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[Congressional Bills 103th Congress]
[From the U.S. Government Publishing Office]
[S. 2452 Introduced in Senate (IS)]

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.

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

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Health Innovation Partnership Act of 
1994''.

SEC. 2. FINDINGS.

    The Congress finds the following:
            (1) Americans support universal coverage. The people of 
        this country agree that all Americans, rich and poor, should be 
        guaranteed access to affordable, high-quality health care.
            (2) Although there is common agreement on the goal of 
        universal coverage, there are many different ways to achieve 
        this goal. The States can play an important role in achieving 
        universal coverage for our population, demonstrating additional 
        health reforms that may be needed on a national level to 
        enhance access to affordable, high-quality health care. The 
        States can also serve as testing grounds to identify effective 
        alternatives for making the transition to universal coverage, 
        while maintaining the strengths of the current health care 
        system.
            (3) Maintaining the high quality of health care Americans 
        expect and controlling costs are also important goals of health 
        care reform. As payers of health care, the States have a strong 
        incentive to ensure that such States purchase high-quality, 
        cost-effective services for the residents of such States. The 
        States can develop and test alternative payment and delivery 
        systems to ensure that these goals are achieved.
            (4) There are many health-related issues that should be 
        addressed at the State level before their implementation on the 
        national level. As with social security and child labor 
        protections, States can lead the way in testing ideas for 
        national application.
            (5) The States should have the flexibility to test 
        alternative health reforms with the objectives of increasing 
        access to care, controlling health care costs, and maintaining 
        or improving the quality of health care.

                    TITLE I--HEALTH INSURANCE REFORM

SEC. 1001. ESTABLISHMENT OF STANDARDS.

    (a) In General.--The Secretary of Health and Human Services 
(hereafter referred to in this section as the ``Secretary'') shall 
request that the National Association of Insurance Commissioners 
(hereafter referred to in this section as the ``Association'') develop, 
not later than 6 months after the date of enactment of this Act, 
standards for health insurance plans with respect to--
            (1) the renewability of coverage under such plans;
            (2) the portability of coverage under such plans, 
        including--
                    (A) limitations on the use of pre-existing 
                conditions;
                    (B) the concept of an ``amnesty period'' during 
                which limitations on pre-existing conditions would be 
                suspended; and
                    (C) the advisability of open enrollment periods;
            (3) guaranteed issue with respect to all health insurance 
        coverage products;
            (4) the establishment of an adjusted community rating 
        system with adjustment factors limited to age (with no more 
        than a 2:1 variation in premiums based on age) and geography;
            (5) solvency standards for health insurance plans 
        regulations under Federal and State law, including the 
        development of risk-based capital standards for health plans, 
        solvency standards for health plans, self-funded employer-
        sponsored health plans, and multi-employer welfare arrangements 
        and association plans;
            (6) stop-loss standards for self-funded health insurance 
        plans and multi-employer welfare arrangements and association 
        plans;
            (7) the identification of minimum employer size for self-
        funding and the interrelationship between self-funding and the 
        community-rated pool of enrollees; and
            (8) any other areas determined appropriate by the 
        Secretary.
    (b) Review.--Not later than 30 days after receipt of the standards 
developed by the Association under subsection (a), the Secretary shall 
complete a review of such standards. If the Secretary, based on such 
review, approves such standards, such standards shall apply with 
respect to all health insurance plans offered or operating in a State 
on and after the date specified in subsection (d) herein.
    (c) Failure To Develop Standards or Failure to Approve.--If the 
Association fails to develop standards within the 6-month period 
referred to in subsection (a), or the Secretary fails to approve any 
standards developed under such subsection, the Secretary shall develop, 
not later than 15 months after the date of enactment of this Act, 
standards applicable to health insurance plans, including standards 
related to the matter described in paragraphs (1) through (7) of 
subsection (a) (``Federal standards'') and such standards shall apply 
with respect to all health insurance plans offered or operating in a 
State on and after the date specified in subsection (d) herein.
    (d)(1) Subject to clause (ii), the date specified in this 
subparagraph for a State is the date the State adopts the NAIC 
standards or the Federal standards or 1 year after the date the 
Association or the Secretary first adopts such standards, whichever is 
earlier.
    (2) In the case of a State which the Secretary identifies, in 
consultation with the Association, as--
            (A) requiring State legislation (other than legislation 
        appropriating funds) in order for health insurance policies to 
        meet the NAIC or Federal standards, but
            (B) having a legislature which is not scheduled to meet in 
        1992 in a legislative session in which such legislation may be 
        considered, the date specified in this subparagraph is the 
        first day of the first calendar quarter beginning after the 
        close of the first legislative session of the State legislature 
        that begins on or after January 1, 1992. For purposes of the 
        previous sentence, in the case of a State that has a 2-year 
        legislative session, each year of such session shall be deemed 
        to be a separate regular session of the State legislature.
    (e) In promulgating standards under this paragraph, the Association 
or Secretary shall consult with a working group composed or 
representatives of issuers of health insurance policies, consumer 
groups, health insurance beneficiaries, and other qualified 
individuals. Such representatives shall be selected in a manner so as 
to assure balanced representation among the interested groups.
    (f) Effect on State Law.--Nothing in this section shall be 
construed to preempt any State law to the extent that such State law 
implements more progressive reforms than those implemented under the 
standards developed under this section, as determined by the Secretary.

SEC. 1002. MEDICARE SELECT.

    (a) Amendments to Provisions Relating to Medicare Select 
Policies.--
            (1) Permitting medicare select policies in all states.--
        Subsection (c) of section 4358 of the Omnibus Budget 
        Reconciliation Act of 1990 is hereby repealed.
            (2) Requirements of medicare select policies.--Section 
        1882(t)(1) (42 U.S.C. 1395ss(t)(1)) is amended to read as 
        follows:
    ``(1)(A) If a medicare supplemental policy meets the requirements 
of the 1991 NAIC Model Regulation or 1991 Federal Regulation and 
otherwise complies with the requirements of this section except that--
            ``(i) the benefits under such policy are restricted to 
        items and services furnished by certain entities (or reduced 
        benefits are provided when items or services are furnished by 
        other entities), and
            ``(ii) in the case of a policy described in subparagraph 
        (C)(i)--
                    ``(I) the benefits under such policy are not one of 
                the groups or packages of benefits described in 
                subsection (p)(2)(A),
                    ``(II) except for nominal copayments imposed for 
                services covered under part B of this title, such 
                benefits include at least the core group of basic 
                benefits described in subsection (p)(2)(B), and
                    ``(III) an enrollee's liability under such policy 
                for physician's services covered under part B of this 
                title is limited to the nominal copayments described in 
                subclause (II),
        the policy shall nevertheless be treated as meeting those 
        requirements if the policy meets the requirements of 
        subparagraph (B).
    ``(B) A policy meets the requirements of this subparagraph if--
            ``(i) full benefits are provided for items and services 
        furnished through a network of entities which have entered into 
        contracts or agreements with the issuer of the policy,
            ``(ii) full benefits are provided for items and services 
        furnished by other entities if the services are medically 
        necessary and immediately required because of an unforeseen 
        illness, injury, or condition and it is not reasonable given 
        the circumstances to obtain the services through the network,
            ``(iii) the network offers sufficient access,
            ``(iv) the issuer of the policy has arrangements for an 
        ongoing quality assurance program for items and services 
        furnished through the network,
            ``(v)(I) the issuer of the policy provides to each enrollee 
        at the time of enrollment an explanation of--
                    ``(aa) the restrictions on payment under the policy 
                for services furnished other than by or through the 
                network,
                    ``(bb) out of area coverage under the policy,
                    ``(cc) the policy's coverage of emergency services 
                and urgently needed care, and
                    ``(dd) the availability of a policy through the 
                entity that meets the 1991 Model NAIC Regulation or 
                1991 Federal Regulation without regard to this 
                subsection and the premium charged for such policy, and
            ``(II) each enrollee prior to enrollment acknowledges 
        receipt of the explanation provided under subclause (I), and
            ``(vi) the issuer of the policy makes available to 
        individuals, in addition to the policy described in this 
        subsection, any policy (otherwise offered by the issuer to 
        individuals in the State) that meets the 1991 Model NAIC 
        Regulation or 1991 Federal Regulation and other requirements of 
        this section without regard to this subsection.
    ``(C)(i) A policy described in this subparagraph--
            ``(I) is offered by an eligible organization (as defined in 
        section 1876(b)),
            ``(II) is not a policy or plan providing benefits pursuant 
        to a contract under section 1876 or an approved demonstration 
        project described in section 603(c) of the Social Security 
        Amendments of 1983, section 2355 of the Deficit Reduction Act 
        of 1984, or section 9412(b) of the Omnibus Budget 
        Reconciliation Act of 1986, and
            ``(III) provides benefits which, when combined with 
        benefits which are available under this title, are 
        substantially similar to benefits under policies offered to 
        individuals who are not entitled to benefits under this title.
    ``(ii) In making a determination under subclause (III) of clause 
(i) as to whether certain benefits are substantially similar, there 
shall not be taken into account, except in the case of preventive 
services, benefits provided under policies offered to individuals who 
are not entitled to benefits under this title which are in addition to 
the benefits covered by this title and which are benefits an entity 
must provide in order to meet the definition of an eligible 
organization under section 1876(b)(1).''.
    (b) Renewability of Medicare Select Policies.--Section 1882(q)(1) 
(42 U.S.C. 1395ss(q)(1)) is amended--
            (1) by striking ``(1) Each'' and inserting ``(1)(A) Except 
        as provided in subparagraph (B), each'';
            (2) by redesignating subparagraphs (A) and (B) as clauses 
        (i) and (ii), respectively; and
            (3) by adding at the end the following new subparagraph:
            ``(B)(i) In the case of a policy that meets the 
        requirements of subsection (t), an issuer may cancel or 
        nonrenew such policy with respect to an individual who leaves 
        the service area of such policy; except that, if such 
        individual moves to a geographic area where such issuer, or 
        where an affiliate of such issuer, is issuing medicare 
        supplemental policies, such individual must be permitted to 
        enroll in any medicare supplemental policy offered by such 
        issuer or affiliate that provides benefits comparable to or 
        less than the benefits provided in the policy being canceled or 
        nonrenewed. An individual whose coverage is canceled or 
        nonrenewed under this subparagraph shall, as part of the notice 
        of termination or nonrenewal, be notified of the right to 
        enroll in other medicare supplemental policies offered by the 
        issuer or its affiliates.
            ``(ii) For purposes of this subparagraph, the term 
        `affiliate' shall have the meaning given such term by the 1991 
        NAIC Model Regulation.''.
    (c) Civil Penalty.--Section 1882(t)(2) (42 U.S.C. 1395ss(t)(2)) is 
amended--
            (1) by striking ``(2)'' and inserting ``(2)(A)'';
            (2) by redesignating subparagraphs (A), (B), (C), and (D) 
        as clauses (i), (ii), (iii), and (iv), respectively;
            (3) in clause (iv), as redesignated--
                    (A) by striking ``paragraph (1)(E)(i)'' and 
                inserting ``paragraph (1)(B)(v)(I); and
                    (B) by striking ``paragraph (1)(E)(ii)'' and 
                inserting ``paragraph (1)(B)(v)(II)'';
            (4) by striking ``the previous sentence'' and inserting 
        ``this subparagraph''; and
            (5) by adding at the end the following new subparagraph:
    ``(B) If the Secretary determines that an issuer of a policy 
approved under paragraph (1) has made a misrepresentation to the 
Secretary or has provided the Secretary with false information 
regarding such policy, the issuer is subject to a civil money penalty 
in an amount not to exceed $100,000 for each such determination. The 
provisions of section 1128A (other than the first sentence of 
subsection (a) and other than subsection (b)) shall apply to a civil 
money penalty under this subparagraph in the same manner as such 
provisions apply to a penalty or proceeding under section 1128A(a).''.
    (d) Effective Dates.--
            (1) NAIC standards.--If, within 9 months after the date of 
        the enactment of this Act, the National Association of 
        Insurance Commissioners (hereafter in this subsection referred 
        to as the ``NAIC'') makes changes in the 1991 NAIC Model 
        Regulation (as defined in section 1882(p)(1)(A) of the Social 
        Security Act) to incorporate the additional requirements 
        imposed by the amendments made by this section, section 
        1882(g)(2)(A) of such Act shall be applied in each State, 
        effective for policies issued to policyholders on and after the 
        date specified in paragraph (3), as if the reference to the 
        Model Regulation adopted on June 6, 1979, were a reference to 
        the 1991 NAIC Model Regulation (as so defined) as changed under 
        this paragraph (such changed Regulation referred to in this 
        subsection as the ``1995 NAIC Model Regulation'').
            (2) Secretary standards.--If the NAIC does not make changes 
        in the 1991 NAIC Model Regulation (as so defined) within the 9-
        month period specified in paragraph (1), the Secretary of 
        Health and Human Services (hereafter in this subsection 
        referred to as the ``Secretary'') shall promulgate a regulation 
        and section 1882(g)(2)(A) of the Social Security Act shall be 
        applied in each State, effective for policies issued to 
        policyholders on and after the date specified in paragraph (3), 
        as if the reference to the Model Regulation adopted on June 6, 
        1979, were a reference to the 1991 NAIC Model Regulation (as so 
        defined) as changed by the Secretary under this paragraph (such 
        changed Regulation referred to in this subsection as the ``1995 
        Federal Regulation'').
            (3) Date specified.--
                    (A) In general.--Subject to subparagraph (B), the 
                date specified in this paragraph for a State is the 
                earlier of--
                            (i) the date the State adopts the 1995 NAIC 
                        Model Regulation or the 1995 Federal 
                        Regulation, or
                            (ii) 1 year after the date the NAIC or the 
                        Secretary first adopts such regulations.
                    (B) Additional legislative action required.--In the 
                case of a State which the Secretary identifies, in 
                consultation with the NAIC, as--
                            (i) requiring State legislation (other than 
                        legislation appropriating funds) in order for 
                        medicare supplemental policies to meet the 1995 
                        NAIC Model Regulation or the 1995 Federal 
                        Regulation, but
                            (ii) having a legislature which is not 
                        scheduled to meet in 1995 in a legislative 
                        session in which such legislation may be 
                        considered,
                the date specified in this paragraph is the first day 
                of the first calendar quarter beginning after the close 
                of the first legislative session of the State 
                legislature that begins on or after January 1, 1996. 
                For purposes of the previous sentence, in the case of a 
                State that has a 2-year legislative session, each year 
                of such session shall be deemed to be a separate 
                regular session of the State legislature.

                       TITLE II--STATE INNOVATION

                   Subtitle A--State Waiver Authority

SEC. 2001. STATE HEALTH REFORM PROJECTS.

    (a) Objectives.--The objectives of the waiver programs approved 
under this section shall include, but not be limited to--
            (1) achieving the goals of increased health coverage and 
        access;
            (2) containing the annual rate of growth in public and 
        private health care expenditures;
            (3) ensuring that patients receive high-quality, 
        appropriate health care; and
            (4) testing alternative reforms, such as building on the 
        private health insurance system or creating new systems, to 
        achieve the objectives of this Act.
    (b) State Health Reform Applications.--
            (1) In general.--A State may apply for--
                    (A) an alternative State health program waiver 
                under paragraph (2); or
                    (B) a limited State health care waiver under 
                paragraph (3).
            (2) Alternative state health program waivers.--
                    (A) In general.--In accordance with this paragraph, 
                each State desiring to implement an alternative State 
                health program may submit an application for waiver to 
                the Secretary for approval.
                    (B) Waiver requirements specified.--A State that 
                desires to receive a program waiver under this 
                paragraph shall prepare and submit to the Secretary, as 
                part of the application, a State health care plan that 
                shall--
                            (i) provide and describe the manner in 
                        which the State will ensure that individuals 
                        residing within the State have expanded access 
                        to health care coverage;
                            (ii) describe the number and percentage of 
                        current uninsured individuals who will achieve 
                        coverage under the alternative State health 
                        program;
                            (iii) describe the benefits package that 
                        will be provided to all classes of 
                        beneficiaries under the alternative State 
                        health program;
                            (iv) identify Federal, State, or local 
                        programs that currently provide health care 
                        services in the State and describe how such 
                        programs could be incorporated into or 
                        coordinated with the alternative State health 
                        program, to the extent practicable;
                            (v) provide that the State will develop and 
                        implement health care cost containment 
                        procedures;
                            (vi) describe the public and private sector 
                        financing to be provided for the alternative 
                        State health program;
                            (vii) estimate the amount of Federal, 
                        State, and local expenditures, as well as, the 
                        costs to business and individuals under the 
                        alternative State health program;
                            (viii) describe how the State plan will 
                        ensure the financial solvency of the 
                        alternative State health program;
                            (ix) describe any changes in eligibility 
                        for public subsidies;
                            (x) provide assurances that Federal 
                        expenditures under the alternative State health 
                        program shall not exceed the Federal 
                        expenditures which would otherwise be made in 
                        the aggregate for the entire program period;
                            (xi) provide quality control assurances and 
                        agreements as required by the Secretary;
                            (xii) provide for the development and 
                        implementation of a State health care delivery 
                        system that provides increased access to care 
                        in areas of the State where there is an 
                        inadequate supply of health care providers;
                            (xiii) identify all Federal law waivers 
                        required to implement the alternative State 
                        health program, including such waivers 
                        necessary to achieve the access, cost 
                        containment, and quality goals of this Act and 
                        the alternative State health program; and
                            (xiv) provide that the State will prepare 
                        and submit the Secretary such reports as the 
                        Secretary may require to carry out program 
                        evaluations.
                    (C) Project waivers.--
                            (i) Criteria for selection.--In selecting 
                        from among the applications for alternative 
                        State health program waivers, the Secretary 
                        shall be satisfied that each approved State 
                        alternative State health program--
                                    (I) will not have a negative effect 
                                on quality of care;
                                    (II) increase coverage of or access 
                                for the State's population; and
                                    (III) will--
                                            (aa) provide quality of 
                                        care and premium comparisons 
                                        directly to employers and 
                                        individuals in an easy-to-use 
                                        format,
                                            (bb) contract with an 
                                        external peer review 
                                        organization to monitor the 
                                        quality of health care plans, 
                                        and
                                            (cc) establish a mechanism 
                                        within the State's grievance 
                                        process that allows members of 
                                        a health plan to disenroll at 
                                        any time if it can be shown 
                                        that such members were provided 
                                        erroneous information that 
                                        biased their health plan 
                                        selection.
                            (ii) Waiver approval.--The Secretary shall 
                        approve applications submitted by States that 
                        meet the access, cost containment, and quality 
                        goals established in this Act and shall waive 
                        to the extent necessary to conduct each 
                        alternative State health program any of the 
                        requirements of this Act, including, but not 
                        limited to, eligibility requirements; 
                        alternative data collection systems and 
                        sampling designs that focus on measuring health 
                        status, patient treatment outcomes, and patient 
                        satisfaction with health plans, rather than on 
                        the collection of 100 percent of patient 
                        encounters; and benefit designs; and any 
                        provisions of Federal law contained in the 
                        following:
                                    (I) Titles V, XVIII, XIX, and XX of 
                                the Social Security Act.
                                    (II) The Public Health Service Act.
                                    (III) Any other Federal law 
                                authorizing a Federal health care 
                                program that the Secretary identifies 
                                as providing health care services to 
                                qualified recipients.
            (3) Limited state health care waivers.--Each State which 
        does not receive an approved application under paragraph (2) 
        may apply for a limited State health care waiver. The Secretary 
        shall award limited State health care waivers to ensure State 
        demonstrations of health reforms that could address, but are 
        not limited to addressing, the following issues that are likely 
        to provide guidance for the development of additional national 
        health reforms:
                    (A) Integration of acute and long-term care 
                systems, including delivery and financing systems.
                    (B) Establishment of methodologies that limit 
                expenditures or establish global budgets, including 
                rate setting and provider reimbursements.
                    (C) Implementation of a quality management and 
                improvement system.
                    (D) Strategies to improve the proper speciality and 
                geographic distribution of the health care work force.
                    (E) Initiatives to improve the population's health 
                status.
                    (F) Development of uniform health data sets that 
                emphasize the measurement of patient satisfaction, 
                treatment outcomes, and health status.
                    (G) Methods for coordinating or integrating State-
                funded programs that provide services for low-income 
                individuals, including programs authorized by this Act.
                    (H) Programs to improve public health.
                    (I) Reforms intended to reduce health care fraud 
                and abuse.
                    (J) Reforms to reduce the incidence of defensive 
                medicine and practitioner liability costs associated 
                with medical malpractice.
                    (K) Development of a uniform billing system.
    (c) Additional Rules Regarding Applications.--
            (1) Technical assistance.--The Secretary shall, if 
        requested, provide technical assistance to States to assist 
        such States in developing waiver applications under this 
        section.
            (2) Initial review.--The Secretary shall complete an 
        initial review of each State application for a waiver under 
        paragraph (2) or (3) of subsection (b) within 40 days of the 
        receipt of such application, analyze the scope of the proposal, 
        and determine whether additional information is needed from the 
        State. The Secretary shall issue a preliminary opinion 
        concerning the likelihood that the application will be approved 
        within such 40-day period and shall advise the State within 
        such period of the need to submit additional information.
            (3) Final decision.--The Secretary shall, within 90 days of 
        the later of--
                    (A) the receipt of a State application for a waiver 
                under paragraph (2) or (3) of subsection (b), or
                    (B) the date on which the Secretary receives 
                additional information requested from a State under 
                paragraph (1),
        issue a final decision concerning such application.
            (4) Waiver period.--A State waiver may be approved for a 
        period of 5 years and may be extended for subsequent 5-year 
        periods upon approval by the Secretary, except that a shorter 
        period may be requested by a State and granted by the 
        Secretary.
    (d) Qualification for Federal Funds.--For purposes of this Act, a 
State with an approved alternative health care system under subsection 
(b)(2) shall be considered a participating State and shall maintain 
such status if such State meets the requirements established by the 
Secretary in the waiver approval and in this section.
    (e) Evaluation, Monitoring, and Compliance.--
            (1) State health reform advisory board.--Within 90 days 
        after the date of the enactment of this Act, the Secretary 
        shall establish a 7-member State Health Reform Advisory Board 
        (hereafter in this subsection referred to as the ``Board'') 
        that will be responsible for monitoring the status and progress 
        achieved under waivers granted under this section and promoting 
        information exchange between States and the Federal Government. 
        The Board shall be comprised of members representing relevant 
        participants in State programs, including representatives of 
        State government, employers, consumers, providers, and 
        insurers. The Board shall also be responsible for making 
        recommendations to the Secretary, using equivalency or minimum 
        standards, for minimizing the negative effect of State waivers 
        on national employer groups, provider organizations, and 
        insurers because of differing State requirements under the 
        waivers.
            (2) Annual reports by states.--Each State that has received 
        a waiver approval shall submit to the Secretary an annual 
        report based on the period representing the respective State's 
        fiscal year, detailing compliance with the requirements 
        established by the Secretary in the waiver approval and in this 
        section.
            (3) Corrective action plans.--If a State is not in 
        compliance, the Secretary shall develop, in conjunction with 
        all the approved States, a corrective action plan.
            (4) Termination.--For good cause, the Secretary may revoke 
        any waiver of Federal law granted under this section, and if 
        necessary, may terminate any alternative State health program. 
        Such decisions shall be subject to a petition for 
        reconsideration and appeal pursuant to regulations established 
        by the Secretary.
            (5) Evaluations by secretary.--The Secretary shall prepare 
        and submit to the Committee on Finance and the Committee on 
        Labor and Human Resources of the Senate and the Committee on 
        Energy and Commerce and the Committee on Ways and Means of the 
        House of Representatives annual reports that shall contain--
                    (A) a description of the effects of the reforms 
                undertaken in States receiving waiver approvals under 
                this section;
                    (B) an evaluation of the effectiveness of such 
                reforms in--
                            (i) expanding health care coverage for 
                        State residents;
                            (ii) providing health care to State 
                        residents with special needs;
                            (iii) reducing or containing health care 
                        costs in the States; and
                            (iv) improving the quality of health care 
                        provided in the States; and
                    (C) recommendations regarding the advisability of 
                increasing Federal financial assistance for State 
                alternative State health program initiatives, including 
                the amount and source of such assistance.
    (f) Funding.--
            (1) In general.--The Secretary may provide a grant to a 
        State that has an application for a waiver approved under this 
        section to enable such State to carry out an alternative State 
        health program in the State.
            (2) Amount of grant.--The amount of a grant provided to a 
        State under paragraph (1) shall be determined pursuant to an 
        allocation formula established by the Secretary.
            (3) Priority.--In awarding grants under paragraph (1), the 
        Secretary shall give priority to those State projects that the 
        Secretary determines have the greatest opportunity to succeed 
        in providing expanded health insurance coverage and in 
        providing children and youth with access to health care items 
        and services.
            (4) Maintenance of effort.--A State, in utilizing the 
        proceeds of a grant received under paragraph (1), shall 
        maintain the expenditures of the State for health care coverage 
        purposes at a level equal to not less than the level of such 
        expenditures maintained by the State for the fiscal year 
        preceding the fiscal year for which the grant is received. The 
        requirement of this paragraph shall not apply in the case of a 
        State that desires to alter health care coverage funding levels 
        within the scope of the State's alternative health program.
            (5) Report.--At the end of the 5-year period beginning on 
        the date on which the Secretary awards the first grant under 
        paragraph (1), the State Health Reform Advisory Board 
        established under subsection (e)(1) shall prepare and submit to 
        the appropriate committees of Congress, a report on the 
        progress made by States receiving grants under paragraph (1) in 
        achieving universal health care coverage in such States during 
        the 5-year period of the grant. Such report shall contain the 
        recommendation of the Board concerning any future action that 
        Congress should take concerning health care reform, including 
        whether or not to extend the program established under this 
        subsection.
    (g) Availability of Funds.--With respect to each of the calendar 
years 1996 through 2000, $10,000,000,000 shall be available for a 
calendar year to carry out this section from the Health Care Reform 
Trust Fund established under section 9551(a)(2)(A) of the Internal 
Revenue Code of 1986. Amounts made available in a calendar year under 
this paragraph and not expended may be used in subsequent calendar 
years to carry out this section.
    (h) Amendment to Criminal Penalties for Acts Involving Medicare or 
State Health Care Programs.--Section 1128B(b) of the Social Security 
Act (42 U.S.C. 1320a-7b(b)) is amended by adding at the end the 
following new paragraph:
    ``(4) Paragraphs (1) and (2) shall not apply to--
            ``(A) any payment to a health insurer or health maintenance 
        organization for which the premium is paid in whole or in part 
        by a State health care program; and
            ``(B) any payment made by a health insurer or a health 
        maintenance organization to a sales representative or a 
        licensed insurance agent as compensation for the services of 
        the representative or agent in marketing and enrolling an 
        individual in a health plan for which the premium is paid in 
        whole or in part by a State health care program.''.

                    Subtitle B--Existing State Laws

SEC. 2101. CONTINUANCE OF EXISTING FEDERAL LAW WAIVERS.

    Nothing in this Act shall preempt any feature of a State health 
care system operating under a waiver granted before the date of the 
enactment of this Act under titles XVIII or XIX of the Social Security 
Act (42 U.S.C. 1395 et seq. or 1396 et seq.) or the Employee Retirement 
Income Security Act of 1974 (29 U.S.C. 1001 et seq.).

SEC. 2102. HAWAII PREPAID HEALTH CARE ACT.

    (a) ERISA Waiver.--
            (1) In general.--Section 514(b)(5) of the Employee 
        Retirement Income Security Act of 1974 (29 U.S.C. 1144(b)(5)) 
        is amended to read as follows:
            ``(5)(A) Except as provided in subparagraphs (B) and (C), 
        subsection (a) shall not apply to the Hawaii Prepaid Health 
        Care Act (Haw. Rev. Stat. Sec. Sec. 393-1 through 393-51).
            ``(B) Nothing in subparagraph (A) shall be construed to 
        exempt from subsection (a) any State tax law relating to 
        employee benefits plans.
            ``(C) If the Secretary of Labor notifies the Governor of 
        the State of Hawaii that as the result of an amendment to the 
        Hawaii Prepaid Health Care Act enacted after the date of the 
        enactment of this paragraph--
                    ``(i) the proportion of the population with health 
                care coverage under such Act is less than such 
                proportion on such date, or
                    ``(ii) the level of benefit coverage provided under 
                such Act is less than the actuarial equivalent of such 
                level of coverage on such date,
        subparagraph (A) shall not apply with respect to the 
        application of such amendment to such Act after the date of 
        such notification.''.
            (2) Effective date.--The amendment made by paragraph (1) 
        shall take effect on the date of the enactment of this Act.
    (b) HSA Waiver.--
            (1) In general.--The Secretary shall, at the request of the 
        Governor of the State of Hawaii and in accordance with this 
        section, grant a waiver to the State from the requirements of 
        this Act (other than the requirements specified in paragraph 
        (3)).
            (2) Scope of waiver.--The waiver granted under paragraph 
        (1) shall exempt--
                    (A) the State of Hawaii;
                    (B) health plans offered within the State; and
                    (C) health plan participants, including employers, 
                employees, residents, and health plan sponsors within 
                the State,
        from requirements otherwise applicable to the State and such 
        plans and participants.
            (3) Required compliance of other requirements.--The waiver 
        shall initially be granted under paragraph (1) if the State of 
        Hawaii demonstrates to the Secretary that the State maintains--
                    (A) a requirement that employers make premium 
                contributions in accordance with the requirements of 
                title I;
                    (B) a comprehensive benefit package (including cost 
                sharing) that is comparable with the requirements of 
                title I;
                    (C) a percentage of State population with health 
                care coverage that is not less than the national 
                average;
                    (D) a quality control mechanism and data system; 
                and
                    (E) health care cost containment consistent with 
                the provisions of title I.
            (4) Waiver period.--The waiver initially granted under 
        paragraph (1) shall extend for the period during which the 
        State of Hawaii continues to comply with the requirements 
        specified in paragraph (3). The Secretary may require the 
        State, every 5 years, to demonstrate to the Secretary the 
        State's continued compliance with such requirements.
            (5) Procedure in the event of non-compliance.--
                    (A) Notice.--If, at any time after granting a 
                waiver under paragraph (1), the Secretary finds that 
                the State of Hawaii is not meeting the requirements 
                specified in paragraph (3), the Secretary shall notify 
                the State of the Secretary's findings.
                    (B) Opportunity to contest.--The State may contest 
                the Secretary's findings.
                    (C) Opportunity for correction.--
                            (i) Findings not contested.--If the State 
                        does not contest the Secretary's findings 
                        within the 30-day period beginning on the date 
                        of receipt of a notice of such findings, the 
                        State shall have--
                                    (I) a 90-day period beginning on 
                                such date to show a good faith effort 
                                to remedy the non-compliance, and
                                    (II) an additional 12-month period 
                                to take such actions as may be required 
                                to bring the State into compliance with 
                                the requirements specified in paragraph 
                                (3).
                            (ii) Contested findings.--If the State 
                        contests the Secretary's findings within such 
                        30-day period but such findings are upheld, the 
                        State shall have--
                                    (I) a 90-day period beginning on 
                                the date of final adjudication to show 
                                a good faith effort to remedy the non-
                                compliance, and
                                    (II) an additional 12-month period 
                                to take such actions as may be required 
                                to bring the State into compliance with 
                                the requirements specified in paragraph 
                                (3).
                    (D) Termination.--If the State fails to demonstrate 
                a good faith effort under subparagraph (C)(i)(I) or 
                (C)(ii)(I) or to take actions under subparagraph 
                (C)(i)(II) or (C)(ii)(II) within the time period 
                specified, the Secretary may revoke the waiver granted 
                in paragraph (1).
            (6) Cooperative agreement with the secretary.--The 
        Secretary shall enter into cooperative agreements with 
        appropriate officials of the State of Hawaii--
                    (A) to develop standards and reporting requirements 
                necessary for the issuance and maintenance of the 
                State's waiver under paragraph (1); and
                    (B) otherwise to effectuate the provisions of this 
                subsection.
            (7) Eligibility for federal funds provided to participating 
        states.--Nothing in this subsection shall preclude the 
        eligibility of the State of Hawaii to participate in any public 
        health initiative, grant, or financial aid program under this 
        Act (including the medicaid program under title XIX of the 
        Social Security Act), designed to implement the purpose of this 
        Act. The Secretary shall work with appropriate officials of the 
        State of Hawaii to develop comparable, alternative standards to 
        govern the State's entitlement under title XI.

SEC. 2103. ALTERNATIVE STATE PROVIDER PAYMENT SYSTEMS.

    Notwithstanding any other provision of law, if a hospital 
reimbursement system operated by a State meets the requirements of 
section 1814(b) of the Social Security Act (42 U.S.C. 1395f(b)) and has 
been approved by the Secretary and in continuous operation since July 
1, 1977, the payment rates and methodologies required under the system 
for services provided in the State shall apply to all purchasers and 
payers, including those under employee welfare benefit plans authorized 
under the Employee Retirement Income Security Act of 1974 (29 U.S.C. 
1001 et seq.), workers' compensation programs under State law, the 
Federal Employees' Compensation Act under chapter 81 of title 5, United 
States Code, and Federal employee health benefit plans under chapter 89 
of title 5, United States Code.

SEC. 2104. ALTERNATIVE STATE HOSPITAL SERVICES PAYMENT SYSTEMS.

    (a) In General.--No State shall be prevented from enforcing--
            (1) a State system described in subsection (b), or
            (2) a State system described in subsection (c),
by any provision of the Employee Retirement Income Security Act of 1974 
(29 U.S.C. 1001 et seq.) or chapter 81 or 89 of title 5, United States 
Code.
    (b) Reimbursement Control System.--A State system is described in 
this subsection if it is a State reimbursement control system in 
operation before the date of the enactment of this Act which--
            (1) applies to substantially all non-Federal acute care 
        hospitals in the State, and
            (2) regulates substantially all rates of payment (including 
        maximum charges) in the State for inpatient hospital services, 
        except payments made under title XVIII of the Social Security 
        Act (42 U.S.C. 1395 et seq.).
    (c) Health Insurance Reform System.--A State system is described in 
this subsection if it is a State health insurance reform system in 
operation before the date of the enactment of this Act which requires 
any insurer (including a health maintenance organization) to comply 
with requirements governing open enrollment and community rating, 
including premium adjustments or other health care assessments for the 
purpose of risk adjustment.
    (d) Effective Dates.--
            (1) Subsection (b).--In the case of a State system 
        described in subsection (b), the provisions of this section 
        shall apply before, on, and after the date of the enactment of 
        this Act.
            (2) Subsection (c).--In the case of a State system 
        described in subsection (c), the provisions of this section 
        shall apply before, on, and after the date of the enactment of 
        this Act, and before the date of enactment of this Act.

SEC. 2105. EXEMPTION FROM ERISA PREEMPTION OF CERTAIN PROVISIONS OF THE 
              LAW OF THE STATE OF OREGON RELATING TO HEALTH PLANS.

    (a) In General.--Section 514(b) of the Employee Retirement Income 
Security Act of 1974 (29 U.S.C. 1144(b)) is amended by adding at the 
end the following new paragraph:
    ``(9)(A) Subject to subparagraph (B), subsection (a) shall not 
apply to the following provisions of the law of the State of Oregon as 
applied to a group health plan:
            ``(i) Chapter 838, Oregon Laws 1989 (relating to the 
        creation and operation of a high-risk insurance pool).
            ``(ii) Chapter 591, Oregon Laws 1987, chapter 381, Oregon 
        Laws 1989, and chapter 916, Oregon Laws 1991 (relating to 
        employer-based health plan coverage reforms).
            ``(iii) Chapter 470, Oregon Laws 1991 (relating to health 
        care cost containment and technology assessment).
            ``(iv) Chapter 836, Oregon Laws 1989 and chapter 753, 
        Oregon Laws 1991 (relating to prioritization and medical 
        assistance reforms).
            ``(v) Chapter 815, Oregon Laws 1993 (relating to phasing in 
        of employer coverage and other revisions of the Oregon Health 
        Plan).
            ``(vi) Any other provision of the law of the State of 
        Oregon, to the extent that such provision is necessary to 
        achieve universal coverage under the Oregon Health Plan.
    ``(B) Subparagraph (A) shall apply with respect to any provision of 
the law of the State of Oregon which provides, directly or indirectly, 
for taxation of employers or group health plans only if under such 
provision the assessment of the tax is under a uniform schedule, 
applicable to all employers and group health plans, and does not 
discriminate on the basis of the extent to which a group health plan is 
insured.
    ``(C) For purposes of this paragraph, the term `group health plan' 
has the meaning provided in section 607(1).''.
    (b) Applicability of Federal Health Reform Legislation.--The State 
of Oregon shall not be treated as failing to comply with applicable 
requirements of any Federal health reform law, which is enacted on or 
after the date of the enactment of this Act and which provides for 
coverage of individuals under a comprehensive benefit package, before 
the first day of the first calendar year following the calendar year in 
which all other States have in effect plans under which individuals are 
eligible for coverage under a comprehensive benefit package in 
compliance with such law.

SEC. 2106. EXEMPTION FROM ERISA PREEMPTION OF CERTAIN PROVISIONS OF THE 
              LAW OF THE STATE OF MINNESOTA RELATING TO HEALTH PLANS.

    (a) ERISA Waiver.--
            (1) In general.--Section 514(b)(5) of the Employee 
        Retirement Income Security Act of 1974 (29 U.S.C. 1144(b)(5)) 
        is amended to read as follows:
    ``(5)(A)(i) Except as provided in clauses (ii) and (iii), 
subsection (a) shall not apply to the following provisions of the law 
of the State of Minnesota:
            ``(I) Sections 295.50 through 295.59 Minnesota Statutes 
        relating to gross revenues, hospitals and health care surgical 
        centers and pass through of such tax.
            ``(II) Sections 62J.30 through 62.J.45 Minnesota Statutes 
        relating to data to the extent those provisions authorize or 
        require submission of data by health care providers, health 
        insurers, health maintenance organizations, or third party 
        administrators.
    ``(ii) Nothing in clause (i) shall be construed to exempt from 
subsection (a)--
            ``(I) any State tax law relating to employee benefit plans 
        (other than a provision described in clause (i)), and
            ``(II) any amendment of any provision referred to in clause 
        (i) enacted on or after May 31, 1994; to the extent it provides 
        for more than the effective administration of such provision as 
        in effect on such date.
    ``(iii) Notwithstanding clause (i), parts 1 and 4 of this subtitle, 
and the preceding sections of this part to the extent they govern 
matters which are governed by the provisions of such parts 1 and 4, 
shall supersede the provisions described in clause (i) (as in effect on 
or after May 31, 1994), but the Secretary may enter into cooperative 
arrangements under this subparagraph and section 506 with officials of 
the State of Minnesota to assist them in effectuating the policies of 
such provisions which are superseded by such parts 1 and 4 and the 
preceding sections of this part.''.

SEC. 2107. EXEMPTION FROM ERISA PREEMPTION OF CERTAIN PROVISIONS OF THE 
              LAW OF THE STATE OF WASHINGTON RELATING TO HEALTH PLANS.

    Section 514(b) of the Employee Retirement Income Security Act of 
1974 (29 U.S.C. 1144(b)) is amended by adding at the end of the 
following new paragraph:
    ``(9) Subsection (a) of this section shall not apply to the 
following provisions of the law of the State of Washington--
            ``(A) section 212 of Chapter 492, Laws of 1993 (relating to 
        enrollment of certain employees in the Washington basic health 
        plan);
            ``(B) sections 301 and 304 of Chapter 492, Laws of 1993 
        (relating to taxation of premiums and hospitals);
            ``(C) sections 406(7) and 454 of Chapter 492, Laws of 1993 
        (relating to medical risk adjustment mechanisms);
           ``(D) section 427 of Chapter 492, Laws of 1993 (relating to 
        benefits required to be offered by registered employer health 
        plans);
            ``(E) section 430 of Chapter 492, Laws of 1993 (relating to 
        requirements applicable to registered employer health plans); 
        and
            ``(F) section 464 of Chapter 492, Laws of 1993, as amended 
        by section 3 of Chapter 494, Laws of 1993 (relating to 
        requirements that employers offer and pay a portion of the 
        costs of employee health care coverage).''.

SEC. 2108. EXEMPTION FROM ERISA PREEMPTION OF CERTAIN PROVISIONS OF THE 
              LAW OF THE STATE OF CONNECTICUT RELATING TO HEALTH PLANS.

    Section 514(b) of the Employee Retirement Income Security Act (29 
U.S.C. 1144(b)) is amended by adding at the end of the following new 
subsection:
    ``(9) Subsection (a) of this section shall not apply to any State 
law enacted in the State of Connecticut in accordance with Public Law 
102-234 which taxes or otherwise assesses short-term acute care 
hospitals for the purpose of providing funds to be used to pay for the 
cost of uncompensated care. This subsection shall take effect January 
1, 1992.''.

 TITLE III--PUBLIC HEALTH AND RURAL AND UNDERSERVED ACCESS IMPROVEMENT

SEC. 3001. SHORT TITLE.

    This title may be cited as the ``Public Health and Rural and 
Underserved Access Improvement Act of 1994''.

SEC. 3002. ESTABLISHMENT OF NEW TITLE XXVII REGARDING PUBLIC HEALTH 
              PROGRAMS.

    The Public Health Service Act (42 U.S.C. 201 et seq.) is amended by 
adding at the end the following title:

           ``TITLE XXVII--PUBLIC HEALTH PROGRAMS IMPROVEMENT

         ``Subtitle A--Core Functions of Public Health Programs

                   ``PART 1--FORMULA GRANTS TO STATES

``SEC. 2711. AUTHORIZATIONS OF APPROPRIATIONS FROM FUND.

    ``For the purpose of carrying out this subtitle, there are 
authorized to be appropriated from the Health Care Reform Trust Fund 
established under section 9551(a)(2)(A) of the Internal Revenue Code of 
1986 (hereafter referred to in this title as the ``Fund''), 
$200,000,000 for fiscal year 1996, $350,000,000 for fiscal year 1997, 
$500,000,000 for fiscal year 1998, $650,000,000 for fiscal year 1999, 
and $700,000,000 for fiscal year 2000.

``SEC. 2712. FORMULA GRANTS TO STATES FOR CORE HEALTH FUNCTIONS.

    ``(a) In General.--In the case of each State that submits to the 
Secretary an application in accordance with section 2715 for a fiscal 
year, the Secretary of Health and Human Services, acting through the 
Director of the Centers for Disease Control and Prevention, shall make 
a grant to the State for carrying out the activities described in 
subsection (c). The award shall consist of the allotment determined 
under section 2716 for the State.
    ``(b) General Purpose.--The purpose of this subtitle is to provide 
for improvements in the health status of the public through carrying 
out the activities described in subsection (b) toward attaining the 
Healthy People 2000 Objectives (as defined in section 2799). A funding 
agreement for a grant under subsection (a) is that--
            ``(1) the grant will be expended for such activities; and
            ``(2) the activities will be carried out by the State in 
        collaboration with local public health departments, health 
        education and training centers, neighborhood health centers, 
        and other community health providers.
    ``(c) Core Functions of Public Health Programs.--Subject to the 
purpose described in subsection (b), the activities referred to in 
subsection (a) are the following:
            ``(1) Data collection, and analytical activities, related 
        to population-based status and outcomes monitoring, including 
        the following:
                    ``(A) The regular collection and analysis of public 
                health data (including the 10 leading causes of death 
                and their costs to society).
                    ``(B) Vital statistics.
                    ``(C) Personal health services data.
                    ``(D) The supply and distribution of health 
                professionals.
            ``(2) Activities to reduce environmental risk and to assure 
        the safety of housing, schools, workplaces, day-care centers, 
        food and water, including the following activities:
                    ``(A) Monitoring the overall public health status 
                and safety of communities.
                    ``(B) Assessing exposure to high lead levels and 
                other environmental contaminants; and activities for 
                abatement of toxicant hazards, including lead-related 
                hazards.
                    ``(C) Monitoring the quality of community water 
                supplies used for consumption or for recreational 
                purposes.
                    ``(D) Monitoring sewage and solid waste disposal, 
                radiation exposure, radon exposure, and noise levels.
                    ``(E) Monitoring indoor and ambient air quality and 
                related risks to vulnerable populations.
                    ``(F) Assuring recreation, worker, and school 
                safety.
                    ``(G) Enforcing public health safety and sanitary 
                codes.
                    ``(H) Monitoring community access to appropriate 
                health services.
                    ``(I) Other activities relating to promoting and 
                protecting the public health of communities.
            ``(3) Investigation, control, and public-awareness 
        activities regarding adverse health conditions (such as 
        emergency treatment preparedness, community efforts to reduce 
        violence, outbreaks of communicable diseases within 
        communities, chronic disease and dysfunction exposure-related 
        conditions, toxic environmental pollutants, occupational and 
        recreational hazards, motor vehicle accidents, and other 
        threats to the health status of individuals).
            ``(4) Public information and education programs to reduce 
        risks to health (such as use of tobacco;, alcohol and other 
        drugs; unintentional injury from accidents, including motor 
        vehicle accidents; sexual activities that increase the risk to 
        HIV transmission and sexually transmitted diseases; poor diet; 
        physical inactivity; stress-related illness; mental health 
        problems; genetic disorders; and low childhood immunization 
        levels).
            ``(5) Provision of public health laboratory services to 
        complement private clinical laboratory services and that screen 
        for diseases and conditions (such as metabolic diseases in 
        newborns, provide assessments of blood lead levels and other 
        environmental toxicants, diagnose and contact tracing of 
        sexually transmitted diseases, tuberculosis and other diseases 
        requiring partner notification, test for infectious and food-
        borne diseases, and monitor the safety of water and food 
        supplies).
            ``(6) Training and education of new and existing health 
        professionals in the field of public health, with special 
        emphasis on epidemiology, biostatistics, health education, 
        public health administration, public health nursing and 
        dentistry, environmental and occupational health sciences, 
        public health nutrition, social and behavioral health sciences, 
        operations research, and laboratory technology.
            ``(7) Leadership, policy development and administration 
        activities, including assessing needs and the supply and 
        distribution of health professionals; the setting of public 
        health standards; the development of community public health 
        policies; and the development of community public health 
        coalitions.
    ``(d) Restrictions on Use of Grant.--
            ``(1) In general.--A funding agreement for a grant under 
        subsection (a) for a State is that the grant will not be 
        expended--
                    ``(A) to provide inpatient services;
                    ``(B) to make cash payments to intended recipients 
                of health services;
                    ``(C) to purchase or improve land, purchase, 
                construct, or permanently improve (other than minor 
                remodeling) any building or other facility, or purchase 
                major medical equipment;
                    ``(D) to satisfy any requirement for the 
                expenditure of non-Federal funds as a condition for the 
                receipt of Federal funds; or
                    ``(E) to provide financial assistance to any entity 
                other than a public or nonprofit private entity.
            ``(2) Limitation on administrative expenses.--A funding 
        agreement for a grant under subsection (a) is that the State 
        involved will not expend more than 20 percent of the grant for 
        administrative expenses with respect to the grant.
    ``(e) Maintenance of Effort.--A funding agreement for a grant under 
subsection (a) is that the State involved will maintain expenditures of 
non-Federal amounts for core health functions at a level that is not 
less than the level of such expenditures maintained by the State for 
the fiscal year preceding the first fiscal year for which the State 
receives such a grant.

``SEC. 2713. NUMBER OF FUNCTIONS; PLANNING.

    ``(a) Number of Functions.--Subject to subsection (b), a funding 
agreement for a grant under section 2712 is that the State involved 
will carry out each of the activities described in subsection (c) of 
such section.
    ``(b) Planning.--In making grants under section 2712, the Secretary 
shall for each State designate a period during which the State is to 
engage in planning to meet the responsibilities of the State under 
subsection (a). The period so designated may not exceed 18 months. With 
respect to such period for a State, a funding agreement for a grant 
under section 2712 for any fiscal year containing any portion of the 
period is that, during the period, the State will expend the grant only 
for such planning.

``SEC. 2714. SUBMISSION OF INFORMATION; REPORTS.

    ``(a) Submission of Information.--The Secretary may make a grant 
under section 2712 only if the State involved submits to the Secretary 
the following information:
            ``(1) A description of the relationship between community 
        health providers, public and private health plans, and the 
        public health system of the State.
            ``(2) A description of existing deficiencies in the public 
        health system at the State level and the local level, using 
        standards under the Healthy People 2000 Objectives.
            ``(3) A description of public health priorities identified 
        at the State level and local levels, including the 10 leading 
        causes of death and their respective direct and indirect costs 
        to the State and the Federal Government.
            ``(4) Measurable outcomes and process objectives (using 
        criteria under the Healthy People 2000 Objectives) which 
        indicate improvements in health status as a result of the 
        activities carried out under section 2712(c).
            ``(5) Information regarding each such activity, which--
                    ``(A) identifies the amount of State and local 
                funding expended on each such activity for the fiscal 
                year preceding the fiscal year for which the grant is 
                sought; and
                    ``(B) provides a detailed description of how 
                additional Federal funding will improve each such 
                activity by both the State and local public health 
                agencies.
            ``(6) A description of activities under section 2712(c) to 
        be carried out at the local level, and a specification for each 
        such activity of--
                    ``(A) the communities in which the activity will be 
                carried out and any collaborating agencies; and
                    ``(B) the amount of the grant to be expended for 
                the activity in each community so specified.
            ``(7) A description of how such activities have been 
        coordinated with activities supported under title V of the 
        Social Security Act (relating to maternal and child health).
    ``(b) Reports.--A funding agreement for a grant under section 2712 
is that the States involved will, not later than the date specified by 
the Secretary, submit to the Secretary a report describing--
            ``(1) the purposes for which the grant was expended;
            ``(2) the health status of the population of the State, as 
        measured by criteria under the Healthy People 2000 Objectives; 
        and
            ``(3) the progress achieved and obstacles encountered in 
        using uniform data sets under such Objectives.

``SEC. 2715. APPLICATION FOR GRANT.

    ``The Secretary may make a grant under section 2712 only if an 
application for the grant is submitted to the Secretary, the 
application contains each agreement described in this part, the 
application contains the information required in section 2712(c), and 
the application is in such form, is made in such manner, and contains 
such agreements, assurances, and information as the Secretary 
determines to be necessary to carry out this part.

``SEC. 2716. DETERMINATION OF AMOUNT OF ALLOTMENT.

    ``For purposes of section 2712, the allotment under this section 
for a State for a fiscal year shall be determined through a formula 
established by the Secretary on the basis of the population, economic 
indicators, and health status of each State. Such allotment shall be 
the product of--
            ``(1) a percentage determined under the formula; and
            ``(2) the amount appropriated under section 2711 for the 
        fiscal year, less any amounts reserved under section 2717.

``SEC. 2717. ALLOCATIONS FOR CERTAIN ACTIVITIES.

    ``Of the amounts made available under section 2711 for a fiscal 
year for carrying out this part, the Secretary may reserve not more 
than 15 percent for carrying out the following activities:
            ``(1) Technical assistance with respect to planning, 
        development, and operation of activities under section 2712(b), 
        including provision of biostatistical and epidemiological 
        expertise, provision of laboratory expertise, and the 
        development of uniform data sets under the Health People 2000 
        Objectives.
            ``(2) Development and operation of a national information 
        network among State and local health agencies for utilizing 
        such uniform data sets.
            ``(3) Program monitoring and evaluation of activities 
        carried out under section 2712(b).
            ``(4) Development of a unified electronic reporting 
        mechanism to improve the efficiency of administrative 
        management requirements regarding the provision of Federal 
        grants to State public health agencies.

  ``PART 2--COMPREHENSIVE EVALUATION OF DISEASE PREVENTION AND HEALTH 
                           PROMOTION PROGRAMS

``SEC. 2718. AUTHORIZATIONS OF APPROPRIATIONS FROM FUND.

    ``For the purpose of carrying out this part, there are authorized 
to be appropriated from the Fund, $100,000,000 for fiscal year 1996, 
and $150,000,000 for each of the fiscal years 1997 through 2000.

``SEC. 2719. EVALUATION OF PROGRAMS.

    ``(a) Grants.--The Secretary may make grants to, or enter into 
cooperative agreements or contracts with, eligible entities for the 
purpose of enabling such entities to carry out evaluations of the type 
described in subsection (c). The Secretary shall carry out this section 
acting through the Director of the Centers for Disease Control and 
Prevention, subject to subsection (g).
    ``(b) Requirements.--
            ``(1) Eligible entities.--To be eligible to receive an 
        award of a grant, cooperative agreement, or contract under 
        subsection (a), an entity must--
                    ``(A) be a public, nonprofit, or private entity or 
                a university;
                    ``(B) prepare and submit to the Secretary an 
                application at such time, in such form, and containing 
                such information as the Secretary may require, 
                including a plan for the conduct of the evaluation 
                under the grant;
                    ``(C) provide assurances that any information 
                collected while conducting evaluations under this 
                section will be maintained in a confidential manner 
                with respect to the identities of the individuals from 
                which such information is obtained; and
                    ``(D) meet any other requirements that the 
                Secretary determines to be appropriate.
            ``(2) Types of entities.--In making awards under subsection 
        (a), the Secretary shall consider applications from entities 
        proposing to conduct evaluations using community programs, 
        managed care programs, State and county health departments, 
        public education campaigns, school programs, and other 
        appropriate programs. The Secretary shall ensure that not less 
        than 25 percent of the amounts appropriated under section 2718 
        for a fiscal year are used for making such awards to entities 
        that will use the amounts to conduct evaluations in the 
        workplace.
    ``(c) Use of Funds.--
            ``(1) Evaluations.--An award under subsection (a) shall be 
        used to--
                    ``(A) conduct evaluations to determine the extent 
                to which clinical preventive services, health promotion 
                and unintentional injury prevention activities, and 
                interpersonal and community violence prevention 
                activities, achieve short-term and long-term health 
                care cost reductions and health status improvement with 
                respect to the Healthy People 2000 Objectives; and
                    ``(B) evaluate other areas determined appropriate 
                by the Secretary.
            ``(2) Inclusion of certain population groups.--In carrying 
        out this section, the Secretary shall ensure that data 
        concerning women, children, minorities, older individuals with 
        different income levels, retirees, and individuals from diverse 
        geographical backgrounds, are obtained.
            ``(3) Minimum services.--The evaluations that the Secretary 
        may provide for under this section include (but are not limited 
        to) evaluations of programs that provide one or more of the 
        following services:
                    ``(A) Blood pressure screening and control (to 
                detect and control hypertension and coronary health 
                disease).
                    ``(B) Early cancer screening.
                    ``(C) Blood cholesterol screening and control.
                    ``(D) Smoking cessation programs.
                    ``(E) Substance abuse programs.
                    ``(F) Dietary and nutrition counseling, including 
                nutrition.
                    ``(G) Physical fitness counseling.
                    ``(H) Stress management.
                    ``(I) Diabetes education and screening.
                    ``(J) Intraocular pressure screening.
                    ``(K) Monitoring of prescription drug use.
                    ``(L) Violence and injury prevention programs.
                    ``(M) Health education.
                    ``(N) Immunization rates.
            ``(4) Environmental data.--Evaluations conducted under this 
        section may consider the health effects and cost-effectiveness 
        of certain environmental programs, including fluoridation 
        programs, traffic safety programs, pollution control programs, 
        accident prevention programs, and antismoking programs.
            ``(5) Public policies.--Evaluations conducted under this 
        section may consider the effects of prevention-oriented social 
        and economic policies on improvement of health status and their 
        long-term cost effectiveness.
            ``(6) Use of existing data.--In conducting evaluations 
        under this section, entities shall use existing data and health 
        promotion and screening programs where practicable.
            ``(7) Cooperation.--In providing for an evaluation under 
        this section, the Secretary shall encourage the recipient of 
        the award and public and private entities with relevant 
        expertise (including State and local agencies) to collaborate 
        for purposes of conducting the evaluation.
    ``(d) Sites.--Recipients of awards under subsection (a) shall 
select evaluation sites under the award that present the greatest 
potential for new and relevant knowledge. Such recipients, in selecting 
such sites, shall ensure that--
            ``(1) the sites provide evidence of pilot testing, process 
        evaluation, formative evaluation, availability assessment 
        strategies and results;
            ``(2) the sites provide evidence of a clear definition of 
        the program and protocols for the implementation of the 
        evaluation; and
            ``(3) the sites provide evidence of valid, appropriate and 
        feasible assessment methods and tools and a willingness to use 
        common data items and instruments across such sites.
    ``(e) Reporting Requirements.--Not later than 1 year after an 
entity first receives an award under subsection (a), and not less than 
once during each 1-year period thereafter for which such an award is 
made to the entity, the entity shall prepare and submit to the 
Secretary a report containing a description of the activities under 
this section conducted during the period for which the report is 
prepared, and the findings derived as a result of such activities.
    ``(f) Term of Evaluations.--Evaluations conducted under this 
section shall be for a period of not less than 3 years and may continue 
as necessary to permit the grantee to adequately measure the full 
benefit of the evaluations.
    ``(g) Dissemination and Guidelines.--
            ``(1) Consultation.--The Secretary shall carry out this 
        subsection acting through the Director of the Centers for 
        Disease Control and Prevention and the Administrator for Health 
        Care Policy and Research.
            ``(2) Guidelines.--The Secretary shall, where feasible and 
        practical, develop and issue practice guidelines that are based 
        on the results of evaluations conducted under this section. The 
        practice guidelines shall be developed by the Secretary 
        utilizing expert practitioners to assist in the development and 
        implementation of these guidelines.
            ``(3) Data.--
                    ``(A) In general.--The Secretary shall collect, 
                store, analyze, and make available data related to the 
                formulation of the guidelines that is provided to the 
                Centers for Disease Control and Prevention by entities 
                conducting evaluations under this section.
                    ``(B) Use of data.--The Secretary shall--
                            ``(i) identify activities that prevent 
                        disease, illness, injury and disability, and 
                        promote good health practices; ascertain their 
                        cost-effectiveness; and identify their 
                        potential to overall health status with respect 
                        to Healthy People 2000 Objectives;
                            ``(ii) disseminate practice guidelines to 
                        State and county health departments, State 
                        insurance departments, insurance companies, 
                        employers, professional medical organizations, 
                        and others determined appropriate by the 
                        Secretary; and
                            ``(iii) provide information with respect to 
                        recidivism rates of participation in the 
                        evaluations.
            ``(4) Dissemination.--The Secretary may disseminate 
        information collected from evaluations under this section.
    ``(h) Limitation.--Amounts appropriated for carrying out this 
section shall not be utilized to provide services.

``Subtitle B--Opportunities for Education and Training in Public Health

``PART 1--SCHOLARSHIP AND LOAN REPAYMENT PROGRAMS REGARDING SERVICE IN 
                        PUBLIC HEALTH POSITIONS

``SEC. 2721. AUTHORIZATIONS OF APPROPRIATIONS FROM FUND.

    ``For the purpose of carrying out this part, there are authorized 
to be appropriated from the Fund, $50,000,000 for each of the fiscal 
years 1996 through 2000.

``SEC. 2722. SCHOLARSHIP PROGRAM.

    ``(a) In General.--The Secretary, acting through the Administrator 
of the Health Resources and Services Administration and in consultation 
with the Director of the Centers for Disease Control and Prevention, 
shall carry out a program under which the Secretary awards scholarships 
to individuals described in subsection (b) for the purpose of assisting 
the individuals with the costs of attending public and nonprofit 
private schools of public health (or other public or nonprofit private 
institutions providing graduate or specialized training in public 
health).
    ``(b) Eligible Individuals.--An individual referred to in 
subsection (a) is any individual meeting the following conditions:
            ``(1) The individual is enrolled (or accepted for 
        enrollment) at a school or other institution referred to in 
        subsection (a) as a full-time or part-time student in a program 
        providing training in a health profession in a field of public 
        health (including the fields of epidemiology, biostatistics, 
        environmental health, health administration and planning, 
        behavioral sciences, maternal and child health, occupational 
        safety, public health nursing, nutrition, and toxicology).
            ``(2) The individual enters into the contract required 
        pursuant to subsection (d) as a condition of receiving the 
        scholarship (relating to an agreement to provide services in 
        approved public health positions, as defined in section 2724).
    ``(c) Eligible Schools.--For fiscal year 1996 and subsequent fiscal 
years, the Secretary may make an award of a scholarship under 
subsection (a) only if the Secretary determines that--
            ``(1) the school or other institution with respect to which 
        the award is to be provided has coordinated the activities of 
        the school or institution with relevant activities of the 
        Health Resources and Services Administration and the Centers 
        for Disease Control and Prevention; and
            ``(2) not fewer than 60 percent of the graduates of the 
        school or institution are in public health positions determined 
        by the Secretary to be consistent with the needs of the United 
        States regarding such professionals.
    ``(d) Applicability of Certain Provisions.--Except as inconsistent 
with this section or section 2724, the provisions of subpart III of 
part D of title III (relating to the Scholarship and Loan Repayment 
Programs of the National Health Service Corps) apply to an award of a 
scholarship under subsection (a) to the same extent and in the same 
manner as such provisions apply to an award of a scholarship under 
section 338A.

``SEC. 2723. LOAN REPAYMENT PROGRAM.

    ``(a) In General.--The Secretary, acting through the Administrator 
of the Health Resources and Services Administration and in consultation 
with the Director of the Centers for Disease Control and Prevention, 
shall carry out a program under which the Federal Government enters 
into agreements to repay all or part of the educational loans of 
individuals meeting the following conditions:
            ``(1) The individual involved is a graduate of a school or 
        other institution described in section 2722(a).
            ``(2) The individual meets the applicable legal 
        requirements to provide services as a public health 
        professional (including a professional in any of the fields 
        specified in section 2722(b)(1)).
            ``(3) The individual enters into the contract required 
        pursuant to subsection (b) as a condition of the Federal 
        Government repaying such loans (relating to an agreement to 
        provide services in approved public health positions, as 
        defined in section 2724).
    ``(b) Applicability of Certain Provisions.--Except as inconsistent 
with this section or section 2724, the provisions of subpart III of 
part D of title III (relating to the Scholarship and Loan Repayment 
Programs of the National Health Service Corps) apply to an agreement 
regarding repayment under subsection (a) to the same extent and in the 
same manner as such provisions apply to an agreement regarding 
repayment under section 338B.
    ``(c) Amount of Repayments.--For each year for which an individual 
contracts to serve in an approved public health position pursuant to 
subsection (b), the Secretary may repay not more than $20,000 of the 
principal and interest of the educational loans of the individual.

``SEC. 2724. APPROVED PUBLIC HEALTH POSITIONS.

    ``(a) Position Regarding Populations With Significant Need for 
Services.--
            ``(1) In general.--With respect to the programs under this 
        part, the obligated service of a program participant pursuant 
        to sections 2722(d) and 2723(b) shall be provided through an 
        assignment, to an entity described in subsection (b), for a 
        position in which the participant provides services as a public 
        health professional to a population determined by the Secretary 
        to have a significant unmet need for the services of such a 
        professional.
            ``(2) Period of service.--For purposes of sections 2722(d) 
        and 2723(d), the period of obligated service is the following, 
        as applicable to the program participant involved:
                    ``(A) In the case of scholarships under section 
                2722 for full-time students, the greater of--
                            ``(i) 1 year for each year for which such a 
                        scholarship is provided; or
                            ``(ii) 2 years.
                    ``(B) In the case of scholarships under section 
                2722 for part-time students, a period determined by the 
                Secretary on the basis of the number of hours of 
                education or training received under the scholarship, 
                considering the percentage constituted by the ratio of 
                such number to the number of hours for a full-time 
                student in the program involved.
                    ``(C) In the case of the loan repayments under 
                section 2723, such period as the Secretary and the 
                participant may agree, except that the period may not 
                be less than 2 years.
    ``(b) Approval of Entities for Assignment of Program 
Participants.--The entities referred to in subsection (a) are public 
and nonprofit private entities approved by the Secretary as meeting 
such requirements for the assignment of a program participant as the 
Secretary may establish. The entities that the Secretary may so approve 
include State and local departments of health, public hospitals, 
community and neighborhood health clinics, migrant health clinics, 
community-based health-related organizations, certified regional poison 
control centers, purchasing cooperatives regarding health insurance, 
and any other public or nonprofit private entity.
    ``(c) Definitions.--For purposes of this part:
            ``(1) The term `approved public health position', with 
        respect to a program participant, means a position to which the 
        participant is assigned pursuant to subsection (a).
            ``(2) The term `program participant' means an individual 
        who enters into a contract pursuant to section 2722(b)(2) or 
        2723(a)(3).

``SEC. 2725. ALLOCATION OF FUNDS; SPECIAL CONSIDERATIONS.

    ``(a) Allocations Regarding New Participants in Scholarship 
Program.--Of the amounts appropriated under section 2721 for a fiscal 
year, the Secretary shall obligate not less than 30 percent for the 
purpose of providing awards for scholarships under section 2722 to 
individuals who have not previously received such scholarships.
    ``(b) Special Consideration for Certain Individuals.--In making 
awards of scholarships under section 2722 and making repayments under 
section 2723, the Secretary shall give special consideration to 
individuals who are in the armed forces of the United States or who are 
veterans of the armed forces.

       ``PART 2--EDUCATIONAL INSTITUTIONS REGARDING PUBLIC HEALTH

``SEC. 2731. AUTHORIZATIONS OF APPROPRIATIONS FROM FUND.

    ``For the purpose of carrying out this part from the Fund, there 
are authorized to be appropriated from the Fund, $100,000,000 for each 
of the fiscal years 1996 through 2000.

``SEC. 2732. GRANTS FOR EXPANDING CAPACITY OF INSTITUTIONS.

    ``(a) In General.--The Secretary may make grants to institutions 
described in subsection (b) for the purpose of expanding the 
educational capacities of the institutions through recruiting and 
retaining faculty, curriculum development, and coordinating the 
activities of the institutions regarding education, training, and field 
placements.
    ``(b) Relevant Institutions.--The institutions referred to in 
subsection (a) are public and nonprofit private--
            ``(1) schools of public health;
            ``(2) departments of community and preventive medicine 
        that--
                    ``(A) are within schools of medicine and schools of 
                osteopathic medicine; and
                    ``(B) have established formal arrangements with 
                schools of public health in order to award joint 
                degrees in public health and another health profession; 
                and
            ``(3) schools of nursing or dentistry that have established 
        formal arrangements with schools of public health in order to 
        carry out educational programs in public health at the schools 
        of nursing or dentistry, respectively.
    ``(c) Requirements Regarding Curriculum Development.--A funding 
agreement for a grant under subsection (a) for an institution is that, 
to the extent determined to be appropriate by the Secretary, the 
curriculum of institution will include the following:
            ``(1) Subject to subsection (d)(1), part-time nondegree 
        programs for public health professionals who need further 
        training in fields of public health.
            ``(2) With respect to the program of community health 
        advisors established in part 5 of subtitle E, a program to 
        train individuals to serve as supervisors under such part 
        (including training and evaluating the community health 
        advisors), which program is carried out in collaboration with 
        local public health departments and health education and 
        training centers.
            ``(3) A program under which the institution collaborates 
        with health departments and elementary and secondary schools to 
        develop a health education curriculum for use in the program 
        established under subtitle B of the Public Health Improvement 
        Act of 1994.
    ``(d) Additional Requirements.--Funding agreements for a grant 
under subsection (a) for an institution are as follows:
            ``(1) In developing the curriculum under the grant, the 
        institution will consult with the health departments in the 
        State involved, and will follow the relevant priorities of such 
        departments.
            ``(2) The institution will, as appropriate in the 
        determination of the Secretary, coordinate the activities of 
        the institution under the grant with relevant activities of the 
        Health Resources and Services Administration and the Centers 
        for Disease Control and Prevention.

``SEC. 2733. COORDINATION OF GRANT ACTIVITIES WITH NATIONAL PRIORITIES.

    ``The Secretary shall--
            ``(1) determine the needs of the United States regarding 
        the education and geographic distribution of public health 
        professionals;
            ``(2) determine priorities among such needs; and
            ``(3) in making grants under section 2732, ensure that the 
        curricula developed under such section, and the expertise of 
        the faculty recruited and retained under such section, are 
        consistent with such priorities.

``SEC. 2734. CERTAIN REQUIREMENTS FOR GRANTS.

    ``For fiscal year 1997 and subsequent fiscal years, the Secretary 
may make a grant under section 2732 only if the institution involved is 
in compliance with the following:
            ``(1) The institution has coordinated the activities of the 
        school or institution with relevant activities of the Health 
        Resources and Services Administration and the Centers for 
        Disease Control and Prevention.
            ``(2) A significant number of the faculty of the 
        institution has served as practitioners in public health.
            ``(3) The institution has consulted with public health 
        departments and public hospital systems in the State involved 
        in order to develop a curriculum that reflects the needs and 
        priorities of the State regarding the public health.
            ``(4) The institution has coordinated the activities of the 
        institution with the activities of the health departments and 
        of community groups.
            ``(5) The institution carries out a program for part-time 
        students to receive training in fields of public health.
            ``(6) Not less than 60 percent of the graduates of the 
        school or institution are in public health positions determined 
        by the Secretary to be consistent with the needs of the United 
        States regarding such professionals.

           ``PART 3--EXPANSION OF COMPETENCY IN PUBLIC HEALTH

``SEC. 2736. AUTHORIZATIONS OF APPROPRIATIONS FROM FUND.

    ``For the purpose of carrying out this section, there is authorized 
to be appropriated from the Fund, $60,000,000 for each of the fiscal 
years 1996 through 2000.

``SEC. 2737. GRANTS TO STATES.

    ``(a) States Lacking Adequate Training Programs.--
            ``(1) In general.--The Secretary may make grants to States 
        in which there is one or no program of training in a field of 
        public health but in which there are 1 or more schools of 
        medicine, osteopathic medicine, nursing, dentistry, social 
        work, pharmacy, or health administration. A funding agreement 
        for such a grant is that the purpose of the grant is for the 
        State involved to assist 1 or more of such schools in 
        developing and integrating public health curricula for the 
        schools.
            ``(2) Special considerations in making grants.--In making 
        grants under paragraph (1), the Secretary shall give special 
        consideration to States that agree to consult with 1 or more 
        schools of public health in carrying out the purpose described 
        in such subsection.
    ``(b) States With Nonaccredited Schools.--The Secretary may make 
grants to States in which there are 1 or more nonaccredited schools of 
public health. A funding agreement for such a grant is that the purpose 
of the grant is for the State involved to assist 1 or more of such 
schools in improving the schools.
    ``(c) Amount of Grant; Limitation Regarding Individual Educational 
Entities.--
            ``(1) Amount.--The amount of a grant under this section to 
        a State may not exceed $6,000,000.
            ``(2) Limitation.--A funding agreement for a grant under 
        this section for a State is that, with respect to the school 
        involved, the State will not provide more than 2 years of 
        assistance to the school from grants under this section.

                ``PART 4--AREA HEALTH EDUCATION CENTERS

``SEC. 2738. AUTHORIZATIONS OF APPROPRIATIONS FROM FUND.

    ``(a) Additional Funding.--For the purpose of carrying out programs 
under section 746, there are authorized to be appropriated from the 
Fund, $35,000,000 for each of the fiscal years 1996 through 2000.
    ``(b) Relation to Other Funds.--The authorizations of 
appropriations established in subsection (a) are in addition to any 
other authorizations of appropriations that are available for the 
purpose described in such subsection.

               ``PART 5--HEALTH EDUCATION TRAINING CENTER

``SEC. 2739. AUTHORIZATIONS OF APPROPRIATIONS FROM FUND.

    ``(a) Additional Funding.--For the purpose of carrying out Health 
Education Training Center programs, there are authorized to be 
appropriated from the Fund, $20,000,000 for each of the fiscal years 
1996 through 2000.
    ``(b) Relation to Other Funds.--The authorizations of 
appropriations established in subsection (a) are in addition to any 
other authorizations of appropriations that are available for the 
purpose described in such subsection.

             ``Subtitle C--Regional Poison Control Centers

``SEC. 2741. AUTHORIZATIONS OF APPROPRIATIONS FROM FUND.

    ``For the purpose of carrying out this subtitle, there is 
authorized to be appropriated from the Fund, $50,000,000 for each of 
the fiscal years 1996 through 2000.

``SEC. 2742. GRANTS FOR REGIONAL CENTERS.

    ``(a) In General.--The Secretary may make grants to public and 
nonprofit private entities for centers to carry out activities 
regarding--
            ``(1) the prevention and treatment of poisoning; and
            ``(2) such other activities regarding the control of 
        poisons as the Secretary determines to be appropriate.
    ``(b) Regional Considerations.--In making grants under subsection 
(a), the Secretary shall determine the need in each of the principal 
geographic regions of the United States for a center under such 
subsection, and shall make the grants according to priorities 
established by the Secretary on the basis of the extent of such need in 
each of the regions. In carrying out the preceding sentence, the 
Secretary shall ensure that no two centers receive grants for the same 
geographic service area.
    ``(c) Matching Funds.--
            ``(1) In general.--With respect to the costs of an entity 
        in providing for centers under subsection (a), the Secretary 
        may make a grant under such subsection only if the State in 
        which the center is to operate, or other public entities in the 
        State, agree to make available (directly or through donations 
        from public or private entities) non-Federal contributions 
        toward such costs in an amount determined by the Secretary.
            ``(2) Determination of amount contributed.--Non-Federal 
        contributions required under paragraph (1) may be in cash or in 
        kind, fairly evaluated, including plant, equipment, or 
        services. Amounts provided by the Federal Government, or 
        services assisted or subsidized to any significant extent by 
        the Federal Government, may not be included in determining the 
        amount of such non-Federal contributions.

``SEC. 2743. REQUIREMENTS REGARDING CERTIFICATION.

    ``(a) In General.--Subject to subsection (b), the Secretary may 
make a grant under section 2742 only if the center involved has been 
certified by a professional organization in the field of poison 
control, and the Secretary has approved the organization as having in 
effect standards for certification that reasonably provide for the 
protection of the public health with respect to poisoning. In carrying 
out the preceding sentence, the Secretary shall consider the standards 
established by the American Association of Poison Control Centers.
    ``(b) Temporary Waiver.--The Secretary may waive the requirement of 
subsection (a) for a center for a period not exceeding 1 year.

``SEC. 2744. GENERAL PROVISIONS.

    ``(a) Duration of Grant.--The period during which payments are made 
under a grant under section 2742 may not exceed 3 years. The provision 
of such payments is subject to annual approval by the Secretary of the 
payments and subject to the availability of appropriations for the 
fiscal year involved to make the payments. The preceding sentence may 
not be construed as establishing a limitation on the number of such 
grants that may be made to an entity.
    ``(b) Study Regarding Need for Centers.--
            ``(1) In general.--The Secretary shall conduct a study of 
        each of the centers for which a grant under section 2742 has 
        been provided. The purpose of the study shall be to determine 
        the effectiveness of the centers in carrying out the activities 
        described in such section and the extent to which the 
        activities have been carried out in a cost-effective manner.
            ``(2) Alternatives to centers.--In carrying out the study 
        under paragraph (1), the Secretary shall determine the extent 
        to which the activities described in section 2742 can be 
        effectively carried out through means other than centers under 
        such section. The alternative means considered by the Secretary 
        under the preceding sentence shall include the alternative of 
        requiring public and private health plans to carry out such 
        activities.
            ``(3) Date certain for completion.--Not later than November 
        1, 1996, the Secretary shall submit to the Congress a report 
        describing the findings made in the study under paragraph (1).
            ``(4) Notice to centers.--Not later than February 1, 1997, 
        the Secretary shall notify each grantee under section 2742 
        whether the Secretary considers the continued operation of the 
        center involved to be necessary in meeting the needs of the 
        geographic region involved for the activities described in such 
        section.

              ``Subtitle D--School-Related Health Services

``SEC. 2746. AUTHORIZATION OF APPROPRIATIONS FROM FUND.

    ``(a) Funding for School-Related Health Services.--For the purpose 
of carrying out this subtitle, there are authorized to be appropriated 
from the Fund, $100,000,000 for fiscal year 1996, $200,000,000 for 
fiscal year 1997, $300,000,000 for fiscal year 1998, $400,000,000 for 
fiscal year 1999, and $500,000,000 for fiscal year 2000.
    ``(b) Funding for Planning and Development Grants.--Of amounts made 
available under this section, not to exceed $10,000,000 for each of 
fiscal years 1996 and 1997 may be utilized to carry out section 2749.

``SEC. 2747. ELIGIBILITY FOR GRANTS.

    ``(a) In General.--
            ``(1) Planning and development grants.--Entities eligible 
        to apply for and receive grants under section 2749 are--
                    ``(A) State health agencies that apply on behalf of 
                local community partnerships; or
                    ``(B) local community partnerships in States in 
                which health agencies have not successfully applied.
            ``(2) Operational grants.--Entities eligible to apply for 
        and receive grants under section 2750 are--
                    ``(A) a qualified State as designated under 
                subsection (c) that apply on behalf of local community 
                partnerships; or
                    ``(B) local community partnerships in States that 
                are not designated under subparagraph (A).
    ``(b) Local Community Partnerships.--
            ``(1) In general.--A local community partnership under 
        subsection (a)(1)(B) and (a)(2)(B) is an entity that, at a 
        minimum includes--
                    ``(A) a local health care provider, which may be a 
                local public health department, with experience in 
                delivering services to children and youth or medically 
                underserved populations;
                    ``(B) local educational agency on behalf of one or 
                more public schools; and
                    ``(C) one community based organization located in 
                the community to be served that has a history of 
                providing services to at-risk children and youth.
            ``(2) Rural communities.--In rural communities, local 
        partnerships should seek to include, to the fullest extent 
        practicable, providers and community based organizations with 
        experience in serving the target population.
            ``(3) Parent and community participation.--An applicant 
        described in subsection (a) shall, to the maximum extent 
        feasible, involve broad-based community participation 
        (including parents of the youth to be served).
    ``(c) Qualified State.--A qualified State under subsection 
(a)(2)(A) is a State that, at a minimum--
            ``(1) demonstrates an organizational commitment (including 
        a strategic plan) to providing a broad range of health, health 
        education and support services to at-risk youth; and
            ``(2) has a memorandum of understanding or cooperative 
        agreement jointly entered into by the State agencies 
        responsible for health and education regarding the planned 
        delivery of health and support services in school-based or 
        school-linked centers.

``SEC. 2748. PREFERENCES.

    ``In making grants under sections 2749 and 2750, the Secretary 
shall give priority to applicants whose-communities to be served show 
the most substantial level of need for health services among children 
and youth.

``SEC. 2749. PLANNING AND DEVELOPMENT GRANTS.

    ``(a) In General.--The Secretary may make grants during fiscal 
years 1996 and 1997 to entities eligible under section 2747 to develop 
school-based or school-linked health service sites.
    ``(b) Use of Funds.--Amounts provided under a grant under this 
section may be used for the following:
            ``(1) Planning for the provision of school health services, 
        including--
                    ``(A) an assessment of the need for health services 
                among youth in the communities to be served;
                    ``(B) the health services to be provided and how 
                new services will be integrated with existing services;
                    ``(C) assessing and planning for the modernization 
                and expansion of existing facilities and equipment to 
                accommodate such services; and
                    ``(D) an affiliation with relevant health plans.
            ``(2) Recruitment and training of staff for the 
        administration and delivery of school health services.
            ``(3) The establishment of local community partnerships as 
        described in section 2747(b).
            ``(4) In the case of States, the development of memorandums 
        of understanding or cooperative agreements for the coordinated 
        delivery of health and support services through school health 
        service sites.
            ``(5) Other activities necessary to assume operational 
        status.
    ``(c) Application for Grants.--To be eligible to receive a grant 
under this section an entity described in section 2747(a) shall submit 
an application in a form and manner prescribed by the Secretary.
    ``(d) Number of Grants.--Not more than one planning grant may be 
made to a single applicant. A planning grant may not exceed 2 years in 
duration.
    ``(e) Amount Available for Development Grant.--The Secretary may 
award not to exceed--
            ``(1) $150,000 to entities under section 2747(a)(1)(A) and 
        to localities planning for a citywide or countywide school 
        health services delivery system; and
            ``(2) $50,000 to entities under section 2747(a)(1)(B).

``SEC. 2759. GRANTS FOR OPERATION OF SCHOOL HEALTH SERVICES.

    ``(a) In General.--The Secretary may make grants to eligible 
entities described in section 2747(a)(2) that submit applications 
consistent with the requirements of this section, to pay the cost of 
operating school-based or school-linked health service sites.
    ``(b) Use of Grant.--Amounts provided under a grant under this 
section may be used for the following--
            ``(1) health services, including diagnosis and treatment of 
        simple illnesses and minor injuries;
            ``(2) preventive health services, including health 
        screenings follow-up health care, mental health, and preventive 
        health education;
            ``(3) enabling services and other necessary support 
        services;
            ``(4) training, recruitment, and compensation of health 
        professionals and other staff necessary for the administration 
        and delivery of school health services; and
            ``(5) referral services, including the linkage of 
        individuals to health plans, and community-based health and 
        social service providers.
    ``(c) Application for Grant.--To be eligible to receive a grant 
under this section an entity described in section 2747(a)(2) shall 
submit an application in a form and manner prescribed by the Secretary. 
In order to receive a grant under this section, an applicant must 
include in the application the following information--
            ``(1) a description of the services to be furnished by the 
        applicant;
            ``(2) the amounts and sources of funding that the applicant 
        will expend, including estimates of the amount of payments the 
        applicant will receive from health plans and other sources;
            ``(3) a description of local community partnerships, 
        including parent and community participation;
            ``(4) a description of the linkages with other health and 
        social service providers; and
            ``(5) such other information as the Secretary determines to 
        be appropriate.
    ``(d) Assurances.--In order to receive a grant under this section, 
an applicant must meet the following conditions--
            ``(1) school health service sites will, directly or 
        indirectly, provide a broad range of health services, in 
        accordance with the determinations of the local community 
        partnership, that may include--
                    ``(A) diagnosis and treatment of simple illnesses 
                and minor injuries;
                    ``(B) preventive health services, including health 
                screenings and follow-up health care, mental health and 
                preventive health education;
                    ``(C) enabling services; and
                    ``(D) referrals (including referrals regarding 
                mental health and substance abuse) with follow-up to 
                ensure that needed services are received;
            ``(2) the applicant provides services recommended by the 
        health provider, in consultation with the local community 
        partnership, and with the approval of the local education 
        agency;
            ``(3) the applicant provides the services under this 
        subsection to adolescents, and other school age children and 
        their families as deemed appropriate by the local partnership;
            ``(4) the applicant maintains agreements with community-
        based health care providers with a history of providing 
        services to such populations for the provision of health care 
        services not otherwise provided directly or during the hours 
        when school health services are unavailable;
            ``(5) the applicant establishes an affiliation with 
        relevant health plans and will establish reimbursement 
        procedures and will make every reasonable effort to collect 
        appropriate reimbursement for services provided;
            ``(6) the applicant agrees to supplement and not supplant 
        the level of State or local funds under the direct control of 
        the applying State or participating local education or health 
        authority expended for school health services as defined by 
        this Act;
            ``(7) services funded under this Act will be coordinated 
        with existing school health services provided at a 
        participating school; and
            ``(8) for applicants in rural areas, the assurances 
        required under paragraph (4) shall be fulfilled to the maximum 
        extent possible.
    ``(e) State Laws.--Notwithstanding any other provision in this 
subtitle, no school based health clinic may provide services, to any 
minor, when to do so is a violation of State laws or regulations 
pertaining to informed consent for medical services to minors.
    ``(f) Limitation on Administrative Funds.--In the case of a State 
applying on behalf of local educational partnerships, the applicant may 
retain not more than 5 percent of grants awarded under this subpart for 
administrative costs.
    ``(g) Duration of Grant.--A grant under this section shall be for a 
period determined appropriate by the Secretary.
    ``(h) Amount of Grant.--The annual amount of a grant awarded under 
this section shall not be more than $200,000 per school-based or 
school-linked health service site.
    ``(i) Federal Share.--
            ``(1) In general.--Subject to paragraph (3), a grant for 
        services awarded under this section may not exceed--
                    ``(A) 90 percent of the non-reimbursed cost of the 
                activities to be funded under the program for the first 
                2 fiscal years for which the program receives 
                assistance under this section; and
                    ``(B) 75 percent of the non-reimbursed cost of such 
                activities for subsequent years for which the program 
                receives assistance under this section.
        The remainder of such costs shall be made available as provided 
        in paragraph (2).
            ``(2) Form of non-federal share.--The non-Federal share 
        required by paragraph (1) may be in cash or in-kind, fairly 
        evaluated, including facilities, equipment, personnel, or 
        services, but may not include amounts provided by the Federal 
        Government. In-kind contributions may include space within 
        school facilities, school personnel, program use of school 
        transportation systems, outposted health personnel, and 
        extension of health provider medical liability insurance.
            ``(3) Waiver.--The Secretary may waive the requirements of 
        paragraph (1) for any year in accordance with criteria 
        established by regulation. Such criteria shall include a 
        documented need for the services provided under this section 
        and an inability of the grantee to meet the requirements of 
        paragraph (1) despite a good faith effort.
    ``(j) Training and Technical Assistance.--Entities that receive 
assistance under this section may use not to exceed 10 percent of the 
amount of such assistance to provide staff training and to secure 
necessary technical assistance. To the maximum extent feasible, 
technical assistance should be sought through local community-based 
entities. The limitation contained in this subsection shall apply to 
individuals employed to assist in obtaining funds under this subtitle. 
Staff training should include the training of teachers and other school 
personnel necessary to ensure appropriate referral and utilization of 
services, and appropriate linkages between class-room activities and 
services offered.
    ``(k) Report and Monitoring.--The Secretary will submit to the 
Committee on Labor and Human Resources in the Senate and the Committee 
on Energy and Commerce in the House of Representatives a biennial 
report on the activities funded under this Act, consistent with the 
ongoing monitoring activities of the Department. Such reports are 
intended to advise the relevant Committees of the availability and 
utilization of services, and other relevant information about program 
activities.

``Subtitle E--Expansion of Rural and Underserved Areas Access to Health 
                                Services

             ``PART 1--COMMUNITY AND MIGRANT HEALTH CENTERS

``SEC. 2756. AUTHORIZATIONS OF APPROPRIATIONS FROM FUND.

    ``(a) In General.--For the purpose of carrying out this part, there 
is authorized to be appropriated from the Fund, $100,000,000 for each 
of the fiscal years 1996 through 2000.
    ``(b) Relation to Other Funds.--The authorizations of 
appropriations established in subsection (a) for the purpose described 
in such subsection are in addition to any other authorizations of 
appropriations that are available for such purpose.

``SEC. 2757. GRANTS TO COMMUNITY AND MIGRANT HEALTH CENTERS.

    ``(a) In General.--The Secretary shall make grants in accordance 
with this section to migrant health centers and community health 
centers.
    ``(b) Use of Funds.--
            ``(1) Development, operation, and other purposes regarding 
        centers.--Subject to paragraph (2), grants under subsection (a) 
        to migrant health centers and community health centers may be 
        made only in accordance with the conditions upon which grants 
        are made under sections 329 and 330, respectively.
            ``(2) Required financial reserves.--The Secretary may 
        authorize migrant health centers and community health centers 
        to expend a grant under subsection (a) to establish and 
        maintain financial reserves required for purposes of health 
        plans.
    ``(c) Definitions.--For purposes of this subtitle, the terms 
`migrant health center' and `community health center' have the meanings 
given such terms in sections 329(a)(1) and 330(a), respectively.

                ``PART 2--NATIONAL HEALTH SERVICE CORPS

``SEC. 2781. AUTHORIZATIONS OF APPROPRIATIONS FROM FUND.

    ``(a) Additional Funding; General Corps Program; Allocations 
Regarding Nurses.--For the purpose of carrying out subpart II of part D 
of title III, and for the purpose of carrying out subsection (c), there 
are authorized to be appropriated from the Fund, $100,000,000 for each 
of the fiscal years 1996 through 2000.
    ``(b) Relation to Other Funds.--The authorizations of 
appropriations established in subsection (a) are in addition to any 
other authorizations of appropriations that are available for the 
purpose described in such subsection.
    ``(c) Allocation for Participation of Nurses in Scholarship and 
Loan Repayment Programs.--Of the amounts appropriated under subsection 
(a), the Secretary shall reserve such amounts as may be necessary to 
ensure that, of the aggregate number of individuals who are 
participants in the Scholarship Program under section 338A, or in the 
Loan Repayment Program under section 338B, the total number who are 
being educated as nurses or are serving as nurses, respectively, is 
increased to 30 percent.
    ``(d) Availability of Funds.--An appropriation under this section 
for any fiscal year may be made at any time before that fiscal year and 
may be included in an Act making an appropriation under an 
authorization under subsection (a) for another fiscal year; but no 
funds may be made available from any appropriation under this section 
for obligation under sections 331 through 335, section 336A, and 
section 337 before the fiscal year involved.

       ``PART 3--SATELLITE CLINICS REGARDING PRIMARY HEALTH CARE

``SEC. 2783. AUTHORIZATION OF APPROPRIATIONS FROM FUND.

    ``For the purpose of carrying out this part, there is authorized to 
be appropriated from the Fund, $50,000,000 for each of the fiscal years 
1996 through 2000.

``SEC. 2783A. GRANTS TO STATES FOR DEVELOPMENT AND OPERATION OF 
              SATELLITE CLINICS.

    ``(a) In General.--With respect to outpatient health centers that 
are providers of comprehensive health services, the Secretary may make 
grants to States for the purpose of assisting such centers in 
developing or operating facilities that--
            ``(1) provide clinical preventive services, treatment of 
        minor illnesses and injuries, family planning services, and 
        referrals for health services, mental health services, and 
        health-related social services; and
            ``(2) are located at a distance from the center sufficient 
        to increase the extent to which individuals in the geographic 
        area involved have access to the services specified in 
        paragraph (1).
    ``(b) Certain Requirements.--The Secretary may make a grant under 
subsection (a) only if the State agrees that the health facility for 
which the grant is made, once in operation, will meet the following 
conditions:
            ``(1) The clinical preventive services provided by the 
        facility will include routine preventive services, including 
        family planning services, for pregnant and postpartum women and 
        for children, including health screenings and immunizations.
            ``(2) The principal providers of health services at the 
        facility, and the principal managers of the facility, will be 
        nurse practitioners, physician assistants, or nurse clinicians, 
        subject to applicable law.
            ``(3) The outpatient health center operating the facility 
        will serve as a referral center for physician services and will 
        provide for the ongoing monitoring of the activities of the 
        facility.
    ``(c) Matching Funds.--The Secretary may make a grant under 
subsection (a) only if the State involved agrees to make non-Federal 
contributions toward the costs of developing and operating the health 
facilities involved.
    ``(d) Application for Grant.--The Secretary may make a grant under 
subsection (a) only if an application for the grant is submitted to the 
Secretary and the application is in such form, is made in such manner, 
and contains such agreements, assurances, and information as the 
Secretary determines to be necessary to carry out this part.
    ``(e) Limitation on Amount of Assistance Per Facility.--With 
respect to a health facility for which one or more grants under 
subsection (a) are made, the Secretary may not provide more than an 
aggregate $250,000 for the development and operation of the facility.

                  ``PART 4--COMMUNITY HEALTH ADVISORS

``SEC. 2784. AUTHORIZATION OF APPROPRIATIONS FROM FUND.

    ``For the purpose of carrying out this part, there is authorized to 
be appropriated from the Fund, $100,000,000 for each of the fiscal 
years 1996 through 2000.

``SEC. 2785. FORMULA GRANTS REGARDING COMMUNITY HEALTH ADVISOR 
              PROGRAMS.

    ``(a) Formula Grants.--
            ``(1) In general.--In the case of each State (or entity 
        designated by a State under subsection (b)) that submits to the 
        Secretary an application in accordance with section 2788 for a 
        fiscal year, the Secretary of Health and Human Services, acting 
        through the Director of the Centers for Disease Control and 
        Prevention and in coordination with the heads of the agencies 
        specified in paragraph (2), shall make an award of financial 
        assistance to the State or entity for the development and 
        operation of community health advisor programs under section 
        2786(b). The award shall consist of the allotment determined 
        under section 2789 with respect to the State, subject to 
        section 2794.
            ``(2) Coordination with other agencies.--The agencies 
        referred to in paragraph (1) regarding coordination are the 
        Health Resources and Services Administration, the National 
        Institutes of Health, the Substance Abuse and Mental Health 
        Services Administration, and the Health Education and Training 
        Center.
    ``(b) Designated Entities.--With respect to the State involved, an 
entity other than the State may receive an award under subsection (a) 
only if the entity--
            ``(1) is a public or nonprofit private academic 
        organization (or other public or nonprofit private entity); and
            ``(2) has been designated by the State to carry out the 
        purpose described in such subsection in the State and to 
        receive amounts under such subsection in lieu of the State.
    ``(c) Role of State Agency for Public Health.--A funding agreement 
for an award under subsection (a) is that--
            ``(1) if the applicant is a State, the award will be 
        administered by the State agency with the principal 
        responsibility for carrying out public health programs; and
            ``(2) if the applicant is an entity designated under 
        subsection (b), the award will be administered in consultation 
        with such State agency.
    ``(d) Statewide Responsibilities; Limitation on Expenditures.--
            ``(1) Statewide responsibilities.--A funding agreement for 
        an award under subsection (a) is that the applicant involved 
        will--
                    ``(A) operate a clearinghouse to maintain and 
                disseminate information on community health advisor 
                programs (and similar programs) in the State, including 
                information on developing and operating such programs, 
                on training individuals to participate in the programs, 
                and on evaluation of the programs;
                    ``(B) collaborate with schools of public health to 
                provide to community health advisor programs in the 
                State technical assistance in training and supervising 
                community health advisors under section 2787(g)(1); and
                    ``(C) coordinate the activities carried out in the 
                State under the award, including coordination between 
                the various community health advisor programs and 
                coordination between such programs and related 
                activities of the State and of other public or private 
                entities.
            ``(2) Limitation.--A funding agreement for an award under 
        subsection (a) is that the applicant involved will not expend 
        more than 15 percent of the award in the aggregate for carrying 
        out paragraph (1) and for the expenses of administering the 
        award with respect to the State involved, including the process 
        of receiving payments from the Secretary under the award, 
        allocating the payments among the entities that are to develop 
        and operate the community health advisor programs involved, and 
        monitoring compliance with the funding agreements made under 
        this subtitle by the applicant.

``SEC. 2786. REQUIREMENTS REGARDING COMMUNITY HEALTH ADVISOR PROGRAMS.

    ``(a) Purpose of Award; Healthy People 2000 Objectives.--
            ``(1) In general.--Subject to paragraph (2), a funding 
        agreement for an award under section 2785 for an applicant is 
        that the purpose of the award is, through community health 
        advisor programs under subsection (b), to assist the State 
        involved in attaining the Healthy People 2000 Objectives.
            ``(2) Authority regarding selection of priority 
        objectives.--With respect to compliance with the agreement made 
        under paragraph (1), an applicant receiving an award under 
        section 2785 may, from among the various Healthy People 2000 
        Objectives, select one or more Objectives to be given priority 
        in the operation of a community health advisor program of the 
        applicant, subject to the applicant selecting such priorities 
        in consultation with the entity that is to carry out the 
        program and the local health department involved.
    ``(b) Requirements for Programs.--
            ``(1) In general.--A funding agreement for an award under 
        section 2785 for an applicant is that, in expending the award, 
        the purpose described in subsection (a)(1) will be carried out 
        in accordance with the following:
                    ``(A) For each community for which the purpose is 
                to be carried out, the applicant will establish a 
                program in accordance with this subsection.
                    ``(B) The program will be carried out in a 
                community only if the applicant has, under section 
                2787(a), identified the community as having a 
                significant need for the program.
                    ``(C) The program will be operated by a public or 
                nonprofit private entity with experience in providing 
                health or health-related social services to individuals 
                who are underserved with respect to such services.
                    ``(D) The services of the program, as specified in 
                paragraph (2), will be provided principally by 
                community health advisors (as defined in subsection 
                (d)).
            ``(2) Authorized program services.--For purposes of 
        paragraph (1)(D), the services specified in this paragraph for 
        a program are as follows:
                    ``(A) The program will collaborate with health care 
                providers and related entities in order to facilitate 
                the provision of health services and health-related 
                social services (including collaborating with local 
                health departments, community health centers, public 
                hospital systems, migrant health centers, rural health 
                clinics, hospitals, physicians and nurses, providers of 
                health education, pre-school facilities for children, 
                elementary and secondary schools, and providers of 
                social services).
                    ``(B) The program will provide public education on 
                health promotion and on the prevention of diseases, 
                illnesses, injuries, and disabilities, and will 
                facilitate the appropriate use of available health 
                services and health-related social services.
                    ``(C) The program will provide health-related 
                counseling.
                    ``(D) The program will provide referrals for 
                available health services and health-related social 
                services.
                    ``(E) For the purpose of increasing the capacity of 
                individuals to utilize health services and health-
                related social services under Federal, State, and local 
                programs, the following conditions will be met:
                            ``(i) The program will assist individuals 
                        in establishing eligibility under the programs 
                        and in receiving the services or other benefits 
                        of the programs.
                            ``(ii) The program will provide such other 
                        services as the Secretary determines to be 
                        appropriate, which services may include (but 
                        are not limited to) transportation and 
                        translation services.
                    ``(F) The program will provide outreach services to 
                inform the community of the availability of the 
                services of the program.
    ``(c) Priority for Medically Underserved Communities.--A funding 
agreement for an award under section 2785 is that the applicant 
involved will give priority to developing and operating community 
health advisor programs for medically underserved communities.
    ``(d) Definition of Community Health Advisor.--For purposes of this 
part, the term `community health advisor' means an individual--
            ``(1) who has demonstrated the capacity to carry out one or 
        more of the authorized program services;
            ``(2) who, for not less than 1 year, has been a resident of 
        the community in which the community health advisor program 
        involved is to be operated; and
            ``(3) is a member of a socioeconomic group to be served by 
        the program.

``SEC. 2787. ADDITIONAL AGREEMENTS.

    ``(a) Identification of Community Needs.--A funding agreement for 
an award under section 2785 is that the applicant involved will--
            ``(1) identify the needs of the community involved for the 
        authorized program services, including the identifying the 
        resources of the community that are available for carrying out 
        the program;
            ``(2) in identifying such needs, consult with members of 
        the community, with individuals and programs that provide 
        health services in the community, and with individuals and 
        programs that provide health-related social services in the 
        community; and
            ``(3) consider such needs in carrying out a community 
        health advisor program for the community.
    ``(b) Matching Funds.--
            ``(1) In general.--With respect to the cost of carrying out 
        a community health advisor program, a funding agreement for an 
        award under section 2785 is that the applicant involved will 
        make available (directly or through donations from public or 
        private entities) non-Federal contributions toward such cost in 
        an amount that is not less than 25 percent of such cost.
            ``(2) Determination of amount contributed.--
                    ``(A) Non-Federal contributions required in 
                paragraph (1) may be in cash or in kind, fairly 
                evaluated, including plant, equipment, or services. 
                Amounts provided by the Federal Government, or services 
                assisted or subsidized to any significant extent by the 
                Federal Government, may not be included in determining 
                the amount of such non-Federal contributions.
                    ``(B) With respect to the State in which the 
                community health advisor program involved is to be 
                carried out, amounts provided by the State in 
                compliance with subsection (c) shall be included in 
                determining the amount of non-Federal contributions 
                under paragraph (1).
    ``(c) Maintenance of Effort.--With respect to the purposes for 
which an award under section 2785 is authorized in this subtitle to be 
expended, the Secretary may make such an award only if the State 
involved agrees to maintain expenditures of non-Federal amounts for 
such purposes at a level that is not less than the level of such 
expenditures maintained by the State for the fiscal year preceding the 
first fiscal year for which such an award is made with respect to the 
State.
    ``(d) Cultural Context of Services.--A funding agreement for an 
award under section 2785 for an applicant is that the services of the 
community health advisor program involved will be provided in the 
language and cultural context most appropriate for the individuals 
served by the program, and that for such purpose the community health 
advisors of the program will include an appropriate number of advisors 
who are fluent in both English and not less than one of the other 
relevant languages.
    ``(e) Number of Programs Per Award; Programs for Urban and Rural 
Areas.--A funding agreement for an award under section 2785 for an 
applicant is that the number of community health advisor programs 
operated in the State with the award will be determined by the 
Secretary, except that (subject to section 2786(b)(1)(B)) such a 
program will be carried out in not less than one urban area of the 
State, and in not less than one rural area of the State.
    ``(f) Ongoing Supervision of Advisors.--A funding agreement for an 
award under section 2785 is that the applicant involved will ensure 
that each community health advisor program operated with the award 
provides for the ongoing supervision of the community health advisors 
of the program, and that the individuals serving as supervisors in the 
program will include 1 or more public health nurses with field 
experience and managerial experience.
    ``(g) Certain Expenditures.--
            ``(1) Training; continuing education.--Funding agreements 
        for an award under section 2785 include the following:
                    ``(A) The applicant involved will ensure that, for 
                each community health advisor program operated with the 
                award, a program is carried out to train community 
                health advisors to provide the authorized program 
                services, including practical experiences in providing 
                services for health promotion and disease prevention.
                    ``(B) The program of training will provide for the 
                continuing education of the community health advisors.
                    ``(C) Not more than 15 percent of the award will be 
                expended for the program of training.
            ``(2) Compensation.--With respect to compliance with the 
        agreements made under this subtitle, the purposes for which an 
        award under section 2785 may be expended include providing 
        compensation for the services of community health advisors.
    ``(h) Reports to Secretary; Assessment of Effectiveness.--Funding 
agreements for an award under section 2785 for an applicant include the 
following:
            ``(1) The applicant will ensure that, for each fiscal year 
        for which a community health advisor program receives amounts 
        from the award, the program will prepare a report describing 
        the activities of the program for such year, including--
                    ``(A) a specification of the number of individuals 
                served by the program;
                    ``(B) a specification of the entities with which 
                the program has collaborated in carrying out the 
                purpose described in section 2786(a)(1); and
                    ``(C) an assessment of the extent of the 
                effectiveness of the program in carrying out such 
                purpose.
            ``(2) Such reports will include such additional information 
        regarding the applicant and the programs as the Secretary may 
        require.
            ``(3) The applicant will prepare the reports as a single 
        document and will submit the document to the Secretary not 
        later than February 1 of the fiscal year following the fiscal 
        year for which the reports were prepared.

``SEC. 2788. APPLICATION FOR ASSISTANCE; STATE PLAN.

    ``For purposes of section 2785, an application is in accordance 
with this section if--
            ``(1) the application is submitted not later than the date 
        specified by the Secretary;
            ``(2) the application contains each funding agreement 
        described in this subtitle;
            ``(3) the application contains a State plan describing the 
        purposes for which the award is to be expended in the State, 
        including a description of the manner in which the applicant 
        will comply with each such funding agreement; and
            ``(4) the application is in such form, is made in such 
        manner, and contains such agreements, assurances, and 
        information as the Secretary determines to be necessary to 
        carry out this subtitle.

``SEC. 2789. DETERMINATION OF AMOUNT OF ALLOTMENT.

    ``(a) In General.--For purposes of section 2785, the allotment 
under this section with respect to a State for a fiscal year is the sum 
of the respective amounts determined for the State under subsection (b) 
and subsection (c).
    ``(b) Amount Relating to Population.--For purposes of subsection 
(a), the amount determined under this subsection is the product of--
            ``(1) an amount equal to 50 percent of the amount 
        appropriated under section 2784 for the fiscal year and 
        available for awards under section 2785; and
            ``(2) the percentage constituted by the ratio of--
                    ``(A) the number of individuals residing in the 
                State involved; to
                    ``(B) the sum of the respective amounts determined 
                for each State under subparagraph (A).
    ``(c) Amount Relating to Poverty Level.--For purposes of subsection 
(a), the amount determined under this subsection is the product of--
            ``(1) the amount determined under subsection (b)(1); and
            ``(2) the percentage constituted by the ratio of--
                    ``(A) the number of individuals residing in the 
                State whose income is at or below an amount equal to 
                200 percent of the official poverty line; to
                    ``(B) the sum of the respective amounts determined 
                for each State under subparagraph (A).

``SEC. 2790. QUALITY ASSURANCE; COST-EFFECTIVENESS.

    ``The Secretary shall establish guidelines for assuring the quality 
of community health advisor programs (including quality in the training 
of community health advisors) and for assuring the cost-effectiveness 
of the programs. A funding agreement for an award under section 2785 is 
that the applicant involved will carry out such programs in accordance 
with the guidelines.

``SEC. 2791. EVALUATIONS; TECHNICAL ASSISTANCE.

    ``(a) Evaluations.--The Secretary shall conduct evaluations of 
community health advisor programs and disseminate information developed 
as result of the evaluations to the States. In conducting such 
evaluations, the Secretary shall determine whether the programs are in 
compliance with the guidelines established under section 2790.
    ``(b) Technical Assistance.--The Secretary may provide technical 
assistance to recipients of awards under section 2785 with respect to 
the planning, development, and operation of community health advisor 
programs.
    ``(c) Grants and Contracts.--The Secretary may carry out this 
section directly or through grants, cooperative agreements, or 
contracts.
    ``(d) Limitation on Expenditures.--Of the amounts appropriated 
under section 2784 for a fiscal year, the Secretary may reserve not 
more than 10 percent for carrying out this section.

``SEC. 2792. RULE OF CONSTRUCTION REGARDING PROGRAMS OF INDIAN HEALTH 
              SERVICE.

    ``This subtitle may not be construed as requiring the Secretary to 
modify or terminate the program carried out by the Director of the 
Indian Health Service and designated by such Director as the Community 
Health Representative Program. The Secretary shall ensure that support 
for such Program is not supplanted by awards under section 2785. In 
communities in which both such Program and a community health advisor 
program are being carried out, the Secretary shall ensure that the 
community health advisor program works in cooperation with, and as a 
complement to, the Community Health Representative Program.

``SEC. 2793. DEFINITIONS.

    ``For purposes of this subtitle:
            ``(1) The term `authorized program services', with respect 
        to a community health advisor program, means the services 
        specified in section 2786(b)(2).
            ``(2) The term `community health advisor' has the meaning 
        given such term in section 2786(d).
            ``(3) The term `community health advisor program' means a 
        program carried out under section 2786(b).
            ``(4) The term `financial assistance', with respect to an 
        award under section 2785, means a grant, cooperative agreement, 
        or a contract.
            ``(5) The term `funding agreement' means an agreement 
        required as a condition of receiving an award under section 
        2785.
            ``(6) The term `official poverty line' means the official 
        poverty line established by the Director of the Office of 
        Management and Budget and revised by the Secretary in 
        accordance with section 673(2) of the Omnibus Budget 
        Reconciliation Act of 1981, which poverty line is applicable 
        the size of the family involved.
            ``(7) The term `State involved', with respect to an 
        applicant for an award under section 2785, means the State in 
        which the applicant is to carry out a community health advisor 
        program.

``SEC. 2794. EFFECT OF INSUFFICIENT APPROPRIATIONS FOR MINIMUM 
              ALLOTMENTS.

    ``(a) In General.--If the amounts made available under section 2784 
for a fiscal year are insufficient for providing each State (or entity 
designated by the State pursuant to section 2785, as the case may be) 
with an award under section 2785 in an amount equal to or greater than 
the amount specified in section 2789(a)(2), the Secretary shall, from 
such amounts as are made available under subsection (a), make such 
awards on a discretionary basis.
    ``(b) Rule of Construction.--For purposes of subsection (a), awards 
under section 2785 are made on a discretionary basis if the Secretary 
determines which States (or entities designated by States pursuant to 
such section, as the case may be) are to receive such awards, subject 
to meeting the requirements of this subtitle for such an award, and the 
Secretary determines the amount of such awards.

                    ``Subtitle F--General Provisions

``SEC. 2798. REQUIREMENT REGARDING ACCREDITATION OF SCHOOLS, 
              DEPARTMENTS, AND PROGRAMS.

    ``Except as indicated otherwise in this title:
            ``(1) A reference in this title to a school of public 
        health, a school of nursing, or any other entity providing 
        education or training in a health profession (whether a school, 
        department, program, or other entity) is a reference to the 
        entity as defined under section 799 or 853.
            ``(2) If an entity is not defined in either of such 
        sections, the reference in this title to the entity has the 
        meaning provided by the Secretary, except that the Secretary 
        shall require for purposes of this title that the entity be 
        accredited for the provision of the education or training 
        involved.

``SEC. 2799. RELATION TO OTHER FUNDS.

    ``Notwithstanding any other provision of law, the authorizations of 
appropriations established in this title are in addition to any other 
authorizations of appropriations that are available for the purposes 
described with respect to such appropriations in this title.

``SEC. 2799A. DEFINITIONS.

    ``(a) In General.--For purposes of this title:
            ``(1) The term `Healthy People 2000 Objectives' means the 
        objectives established by the Secretary toward the goals of 
        increasing the span of healthy life, reducing health 
        disparities among various populations, and providing access to 
        preventive services, which objectives apply to the health 
        status of the population of the United States for the year 
        2000.
            ``(2) The term `medically underserved community' means--
                    ``(A) a community that has a substantial number of 
                individuals who are members of a medically underserved 
                population, as defined in section 330; or
                    ``(B) a community a significant portion of which is 
                a health professional shortage area designated under 
                section 332.''.

                       TITLE IV--MEDICAL RESEARCH

SEC. 4001. FINDINGS.

    The Congress finds the following:
            (1) Nearly 4 of 5 peer reviewed research projects deemed 
        worthy of funding by the National Institutes of Health are not 
        funded.
            (2) Less than 2 percent of the nearly one trillion dollars 
        our Nation spends on health care is devoted to health research, 
        while the defense industry spends 15 percent of its budget on 
        research.
            (3) Public opinion surveys have shown that Americans want 
        more Federal resources put into health research and support by 
        having a portion of their health insurance premiums set aside 
        for this purpose.
            (4) Ample evidence exists to demonstrate that health 
        research has improved the quality of health care in the United 
        States. Advances such as the development of vaccines, the cure 
        of many childhood cancers, drugs that effectively treat a host 
        of diseases and disorders, a process to protect our Nation's 
        blood supply from the HIV virus, progress against 
        cardiovasculor disease including heart attack and stroke, and 
        new strategies for the early detection and treatment of 
        diseases such as colon, breast, and prostate cancer clearly 
        demonstrates the benefits of health research.
            (5) Among the most effective methods to control health care 
        costs are prevention and cure of disease and disability, thus, 
        health research which holds the promise of cure and prevention 
        of disease and disability is a critical component of any 
        comprehensive health care reform plan.
            (6) The state of our Nation's research facilities at the 
        National Institutes of Health and at universities is 
        deteriorating significantly. Renovation and repair of these 
        facilities are badly needed to maintain and improve the quality 
        of research.
            (7) Because the Omnibus Budget Reconciliation Act of 1993 
        freezes discretionary spending for the next 5 years, the 
        Nation's investment in health research through the National 
        Institutes of Health is likely to decline in real terms unless 
        corrective legislative action is taken.
            (8) A health research fund is needed to maintain our 
        Nation's commitment to health research and to increase the 
        percentage of approved projects which receive funding at the 
        National Institutes of Health to at least 33 percent.

SEC. 4002. NATIONAL FUND FOR HEALTH RESEARCH.

    (a) Establishment.--There is established in the Treasury of the 
United States an account, to be known as the ``National Fund for Health 
Research'' (hereafter referred to in this section as the ``Fund''), 
consisting of such amounts as are transferred to the Fund under 
subsection (b) and any interest earned on investment of amounts in the 
Fund.
    (b) Transfers to Fund.--
            (1) In general.--With respect to each of the 5 full 
        calendar years beginning after the date of enactment of this 
        Act, the Secretary of the Treasury shall transfer to the Fund 
        an amount equal to the applicable amount under paragraph (2).
            (2) Applicable amount.--The applicable amount under this 
        paragraph is--
                    (A) with respect to amounts in the Health Care 
                Reform Trust Fund established under section 
                9551(a)(2)(A) of the Internal Revenue Code of 1986, 
                $1,200,000,000 for each calendar year described in 
                paragraph (1); and
                    (B) with respect to amounts received in the 
                Treasury under section 6097 of the Internal Revenue 
                Code of 1986, 100 percent of the amounts received under 
                such section in each calendar year described in 
                paragraph (1).
            (3) Designation of overpayments and contributions.--
                    (A)  In general.--Subchapter A of chapter 61 of the 
                Internal Revenue Code of 1986 (relating to returns and 
                records) is amended by adding at the end the following 
                new part:

   ``PART IX--DESIGNATION OF OVERPAYMENTS AND CONTRIBUTIONS FOR THE 
                   NATIONAL FUND FOR HEALTH RESEARCH

``Sec. 6097. Amounts for the National Fund for Health Research.

``SEC. 6097. AMOUNTS FOR THE NATIONAL FUND FOR HEALTH RESEARCH.

    ``(a) In General.--Every individual (other than a nonresident 
alien) may designate that--
            ``(1) a portion (not less than $1) of any overpayment of 
        the tax imposed by chapter 1 for the taxable year, and
            ``(2) a cash contribution (not less than $1),
be paid over to the National Fund for Health Research established under 
section 4002 of the Health Innovation Partnership Act of 1994. In the 
case of a joint return of a husband and wife, each spouse may designate 
one-half of any such overpayment of tax (not less than $2).
    ``(b) Manner and Time of Designation.--Any designation under 
subsection (a) may be made with respect to any taxable year only at the 
time of filing the original return of the tax imposed by chapter 1 for 
such taxable year. Such designation shall be made either on the 1st 
page of the return or on the page bearing the taxpayer's signature.
    ``(c) Overpayments Treated as Refunded.--For purposes of this 
section, any overpayment of tax designated under subsection (a) shall 
be treated as being refunded to the taxpayer as of the last day 
prescribed for filing the return of tax imposed by chapter 1 
(determined with regard to extensions) or, if later, the date the 
return is filed.
    ``(d) Designated Amounts Not Deductible.--No amount designated 
pursuant to subsection (a) shall be allowed as a deduction under 
section 170 or any other section for any taxable year.
    ``(e) Termination.--This section shall not apply to taxable years 
beginning in a calendar year after a determination by the Secretary 
that the sum of all designations under subsection (a) for taxable years 
beginning in the second and third calendar years preceding the calendar 
year is less than $5,000,000.''.
                    (B) Clerical amendment.--The table of parts for 
                subchapter A of chapter 61 of such Code is amended by 
                adding at the end the following new item:

                              ``Part IX. Designation of overpayments 
                                        and contributions for the 
                                        National Fund for Health 
                                        Research.''.
                    (C) Effective date.--The amendments made by this 
                paragraph shall apply to taxable years beginning after 
                December 31, 1994.
    (c) Expenditures From Fund.--
            (1) In general.--The Secretary of the Treasury shall pay 
        annually, within 30 days after the President signs an 
        appropriations Act for the Departments of Labor, Health and 
        Human Services, and Education and related agencies, or by the 
        end of the first quarter of the fiscal year, to the Secretary 
        of Health and Human Services on behalf of the National 
        Institutes of Health, an amount equal to the amount in the 
        National Fund for Health Research at the time of such payment, 
        to enable the Secretary to carry out the purpose of section 
        404F of the Public Health Service Act, less any administrative 
        expenses which may be paid under paragraph (3).
            (2) Purposes for expenditures from fund.--Part A of title 
        IV of the Public Health Service Act (42 U.S.C. 281 et seq.) is 
        amended by adding at the end the following new section:

``SEC. 404F. EXPENDITURES FROM THE NATIONAL FUND FOR HEALTH RESEARCH.

    ``(a) In General.--From amounts received for any fiscal year from 
the National Fund for Health Research, the Secretary of Health and 
Human Services shall distribute--
            ``(1) 2 percent of such amounts during any fiscal year to 
        the Office of the Director of the National Institutes of Health 
        to be allocated at the Director's discretion for the following 
        activities:
                    ``(A) for carrying out the responsibilities of the 
                Office of the Director, National Institutes of Health, 
                including the Office of Research on Women's Health and 
                the Office of Research on Minority Health, the Office 
                of the Alternative Medicine and the Office of Rare 
                Diseases Research; and
                    ``(B) for construction and acquisition of equipment 
                for or facilities of or used by the National Institutes 
                of Health;
            ``(2) 2 percent of such amounts for transfer to the 
        National Center for Research Resources to carry out section 
        1502 of the National Institutes of Health Revitalization Act of 
        1993 concerning Biomedical and Behavioral Research Facilities;
            ``(3) 1 percent of such amounts during any fiscal year for 
        carrying out section 301 and part D of title IV with respect to 
        health information communications; and
            ``(4) the remainder of such amounts during any fiscal year 
        to member institutes of the National Institutes of Health and 
        centers in the same proportion to the total amount received 
        under this section, as the amount of annual appropriations 
        under appropriations Acts for each member institute and center 
        for the fiscal year bears to the total amount of appropriations 
        under appropriations Acts for all member institutes and centers 
        of the National Institutes of Health for the fiscal year.
    ``(b) Plans of Allocation.--The amounts transferred under 
subsection (a) shall be allocated by the Director of NIH or the various 
directors of the institutes and centers, as the case may be, pursuant 
to allocation plans developed by the various advisory councils to such 
directors, after consultation with such directors.''.
            (3) Administrative expenses.--Amounts in the National Fund 
        for Health Research shall be available to pay the 
        administrative expenses of the Department of the Treasury 
        directly allocable to--
                    (A) modifying the individual income tax return 
                forms to carry out section 6097 of the Internal Revenue 
                Code of 1986;
                    (B) carrying out this section with respect to such 
                Fund; and
                    (C) processing amounts received under this section 
                and transferring such amounts to such Fund.
            (4) Trigger and release of fund monies.--No expenditures 
        shall be made pursuant to section 4002(c) during any fiscal 
        year in which the annual amount appropriated for the National 
        Institutes of Health is less than the amount so appropriated 
        for the prior fiscal year.
    (d) Budget Enforcement.--Amounts contained in the National Fund for 
Health Research shall be excluded from, and shall not be taken into 
account for purposes of, any budget enforcement procedures under the 
Congressional Budget Act of 1974 or the Balanced Budget Emergency 
Deficit Control Act of 1985.

                      TITLE V--REVENUE PROVISIONS

SEC. 5000. AMENDMENT OF 1986 CODE.

    Except as otherwise expressly provided, whenever in this title an 
amendment or repeal is expressed in terms of an amendment to, or repeal 
of, a section or other provision, the reference shall be considered to 
be made to a section or other provision of the Internal Revenue Code of 
1986.

                    Subtitle A--Financing Provisions

              PART I--INCREASE IN TAX ON TOBACCO PRODUCTS

SEC. 5001. INCREASE IN EXCISE TAXES ON TOBACCO PRODUCTS.

    (a) Cigarettes.--Subsection (b) of section 5701 is amended--
            (1) by striking ``$12 per thousand ($10 per thousand on 
        cigarettes removed during 1991 or 1992)'' in paragraph (1) and 
        inserting ``$62 per thousand'', and
            (2) by striking ``$25.20 per thousand ($21 per thousand on 
        cigarettes removed during 1991 or 1992)'' in paragraph (2) and 
        inserting ``$130.20 per thousand''.
    (b) Cigars.--Subsection (a) of section 5701 is amended--
            (1) by striking ``$1.125 cents per thousand (93.75 cents 
        per thousand on cigars removed during 1991 or 1992)'' in 
        paragraph (1) and inserting ``$51.13 per thousand'', and
            (2) by striking ``equal to'' and all that follows in 
        paragraph (2) and inserting ``equal to 66 percent of the price 
        for which sold but not more than $155 per thousand.''
    (c) Cigarette Papers.--Subsection (c) of section 5701 is amended by 
striking ``0.75 cent (0.625 cent on cigarette papers removed during 
1991 or 1992)'' and inserting ``3.88 cents''.
    (d) Cigarette Tubes.--Subsection (d) of section 5701 is amended by 
striking ``1.5 cents (1.25 cents on cigarette tubes removed during 1991 
or 1992)'' and inserting ``7.76 cents''.
    (e) Smokeless Tobacco.--Subsection (e) of section 5701 is amended--
            (1) by striking ``36 cents (30 cents on snuff removed 
        during 1991 or 1992)'' in paragraph (1) and inserting 
        ``$13.69'', and
            (2) by striking ``12 cents (10 cents on chewing tobacco 
        removed during 1991 or 1992)'' in paragraph (2) and inserting 
        ``$5.45''.
    (f) Pipe Tobacco.--Subsection (f) of section 5701 is amended by 
striking ``67.5 cents (56.25 cents on pipe tobacco removed during 1991 
or 1992)'' and inserting ``$17.35''.
    (g) Application of Tax Increase to Puerto Rico.--Section 5701 is 
amended by adding at the end the following new subsection:
    ``(h) Application to Taxes to Puerto Rico.--Notwithstanding 
subsections (b) and (c) of section 7653 and any other provision of 
law--
            ``(1) In general.--On tobacco products and cigarette papers 
        and tubes, manufactured or imported into the Commonwealth of 
        Puerto Rico, there is hereby imposed a tax at the rate equal to 
        the excess of--
                    ``(A) the rate of tax applicable under this section 
                to like articles manufactured in the United States, 
                over
                    ``(B) the rate referred to in subparagraph (A) as 
                in effect on the day before the date of the enactment 
                of the Health Innovation Partnership Act of 1994.
            ``(2) Shipments to puerto rico from the united states.--
        Only the rates of tax in effect on the day before the date of 
        the enactment of this subsection shall be taken into account in 
        determining the amount of any exemption from, or credit or 
        drawback of, any tax imposed by this section on any article 
        shipped to the Commonwealth of Puerto Rico from the United 
        States.
            ``(3) Shipments from puerto rico to the united states.--The 
        rates of tax taken into account under section 7652(a) with 
        respect to tobacco products and cigarette papers and tubes 
        coming into the United States from the Commonwealth of Puerto 
        Rico shall be the rates of tax in effect on the day before the 
        date of the enactment of the Health Innovation Partnership Act 
        of 1994.
            ``(4) Disposition of revenues.--The provisions of section 
        7652(a)(3) shall not apply to any tax imposed by reason of this 
        subsection.''
    (h) Effective Date.--The amendments made by this section shall 
apply to articles removed (as defined in section 5702(k) of the 
Internal Revenue Code of 1986, as amended by this Act) after December 
31, 1994.
    (i) Floor Stocks Taxes.--
            (1) Imposition of tax.--On tobacco products and cigarette 
        papers and tubes manufactured in or imported into the United 
        States or the Commonwealth of Puerto Rico which are removed 
        before any tax-increase date, and held on such date for sale by 
        any person, there is hereby imposed a tax in an amount equal to 
        the excess of--
                    (A) the tax which would be imposed under section 
                5701 of the Internal Revenue Code of 1986 on the 
                article if the article had been removed on such date, 
                over
                    (B) the prior tax (if any) imposed under section 
                5701 or 7652 of such Code on such article.
            (2) Authority to exempt cigarettes held in vending 
        machines.--To the extent provided in regulations prescribed by 
        the Secretary, no tax shall be imposed by paragraph (1) on 
        cigarettes held for retail sale on any tax-increase date, by 
        any person in any vending machine. If the Secretary provides 
        such a benefit with respect to any person, the Secretary may 
        reduce the $500 amount in paragraph (3) with respect to such 
        person.
            (3) Credit against tax.--Each person shall be allowed as a 
        credit against the taxes imposed by paragraph (1) an amount 
        equal to $500. Such credit shall not exceed the amount of taxes 
        imposed by paragraph (1) on each tax-increase date for which 
        such person is liable.
            (4) Liability for tax and method of payment.--
                    (A) Liability for tax.--A person holding cigarettes 
                on any tax-increase date, to which any tax imposed by 
                paragraph (1) applies shall be liable for such tax.
                    (B) Method of payment.--The tax imposed by 
                paragraph (1) shall be paid in such manner as the 
                Secretary shall prescribe by regulations.
                    (C) Time for payment.--The tax imposed by paragraph 
                (1) shall be paid on or before the date which is 3 
                months after the tax-increase date.
            (5) Articles in foreign trade zones.--Notwithstanding the 
        Act of June 18, 1934 (48 Stat. 998, 19 U.S.C. 81a) and any 
        other provision of law, any article which is located in a 
        foreign trade zone on any tax-increase date shall be subject to 
        the tax imposed by paragraph (1) if--
                    (A) internal revenue taxes have been determined, or 
                customs duties liquidated, with respect to such article 
                before such date pursuant to a request made under the 
                1st proviso of section 3(a) of such Act, or
                    (B) such article is held on such date under the 
                supervision of a customs officer pursuant to the 2d 
                proviso of such section 3(a).
            (6) Definitions.--For purposes of this subsection--
                    (A) In general.--Terms used in this subsection 
                which are also used in section 5702 of the Internal 
                Revenue Code of 1986 shall have the respective meanings 
                such terms have in such section, as amended by this 
                Act.
                    (B) Secretary.--The term ``Secretary'' means the 
                Secretary of the Treasury or his delegate.
                    (C) Tax-increase date.--The term ``tax-increase 
                date'' means January 1, 1995, and July 1, 1996.
            (7) Controlled groups.--Rules similar to the rules of 
        section 5061(e)(3) of such Code shall apply for purposes of 
        this subsection.
            (8) Other laws applicable.--All provisions of law, 
        including penalties, applicable with respect to the taxes 
        imposed by section 5701 of such Code shall, insofar as 
        applicable and not inconsistent with the provisions of this 
        subsection, apply to the floor stocks taxes imposed by 
        paragraph (1), to the same extent as if such taxes were imposed 
        by such section 5701. The Secretary may treat any person who 
        bore the ultimate burden of the tax imposed by paragraph (1) as 
        the person to whom a credit or refund under such provisions may 
        be allowed or made.

SEC. 5002. MODIFICATIONS OF CERTAIN TOBACCO TAX PROVISIONS.

    (a) Exemption for Exported Tobacco Products and Cigarette Papers 
and Tubes To Apply Only to Articles Marked for Export.--
            (1) Subsection (b) of section 5704 is amended by adding at 
        the end the following new sentence: ``Tobacco products and 
        cigarette papers and tubes may not be transferred or removed 
        under this subsection unless such products or papers and tubes 
        bear such marks, labels, or notices as the Secretary shall by 
        regulations prescribe.''
            (2) Section 5761 is amended by redesignating subsections 
        (c) and (d) as subsections (d) and (e), respectively, and by 
        inserting after subsection (b) the following new subsection:
    ``(c) Sale of Tobacco Products and Cigarette Papers and Tubes for 
Export.--Except as provided in subsections (b) and (d) of section 
5704--
            ``(1) every person who sells, relands, or receives within 
        the jurisdiction of the United States any tobacco products or 
        cigarette papers or tubes which have been labeled or shipped 
        for exportation under this chapter,
            ``(2) every person who sells or receives such relanded 
        tobacco products or cigarette papers or tubes, and
            ``(3) every person who aids or abets in such selling, 
        relanding, or receiving,
shall, in addition to the tax and any other penalty provided in this 
title, be liable for a penalty equal to the greater of $1,000 or 5 
times the amount of the tax imposed by this chapter. All tobacco 
products and cigarette papers and tubes relanded within the 
jurisdiction of the United States, and all vessels, vehicles, and 
aircraft used in such relanding or in removing such products, papers, 
and tubes from the place where relanded, shall be forfeited to the 
United States.''.
            (3) Subsection (a) of section 5761 is amended by striking 
        ``subsection (b)'' and inserting ``subsection (b) or (c)''.
            (4) Subsection (d) of section 5761, as redesignated by 
        paragraph (2), is amended by striking ``The penalty imposed by 
        subsection (b)'' and inserting ``The penalties imposed by 
        subsections (b) and (c)''.
            (5)(A) Subpart F of chapter 52 is amended by adding at the 
        end the following new section:

``SEC. 5754. RESTRICTION ON IMPORTATION OF PREVIOUSLY EXPORTED TOBACCO 
              PRODUCTS.

    ``(a) In General.--Tobacco products and cigarette papers and tubes 
previously exported from the United States may be imported or brought 
into the United States only as provided in section 5704(d). For 
purposes of this section, section 5704(d), section 5761, and such other 
provisions as the Secretary may specify by regulations, references to 
exportation shall be treated as including a reference to shipment to 
the Commonwealth of Puerto Rico.
    ``(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).''.
            (B) The table of sections for subpart F of chapter 52 is 
        amended by adding at the end the following new item:

                              ``Sec. 5754. Restriction on importation 
                                        of previously exported tobacco 
                                        products.''.
    (b) Importers Required To Be Qualified.--
            (1) Sections 5712, 5713(a), 5721, 5722, 5762(a)(1), and 
        5763(b) and (c) are each amended by inserting ``or importer'' 
        after ``manufacturer''.
            (2) The heading of subsection (b) of section 5763 is 
        amended by inserting ``Qualified Importers,'' after 
        ``Manufacturers,''.
            (3) The heading for subchapter B of chapter 52 is amended 
        by inserting ``and Importers'' after ``Manufacturers''.
            (4) The item relating to subchapter B in the table of 
        subchapters for chapter 52 is amended by inserting ``and 
        importers'' after ``manufacturers''.
    (c) Repeal of Tax-Exempt Sales to Employees of Cigarette 
Manufacturers.--
            (1) Subsection (a) of section 5704 is amended--
                    (A) by striking ``Employee Use or'' in the heading, 
                and
                    (B) by striking ``for use or consumption by 
                employees or'' in the text.
            (2) Subsection (e) of section 5723 is amended by striking 
        ``for use or consumption by their employees, or for 
        experimental purposes'' and inserting ``for experimental 
        purposes''.
    (d) Repeal of Tax-Exempt Sales to United States.--Subsection (b) of 
section 5704 is amended by striking ``and manufacturers may similarly 
remove such articles for use of the United States;''.
    (e) Books of 25 or Fewer Cigarette Papers Subject to Tax.--
Subsection (c) of section 5701 is amended by striking ``On each book or 
set of cigarette papers containing more than 25 papers,'' and inserting 
``On cigarette papers,''.
    (f) Storage of Tobacco Products.--Subsection (k) of section 5702 is 
amended by inserting ``under section 5704'' after ``internal revenue 
bond''.
    (g) Authority To Prescribe Minimum Manufacturing Activity 
Requirements.--Section 5712 is amended by striking ``or'' at the end of 
paragraph (1), by redesignating paragraph (2) as paragraph (3), and by 
inserting after paragraph (1) the following new paragraph:
            ``(2) the activity proposed to be carried out at such 
        premises does not meet such minimum capacity or activity 
        requirements as the Secretary may prescribe, or''.
    (h) Special Rules Relating to Puerto Rico and the Virgin Islands.--
Section 7652 is amended by adding at the end the following new 
subsection:
    ``(h) Limitation on Cover Over of Tax on Tobacco Products.--For 
purposes of this section, with respect to taxes imposed under section 
5701 or this section on any tobacco product or cigarette paper or tube, 
the amount covered into the treasuries of Puerto Rico and the Virgin 
Islands shall not exceed the rate of tax under section 5701 in effect 
on the article on the day before the date of the enactment of the 
Health Innovation Partnership Act of 1994.''.
    (i) Effective Date.--The amendments made by this section shall 
apply to articles removed (as defined in section 5702(k) of the 
Internal Revenue Code of 1986, as amended by this Act) after December 
31, 1994.

SEC. 5003. IMPOSITION OF EXCISE TAX ON MANUFACTURE OR IMPORTATION OF 
              ROLL-YOUR-OWN TOBACCO.

    (a) In General.--Section 5701 (relating to rate of tax), as amended 
by section 701, is amended by redesignating subsections (g) and (h) as 
subsections (h) and (i) and by inserting after subsection (f) the 
following new subsection:
    ``(g) Roll-Your-Own Tobacco.--On roll-your-own tobacco, 
manufactured in or imported into the United States, there shall be 
imposed a tax of $17.35 per pound (and a proportionate tax at the like 
rate on all fractional parts of a pound).''.
    (b) Roll-Your-Own Tobacco.--Section 5702 (relating to definitions) 
is amended by adding at the end the following new subsection:
    ``(p) Roll-Your-Own Tobacco.--The term `roll-your-own tobacco' 
means any tobacco which, because of its appearance, type, packaging, or 
labeling, is suitable for use and likely to be offered to, or purchased 
by, consumers as tobacco for making cigarettes.''.
    (c) Technical Amendments.--
            (1) Subsection (c) of section 5702 is amended by striking 
        ``and pipe tobacco'' and inserting ``pipe tobacco, and roll-
        your-own tobacco''.
            (2) Subsection (d) of section 5702 is amended--
                    (A) in the material preceding paragraph (1), by 
                striking ``or pipe tobacco'' and inserting ``pipe 
                tobacco, or roll-your-own tobacco'', and
                    (B) by striking paragraph (1) and inserting the 
                following new paragraph:
            ``(1) a person who produces cigars, cigarettes, smokeless 
        tobacco, pipe tobacco, or roll-your-own tobacco solely for the 
        person's own personal consumption or use, and''.
            (3) The chapter heading for chapter 52 is amended to read 
        as follows:

    ``CHAPTER 52--TOBACCO PRODUCTS AND CIGARETTE PAPERS AND TUBES''.

            (4) The table of chapters for subtitle E is amended by 
        striking the item relating to chapter 52 and inserting the 
        following new item:

                              ``Chapter 52. Tobacco products and 
                                        cigarette papers and tubes.''.
    (d) Effective Date.--
            (1) In general.--The amendments made by this section shall 
        apply to roll-your-own tobacco removed (as defined in section 
        5702(k) of the Internal Revenue Code of 1986, as amended by 
        this Act) after December 31, 1994.
            (2) Transitional rule.--Any person who--
                    (A) on the date of the enactment of this Act is 
                engaged in business as a manufacturer of roll-your-own 
                tobacco or as an importer of tobacco products or 
                cigarette papers and tubes, and
                    (B) before January 1, 1995, submits an application 
                under subchapter B of chapter 52 of such Code to engage 
                in such business,
        may, notwithstanding such subchapter B, continue to engage in 
        such business pending final action on such application. Pending 
        such final action, all provisions of such chapter 52 shall 
        apply to such applicant in the same manner and to the same 
        extent as if such applicant were a holder of a permit under 
        such chapter 52 to engage in such business.

               Subtitle B--Health Care Reform Trust Fund

SEC. 5101. ESTABLISHMENT OF GRADUATE MEDICAL EDUCATION AND ACADEMIC 
              HEALTH CENTERS TRUST FUND.

    (a) In General.--Subchapter A of chapter 98 (relating to 
establishment of trust funds) is amended by adding at the end the 
following new part:

                   ``PART II--HEALTH CARE TRUST FUNDS

                              ``Sec. 9551. Health Care Reform Trust 
                                        Fund

``SEC. 9551. HEALTH CARE REFORM TRUST FUND.

    ``(a) Creation of Trust Fund.--There is established in the Treasury 
of the United States a trust fund to be known as the `Health Care 
Reform Trust Fund', consisting of such amounts as may be appropriated 
or credited to the Health Care Reform Trust Fund as provided in this 
section.
    ``(b) Transfers to the Trust Fund.--There are hereby appropriated 
to the Health Care Reform Trust Fund amounts received in the Treasury 
under section 5701 (relating to taxes on tobacco products) to the 
extent attributable to the increases in such taxes as the result of the 
enactment of section 5001 of the Health Innovation Partnership Act of 
1994.
    ``(c) Expenditures.--Amounts in the Health Care Reform Trust Fund 
are appropriated as provided for in sections 1001 and 4002 of the 
Health Innovation Partnership Act of 1994, and title XXVII of the 
Public Health Service Act, and to the extent any such amount is not 
expended during any fiscal year, such amount shall be available for 
such purpose for subsequent fiscal years.
    ``(d) Other Rules.--
            ``(1) Insufficient funds.--If, for any fiscal year, the sum 
        of the amounts required to be allocated under subsection (c) 
        exceeds the amounts received in the Health Care Reform Trust 
        Fund, then each of such amounts required to be so allocated 
        shall be reduced to an amount which bears the same ratio to 
        such amount as the amounts received in the trust fund bear to 
        the amounts required to be so allocated (without regard to this 
        paragraph).
            ``(2) Allocation of excess funds and interest.--Amounts 
        received in the Health Care Reform Trust Fund in excess of the 
        amounts required to be allocated under subsection (c), for any 
        fiscal year shall be allocated ratably on the basis of the 
        amounts allocated for the fiscal year (without regard to this 
        paragraph).''.
    (b) Conforming Amendment.--Subchapter A of chapter 98 is amended by 
inserting after the subchapter heading the following new items:

                              ``Part I.  General trust funds.
                              ``Part II. Health care trust fund.

                    ``PART I--GENERAL TRUST FUNDS''.

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```