or other public or nonprofit private institutions

23 providing graduate or specialized training in public

24 health).
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1 ‘‘(b) ELIGIBLE INDIVIDUALS.—An individual re2 ferred to in subsection (a) is any individual meeting the

3 following conditions:

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

5 enrollment) at a school or other institution referred

6 to in subsection (a) as a full-time or part-time stu7 dent in a program providing training in a health

8 profession in a field of public health (including the

9 fields of epidemiology, biostatistics, environmental

10 health, health administration and planning, behav11 ioral sciences, maternal and child health, occupa12 tional safety, public health nursing, nutrition, and

13 toxicology).

14 ‘‘(2) The individual enters into the contract re15 quired pursuant to subsection (d) as a condition of

16 receiving the scholarship (relating to an agreement

17 to provide services in approved public health posi18 tions, as defined in section 2724).

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

20 subsequent fiscal years, the Secretary may make an award

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

22 determines that—

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

24 to which the award is to be provided has coordinated

25 the activities of the school or institution with rel-
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•S 2452 IS

1 evant activities of the Health Resources and Services

2 Administration and the Centers for Disease Control

3 and Prevention; and

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

5 of the school or institution are in public health posi6 tions determined by the Secretary to be consistent

7 with the needs of the United States regarding such

8 professionals.

9 ‘‘(d) APPLICABILITY OF CERTAIN PROVISIONS.—Ex10 cept as inconsistent with this section or section 2724, the

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

12 to the Scholarship and Loan Repayment Programs of the

13 National Health Service Corps) apply to an award of a

14 scholarship under subsection (a) to the same extent and

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

16 of a scholarship under section 338A.

17 ‘‘SEC. 2723. LOAN REPAYMENT PROGRAM.

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

19 the Administrator of the Health Resources and Services

20 Administration and in consultation with the Director of

21 the Centers for Disease Control and Prevention, shall

22 carry out a program under which the Federal Government

23 enters into agreements to repay all or part of the edu24 cational loans of individuals meeting the following condi25 tions:
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1 ‘‘(1) The individual involved is a graduate of a

2 school or other institution described in section

3 2722(a).

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

5 requirements to provide services as a public health

6 professional (including a professional in any of the

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

8 ‘‘(3) The individual enters into the contract re9 quired pursuant to subsection (b) as a condition of

10 the Federal Government repaying such loans (relat11 ing to an agreement to provide services in approved

12 public health positions, as defined in section 2724).

13 ‘‘(b) APPLICABILITY OF CERTAIN PROVISIONS.—Ex14 cept as inconsistent with this section or section 2724, the

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

16 to the Scholarship and Loan Repayment Programs of the

17 National Health Service Corps) apply to an agreement re18 garding repayment under subsection (a) to the same ex19 tent and in the same manner as such provisions apply to

20 an agreement regarding repayment under section 338B.

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

22 which an individual contracts to serve in an approved pub23 lic health position pursuant to subsection (b), the Sec24 retary may repay not more than $20,000 of the principal

25 and interest of the educational loans of the individual.
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1 ‘‘SEC. 2724. APPROVED PUBLIC HEALTH POSITIONS.

2 ‘‘(a) POSITION REGARDING POPULATIONS WITH SIG3 NIFICANT NEED FOR SERVICES.—

4 ‘‘(1) IN GENERAL.—With respect to the pro5 grams under this part, the obligated service of a

6 program participant pursuant to sections 2722(d)

7 and 2723(b) shall be provided through an assign8 ment, to an entity described in subsection (b), for a

9 position in which the participant provides services as

10 a public health professional to a population deter11 mined by the Secretary to have a significant unmet

12 need for the services of such a professional.

13 ‘‘(2) PERIOD OF SERVICE.—For purposes of

14 sections 2722(d) and 2723(d), the period of obli15 gated service is the following, as applicable to the

16 program participant involved:

17 ‘‘(A) In the case of scholarships under sec18 tion 2722 for full-time students, the greater

19 of—

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

21 such a scholarship is provided; or

22 ‘‘(ii) 2 years.

23 ‘‘(B) In the case of scholarships under sec24 tion 2722 for part-time students, a period de25 termined by the Secretary on the basis of the

26 number of hours of education or training re-
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•S 2452 IS

1 ceived under the scholarship, considering the

2 percentage constituted by the ratio of such

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

4 student in the program involved.

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

6 under section 2723, such period as the Sec7 retary and the participant may agree, except

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

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

10 PROGRAM PARTICIPANTS.—The entities referred to in

11 subsection (a) are public and nonprofit private entities ap12 proved by the Secretary as meeting such requirements for

13 the assignment of a program participant as the Secretary

14 may establish. The entities that the Secretary may so ap15 prove include State and local departments of health, public

16 hospitals, community and neighborhood health clinics, mi17 grant health clinics, community-based health-related orga18 nizations, certified regional poison control centers, pur19 chasing cooperatives regarding health insurance, and any

20 other public or nonprofit private entity.

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

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

23 with respect to a program participant, means a posi24 tion to which the participant is assigned pursuant to

25 subsection (a).
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1 ‘‘(2) The term ‘program participant’ means an

2 individual who enters into a contract pursuant to

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

4 ‘‘SEC. 2725. ALLOCATION OF FUNDS; SPECIAL CONSIDER5 ATIONS.

6 ‘‘(a) ALLOCATIONS REGARDING NEW PARTICIPANTS

7 IN SCHOLARSHIP PROGRAM.—Of the amounts appro8 priated under section 2721 for a fiscal year, the Secretary

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

10 providing awards for scholarships under section 2722 to

11 individuals who have not previously received such scholar12 ships.

13 ‘‘(b) SPECIAL CONSIDERATION FOR CERTAIN INDI14 VIDUALS.—In making awards of scholarships under sec15 tion 2722 and making repayments under section 2723, the

16 Secretary shall give special consideration to individuals

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

18 are veterans of the armed forces.

19 ‘‘PART 2—EDUCATIONAL INSTITUTIONS

20 REGARDING PUBLIC HEALTH

21 ‘‘SEC. 2731. AUTHORIZATIONS OF APPROPRIATIONS FROM

22 FUND.

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

24 Fund, there are authorized to be appropriated from the
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1 Fund, $100,000,000 for each of the fiscal years 1996

2 through 2000.

3 ‘‘SEC. 2732. GRANTS FOR EXPANDING CAPACITY OF INSTI4 TUTIONS.

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

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

7 of expanding the educational capacities of the institutions

8 through recruiting and retaining faculty, curriculum devel9 opment, and coordinating the activities of the institutions

10 regarding education, training, and field placements.

11 ‘‘(b) RELEVANT INSTITUTIONS.—The institutions re12 ferred to in subsection (a) are public and nonprofit pri13 vate—

14 ‘‘(1) schools of public health;

15 ‘‘(2) departments of community and preventive

16 medicine that—

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

18 schools of osteopathic medicine; and

19 ‘‘(B) have established formal arrangements

20 with schools of public health in order to award

21 joint degrees in public health and another

22 health profession; and

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

24 established formal arrangements with schools of

25 public health in order to carry out educational pro-
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1 grams in public health at the schools of nursing or

2 dentistry, respectively.

3 ‘‘(c) REQUIREMENTS REGARDING CURRICULUM DE4 VELOPMENT.—A funding agreement for a grant under

5 subsection (a) for an institution is that, to the extent de6 termined to be appropriate by the Secretary, the curricu7 lum of institution will include the following:

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

9 nondegree programs for public health professionals

10 who need further training in fields of public health.

11 ‘‘(2) With respect to the program of community

12 health advisors established in part 5 of subtitle E,

13 a program to train individuals to serve as super14 visors under such part (including training and evalu15 ating the community health advisors), which pro16 gram is carried out in collaboration with local public

17 health departments and health education and train18 ing centers.

19 ‘‘(3) A program under which the institution col20 laborates with health departments and elementary

21 and secondary schools to develop a health education

22 curriculum for use in the program established under

23 subtitle B of the Public Health Improvement Act of

24 1994.
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1 ‘‘(d) ADDITIONAL REQUIREMENTS.—Funding agree2 ments for a grant under subsection (a) for an institution

3 are as follows:

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

5 grant, the institution will consult with the health de6 partments in the State involved, and will follow the

7 relevant priorities of such departments.

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

9 determination of the Secretary, coordinate the activi10 ties of the institution under the grant with relevant

11 activities of the Health Resources and Services Ad12 ministration and the Centers for Disease Control

13 and Prevention.

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

15 NATIONAL PRIORITIES.

16 ‘‘The Secretary shall—

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

18 regarding the education and geographic distribution

19 of public health professionals;

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

21 and

22 ‘‘(3) in making grants under section 2732, en23 sure that the curricula developed under such section,

24 and the expertise of the faculty recruited and re-
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•S 2452 IS

1 tained under such section, are consistent with such

2 priorities.

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

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

5 the Secretary may make a grant under section 2732 only

6 if the institution involved is in compliance with the follow7 ing:

8 ‘‘(1) The institution has coordinated the activi9 ties of the school or institution with relevant activi10 ties of the Health Resources and Services Adminis11 tration and the Centers for Disease Control and

12 Prevention.

13 ‘‘(2) A significant number of the faculty of the

14 institution has served as practitioners in public

15 health.

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

17 health departments and public hospital systems in

18 the State involved in order to develop a curriculum

19 that reflects the needs and priorities of the State re20 garding the public health.

21 ‘‘(4) The institution has coordinated the activi22 ties of the institution with the activities of the health

23 departments and of community groups.
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1 ‘‘(5) The institution carries out a program for

2 part-time students to receive training in fields of

3 public health.

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

5 of the school or institution are in public health posi6 tions determined by the Secretary to be consistent

7 with the needs of the United States regarding such

8 professionals.

9 ‘‘PART 3—EXPANSION OF COMPETENCY IN

10 PUBLIC HEALTH

11 ‘‘SEC. 2736. AUTHORIZATIONS OF APPROPRIATIONS FROM

12 FUND.

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

14 is authorized to be appropriated from the Fund,

15 $60,000,000 for each of the fiscal years 1996 through

16 2000.

17 ‘‘SEC. 2737. GRANTS TO STATES.

18 ‘‘(a) STATES LACKING ADEQUATE TRAINING PRO19 GRAMS.—

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

21 grants to States in which there is one or no program

22 of training in a field of public health but in which

23 there are 1 or more schools of medicine, osteopathic

24 medicine, nursing, dentistry, social work, pharmacy,

25 or health administration. A funding agreement for
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•S 2452 IS

1 such a grant is that the purpose of the grant is for

2 the State involved to assist 1 or more of such

3 schools in developing and integrating public health

4 curricula for the schools.

5 ‘‘(2) SPECIAL CONSIDERATIONS IN MAKING

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

7 the Secretary shall give special consideration to

8 States that agree to consult with 1 or more schools

9 of public health in carrying out the purpose de10 scribed in such subsection.

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

12 The Secretary may make grants to States in which there

13 are 1 or more nonaccredited schools of public health. A

14 funding agreement for such a grant is that the purpose

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

16 of such schools in improving the schools.

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

18 INDIVIDUAL EDUCATIONAL ENTITIES.—

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

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

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

22 grant under this section for a State is that, with re23 spect to the school involved, the State will not pro24 vide more than 2 years of assistance to the school

25 from grants under this section.
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1 ‘‘PART 4—AREA HEALTH EDUCATION CENTERS

2 ‘‘SEC. 2738. AUTHORIZATIONS OF APPROPRIATIONS FROM

3 FUND.

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

5 carrying out programs under section 746, there are au6 thorized to be appropriated from the Fund, $35,000,000

7 for each of the fiscal years 1996 through 2000.

8 ‘‘(b) RELATION TO OTHER FUNDS.—The authoriza9 tions of appropriations established in subsection (a) are

10 in addition to any other authorizations of appropriations

11 that are available for the purpose described in such sub12 section.

13 ‘‘PART 5—HEALTH EDUCATION TRAINING

14 CENTER

15 ‘‘SEC. 2739. AUTHORIZATIONS OF APPROPRIATIONS FROM

16 FUND.

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

18 carrying out Health Education Training Center programs,

19 there are authorized to be appropriated from the Fund,

20 $20,000,000 for each of the fiscal years 1996 through

21 2000.

22 ‘‘(b) RELATION TO OTHER FUNDS.—The authoriza23 tions of appropriations established in subsection (a) are

24 in addition to any other authorizations of appropriations

25 that are available for the purpose described in such sub26 section.
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1 ‘‘Subtitle C—Regional Poison

2 Control Centers

3 ‘‘SEC. 2741. AUTHORIZATIONS OF APPROPRIATIONS FROM

4 FUND.

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

6 is authorized to be appropriated from the Fund,

7 $50,000,000 for each of the fiscal years 1996 through

8 2000.

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

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

11 to public and nonprofit private entities for centers to carry

12 out activities regarding—

13 ‘‘(1) the prevention and treatment of poisoning;

14 and

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

16 of poisons as the Secretary determines to be appro17 priate.

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

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

20 the need in each of the principal geographic regions of

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

22 shall make the grants according to priorities established

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

24 in each of the regions. In carrying out the preceding sen-
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1 tence, the Secretary shall ensure that no two centers re2 ceive grants for the same geographic service area.

3 ‘‘(c) MATCHING FUNDS.—

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

5 an entity in providing for centers under subsection

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

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

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

9 to make available (directly or through donations

10 from public or private entities) non-Federal con11 tributions toward such costs in an amount deter12 mined by the Secretary.

13 ‘‘(2) DETERMINATION OF AMOUNT CONTRIB14 UTED.—Non-Federal contributions required under

15 paragraph (1) may be in cash or in kind, fairly eval16 uated, including plant, equipment, or services.

17 Amounts provided by the Federal Government, or

18 services assisted or subsidized to any significant ex19 tent by the Federal Government, may not be in20 cluded in determining the amount of such non-Fed21 eral contributions.

22 ‘‘SEC. 2743. REQUIREMENTS REGARDING CERTIFICATION.

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

24 Secretary may make a grant under section 2742 only if

25 the center involved has been certified by a professional or-
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1 ganization in the field of poison control, and the Secretary

2 has approved the organization as having in effect stand3 ards for certification that reasonably provide for the pro4 tection of the public health with respect to poisoning. In

5 carrying out the preceding sentence, the Secretary shall

6 consider the standards established by the American Asso7 ciation of Poison Control Centers.

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

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

10 a period not exceeding 1 year.

11 ‘‘SEC. 2744. GENERAL PROVISIONS.

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

13 which payments are made under a grant under section

14 2742 may not exceed 3 years. The provision of such pay15 ments is subject to annual approval by the Secretary of

16 the payments and subject to the availability of appropria17 tions for the fiscal year involved to make the payments.

18 The preceding sentence may not be construed as establish19 ing a limitation on the number of such grants that may

20 be made to an entity.

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

22 ‘‘(1) IN GENERAL.—The Secretary shall con23 duct a study of each of the centers for which a grant

24 under section 2742 has been provided. The purpose

25 of the study shall be to determine the effectiveness
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1 of the centers in carrying out the activities described

2 in such section and the extent to which the activities

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

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

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

6 shall determine the extent to which the activities de7 scribed in section 2742 can be effectively carried out

8 through means other than centers under such sec9 tion. The alternative means considered by the Sec10 retary under the preceding sentence shall include the

11 alternative of requiring public and private health

12 plans to carry out such activities.

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

14 later than November 1, 1996, the Secretary shall

15 submit to the Congress a report describing the find16 ings made in the study under paragraph (1).

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

18 February 1, 1997, the Secretary shall notify each

19 grantee under section 2742 whether the Secretary

20 considers the continued operation of the center in21 volved to be necessary in meeting the needs of the

22 geographic region involved for the activities de23 scribed in such section.
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1 ‘‘Subtitle D—School-Related Health

2 Services

3 ‘‘SEC. 2746. AUTHORIZATION OF APPROPRIATIONS FROM

4 FUND.

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

6 SERVICES.—For the purpose of carrying out this subtitle,

7 there are authorized to be appropriated from the Fund,

8 $100,000,000 for fiscal year 1996, $200,000,000 for fis9 cal year 1997, $300,000,000 for fiscal year 1998,

10 $400,000,000 for fiscal year 1999, and $500,000,000 for

11 fiscal year 2000.

12 ‘‘(b) FUNDING FOR PLANNING AND DEVELOPMENT

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

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

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

16 ‘‘SEC. 2747. ELIGIBILITY FOR GRANTS.

17 ‘‘(a) IN GENERAL.—

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

19 Entities eligible to apply for and receive grants

20 under section 2749 are—

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

22 behalf of local community partnerships; or

23 ‘‘(B) local community partnerships in

24 States in which health agencies have not suc25 cessfully applied.
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1 ‘‘(2) OPERATIONAL GRANTS.—Entities eligible

2 to apply for and receive grants under section 2750

3 are—

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

5 subsection (c) that apply on behalf of local com6 munity partnerships; or

7 ‘‘(B) local community partnerships in

8 States that are not designated under subpara9 graph (A).

10 ‘‘(b) LOCAL COMMUNITY PARTNERSHIPS.—

11 ‘‘(1) IN GENERAL.—A local community partner12 ship under subsection (a)(1)(B) and (a)(2)(B) is an

13 entity that, at a minimum includes—

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

15 may be a local public health department, with

16 experience in delivering services to children and

17 youth or medically underserved populations;

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

19 one or more public schools; and

20 ‘‘(C) one community based organization lo21 cated in the community to be served that has

22 a history of providing services to at-risk chil23 dren and youth.

24 ‘‘(2) RURAL COMMUNITIES.—In rural commu25 nities, local partnerships should seek to include, to
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1 the fullest extent practicable, providers and commu2 nity based organizations with experience in serving

3 the target population.

4 ‘‘(3) PARENT AND COMMUNITY PARTICIPA5 TION.—An applicant described in subsection (a)

6 shall, to the maximum extent feasible, involve broad7 based community participation (including parents of

8 the youth to be served).

9 ‘‘(c) QUALIFIED STATE.—A qualified State under

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

11 ‘‘(1) demonstrates an organizational commit12 ment (including a strategic plan) to providing a

13 broad range of health, health education and support

14 services to at-risk youth; and

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

16 cooperative agreement jointly entered into by the

17 State agencies responsible for health and education

18 regarding the planned delivery of health and support

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

20 ‘‘SEC. 2748. PREFERENCES.

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

22 the Secretary shall give priority to applicants whose-com23 munities to be served show the most substantial level of

24 need for health services among children and youth.
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1 ‘‘SEC. 2749. PLANNING AND DEVELOPMENT GRANTS.

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

3 during fiscal years 1996 and 1997 to entities eligible

4 under section 2747 to develop school-based or school5 linked health service sites.

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

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

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

9 services, including—

10 ‘‘(A) an assessment of the need for health

11 services among youth in the communities to be

12 served;

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

14 how new services will be integrated with exist15 ing services;

16 ‘‘(C) assessing and planning for the mod17 ernization and expansion of existing facilities

18 and equipment to accommodate such services;

19 and

20 ‘‘(D) an affiliation with relevant health

21 plans.

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

23 administration and delivery of school health services.

24 ‘‘(3) The establishment of local community

25 partnerships as described in section 2747(b).
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1 ‘‘(4) In the case of States, the development of

2 memorandums of understanding or cooperative

3 agreements for the coordinated delivery of health

4 and support services through school health service

5 sites.

6 ‘‘(5) Other activities necessary to assume oper7 ational status.

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

9 receive a grant under this section an entity described in

10 section 2747(a) shall submit an application in a form and

11 manner prescribed by the Secretary.

12 ‘‘(d) NUMBER OF GRANTS.—Not more than one plan13 ning grant may be made to a single applicant. A planning

14 grant may not exceed 2 years in duration.

15 ‘‘(e) AMOUNT AVAILABLE FOR DEVELOPMENT

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

17 ‘‘(1) $150,000 to entities under section

18 2747(a)(1)(A) and to localities planning for a city19 wide or countywide school health services delivery

20 system; and

21 ‘‘(2) $50,000 to entities under section

22 2747(a)(1)(B).
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1 ‘‘SEC. 2759. GRANTS FOR OPERATION OF SCHOOL HEALTH

2 SERVICES.

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

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

5 submit applications consistent with the requirements of

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

7 school-linked health service sites.

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

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

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

11 treatment of simple illnesses and minor injuries;

12 ‘‘(2) preventive health services, including health

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

14 preventive health education;

15 ‘‘(3) enabling services and other necessary sup16 port services;

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

18 health professionals and other staff necessary for the

19 administration and delivery of school health services;

20 and

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

22 individuals to health plans, and community-based

23 health and social service providers.

24 ‘‘(c) APPLICATION FOR GRANT.—To be eligible to re25 ceive a grant under this section an entity described in sec26 tion 2747(a)(2) shall submit an application in a form and
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1 manner prescribed by the Secretary. In order to receive

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

3 the application the following information—

4 ‘‘(1) a description of the services to be fur5 nished by the applicant;

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

7 the applicant will expend, including estimates of the

8 amount of payments the applicant will receive from

9 health plans and other sources;

10 ‘‘(3) a description of local community partner11 ships, including parent and community participation;

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

13 health and social service providers; and

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

15 determines to be appropriate.

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

17 under this section, an applicant must meet the following

18 conditions—

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

20 indirectly, provide a broad range of health services,

21 in accordance with the determinations of the local

22 community partnership, that may include—

23 ‘‘(A) diagnosis and treatment of simple ill24 nesses and minor injuries;
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1 ‘‘(B) preventive health services, including

2 health screenings and follow-up health care,

3 mental health and preventive health education;

4 ‘‘(C) enabling services; and

5 ‘‘(D) referrals (including referrals regard6 ing mental health and substance abuse) with

7 follow-up to ensure that needed services are re8 ceived;

9 ‘‘(2) the applicant provides services rec10 ommended by the health provider, in consultation

11 with the local community partnership, and with the

12 approval of the local education agency;

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

14 this subsection to adolescents, and other school age

15 children and their families as deemed appropriate by

16 the local partnership;

17 ‘‘(4) the applicant maintains agreements with

18 community-based health care providers with a his19 tory of providing services to such populations for the

20 provision of health care services not otherwise pro21 vided directly or during the hours when school

22 health services are unavailable;

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

24 relevant health plans and will establish reimburse25 ment procedures and will make every reasonable ef-
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1 fort to collect appropriate reimbursement for serv2 ices provided;

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

4 not supplant the level of State or local funds under

5 the direct control of the applying State or participat6 ing local education or health authority expended for

7 school health services as defined by this Act;

8 ‘‘(7) services funded under this Act will be co9 ordinated with existing school health services pro10 vided at a participating school; and

11 ‘‘(8) for applicants in rural areas, the assur12 ances required under paragraph (4) shall be fulfilled

13 to the maximum extent possible.

14 ‘‘(e) STATE LAWS.—Notwithstanding any other pro15 vision in this subtitle, no school based health clinic may

16 provide services, to any minor, when to do so is a violation

17 of State laws or regulations pertaining to informed con18 sent for medical services to minors.

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

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

21 partnerships, the applicant may retain not more than 5

22 percent of grants awarded under this subpart for adminis23 trative costs.
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1 ‘‘(g) DURATION OF GRANT.—A grant under this sec2 tion shall be for a period determined appropriate by the

3 Secretary.

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

5 grant awarded under this section shall not be more than

6 $200,000 per school-based or school-linked health service

7 site.

8 ‘‘(i) FEDERAL SHARE.—

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

10 grant for services awarded under this section may

11 not exceed—

12 ‘‘(A) 90 percent of the non-reimbursed cost

13 of the activities to be funded under the program

14 for the first 2 fiscal years for which the pro15 gram receives assistance under this section; and

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

17 cost of such activities for subsequent years for

18 which the program receives assistance under

19 this section.

20 The remainder of such costs shall be made available

21 as provided in paragraph (2).

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

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

24 in cash or in-kind, fairly evaluated, including facili25 ties, equipment, personnel, or services, but may not
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1 include amounts provided by the Federal Govern2 ment. In-kind contributions may include space with3 in school facilities, school personnel, program use of

4 school transportation systems, outposted health per5 sonnel, and extension of health provider medical li6 ability insurance.

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

8 requirements of paragraph (1) for any year in ac9 cordance with criteria established by regulation.

10 Such criteria shall include a documented need for

11 the services provided under this section and an in12 ability of the grantee to meet the requirements of

13 paragraph (1) despite a good faith effort.

14 ‘‘(j) TRAINING AND TECHNICAL ASSISTANCE.—Enti15 ties that receive assistance under this section may use not

16 to exceed 10 percent of the amount of such assistance to

17 provide staff training and to secure necessary technical as18 sistance. To the maximum extent feasible, technical assist19 ance should be sought through local community-based en20 tities. The limitation contained in this subsection shall

21 apply to individuals employed to assist in obtaining funds

22 under this subtitle. Staff training should include the train23 ing of teachers and other school personnel necessary to

24 ensure appropriate referral and utilization of services, and
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1 appropriate linkages between class-room activities and

2 services offered.

3 ‘‘(k) REPORT AND MONITORING.—The Secretary will

4 submit to the Committee on Labor and Human Resources

5 in the Senate and the Committee on Energy and Com6 merce in the House of Representatives a biennial report

7 on the activities funded under this Act, consistent with

8 the ongoing monitoring activities of the Department. Such

9 reports are intended to advise the relevant Committees of

10 the availability and utilization of services, and other rel11 evant information about program activities.

12 ‘‘Subtitle E—Expansion of Rural

13 and Underserved Areas Access

14 to Health Services

15 ‘‘PART 1—COMMUNITY AND MIGRANT HEALTH

16 CENTERS

17 ‘‘SEC. 2756. AUTHORIZATIONS OF APPROPRIATIONS FROM

18 FUND.

19 ‘‘(a) IN GENERAL.—For the purpose of carrying out

20 this part, there is authorized to be appropriated from the

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

22 through 2000.

23 ‘‘(b) RELATION TO OTHER FUNDS.—The authoriza24 tions of appropriations established in subsection (a) for

25 the purpose described in such subsection are in addition
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1 to any other authorizations of appropriations that are

2 available for such purpose.

3 ‘‘SEC. 2757. GRANTS TO COMMUNITY AND MIGRANT

4 HEALTH CENTERS.

5 ‘‘(a) IN GENERAL.—The Secretary shall make grants

6 in accordance with this section to migrant health centers

7 and community health centers.

8 ‘‘(b) USE OF FUNDS.—

9 ‘‘(1) DEVELOPMENT, OPERATION, AND OTHER

10 PURPOSES REGARDING CENTERS.—Subject to para11 graph (2), grants under subsection (a) to migrant

12 health centers and community health centers may be

13 made only in accordance with the conditions upon

14 which grants are made under sections 329 and 330,

15 respectively.

16 ‘‘(2) REQUIRED FINANCIAL RESERVES.—The

17 Secretary may authorize migrant health centers and

18 community health centers to expend a grant under

19 subsection (a) to establish and maintain financial re20 serves required for purposes of health plans.

21 ‘‘(c) DEFINITIONS.—For purposes of this subtitle,

22 the terms ‘migrant health center’ and ‘community health

23 center’ have the meanings given such terms in sections

24 329(a)(1) and 330(a), respectively.
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1 ‘‘PART 2—NATIONAL HEALTH SERVICE CORPS

2 ‘‘SEC. 2781. AUTHORIZATIONS OF APPROPRIATIONS FROM

3 FUND.

4 ‘‘(a) ADDITIONAL FUNDING; GENERAL CORPS PRO5 GRAM; ALLOCATIONS REGARDING NURSES.—For the pur6 pose of carrying out subpart II of part D of title III, and

7 for the purpose of carrying out subsection (c), there are

8 authorized to be appropriated from the Fund,

9 $100,000,000 for each of the fiscal years 1996 through

10 2000.

11 ‘‘(b) RELATION TO OTHER FUNDS.—The authoriza12 tions of appropriations established in subsection (a) are

13 in addition to any other authorizations of appropriations

14 that are available for the purpose described in such sub15 section.

16 ‘‘(c) ALLOCATION FOR PARTICIPATION OF NURSES

17 IN SCHOLARSHIP AND LOAN REPAYMENT PROGRAMS.—

18 Of the amounts appropriated under subsection (a), the

19 Secretary shall reserve such amounts as may be necessary

20 to ensure that, of the aggregate number of individuals who

21 are participants in the Scholarship Program under section

22 338A, or in the Loan Repayment Program under section

23 338B, the total number who are being educated as nurses

24 or are serving as nurses, respectively, is increased to 30

25 percent.
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1 ‘‘(d) AVAILABILITY OF FUNDS.—An appropriation

2 under this section for any fiscal year may be made at any

3 time before that fiscal year and may be included in an

4 Act making an appropriation under an authorization

5 under subsection (a) for another fiscal year; but no funds

6 may be made available from any appropriation under this

7 section for obligation under sections 331 through 335, sec8 tion 336A, and section 337 before the fiscal year involved.

9 ‘‘PART 3—SATELLITE CLINICS REGARDING

10 PRIMARY HEALTH CARE

11 ‘‘SEC. 2783. AUTHORIZATION OF APPROPRIATIONS FROM

12 FUND.

13 ‘‘For the purpose of carrying out this part, there is

14 authorized to be appropriated from the Fund,

15 $50,000,000 for each of the fiscal years 1996 through

16 2000.

17 ‘‘SEC. 2783A. GRANTS TO STATES FOR DEVELOPMENT AND

18 OPERATION OF SATELLITE CLINICS.

19 ‘‘(a) IN GENERAL.—With respect to outpatient

20 health centers that are providers of comprehensive health

21 services, the Secretary may make grants to States for the

22 purpose of assisting such centers in developing or operat23 ing facilities that—

24 ‘‘(1) provide clinical preventive services, treat25 ment of minor illnesses and injuries, family planning
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1 services, and referrals for health services, mental

2 health services, and health-related social services;

3 and

4 ‘‘(2) are located at a distance from the center

5 sufficient to increase the extent to which individuals

6 in the geographic area involved have access to the

7 services specified in paragraph (1).

8 ‘‘(b) CERTAIN REQUIREMENTS.—The Secretary may

9 make a grant under subsection (a) only if the State agrees

10 that the health facility for which the grant is made, once

11 in operation, will meet the following conditions:

12 ‘‘(1) The clinical preventive services provided by

13 the facility will include routine preventive services,

14 including family planning services, for pregnant and

15 postpartum women and for children, including

16 health screenings and immunizations.

17 ‘‘(2) The principal providers of health services

18 at the facility, and the principal managers of the fa19 cility, will be nurse practitioners, physician assist20 ants, or nurse clinicians, subject to applicable law.

21 ‘‘(3) The outpatient health center operating the

22 facility will serve as a referral center for physician

23 services and will provide for the ongoing monitoring

24 of the activities of the facility.
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1 ‘‘(c) MATCHING FUNDS.—The Secretary may make

2 a grant under subsection (a) only if the State involved

3 agrees to make non-Federal contributions toward the costs

4 of developing and operating the health facilities involved.

5 ‘‘(d) APPLICATION FOR GRANT.—The Secretary may

6 make a grant under subsection (a) only if an application

7 for the grant is submitted to the Secretary and the appli8 cation is in such form, is made in such manner, and con9 tains such agreements, assurances, and information as the

10 Secretary determines to be necessary to carry out this

11 part.

12 ‘‘(e) LIMITATION ON AMOUNT OF ASSISTANCE PER

13 FACILITY.—With respect to a health facility for which one

14 or more grants under subsection (a) are made, the Sec15 retary may not provide more than an aggregate $250,000

16 for the development and operation of the facility.

17 ‘‘PART 4—COMMUNITY HEALTH ADVISORS

18 ‘‘SEC. 2784. AUTHORIZATION OF APPROPRIATIONS FROM

19 FUND.

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

21 authorized to be appropriated from the Fund,

22 $100,000,000 for each of the fiscal years 1996 through

23 2000.
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1 ‘‘SEC. 2785. FORMULA GRANTS REGARDING COMMUNITY

2 HEALTH ADVISOR PROGRAMS.

3 ‘‘(a) FORMULA GRANTS.—

4 ‘‘(1) IN GENERAL.—In the case of each State

5 (or entity designated by a State under subsection

6 (b)) that submits to the Secretary an application in

7 accordance with section 2788 for a fiscal year, the

8 Secretary of Health and Human Services, acting

9 through the Director of the Centers for Disease

10 Control and Prevention and in coordination with the

11 heads of the agencies specified in paragraph (2),

12 shall make an award of financial assistance to the

13 State or entity for the development and operation of

14 community health advisor programs under section

15 2786(b). The award shall consist of the allotment

16 determined under section 2789 with respect to the

17 State, subject to section 2794.

18 ‘‘(2) COORDINATION WITH OTHER AGENCIES.—

19 The agencies referred to in paragraph (1) regarding

20 coordination are the Health Resources and Services

21 Administration, the National Institutes of Health,

22 the Substance Abuse and Mental Health Services

23 Administration, and the Health Education and

24 Training Center.
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1 ‘‘(b) DESIGNATED ENTITIES.—With respect to the

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

3 an award under subsection (a) only if the entity—

4 ‘‘(1) is a public or nonprofit private academic

5 organization (or other public or nonprofit private en6 tity); and

7 ‘‘(2) has been designated by the State to carry

8 out the purpose described in such subsection in the

9 State and to receive amounts under such subsection

10 in lieu of the State.

11 ‘‘(c) ROLE OF STATE AGENCY FOR PUBLIC

12 HEALTH.—A funding agreement for an award under sub13 section (a) is that—

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

15 be administered by the State agency with the prin16 cipal responsibility for carrying out public health

17 programs; and

18 ‘‘(2) if the applicant is an entity designated

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

20 in consultation with such State agency.

21 ‘‘(d) STATEWIDE RESPONSIBILITIES; LIMITATION ON

22 EXPENDITURES.—

23 ‘‘(1) STATEWIDE RESPONSIBILITIES.—A fund24 ing agreement for an award under subsection (a) is

25 that the applicant involved will—
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1 ‘‘(A) operate a clearinghouse to maintain

2 and disseminate information on community

3 health advisor programs (and similar programs)

4 in the State, including information on develop5 ing and operating such programs, on training

6 individuals to participate in the programs, and

7 on evaluation of the programs;

8 ‘‘(B) collaborate with schools of public

9 health to provide to community health advisor

10 programs in the State technical assistance in

11 training and supervising community health ad12 visors under section 2787(g)(1); and

13 ‘‘(C) coordinate the activities carried out in

14 the State under the award, including coordina15 tion between the various community health ad16 visor programs and coordination between such

17 programs and related activities of the State and

18 of other public or private entities.

19 ‘‘(2) LIMITATION.—A funding agreement for an

20 award under subsection (a) is that the applicant in21 volved will not expend more than 15 percent of the

22 award in the aggregate for carrying out paragraph

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

24 with respect to the State involved, including the

25 process of receiving payments from the Secretary
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1 under the award, allocating the payments among the

2 entities that are to develop and operate the commu3 nity health advisor programs involved, and monitor4 ing compliance with the funding agreements made

5 under this subtitle by the applicant.

6 ‘‘SEC. 2786. REQUIREMENTS REGARDING COMMUNITY

7 HEALTH ADVISOR PROGRAMS.

8 ‘‘(a) PURPOSE OF AWARD; HEALTHY PEOPLE 2000

9 OBJECTIVES.—

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

11 funding agreement for an award under section 2785

12 for an applicant is that the purpose of the award is,

13 through community health advisor programs under

14 subsection (b), to assist the State involved in attain15 ing the Healthy People 2000 Objectives.

16 ‘‘(2) AUTHORITY REGARDING SELECTION OF

17 PRIORITY OBJECTIVES.—With respect to compliance

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

19 applicant receiving an award under section 2785

20 may, from among the various Healthy People 2000

21 Objectives, select one or more Objectives to be given

22 priority in the operation of a community health advi23 sor program of the applicant, subject to the appli24 cant selecting such priorities in consultation with the
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1 entity that is to carry out the program and the local

2 health department involved.

3 ‘‘(b) REQUIREMENTS FOR PROGRAMS.—

4 ‘‘(1) IN GENERAL.—A funding agreement for

5 an award under section 2785 for an applicant is

6 that, in expending the award, the purpose described

7 in subsection (a)(1) will be carried out in accordance

8 with the following:

9 ‘‘(A) For each community for which the

10 purpose is to be carried out, the applicant will

11 establish a program in accordance with this

12 subsection.

13 ‘‘(B) The program will be carried out in a

14 community only if the applicant has, under sec15 tion 2787(a), identified the community as hav16 ing a significant need for the program.

17 ‘‘(C) The program will be operated by a

18 public or nonprofit private entity with experi19 ence in providing health or health-related social

20 services to individuals who are underserved with

21 respect to such services.

22 ‘‘(D) The services of the program, as spec23 ified in paragraph (2), will be provided prin24 cipally by community health advisors (as de25 fined in subsection (d)).
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1 ‘‘(2) AUTHORIZED PROGRAM SERVICES.—For

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

3 in this paragraph for a program are as follows:

4 ‘‘(A) The program will collaborate with

5 health care providers and related entities in

6 order to facilitate the provision of health serv7 ices and health-related social services (including

8 collaborating with local health departments,

9 community health centers, public hospital sys10 tems, migrant health centers, rural health clin11 ics, hospitals, physicians and nurses, providers

12 of health education, pre-school facilities for chil13 dren, elementary and secondary schools, and

14 providers of social services).

15 ‘‘(B) The program will provide public edu16 cation on health promotion and on the preven17 tion of diseases, illnesses, injuries, and disabil18 ities, and will facilitate the appropriate use of

19 available health services and health-related so20 cial services.

21 ‘‘(C) The program will provide health-re22 lated counseling.

23 ‘‘(D) The program will provide referrals

24 for available health services and health-related

25 social services.
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1 ‘‘(E) For the purpose of increasing the ca2 pacity of individuals to utilize health services

3 and health-related social services under Federal,

4 State, and local programs, the following condi5 tions will be met:

6 ‘‘(i) The program will assist individ7 uals in establishing eligibility under the

8 programs and in receiving the services or

9 other benefits of the programs.

10 ‘‘(ii) The program will provide such

11 other services as the Secretary determines

12 to be appropriate, which services may in13 clude (but are not limited to) transpor14 tation and translation services.

15 ‘‘(F) The program will provide outreach

16 services to inform the community of the avail17 ability of the services of the program.

18 ‘‘(c) PRIORITY FOR MEDICALLY UNDERSERVED COM19 MUNITIES.—A funding agreement for an award under sec20 tion 2785 is that the applicant involved will give priority

21 to developing and operating community health advisor

22 programs for medically underserved communities.

23 ‘‘(d) DEFINITION OF COMMUNITY HEALTH ADVI24 SOR.—For purposes of this part, the term ‘community

25 health advisor’ means an individual—
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1 ‘‘(1) who has demonstrated the capacity to

2 carry out one or more of the authorized program

3 services;

4 ‘‘(2) who, for not less than 1 year, has been a

5 resident of the community in which the community

6 health advisor program involved is to be operated;

7 and

8 ‘‘(3) is a member of a socioeconomic group to

9 be served by the program.

10 ‘‘SEC. 2787. ADDITIONAL AGREEMENTS.

11 ‘‘(a) IDENTIFICATION OF COMMUNITY NEEDS.—A

12 funding agreement for an award under section 2785 is

13 that the applicant involved will—

14 ‘‘(1) identify the needs of the community in15 volved for the authorized program services, including

16 the identifying the resources of the community that

17 are available for carrying out the program;

18 ‘‘(2) in identifying such needs, consult with

19 members of the community, with individuals and

20 programs that provide health services in the commu21 nity, and with individuals and programs that provide

22 health-related social services in the community; and

23 ‘‘(3) consider such needs in carrying out a com24 munity health advisor program for the community.

25 ‘‘(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 2785

4 is 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

20 the community health advisor program involved

21 is 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

2 the purposes for which an award under section 2785 is

3 authorized in this subtitle to be expended, the Secretary

4 may make such an award only if the State involved agrees

5 to maintain expenditures of non-Federal amounts for such

6 purposes at a level that is not less than the level of such

7 expenditures maintained by the State for the fiscal year

8 preceding the first fiscal year for which such an award

9 is made with respect to the State.

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

11 agreement for an award under section 2785 for an appli12 cant is that the services of the community health advisor

13 program involved will be provided in the language and cul14 tural context most appropriate for the individuals served

15 by the program, and that for such purpose the community

16 health advisors of the program will include an appropriate

17 number of advisors who are fluent in both English and

18 not less than one of the other relevant languages.

19 ‘‘(e) NUMBER OF PROGRAMS PER AWARD; PRO20 GRAMS FOR URBAN AND RURAL AREAS.—A funding

21 agreement for an award under section 2785 for an appli22 cant is that the number of community health advisor pro23 grams operated in the State with the award will be deter24 mined by the Secretary, except that (subject to section

25 2786(b)(1)(B)) such a program will be carried out in not
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1 less than one urban area of the State, and in not less than

2 one rural area of the State.

3 ‘‘(f) ONGOING SUPERVISION OF ADVISORS.—A fund4 ing agreement for an award under section 2785 is that

5 the applicant involved will ensure that each community

6 health advisor program operated with the award provides

7 for the ongoing supervision of the community health advi8 sors of the program, and that the individuals serving as

9 supervisors in the program will include 1 or more public

10 health nurses with field experience and managerial experi11 ence.

12 ‘‘(g) CERTAIN EXPENDITURES.—

13 ‘‘(1) TRAINING; CONTINUING EDUCATION.—

14 Funding agreements for an award under section

15 2785 include the following:

16 ‘‘(A) The applicant involved will ensure

17 that, for each community health advisor pro18 gram operated with the award, a program is

19 carried out to train community health advisors

20 to provide the authorized program services, in21 cluding practical experiences in providing serv22 ices for health promotion and disease preven23 tion.
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1 ‘‘(B) The program of training will provide

2 for the continuing education of the community

3 health advisors.

4 ‘‘(C) Not more than 15 percent of the

5 award will be expended for the program of

6 training.

7 ‘‘(2) COMPENSATION.—With respect to compli8 ance with the agreements made under this subtitle,

9 the purposes for which an award under section 2785

10 may be expended include providing compensation for

11 the services of community health advisors.

12 ‘‘(h) REPORTS TO SECRETARY; ASSESSMENT OF EF13 FECTIVENESS.—Funding agreements for an award under

14 section 2785 for an applicant include the following:

15 ‘‘(1) The applicant will ensure that, for each

16 fiscal year for which a community health advisor

17 program receives amounts from the award, the pro18 gram will prepare a report describing the activities

19 of the program for such year, including—

20 ‘‘(A) a specification of the number of indi21 viduals served by the program;

22 ‘‘(B) a specification of the entities with

23 which the program has collaborated in carrying

24 out the purpose described in section 2786(a)(1);

25 and
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1 ‘‘(C) an assessment of the extent of the ef2 fectiveness of the program in carrying out such

3 purpose.

4 ‘‘(2) Such reports will include such additional

5 information regarding the applicant and the pro6 grams as the Secretary may require.

7 ‘‘(3) The applicant will prepare the reports as

8 a single document and will submit the document to

9 the Secretary not later than February 1 of the fiscal

10 year following the fiscal year for which the reports

11 were prepared.

12 ‘‘SEC. 2788. APPLICATION FOR ASSISTANCE; STATE PLAN.

13 ‘‘For purposes of section 2785, an application is in

14 accordance with this section if—

15 ‘‘(1) the application is submitted not later than

16 the date specified by the Secretary;

17 ‘‘(2) the application contains each funding

18 agreement described in this subtitle;

19 ‘‘(3) the application contains a State plan de20 scribing the purposes for which the award is to be

21 expended in the State, including a description of the

22 manner in which the applicant will comply with each

23 such funding agreement; and

24 ‘‘(4) the application is in such form, is made in

25 such manner, and contains such agreements, assur-
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1 ances, and information as the Secretary determines

2 to be necessary to carry out this subtitle.

3 ‘‘SEC. 2789. DETERMINATION OF AMOUNT OF ALLOTMENT.

4 ‘‘(a) IN GENERAL.—For purposes of section 2785,

5 the allotment under this section with respect to a State

6 for a fiscal year is the sum of the respective amounts de7 termined for the State under subsection (b) and sub8 section (c).

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 2784 for the fis14 cal year and available for awards under section

15 2785; and

16 ‘‘(2) the percentage constituted by the ratio

17 of—

18 ‘‘(A) the number of individuals residing in

19 the State involved; to

20 ‘‘(B) the sum of the respective amounts

21 determined for each State under subparagraph

22 (A).

23 ‘‘(c) AMOUNT RELATING TO POVERTY LEVEL.—For

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

25 this subsection is the product of—
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1 ‘‘(1) the amount determined under subsection

2 (b)(1); and

3 ‘‘(2) the percentage constituted by the ratio

4 of—

5 ‘‘(A) the number of individuals residing in

6 the State whose income is at or below an

7 amount equal to 200 percent of the official pov8 erty line; to

9 ‘‘(B) the sum of the respective amounts

10 determined for each State under subparagraph

11 (A).

12 ‘‘SEC. 2790. QUALITY ASSURANCE; COST-EFFECTIVENESS.

13 ‘‘The Secretary shall establish guidelines for assuring

14 the quality of community health advisor programs (includ15 ing quality in the training of community health advisors)

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

17 A funding agreement for an award under section 2785 is

18 that the applicant involved will carry out such programs

19 in accordance with the guidelines.

20 ‘‘SEC. 2791. EVALUATIONS; TECHNICAL ASSISTANCE.

21 ‘‘(a) EVALUATIONS.—The Secretary shall conduct

22 evaluations of community health advisor programs and

23 disseminate information developed as result of the evalua24 tions to the States. In conducting such evaluations, the

25 Secretary shall determine whether the programs are in
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1 compliance with the guidelines established under section

2 2790.

3 ‘‘(b) TECHNICAL ASSISTANCE.—The Secretary may

4 provide technical assistance to recipients of awards under

5 section 2785 with respect to the planning, development,

6 and operation of community health advisor programs.

7 ‘‘(c) GRANTS AND CONTRACTS.—The Secretary may

8 carry out this section directly or through grants, coopera9 tive agreements, or contracts.

10 ‘‘(d) LIMITATION ON EXPENDITURES.—Of the

11 amounts appropriated under section 2784 for a fiscal year,

12 the Secretary may reserve not more than 10 percent for

13 carrying out this section.

14 ‘‘SEC. 2792. RULE OF CONSTRUCTION REGARDING PRO15 GRAMS OF INDIAN HEALTH SERVICE.

16 ‘‘This subtitle may not be construed as requiring the

17 Secretary to modify or terminate the program carried out

18 by the Director of the Indian Health Service and des19 ignated by such Director as the Community Health Rep20 resentative Program. The Secretary shall ensure that sup21 port for such Program is not supplanted by awards under

22 section 2785. In communities in which both such Program

23 and a community health advisor program are being carried

24 out, the Secretary shall ensure that the community health

25 advisor program works in cooperation with, and as a com-
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1 plement to, the Community Health Representative Pro2 gram.

3 ‘‘SEC. 2793. DEFINITIONS.

4 ‘‘For purposes of this subtitle:

5 ‘‘(1) The term ‘authorized program services’,

6 with respect to a community health advisor program,

7 means the services specified in section 2786(b)(2).

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

9 the meaning given such term in section 2786(d).

10 ‘‘(3) The term ‘community health advisor pro11 gram’ means a program carried out under section

12 2786(b).

13 ‘‘(4) The term ‘financial assistance’, with re14 spect to an award under section 2785, means a

15 grant, cooperative agreement, or a contract.

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

17 agreement required as a condition of receiving an

18 award under section 2785.

19 ‘‘(6) The term ‘official poverty line’ means the

20 official poverty line established by the Director of

21 the Office of Management and Budget and revised

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

23 of the Omnibus Budget Reconciliation Act of 1981,

24 which poverty line is applicable the size of the family

25 involved.
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1 ‘‘(7) The term ‘State involved’, with respect to

2 an applicant for an award under section 2785,

3 means the State in which the applicant is to carry

4 out a community health advisor program.

5 ‘‘SEC. 2794. EFFECT OF INSUFFICIENT APPROPRIATIONS

6 FOR MINIMUM ALLOTMENTS.

7 ‘‘(a) IN GENERAL.—If the amounts made available

8 under section 2784 for a fiscal year are insufficient for

9 providing each State (or entity designated by the State

10 pursuant to section 2785, as the case may be) with an

11 award under section 2785 in an amount equal to or great12 er than the amount specified in section 2789(a)(2), the

13 Secretary shall, from such amounts as are made available

14 under subsection (a), make such awards on a discretionary

15 basis.

16 ‘‘(b) RULE OF CONSTRUCTION.—For purposes of

17 subsection (a), awards under section 2785 are made on

18 a discretionary basis if the Secretary determines which

19 States (or entities designated by States pursuant to such

20 section, as the case may be) are to receive such awards,

21 subject to meeting the requirements of this subtitle for

22 such an award, and the Secretary determines the amount

23 of such awards.
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1 ‘‘Subtitle F—General Provisions

2 ‘‘SEC. 2798. REQUIREMENT REGARDING ACCREDITATION

3 OF SCHOOLS, DEPARTMENTS, AND PRO4 GRAMS.

5 ‘‘Except as indicated otherwise in this title:

6 ‘‘(1) A reference in this title to a school of pub7 lic health, a school of nursing, or any other entity

8 providing education or training in a health profes9 sion (whether a school, department, program, or

10 other entity) is a reference to the entity as defined

11 under section 799 or 853.

12 ‘‘(2) If an entity is not defined in either of such

13 sections, the reference in this title to the entity has

14 the meaning provided by the Secretary, except that

15 the Secretary shall require for purposes of this title

16 that the entity be accredited for the provision of the

17 education or training involved.

18 ‘‘SEC. 2799. RELATION TO OTHER FUNDS.

19 ‘‘Notwithstanding any other provision of law, the au20 thorizations of appropriations established in this title are

21 in addition to any other authorizations of appropriations

22 that are available for the purposes described with respect

23 to such appropriations in this title.

24 ‘‘SEC. 2799A. DEFINITIONS.

25 ‘‘(a) IN GENERAL.—For purposes of this title:
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1 ‘‘(1) The term ‘Healthy People 2000 Objectives’

2 means the objectives established by the Secretary to3 ward the goals of increasing the span of healthy life,

4 reducing health disparities among various popu5 lations, and providing access to preventive services,

6 which objectives apply to the health status of the

7 population of the United States for the year 2000.

8 ‘‘(2) The term ‘medically underserved commu9 nity’ means—

10 ‘‘(A) a community that has a substantial

11 number of individuals who are members of a

12 medically underserved population, as defined in

13 section 330; or

14 ‘‘(B) a community a significant portion of

15 which is a health professional shortage area

16 designated under section 332.’’.

17 TITLE IV—MEDICAL RESEARCH

18 SEC. 4001. FINDINGS.

19 The Congress finds the following:

20 (1) Nearly 4 of 5 peer reviewed research

21 projects deemed worthy of funding by the National

22 Institutes of Health are not funded.

23 (2) Less than 2 percent of the nearly one tril24 lion dollars our Nation spends on health care is de-
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•S 2452 IS

1 voted to health research, while the defense industry

2 spends 15 percent of its budget on research.

3 (3) Public opinion surveys have shown that

4 Americans want more Federal resources put into

5 health research and support by having a portion of

6 their health insurance premiums set aside for this

7 purpose.

8 (4) Ample evidence exists to demonstrate that

9 health research has improved the quality of health

10 care in the United States. Advances such as the de11 velopment of vaccines, the cure of many childhood

12 cancers, drugs that effectively treat a host of dis13 eases and disorders, a process to protect our Na14 tion’s blood supply from the HIV virus, progress

15 against cardiovasculor disease including heart attack

16 and stroke, and new strategies for the early detec17 tion and treatment of diseases such as colon, breast,

18 and prostate cancer clearly demonstrates the bene19 fits of health research.

20 (5) Among the most effective methods to con21 trol health care costs are prevention and cure of dis22 ease and disability, thus, health research which holds

23 the promise of cure and prevention of disease and

24 disability is a critical component of any comprehen25 sive health care reform plan.
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1 (6) The state of our Nation’s research facilities

2 at the National Institutes of Health and at univer3 sities is deteriorating significantly. Renovation and

4 repair of these facilities are badly needed to main5 tain and improve the quality of research.

6 (7) Because the Omnibus Budget Reconciliation

7 Act of 1993 freezes discretionary spending for the

8 next 5 years, the Nation’s investment in health re9 search through the National Institutes of Health is

10 likely to decline in real terms unless corrective legis11 lative action is taken.

12 (8) A health research fund is needed to main13 tain our Nation’s commitment to health research

14 and to increase the percentage of approved projects

15 which receive funding at the National Institutes of

16 Health to at least 33 percent.

17 SEC. 4002. NATIONAL FUND FOR HEALTH RESEARCH.

18 (a) ESTABLISHMENT.—There is established in the

19 Treasury of the United States an account, to be known

20 as the ‘‘National Fund for Health Research’’ (hereafter

21 referred to in this section as the ‘‘Fund’’), consisting of

22 such amounts as are transferred to the Fund under sub23 section (b) and any interest earned on investment of

24 amounts in the Fund.

25 (b) TRANSFERS TO FUND.—
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1 (1) IN GENERAL.—With respect to each of the

2 5 full calendar years beginning after the date of en3 actment of this Act, the Secretary of the Treasury

4 shall transfer to the Fund an amount equal to the

5 applicable amount under paragraph (2).

6 (2) APPLICABLE AMOUNT.—The applicable

7 amount under this paragraph is—

8 (A) with respect to amounts in the Health

9 Care Reform Trust Fund established under sec10 tion 9551(a)(2)(A) of the Internal Revenue

11 Code of 1986, $1,200,000,000 for each cal12 endar year described in paragraph (1); and

13 (B) with respect to amounts received in

14 the Treasury under section 6097 of the Internal

15 Revenue Code of 1986, 100 percent of the

16 amounts received under such section in each

17 calendar year described in paragraph (1).

18 (3) DESIGNATION OF OVERPAYMENTS AND CON19 TRIBUTIONS.—

20 (A) IN GENERAL.—Subchapter A of chap21 ter 61 of the Internal Revenue Code of 1986

22 (relating to returns and records) is amended by

23 adding at the end the following new part:
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1 ‘‘PART IX—DESIGNATION OF OVERPAYMENTS

2 AND CONTRIBUTIONS FOR THE NATIONAL

3 FUND FOR HEALTH RESEARCH

‘‘Sec. 6097. Amounts for the National Fund for Health Research.

4 ‘‘SEC. 6097. AMOUNTS FOR THE NATIONAL FUND FOR

5 HEALTH RESEARCH.

6 ‘‘(a) IN GENERAL.—Every individual (other than a

7 nonresident alien) may designate that—

8 ‘‘(1) a portion (not less than $1) of any over9 payment of the tax imposed by chapter 1 for the

10 taxable year, and

11 ‘‘(2) a cash contribution (not less than $1),

12 be paid over to the National Fund for Health Research

13 established under section 4002 of the Health Innovation

14 Partnership Act of 1994. In the case of a joint return of

15 a husband and wife, each spouse may designate one-half

16 of any such overpayment of tax (not less than $2).

17 ‘‘(b) MANNER AND TIME OF DESIGNATION.—Any

18 designation under subsection (a) may be made with re19 spect to any taxable year only at the time of filing the

20 original return of the tax imposed by chapter 1 for such

21 taxable year. Such designation shall be made either on the

22 1st page of the return or on the page bearing the tax23 payer’s signature.

24 ‘‘(c) OVERPAYMENTS TREATED AS REFUNDED.—For

25 purposes of this section, any overpayment of tax des-
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1 ignated under subsection (a) shall be treated as being re2 funded to the taxpayer as of the last day prescribed for

3 filing the return of tax imposed by chapter 1 (determined

4 with regard to extensions) or, if later, the date the return

5 is filed.

6 ‘‘(d) DESIGNATED AMOUNTS NOT DEDUCTIBLE.—

7 No amount designated pursuant to subsection (a) shall be

8 allowed as a deduction under section 170 or any other sec9 tion for any taxable year.

10 ‘‘(e) TERMINATION.—This section shall not apply to

11 taxable years beginning in a calendar year after a deter12 mination by the Secretary that the sum of all designations

13 under subsection (a) for taxable years beginning in the

14 second and third calendar years preceding the calendar

15 year is less than $5,000,000.’’.

16 (B) CLERICAL AMENDMENT.—The table of

17 parts for subchapter A of chapter 61 of such

18 Code is amended by adding at the end the fol19 lowing new item:

‘‘Part IX. Designation of overpayments and contributions for the

National Fund for Health Research.’’.

20 (C) EFFECTIVE DATE.—The amendments

21 made by this paragraph shall apply to taxable

22 years beginning after December 31, 1994.

23 (c) EXPENDITURES FROM FUND.—
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1 (1) IN GENERAL.—The Secretary of the Treas2 ury shall pay annually, within 30 days after the

3 President signs an appropriations Act for the De4 partments of Labor, Health and Human Services,

5 and Education and related agencies, or by the end

6 of the first quarter of the fiscal year, to the Sec7 retary of Health and Human Services on behalf of

8 the National Institutes of Health, an amount equal

9 to the amount in the National Fund for Health Re10 search at the time of such payment, to enable the

11 Secretary to carry out the purpose of section 404F

12 of the Public Health Service Act, less any adminis13 trative expenses which may be paid under paragraph

14 (3).

15 (2) PURPOSES FOR EXPENDITURES FROM

16 FUND.—Part A of title IV of the Public Health

17 Service Act (42 U.S.C. 281 et seq.) is amended by

18 adding at the end the following new section:

19 ‘‘SEC. 404F. EXPENDITURES FROM THE NATIONAL FUND

20 FOR HEALTH RESEARCH.

21 ‘‘(a) IN GENERAL.—From amounts received for any

22 fiscal year from the National Fund for Health Research,

23 the Secretary of Health and Human Services shall distrib24 ute—
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1 ‘‘(1) 2 percent of such amounts during any fis2 cal year to the Office of the Director of the National

3 Institutes of Health to be allocated at the Director’s

4 discretion for the following activities:

5 ‘‘(A) for carrying out the responsibilities of

6 the Office of the Director, National Institutes

7 of Health, including the Office of Research on

8 Women’s Health and the Office of Research on

9 Minority Health, the Office of the Alternative

10 Medicine and the Office of Rare Diseases Re11 search; and

12 ‘‘(B) for construction and acquisition of

13 equipment for or facilities of or used by the Na14 tional Institutes of Health;

15 ‘‘(2) 2 percent of such amounts for transfer to

16 the National Center for Research Resources to carry

17 out section 1502 of the National Institutes of

18 Health Revitalization Act of 1993 concerning Bio19 medical and Behavioral Research Facilities;

20 ‘‘(3) 1 percent of such amounts during any fis21 cal year for carrying out section 301 and part D of

22 title IV with respect to health information commu23 nications; and

24 ‘‘(4) the remainder of such amounts during any

25 fiscal year to member institutes of the National In-
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•S 2452 IS

1 stitutes of Health and centers in the same propor2 tion to the total amount received under this section,

3 as the amount of annual appropriations under ap4 propriations Acts for each member institute and cen5 ter for the fiscal year bears to the total amount of

6 appropriations under appropriations Acts for all

7 member institutes and centers of the National Insti8 tutes of Health for the fiscal year.

9 ‘‘(b) PLANS OF ALLOCATION.—The amounts trans10 ferred under subsection (a) shall be allocated by the Direc11 tor of NIH or the various directors of the institutes and

12 centers, as the case may be, pursuant to allocation plans

13 developed by the various advisory councils to such direc14 tors, after consultation with such directors.’’.

15 (3) ADMINISTRATIVE EXPENSES.—Amounts in

16 the National Fund for Health Research shall be

17 available to pay the administrative expenses of the

18 Department of the Treasury directly allocable to—

19 (A) modifying the individual income tax re20 turn forms to carry out section 6097 of the In21 ternal Revenue Code of 1986;

22 (B) carrying out this section with respect

23 to such Fund; and
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1 (C) processing amounts received under this

2 section and transferring such amounts to such

3 Fund.

4 (4) TRIGGER AND RELEASE OF FUND MON5 IES.—No expenditures shall be made pursuant to

6 section 4002(c) during any fiscal year in which the

7 annual amount appropriated for the National Insti8 tutes of Health is less than the amount so appro9 priated for the prior fiscal year.

10 (d) BUDGET ENFORCEMENT.—Amounts contained in

11 the National Fund for Health Research shall be excluded

12 from, and shall not be taken into account for purposes

13 of, any budget enforcement procedures under the Congres14 sional Budget Act of 1974 or the Balanced Budget Emer15 gency Deficit Control Act of 1985.

16 TITLE V—REVENUE PROVISIONS

17 SEC. 5000. AMENDMENT OF 1986 CODE.

18 Except as otherwise expressly provided, whenever in

19 this title an amendment or repeal is expressed in terms

20 of an amendment to, or repeal of, a section or other provi21 sion, the reference shall be considered to be made to a

22 section or other provision of the Internal Revenue Code

23 of 1986.
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1 Subtitle A—Financing Provisions

2 PART I—INCREASE IN TAX ON TOBACCO

3 PRODUCTS

4 SEC. 5001. INCREASE IN EXCISE TAXES ON TOBACCO

5 PRODUCTS.

6 (a) CIGARETTES.—Subsection (b) of section 5701 is

7 amended—

8 (1) by striking ‘‘$12 per thousand ($10 per

9 thousand on cigarettes removed during 1991 or

10 1992)’’ in paragraph (1) and inserting ‘‘$62 per

11 thousand’’, and

12 (2) by striking ‘‘$25.20 per thousand ($21 per

13 thousand on cigarettes removed during 1991 or

14 1992)’’ in paragraph (2) and inserting ‘‘$130.20 per

15 thousand’’.

16 (b) CIGARS.—Subsection (a) of section 5701 is

17 amended—

18 (1) by striking ‘‘$1.125 cents per thousand

19 (93.75 cents per thousand on cigars removed during

20 1991 or 1992)’’ in paragraph (1) and inserting

21 ‘‘$51.13 per thousand’’, and

22 (2) by striking ‘‘equal to’’ and all that follows

23 in paragraph (2) and inserting ‘‘equal to 66 percent

24 of the price for which sold but not more than $155

25 per thousand.’’
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1 (c) CIGARETTE PAPERS.—Subsection (c) of section

2 5701 is amended by striking ‘‘0.75 cent (0.625 cent on

3 cigarette papers removed during 1991 or 1992)’’ and in4 serting ‘‘3.88 cents’’.

5 (d) CIGARETTE TUBES.—Subsection (d) of section

6 5701 is amended by striking ‘‘1.5 cents (1.25 cents on

7 cigarette tubes removed during 1991 or 1992)’’ and in8 serting ‘‘7.76 cents’’.

9 (e) SMOKELESS TOBACCO.—Subsection (e) of section

10 5701 is amended—

11 (1) by striking ‘‘36 cents (30 cents on snuff re12 moved during 1991 or 1992)’’ in paragraph (1) and

13 inserting ‘‘$13.69’’, and

14 (2) by striking ‘‘12 cents (10 cents on chewing

15 tobacco removed during 1991 or 1992)’’ in para16 graph (2) and inserting ‘‘$5.45’’.

17 (f) PIPE TOBACCO.—Subsection (f) of section 5701

18 is amended by striking ‘‘67.5 cents (56.25 cents on pipe

19 tobacco removed during 1991 or 1992)’’ and inserting

20 ‘‘$17.35’’.

21 (g) APPLICATION OF TAX INCREASE TO PUERTO

22 RICO.—Section 5701 is amended by adding at the end the

23 following new subsection:
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1 ‘‘(h) APPLICATION TO TAXES TO PUERTO RICO.—

2 Notwithstanding subsections (b) and (c) of section 7653

3 and any other provision of law—

4 ‘‘(1) IN GENERAL.—On tobacco products and

5 cigarette papers and tubes, manufactured or im6 ported into the Commonwealth of Puerto Rico, there

7 is hereby imposed a tax at the rate equal to the ex8 cess of—

9 ‘‘(A) the rate of tax applicable under this

10 section to like articles manufactured in the

11 United States, over

12 ‘‘(B) the rate referred to in subparagraph

13 (A) as in effect on the day before the date of

14 the enactment of the Health Innovation Part15 nership Act of 1994.

16 ‘‘(2) SHIPMENTS TO PUERTO RICO FROM THE

17 UNITED STATES.—Only the rates of tax in effect on

18 the day before the date of the enactment of this sub19 section shall be taken into account in determining

20 the amount of any exemption from, or credit or

21 drawback of, any tax imposed by this section on any

22 article shipped to the Commonwealth of Puerto Rico

23 from the United States.

24 ‘‘(3) SHIPMENTS FROM PUERTO RICO TO THE

25 UNITED STATES.—The rates of tax taken into ac-
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1 count under section 7652(a) with respect to tobacco

2 products and cigarette papers and tubes coming into

3 the United States from the Commonwealth of Puer4 to Rico shall be the rates of tax in effect on the day

5 before the date of the enactment of the Health Inno6 vation Partnership Act of 1994.

7 ‘‘(4) DISPOSITION OF REVENUES.—The provi8 sions of section 7652(a)(3) shall not apply to any

9 tax imposed by reason of this subsection.’’

10 (h) EFFECTIVE DATE.—The amendments made by

11 this section shall apply to articles removed (as defined in

12 section 5702(k) of the Internal Revenue Code of 1986,

13 as amended by this Act) after December 31, 1994.

14 (i) FLOOR STOCKS TAXES.—

15 (1) IMPOSITION OF TAX.—On tobacco products

16 and cigarette papers and tubes manufactured in or

17 imported into the United States or the Common18 wealth of Puerto Rico which are removed before any

19 tax-increase date, and held on such date for sale by

20 any person, there is hereby imposed a tax in an

21 amount equal to the excess of—

22 (A) the tax which would be imposed under

23 section 5701 of the Internal Revenue Code of

24 1986 on the article if the article had been re25 moved on such date, over
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1 (B) the prior tax (if any) imposed under

2 section 5701 or 7652 of such Code on such ar3 ticle.

4 (2) AUTHORITY TO EXEMPT CIGARETTES HELD

5 IN VENDING MACHINES.—To the extent provided in

6 regulations prescribed by the Secretary, no tax shall

7 be imposed by paragraph (1) on cigarettes held for

8 retail sale on any tax-increase date, by any person

9 in any vending machine. If the Secretary provides

10 such a benefit with respect to any person, the Sec11 retary may reduce the $500 amount in paragraph

12 (3) with respect to such person.

13 (3) CREDIT AGAINST TAX.—Each person shall

14 be allowed as a credit against the taxes imposed by

15 paragraph (1) an amount equal to $500. Such credit

16 shall not exceed the amount of taxes imposed by

17 paragraph (1) on each tax-increase date for which

18 such person is liable.

19 (4) LIABILITY FOR TAX AND METHOD OF PAY20 MENT.—

21 (A) LIABILITY FOR TAX.—A person hold22 ing cigarettes on any tax-increase date, to

23 which any tax imposed by paragraph (1) applies

24 shall be liable for such tax.
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1 (B) METHOD OF PAYMENT.—The tax im2 posed by paragraph (1) shall be paid in such

3 manner as the Secretary shall prescribe by reg4 ulations.

5 (C) TIME FOR PAYMENT.—The tax im6 posed by paragraph (1) shall be paid on or be7 fore the date which is 3 months after the tax8 increase date.

9 (5) ARTICLES IN FOREIGN TRADE ZONES.—

10 Notwithstanding the Act of June 18, 1934 (48 Stat.

11 998, 19 U.S.C. 81a) and any other provision of law,

12 any article which is located in a foreign trade zone

13 on any tax-increase date shall be subject to the tax

14 imposed by paragraph (1) if—

15 (A) internal revenue taxes have been deter16 mined, or customs duties liquidated, with re17 spect to such article before such date pursuant

18 to a request made under the 1st proviso of sec19 tion 3(a) of such Act, or

20 (B) such article is held on such date under

21 the supervision of a customs officer pursuant to

22 the 2d proviso of such section 3(a).

23 (6) DEFINITIONS.—For purposes of this sub24 section—
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1 (A) IN GENERAL.—Terms used in this sub2 section which are also used in section 5702 of

3 the Internal Revenue Code of 1986 shall have

4 the respective meanings such terms have in

5 such section, as amended by this Act.

6 (B) SECRETARY.—The term ‘‘Secretary’’

7 means the Secretary of the Treasury or his del8 egate.

9 (C) TAX-INCREASE DATE.—The term ‘‘tax10 increase date’’ means January 1, 1995, and

11 July 1, 1996.

12 (7) CONTROLLED GROUPS.—Rules similar to

13 the rules of section 5061(e)(3) of such Code shall

14 apply for purposes of this subsection.

15 (8) OTHER LAWS APPLICABLE.—All provisions

16 of law, including penalties, applicable with respect to

17 the taxes imposed by section 5701 of such Code

18 shall, insofar as applicable and not inconsistent with

19 the provisions of this subsection, apply to the floor

20 stocks taxes imposed by paragraph (1), to the same

21 extent as if such taxes were imposed by such section

22 5701. The Secretary may treat any person who bore

23 the ultimate burden of the tax imposed by para24 graph (1) as the person to whom a credit or refund

25 under such provisions may be allowed or made.
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1 SEC. 5002. MODIFICATIONS OF CERTAIN TOBACCO TAX

2 PROVISIONS.

3 (a) EXEMPTION FOR EXPORTED TOBACCO PROD4 UCTS AND CIGARETTE PAPERS AND TUBES TO APPLY

5 ONLY TO ARTICLES MARKED FOR EXPORT.—

6 (1) Subsection (b) of section 5704 is amended

7 by adding at the end the following new sentence:

8 ‘‘Tobacco products and cigarette papers and tubes

9 may not be transferred or removed under this sub10 section unless such products or papers and tubes

11 bear such marks, labels, or notices as the Secretary

12 shall by regulations prescribe.’’

13 (2) Section 5761 is amended by redesignating

14 subsections (c) and (d) as subsections (d) and (e),

15 respectively, and by inserting after subsection (b)

16 the following new subsection:

17 ‘‘(c) SALE OF TOBACCO PRODUCTS AND CIGARETTE

18 PAPERS AND TUBES FOR EXPORT.—Except as provided

19 in subsections (b) and (d) of section 5704—

20 ‘‘(1) every person who sells, relands, or receives

21 within the jurisdiction of the United States any to22 bacco products or cigarette papers or tubes which

23 have been labeled or shipped for exportation under

24 this chapter,
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1 ‘‘(2) every person who sells or receives such

2 relanded tobacco products or cigarette papers or

3 tubes, and

4 ‘‘(3) every person who aids or abets in such

5 selling, relanding, or receiving,

6 shall, in addition to the tax and any other penalty provided

7 in this title, be liable for a penalty equal to the greater

8 of $1,000 or 5 times the amount of the tax imposed by

9 this chapter. All tobacco products and cigarette papers

10 and tubes relanded within the jurisdiction of the United

11 States, and all vessels, vehicles, and aircraft used in such

12 relanding or in removing such products, papers, and tubes

13 from the place where relanded, shall be forfeited to the

14 United States.’’.

15 (3) Subsection (a) of section 5761 is amended

16 by striking ‘‘subsection (b)’’ and inserting ‘‘sub17 section (b) or (c)’’.

18 (4) Subsection (d) of section 5761, as redesig19 nated by paragraph (2), is amended by striking

20 ‘‘The penalty imposed by subsection (b)’’ and insert21 ing ‘‘The penalties imposed by subsections (b) and

22 (c)’’.

23 (5)(A) Subpart F of chapter 52 is amended by

24 adding at the end the following new section:
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1 ‘‘SEC. 5754. RESTRICTION ON IMPORTATION OF PRE2 VIOUSLY EXPORTED TOBACCO PRODUCTS.

3 ‘‘(a) IN GENERAL.—Tobacco products and cigarette

4 papers and tubes previously exported from the United

5 States may be imported or brought into the United States

6 only as provided in section 5704(d). For purposes of this

7 section, section 5704(d), section 5761, and such other pro8 visions as the Secretary may specify by regulations, ref9 erences to exportation shall be treated as including a ref10 erence to shipment to the Commonwealth of Puerto Rico.

11 ‘‘(b) CROSS REFERENCE.—

‘‘For penalty for the sale of tobacco products and

cigarette papers and tubes in the United States

which are labeled for export, see section 5761(c).’’.

12 (B) The table of sections for subpart F of chap13 ter 52 is amended by adding at the end the following

14 new item:

‘‘Sec. 5754. Restriction on importation of previously exported tobacco products.’’.

15 (b) IMPORTERS REQUIRED TO BE QUALIFIED.—

16 (1) Sections 5712, 5713(a), 5721, 5722,

17 5762(a)(1), and 5763(b) and (c) are each amended

18 by inserting ‘‘or importer’’ after ‘‘manufacturer’’.

19 (2) The heading of subsection (b) of section

20 5763 is amended by inserting ‘‘QUALIFIED IMPORT21 ERS,’’ after ‘‘MANUFACTURERS,’’.
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1 (3) The heading for subchapter B of chapter 52

2 is amended by inserting ‘‘and Importers’’ after

3 ‘‘Manufacturers’’.

4 (4) The item relating to subchapter B in the

5 table of subchapters for chapter 52 is amended by

6 inserting ‘‘and importers’’ after ‘‘manufacturers’’.

7 (c) REPEAL OF TAX-EXEMPT SALES TO EMPLOYEES

8 OF CIGARETTE MANUFACTURERS.—

9 (1) Subsection (a) of section 5704 is amend10 ed—

11 (A) by striking ‘‘EMPLOYEE USE OR’’ in

12 the heading, and

13 (B) by striking ‘‘for use or consumption by

14 employees or’’ in the text.

15 (2) Subsection (e) of section 5723 is amended

16 by striking ‘‘for use or consumption by their employ17 ees, or for experimental purposes’’ and inserting

18 ‘‘for experimental purposes’’.

19 (d) REPEAL OF TAX-EXEMPT SALES TO UNITED

20 STATES.—Subsection (b) of section 5704 is amended by

21 striking ‘‘and manufacturers may similarly remove such

22 articles for use of the United States;’’.

23 (e) BOOKS OF 25 OR FEWER CIGARETTE PAPERS

24 SUBJECT TO TAX.—Subsection (c) of section 5701 is

25 amended by striking ‘‘On each book or set of cigarette
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1 papers containing more than 25 papers,’’ and inserting

2 ‘‘On cigarette papers,’’.

3 (f) STORAGE OF TOBACCO PRODUCTS.—Subsection

4 (k) of section 5702 is amended by inserting ‘‘under section

5 5704’’ after ‘‘internal revenue bond’’.

6 (g) AUTHORITY TO PRESCRIBE MINIMUM MANUFAC7 TURING ACTIVITY REQUIREMENTS.—Section 5712 is

8 amended by striking ‘‘or’’ at the end of paragraph (1),

9 by redesignating paragraph (2) as paragraph (3), and by

10 inserting after paragraph (1) the following new paragraph:

11 ‘‘(2) the activity proposed to be carried out at

12 such premises does not meet such minimum capacity

13 or activity requirements as the Secretary may pre14 scribe, or’’.

15 (h) SPECIAL RULES RELATING TO PUERTO RICO

16 AND THE VIRGIN ISLANDS.—Section 7652 is amended by

17 adding at the end the following new subsection:

18 ‘‘(h) LIMITATION ON COVER OVER OF TAX ON TO19 BACCO PRODUCTS.—For purposes of this section, with re20 spect to taxes imposed under section 5701 or this section

21 on any tobacco product or cigarette paper or tube, the

22 amount covered into the treasuries of Puerto Rico and the

23 Virgin Islands shall not exceed the rate of tax under sec24 tion 5701 in effect on the article on the day before the
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1 date of the enactment of the Health Innovation Partner2 ship Act of 1994.’’.

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

4 this section shall apply to articles removed (as defined in

5 section 5702(k) of the Internal Revenue Code of 1986,

6 as amended by this Act) after December 31, 1994.

7 SEC. 5003. IMPOSITION OF EXCISE TAX ON MANUFACTURE

8 OR IMPORTATION OF ROLL-YOUR-OWN TO9 BACCO.

10 (a) IN GENERAL.—Section 5701 (relating to rate of

11 tax), as amended by section 701, is amended by redesig12 nating subsections (g) and (h) as subsections (h) and (i)

13 and by inserting after subsection (f) the following new

14 subsection:

15 ‘‘(g) ROLL-YOUR-OWN TOBACCO.—On roll-your-own

16 tobacco, manufactured in or imported into the United

17 States, there shall be imposed a tax of $17.35 per pound

18 (and a proportionate tax at the like rate on all fractional

19 parts of a pound).’’.

20 (b) ROLL-YOUR-OWN TOBACCO.—Section 5702 (re21 lating to definitions) is amended by adding at the end the

22 following new subsection:

23 ‘‘(p) ROLL-YOUR-OWN TOBACCO.—The term ‘roll24 your-own tobacco’ means any tobacco which, because of

25 its appearance, type, packaging, or labeling, is suitable for
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1 use and likely to be offered to, or purchased by, consumers

2 as tobacco for making cigarettes.’’.

3 (c) TECHNICAL AMENDMENTS.—

4 (1) Subsection (c) of section 5702 is amended

5 by striking ‘‘and pipe tobacco’’ and inserting ‘‘pipe

6 tobacco, and roll-your-own tobacco’’.

7 (2) Subsection (d) of section 5702 is amend8 ed—

9 (A) in the material preceding paragraph

10 (1), by striking ‘‘or pipe tobacco’’ and inserting

11 ‘‘pipe tobacco, or roll-your-own tobacco’’, and

12 (B) by striking paragraph (1) and insert13 ing the following new paragraph:

14 ‘‘(1) a person who produces cigars, cigarettes,

15 smokeless tobacco, pipe tobacco, or roll-your-own to16 bacco solely for the person’s own personal consump17 tion or use, and’’.

18 (3) The chapter heading for chapter 52 is

19 amended to read as follows:

20 ‘‘CHAPTER 52—TOBACCO PRODUCTS AND

21 CIGARETTE PAPERS AND TUBES’’.

22 (4) The table of chapters for subtitle E is

23 amended by striking the item relating to chapter 52

24 and inserting the following new item:

‘‘CHAPTER 52. Tobacco products and cigarette papers and

tubes.’’.
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1 (d) EFFECTIVE DATE.—

2 (1) IN GENERAL.—The amendments made by

3 this section shall apply to roll-your-own tobacco re4 moved (as defined in section 5702(k) of the Internal

5 Revenue Code of 1986, as amended by this Act)

6 after December 31, 1994.

7 (2) TRANSITIONAL RULE.—Any person who—

8 (A) on the date of the enactment of this

9 Act is engaged in business as a manufacturer of

10 roll-your-own tobacco or as an importer of to11 bacco products or cigarette papers and tubes,

12 and

13 (B) before January 1, 1995, submits an

14 application under subchapter B of chapter 52

15 of such Code to engage in such business,

16 may, notwithstanding such subchapter B, continue

17 to engage in such business pending final action on

18 such application. Pending such final action, all pro19 visions of such chapter 52 shall apply to such appli20 cant in the same manner and to the same extent as

21 if such applicant were a holder of a permit under

22 such chapter 52 to engage in such business.
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1 Subtitle B—Health Care Reform

2 Trust Fund

3 SEC. 5101. ESTABLISHMENT OF GRADUATE MEDICAL EDU4 CATION AND ACADEMIC HEALTH CENTERS

5 TRUST FUND.

6 (a) IN GENERAL.—Subchapter A of chapter 98 (re7 lating to establishment of trust funds) is amended by add8 ing at the end the following new part:

9 ‘‘PART II—HEALTH CARE TRUST FUNDS

‘‘Sec. 9551. Health Care Reform Trust Fund

10 ‘‘SEC. 9551. HEALTH CARE REFORM TRUST FUND.

11 ‘‘(a) CREATION OF TRUST FUND.—There is estab12 lished in the Treasury of the United States a trust fund

13 to be known as the ‘Health Care Reform Trust Fund’,

14 consisting of such amounts as may be appropriated or

15 credited to the Health Care Reform Trust Fund as pro16 vided in this section.

17 ‘‘(b) TRANSFERS TO THE TRUST FUND.—There are

18 hereby appropriated to the Health Care Reform Trust

19 Fund amounts received in the Treasury under section

20 5701 (relating to taxes on tobacco products) to the extent

21 attributable to the increases in such taxes as the result

22 of the enactment of section 5001 of the Health Innovation

23 Partnership Act of 1994.
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1 ‘‘(c) EXPENDITURES.—Amounts in the Health Care

2 Reform Trust Fund are appropriated as provided for in

3 sections 1001 and 4002 of the Health Innovation Partner4 ship Act of 1994, and title XXVII of the Public Health

5 Service Act, and to the extent any such amount is not

6 expended during any fiscal year, such amount shall be

7 available for such purpose for subsequent fiscal years.

8 ‘‘(d) OTHER RULES.—

9 ‘‘(1) INSUFFICIENT FUNDS.—If, for any fiscal

10 year, the sum of the amounts required to be allo11 cated under subsection (c) exceeds the amounts re12 ceived in the Health Care Reform Trust Fund, then

13 each of such amounts required to be so allocated

14 shall be reduced to an amount which bears the same

15 ratio to such amount as the amounts received in the

16 trust fund bear to the amounts required to be so al17 located (without regard to this paragraph).

18 ‘‘(2) ALLOCATION OF EXCESS FUNDS AND IN19 TEREST.—Amounts received in the Health Care Re20 form Trust Fund in excess of the amounts required

21 to be allocated under subsection (c), for any fiscal

22 year shall be allocated ratably on the basis of the

23 amounts allocated for the fiscal year (without regard

24 to this paragraph).’’.
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1 (b) CONFORMING AMENDMENT.—Subchapter A of

2 chapter 98 is amended by inserting after the subchapter

3 heading the following new items:

‘‘Part I. General trust funds.

‘‘Part II. Health care trust fund.

4 ‘‘PART I—GENERAL TRUST FUNDS’’.

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