I

106TH CONGRESS

1ST SESSION H. R. 1911

To require that health plans provide coverage for a minimum hospital stay

for mastectomies and lymph node dissection for the treatment of breast

cancer and coverage for secondary consultations.

IN THE HOUSE OF REPRESENTATIVES

MAY 24, 1999

Mr. LOBIONDO introduced the following bill; which was referred to the Committee on Commerce, and in addition to the Committees on Education

and the Workforce, and Ways and Means, for a period to be subsequently

determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned

A BILL

To require that health plans provide coverage for a minimum

hospital stay for mastectomies and lymph node dissection

for the treatment of breast cancer and coverage for secondary consultations.

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

3 SECTION 1. SHORT TITLE.

4 This Act may be cited as the ‘‘Women’s Cancer Re5 covery Act of 1999’’.
2

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1 SEC. 2. AMENDMENTS TO THE EMPLOYEE RETIREMENT IN2 COME SECURITY ACT OF 1974.

3 (a) IN GENERAL.—Subpart B of part 7 of subtitle

4 B of title I of the Employee Retirement Income Security

5 Act of 1974 is amended by adding at the end the following

6 new section:

7 ‘‘SEC. 714. REQUIRED COVERAGE FOR MINIMUM HOSPITAL

8 STAY FOR MASTECTOMIES AND LYMPH NODE

9 DISSECTIONS FOR THE TREATMENT OF

10 BREAST CANCER AND COVERAGE FOR SEC11 ONDARY CONSULTATIONS.

12 ‘‘(a) INPATIENT CARE.—

13 ‘‘(1) IN GENERAL.—A group health plan, and a

14 health insurance issuer providing health insurance

15 coverage in connection with a group health plan,

16 that provides medical and surgical benefits shall en17 sure that inpatient coverage with respect to the sur18 gical treatment of breast cancer (including a mastec19 tomy, lumpectomy, or lymph node dissection for the

20 treatment of breast cancer) is provided for a period

21 of time as is determined by the attending physician,

22 in the physician’s professional judgment consistent

23 with generally accepted principles of professional

24 medical practice, in consultation with the patient, to

25 be medically necessary or appropriate.
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1 ‘‘(2) EXCEPTION.—Nothing in this section shall

2 be construed as requiring the provision of inpatient

3 coverage if the attending physician in consultation

4 with the patient determines that a shorter period of

5 hospital stay is medically necessary or appropriate.

6 ‘‘(b) PROHIBITION ON CERTAIN MODIFICATIONS.—

7 In implementing the requirements of this section, a group

8 health plan, and a health insurance issuer providing health

9 insurance coverage in connection with a group health plan,

10 may not modify the terms and conditions of coverage

11 based on the determination by a participant or beneficiary

12 to request less than the minimum coverage required under

13 subsection (a).

14 ‘‘(c) NOTICE REQUIREMENT.—The imposition of the

15 requirements of this section shall be treated as a material

16 modification in the terms of the plan described in section

17 102(a)(1), for purposes of assuring notice of such require18 ments under the plan; except that the summary descrip19 tion required to be provided under the last sentence of sec20 tion 104(b)(1) with respect to such modification shall be

21 provided by not later than 60 days after the first day of

22 the first plan year in which such requirements apply and

23 shall be made available at the time of initial coverage and

24 at any time upon request of a participant or beneficiary.

25 ‘‘(d) SECONDARY CONSULTATIONS.—
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1 ‘‘(1) IN GENERAL.—A group health plan, and a

2 health insurance issuer providing health insurance

3 coverage in connection with a group health plan,

4 that provides coverage with respect to medical and

5 surgical services provided in relation to the diagnosis

6 and treatment of cancer shall ensure that full cov7 erage is provided for secondary consultations by spe8 cialists in the appropriate medical fields (including

9 pathology, radiology, and oncology) to confirm or re10 fute such diagnosis. Such plan or issuer shall ensure

11 that full coverage is provided for such secondary

12 consultation whether such consultation is based on a

13 positive or negative initial diagnosis. In any case in

14 which the attending physician certifies in writing

15 that services necessary for such a secondary con16 sultation are not sufficiently available from special17 ists operating under the plan with respect to whose

18 services coverage is otherwise provided under such

19 plan or by such issuer, such plan or issuer shall en20 sure that coverage is provided with respect to the

21 services necessary for the secondary consultation

22 with any other specialist selected by the attending

23 physician for such purpose at no additional cost to

24 the individual beyond that which the individual
5

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1 would have paid if the specialist was participating

2 in the network of the plan.

3 ‘‘(2) EXCEPTION.—Nothing in paragraph (1)

4 shall be construed as requiring the provision of sec5 ondary consultations where there is a financial rela6 tionship (including an ownership or investment in7 terest or compensation arrangement) between the

8 specialist and the attending physician or where the

9 patient determines not to seek such a consultation.

10 ‘‘(e) PROHIBITION ON PENALTIES OR INCENTIVES.—

11 A group health plan, and a health insurance issuer pro12 viding health insurance coverage in connection with a

13 group health plan, may not—

14 ‘‘(1) penalize or otherwise reduce or limit the

15 reimbursement of a provider or specialist because

16 the provider or specialist provided care to a partici17 pant or beneficiary in accordance with this section;

18 ‘‘(2) provide financial or other incentives to a

19 physician or specialist to induce the physician or

20 specialist to keep the length of inpatient stays of pa21 tients following a mastectomy, lumpectomy, or a

22 lymph node dissection for the treatment of breast

23 cancer below certain limits or to limit referrals for

24 secondary consultations; or
6

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1 ‘‘(3) provide financial or other incentives to a

2 physician or specialist to induce the physician or

3 specialist to refrain from referring a participant or

4 beneficiary for a secondary consultation that would

5 otherwise be covered by the plan or coverage in6 volved under subsection (d).

7 ‘‘(f) PREEMPTION; EXCEPTION FOR HEALTH INSUR8 ANCE COVERAGE IN CERTAIN STATES.—

9 ‘‘(1) IN GENERAL.—The requirements of this

10 section shall not apply with respect to health insur11 ance coverage if there is a State law (as defined in

12 section 731(d)(1)) for a State that regulates such

13 coverage that is described in any of the following

14 subparagraphs:

15 ‘‘(A) Such State law requires such cov16 erage to provide for at least a 48-hour hospital

17 length of stay following a mastectomy per18 formed for treatment of breast cancer and at

19 least a 24-hour hospital length of stay following

20 a lymph node dissection for treatment of breast

21 cancer.

22 ‘‘(B) Such State law requires, in connec23 tion with such coverage for surgical treatment

24 of breast cancer, that the hospital length of

25 stay for such care is left to the decision of (or
7

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1 required to be made by) the attending provider

2 in consultation with the woman involved.

3 ‘‘(2) CONSTRUCTION.—Section 731(a)(1) shall

4 not be construed as superseding a State law de5 scribed in paragraph (1).’’.

6 (b) CONFORMING AMENDMENT.—Section 731(c) of

7 such Act (29 U.S.C. 1191(c)) is amended by striking ‘‘sec8 tion 711’’ and inserting ‘‘sections 711 and 714’’.

9 (c) CLERICAL AMENDMENT.—The table of contents

10 in section 1 of such Act is amended by inserting after the

11 item relating to section 713 the following new item:

‘‘Sec. 714. Required coverage for minimum hospital stay for mastectomies and

lymph node dissections for the treatment of breast cancer and

coverage for secondary consultations.’’.

12 (d) EFFECTIVE DATES.—

13 (1) IN GENERAL.—The amendments made by

14 this section shall apply with respect to plan years be15 ginning on or after the date of enactment of this

16 Act.

17 (2) SPECIAL RULE FOR COLLECTIVE BAR18 GAINING AGREEMENTS.—In the case of a group

19 health plan maintained pursuant to 1 or more collec20 tive bargaining agreements between employee rep21 resentatives and 1 or more employers ratified before

22 the date of enactment of this Act, the amendments

23 made by this section shall not apply to plan years

24 beginning before the later of—
8

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1 (A) the date on which the last collective

2 bargaining agreements relating to the plan ter3 minates (determined without regard to any ex4 tension thereof agreed to after the date of en5 actment of this Act), or

6 (B) January 1, 2000.

7 For purposes of subparagraph (A), any plan amend8 ment made pursuant to a collective bargaining

9 agreement relating to the plan which amends the

10 plan solely to conform to any requirement added by

11 this section shall not be treated as a termination of

12 such collective bargaining agreement.

13 SEC. 3. AMENDMENTS TO THE PUBLIC HEALTH SERVICE

14 ACT RELATING TO THE GROUP MARKET.

15 (a) IN GENERAL.—Subpart 2 of part A of title

16 XXVII of the Public Health Service Act is amended by

17 adding at the end the following new section:

18 ‘‘SEC. 2707. REQUIRED COVERAGE FOR MINIMUM HOSPITAL

19 STAY FOR MASTECTOMIES AND LYMPH NODE

20 DISSECTIONS FOR THE TREATMENT OF

21 BREAST CANCER AND COVERAGE FOR SEC22 ONDARY CONSULTATIONS.

23 ‘‘(a) INPATIENT CARE.—

24 ‘‘(1) IN GENERAL.—A group health plan, and a

25 health insurance issuer providing health insurance
9

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1 coverage in connection with a group health plan,

2 that provides medical and surgical benefits shall en3 sure that inpatient coverage with respect to the sur4 gical treatment of breast cancer (including a mastec5 tomy, lumpectomy, or lymph node dissection for the

6 treatment of breast cancer) is provided for a period

7 of time as is determined by the attending physician,

8 in the physician’s professional judgment consistent

9 with generally accepted principles of professional

10 medical practice, in consultation with the patient, to

11 be medically necessary or appropriate.

12 ‘‘(2) EXCEPTION.—Nothing in this section shall

13 be construed as requiring the provision of inpatient

14 coverage if the attending physician in consultation

15 with the patient determines that a shorter period of

16 hospital stay is medically necessary or appropriate.

17 ‘‘(b) PROHIBITION ON CERTAIN MODIFICATIONS.—

18 In implementing the requirements of this section, a group

19 health plan, and a health insurance issuer providing health

20 insurance coverage in connection with a group health plan,

21 may not modify the terms and conditions of coverage

22 based on the determination by a participant or beneficiary

23 to request less than the minimum coverage required under

24 subsection (a).
10

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1 ‘‘(c) NOTICE REQUIREMENT.—A group health plan

2 under this part shall comply with the notice requirement

3 under section 714(c) of the Employee Retirement Income

4 Security Act of 1974 with respect to the requirements of

5 this section as if such section applied to such plan.

6 ‘‘(d) SECONDARY CONSULTATIONS.—

7 ‘‘(1) IN GENERAL.—A group health plan, and a

8 health insurance issuer providing health insurance

9 coverage in connection with a group health plan that

10 provides coverage with respect to medical and sur11 gical services provided in relation to the diagnosis

12 and treatment of cancer shall ensure that full cov13 erage is provided for secondary consultations by spe14 cialists in the appropriate medical fields (including

15 pathology, radiology, and oncology) to confirm or re16 fute such diagnosis. Such plan or issuer shall ensure

17 that full coverage is provided for such secondary

18 consultation whether such consultation is based on a

19 positive or negative initial diagnosis. In any case in

20 which the attending physician certifies in writing

21 that services necessary for such a secondary con22 sultation are not sufficiently available from special23 ists operating under the plan with respect to whose

24 services coverage is otherwise provided under such

25 plan or by such issuer, such plan or issuer shall en-
11

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1 sure that coverage is provided with respect to the

2 services necessary for the secondary consultation

3 with any other specialist selected by the attending

4 physician for such purpose at no additional cost to

5 the individual beyond that which the individual

6 would have paid if the specialist was participating in

7 the network of the plan.

8 ‘‘(2) EXCEPTION.—Nothing in paragraph (1)

9 shall be construed as requiring the provision of sec10 ondary consultations where there is a financial rela11 tionship (including an ownership or investment in12 terest or compensation arrangement) between the

13 specialist and the attending physician or where the

14 patient determines not to seek such a consultation.

15 ‘‘(e) PROHIBITION ON PENALTIES OR INCENTIVES.—

16 A group health plan, and a health insurance issuer pro17 viding health insurance coverage in connection with a

18 group health plan, may not—

19 ‘‘(1) penalize or otherwise reduce or limit the

20 reimbursement of a provider or specialist because

21 the provider or specialist provided care to a partici22 pant or beneficiary in accordance with this section;

23 ‘‘(2) provide financial or other incentives to a

24 physician or specialist to induce the physician or

25 specialist to keep the length of inpatient stays of pa-
12

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1 tients following a mastectomy, lumpectomy, or a

2 lymph node dissection for the treatment of breast

3 cancer below certain limits or to limit referrals for

4 secondary consultations; or

5 ‘‘(3) provide financial or other incentives to a

6 physician or specialist to induce the physician or

7 specialist to refrain from referring a participant or

8 beneficiary for a secondary consultation that would

9 otherwise be covered by the plan or coverage in10 volved under subsection (d).

11 ‘‘(f) EXCEPTION FOR HEALTH INSURANCE COV12 ERAGE IN CERTAIN STATES.—

13 ‘‘(1) IN GENERAL.—The requirements of this

14 section shall not apply with respect to health insur15 ance coverage if there is a State law (as defined in

16 section 2723(d)(1) of the Public Health Service Act)

17 for a State that regulates such coverage that is de18 scribed in any of the following subparagraphs:

19 ‘‘(A) Such State law requires such cov20 erage to provide for at least a 48-hour hospital

21 length of stay following a mastectomy per22 formed for treatment of breast cancer and at

23 least a 24-hour hospital length of stay following

24 a lymph node dissection for treatment of breast

25 cancer.
13

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1 ‘‘(B) Such State law requires, in connec2 tion with such coverage for surgical treatment

3 of breast cancer, that the hospital length of

4 stay for such care is left to the decision of (or

5 required to be made by) the attending provider

6 in consultation with the woman involved.

7 ‘‘(2) CONSTRUCTION.—Section 2723(a)(1) shall

8 not be construed as superseding a State law de9 scribed in paragraph (1).’’.

10 (b) CONFORMING AMENDMENT.—Section 2723(c) of

11 such Act (42 U.S.C. 300gg–23(c)) is amended by striking

12 ‘‘section 2704’’ and inserting ‘‘sections 2704 and 2707’’.

13 (c) EFFECTIVE DATES.—

14 (1) IN GENERAL.—The amendments made by

15 this section shall apply to group health plans for

16 plan years beginning on or after the date of enact17 ment of this Act.

18 (2) SPECIAL RULE FOR COLLECTIVE BAR19 GAINING AGREEMENTS.—In the case of a group

20 health plan maintained pursuant to 1 or more collec21 tive bargaining agreements between employee rep22 resentatives and 1 or more employers ratified before

23 the date of enactment of this Act, the amendments

24 made by this section shall not apply to plan years

25 beginning before the later of—
14

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1 (A) the date on which the last collective

2 bargaining agreements relating to the plan ter3 minates (determined without regard to any ex4 tension thereof agreed to after the date of en5 actment of this Act), or

6 (B) January 1, 2000.

7 For purposes of subparagraph (A), any plan amend8 ment made pursuant to a collective bargaining

9 agreement relating to the plan which amends the

10 plan solely to conform to any requirement added by

11 this section shall not be treated as a termination of

12 such collective bargaining agreement.

13 SEC. 4. AMENDMENT TO THE PUBLIC HEALTH SERVICE ACT

14 RELATING TO THE INDIVIDUAL MARKET.

15 (a) IN GENERAL.—Subpart 3 of part B of title

16 XXVII of the Public Health Service Act is amended by

17 adding at the end the following new section:

18 ‘‘SEC. 2753. REQUIRED COVERAGE FOR MINIMUM HOSPITAL

19 STAY FOR MASTECTOMIES AND LYMPH NODE

20 DISSECTIONS FOR THE TREATMENT OF

21 BREAST CANCER AND SECONDARY CON22 SULTATIONS.

23 ‘‘(a) IN GENERAL.—The provisions of section 2707

24 (other than subsection (c)) shall apply to health insurance

25 coverage offered by a health insurance issuer in the indi-
15

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1 vidual market in the same manner as they apply to health

2 insurance coverage offered by a health insurance issuer

3 in connection with a group health plan in the small or

4 large group market.

5 ‘‘(b) REQUIREMENT.—A health insurance issuer

6 under this part shall comply with the notice requirement

7 under section 714(c) of the Employee Retirement Income

8 Security Act of 1974 with respect to the requirements re9 ferred to in subsection (a) as if such section applied to

10 such issuer and such issuer were a group health plan.

11 ‘‘(c) EXCEPTION FOR HEALTH INSURANCE COV12 ERAGE IN CERTAIN STATES.—

13 ‘‘(1) IN GENERAL.—The requirements of this

14 section shall not apply with respect to health insur15 ance coverage if there is a State law (as defined in

16 section 2723(d)(1) of the Public Health Service Act)

17 for a State that regulates such coverage that is de18 scribed in any of the following subparagraphs:

19 ‘‘(A) Such State law requires such cov20 erage to provide for at least a 48-hour hospital

21 length of stay following a mastectomy per22 formed for treatment of breast cancer and at

23 least a 24-hour hospital length of stay following

24 a lymph node dissection for treatment of breast

25 cancer.
16

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1 ‘‘(B) Such State law requires, in connec2 tion with such coverage for surgical treatment

3 of breast cancer, that the hospital length of

4 stay for such care is left to the decision of (or

5 required to be made by) the attending provider

6 in consultation with the woman involved.

7 ‘‘(2) CONSTRUCTION.—Section 2762(a) shall

8 not be construed as superseding a State law de9 scribed in paragraph (1).’’.

10 (b) CONFORMING AMENDMENT.—Section 2762(b)(2)

11 of such Act (42 U.S.C. 300gg–62(b)(2)) is amended by

12 striking ‘‘section 2751’’ and inserting ‘‘sections 2751 and

13 2753’’.

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

15 this section shall apply with respect to health insurance

16 coverage offered, sold, issued, renewed, in effect, or oper17 ated in the individual market on or after the date of enact18 ment of this Act.

19 SEC. 5. AMENDMENTS TO THE INTERNAL REVENUE CODE

20 OF 1986.

21 (a) IN GENERAL.—Subchapter B of chapter 100 of

22 the Internal Revenue Code of 1986 (relating to other re23 quirements) is amended by inserting after section 9812

24 the following new section:
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1 ‘‘SEC. 9813. REQUIRED COVERAGE FOR MINIMUM HOSPITAL

2 STAY FOR MASTECTOMIES AND LYMPH NODE

3 DISSECTIONS FOR THE TREATMENT OF

4 BREAST CANCER AND COVERAGE FOR SEC5 ONDARY CONSULTATIONS.

6 ‘‘(a) INPATIENT CARE.—

7 ‘‘(1) IN GENERAL.—A group health plan that

8 provides medical and surgical benefits shall ensure

9 that inpatient coverage with respect to the surgical

10 treatment of breast cancer (including a mastectomy,

11 lumpectomy, or lymph node dissection for the treat12 ment of breast cancer) is provided for a period of

13 time as is determined by the attending physician, in

14 the physician’s professional judgment consistent with

15 generally accepted principles of professional medical

16 practice, in consultation with the patient, to be

17 medically necessary or appropriate.

18 ‘‘(2) EXCEPTION.—Nothing in this section shall

19 be construed as requiring the provision of inpatient

20 coverage if the attending physician in consultation

21 with the patient determines that a shorter period of

22 hospital stay is medically necessary or appropriate.

23 ‘‘(b) PROHIBITION ON CERTAIN MODIFICATIONS.—

24 In implementing the requirements of this section, a group

25 health plan may not modify the terms and conditions of

26 coverage based on the determination by a participant or
18

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1 beneficiary to request less than the minimum coverage re2 quired under subsection (a).

3 ‘‘(c) SECONDARY CONSULTATIONS.—

4 ‘‘(1) IN GENERAL.—A group health plan that

5 provides coverage with respect to medical and sur6 gical services provided in relation to the diagnosis

7 and treatment of cancer shall ensure that full cov8 erage is provided for secondary consultations by spe9 cialists in the appropriate medical fields (including

10 pathology, radiology, and oncology) to confirm or re11 fute such diagnosis. Such plan or issuer shall ensure

12 that full coverage is provided for such secondary

13 consultation whether such consultation is based on a

14 positive or negative initial diagnosis. In any case in

15 which the attending physician certifies in writing

16 that services necessary for such a secondary con17 sultation are not sufficiently available from special18 ists operating under the plan with respect to whose

19 services coverage is otherwise provided under such

20 plan or by such issuer, such plan or issuer shall en21 sure that coverage is provided with respect to the

22 services necessary for the secondary consultation

23 with any other specialist selected by the attending

24 physician for such purpose at no additional cost to

25 the individual beyond that which the individual
19

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1 would have paid if the specialist was participating

2 in the network of the plan.

3 ‘‘(2) EXCEPTION.—Nothing in paragraph (1)

4 shall be construed as requiring the provision of sec5 ondary consultations where there is a financial rela6 tionship (including an ownership or investment in7 terest or compensation arrangement) between the

8 specialist and the attending physician or where the

9 patient determines not to seek such a consultation.

10 ‘‘(d) PROHIBITION ON PENALTIES.—A group health

11 plan may not—

12 ‘‘(1) penalize or otherwise reduce or limit the

13 reimbursement of a provider or specialist because

14 the provider or specialist provided care to a partici15 pant or beneficiary in accordance with this section;

16 ‘‘(2) provide financial or other incentives to a

17 physician or specialist to induce the physician or

18 specialist to keep the length of inpatient stays of pa19 tients following a mastectomy, lumpectomy, or a

20 lymph node dissection for the treatment of breast

21 cancer below certain limits or to limit referrals for

22 secondary consultations; or

23 ‘‘(3) provide financial or other incentives to a

24 physician or specialist to induce the physician or

25 specialist to refrain from referring a participant or
20

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1 beneficiary for a secondary consultation that would

2 otherwise be covered by the plan involved under sub3 section (d).

4 ‘‘(e) EXCEPTION FOR HEALTH INSURANCE COV5 ERAGE IN CERTAIN STATES.—The requirements of this

6 section shall not apply with respect to health insurance

7 coverage if there is a State law (including a decision, rule,

8 regulation, or other State action having the effect of law)

9 for a State that regulates such coverage that is described

10 in any of the following paragraphs:

11 ‘‘(1) Such State law requires such coverage to

12 provide for at least a 48-hour hospital length of stay

13 following a mastectomy performed for treatment of

14 breast cancer and at least a 24-hour hospital length

15 of stay following a lymph node dissection for treat16 ment of breast cancer.

17 ‘‘(2) Such State law requires, in connection

18 with such coverage for surgical treatment of breast

19 cancer, that the hospital length of stay for such care

20 is left to the decision of (or required to be made by)

21 the attending provider in consultation with the

22 woman involved.’’.

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

24 for such subchapter is amended by adding at the end the

25 following new item:
21

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‘‘Sec. 9813. Required coverage for minimum hospital stay for mastectomies and

lymph node dissections for the treatment of breast cancer and

coverage for secondary consultations.’’.

1 (c) EFFECTIVE DATES.—

2 (1) IN GENERAL.—The amendments made by

3 this section shall apply with respect to plan years be4 ginning on or after the date of enactment of this

5 Act.

6 (2) SPECIAL RULE FOR COLLECTIVE BAR7 GAINING AGREEMENTS.—In the case of a group

8 health plan maintained pursuant to 1 or more collec9 tive bargaining agreements between employee rep10 resentatives and 1 or more employers ratified before

11 the date of enactment of this Act, the amendments

12 made by this section shall not apply to plan years

13 beginning before the later of—

14 (A) the date on which the last collective

15 bargaining agreements relating to the plan ter16 minates (determined without regard to any ex17 tension thereof agreed to after the date of en18 actment of this Act), or

19 (B) January 1, 2000.

20 For purposes of subparagraph (A), any plan amend21 ment made pursuant to a collective bargaining

22 agreement relating to the plan which amends the

23 plan solely to conform to any requirement added by
22

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1 this section shall not be treated as a termination of

2 such collective bargaining agreement.

3 SEC. 6. COORDINATION OF ADMINISTRATION.

4 The Secretary of Labor, the Secretary of the Treas5 ury, and the Secretary of Health and Human Services

6 shall ensure, through the execution of an interagency

7 memorandum of understanding among such Secretaries,

8 that—

9 (1) regulations, rulings, and interpretations

10 issued by such Secretaries relating to the same mat11 ter over which two or more such Secretaries have re12 sponsibility under the provisions of this Act (and the

13 amendments made thereby) are administered so as

14 to have the same effect at all times; and

15 (2) coordination of policies relating to enforcing

16 the same requirements through such Secretaries in

17 order to have a coordinated enforcement strategy

18 that avoids duplication of enforcement efforts and

19 assigns priorities in enforcement.

Æ