I 

110TH CONGRESS 

2D SESSION H. R. 4993 

To amend the Public Health Service Act to increase the availability of 

vaccines, and for other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

JANUARY 16, 2008 

Mr. WAXMAN (for himself and Ms. ROYBAL-ALLARD) introduced the following 

bill; which was referred to the Committee on Energy and Commerce, and 

in addition to the Committees on Education and Labor, Ways and Means, 

and Oversight and Government Reform, 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 amend the Public Health Service Act to increase the 

availability of vaccines, and for other purposes. 

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

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Vaccines for the Unin5 sured Adult Act of 2008’’. 


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1 SEC. 2. CERTAIN AUTHORITIES REGARDING ADULT IMMU2 NIZATIONS. 

3 (a) IN GENERAL.—Part B of title III of the Public 

4 Health Service Act (42 U.S.C. 243 et seq.) is amended— 

5 (1) by redesignating section 317A as section 

6 317A–1; and 

7 (2) by inserting after section 317 the following 

8 section: 

9 ‘‘SEC. 317A. CERTAIN AUTHORITIES REGARDING ADULT IM10 MUNIZATIONS. 

11 ‘‘(a) IMMUNIZATION PROGRAM FOR ELIGIBLE

12 ADULTS.— 

13 ‘‘(1) IN GENERAL.—The Secretary shall by reg14 ulation establish a program for the distribution of 

15 qualified adult vaccines through States with ap16 proved applications under paragraph (4)(C) and the 

17 payment of a fee for the administration of such vac18 cines, under which program— 

19 ‘‘(A) each vaccine-eligible adult, in receiv20 ing an immunization with a qualified adult vac21 cine from a program-registered provider on or 

22 after October 1, 2009, is entitled to receive the 

23 immunization without charge for the cost of 

24 such vaccine; and 

25 ‘‘(B)(i) each program-registered provider 

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1 gible adult on or after such date is entitled to 

2 receive such vaccine under the program without 

3 charge either for the vaccine or its delivery to 

4 the provider and is entitled to receive payment 

5 for the administration of such vaccine; and 

6 ‘‘(ii) no vaccine is distributed under the 

7 program to a provider, and no payment is made 

8 for the administration of the vaccine by such a 

9 provider, unless the provider is a program-reg10 istered provider. 

11 ‘‘(2) RELATIONSHIP TO PROGRAM FOR DIS12 TRIBUTION OF PEDIATRIC VACCINES.—The provi13 sions of the program under section 1928 of the So14 cial Security Act (including provisions taking effect 

15 on or after the effective date of this section, other 

16 than subsection (f) of such section 1928) apply with 

17 respect to immunizations for vaccine-eligible adults 

18 under the program under paragraph (1) to the same 

19 extent and in the same manner as such provisions 

20 apply with respect to immunizations for vaccine-eli21 gible children under the program under such section 

22 1928, except to the extent that such a provision con23 flicts with this subsection. The preceding sentence 

24 may not be construed as having any effect on the 

25 program under title XIX of the Social Security Act, 


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1 or as having the effect that, in the program under 

2 paragraph (1), State plans comparable to State 

3 plans under section 1902 of such Act are required. 

4 ‘‘(3) VACCINE-ELIGIBLE ADULT.— 

5 ‘‘(A) IN GENERAL.—For purposes of this 

6 subsection, the term ‘vaccine-eligible adult’ 

7 means a federally vaccine-eligible adult or a 

8 State vaccine-eligible adult. 

9 ‘‘(B) FEDERALLY VACCINE-ELIGIBLE

10 ADULT.—For purposes of this subsection, the 

11 term ‘federally vaccine-eligible adult’ means any 

12 of the following: 

13 ‘‘(i) An adult who is not insured. 

14 ‘‘(ii) An adult who— 

15 ‘‘(I) is administered a qualified 

16 adult vaccine by a Federally-qualified 

17 health center (as defined in section 

18 1905(l)(2)(B) of the Social Security 

19 Act), by any other entity that is a cov20 ered entity under section 340B(a)(4), 

21 or by any public clinic; and 

22 ‘‘(II) is not insured with respect 

23 to the vaccine. 

24 ‘‘(iii) An adult who— 


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1 ‘‘(I) is administered a qualified 

2 adult vaccine while incarcerated in a 

3 Federal, State, or local penal or cor4 rectional institution, including an 

5 adult who is held pending judicial or 

6 administrative proceedings; and 

7 ‘‘(II) is not insured with respect 

8 to the vaccine. 

9 ‘‘(C) STATE VACCINE-ELIGIBLE ADULT.— 

10 For purposes of this subsection, the term ‘State 

11 vaccine-eligible adult’ means, with respect to a 

12 State and a qualified adult vaccine, an adult 

13 who is within a class of adults for which the 

14 State is purchasing the vaccine pursuant to 

15 provisions that apply pursuant to paragraph 

16 (2). 

17 ‘‘(4) PARTICIPATION OF STATES.— 

18 ‘‘(A) IN GENERAL.—In the case or each 

19 State with an approved application under sub20 paragraph (C), the Secretary shall provide, in 

21 accordance with provisions that apply pursuant 

22 to paragraph (2), for the purchase and delivery 

23 on behalf of the State, without charge to the 

24 State, of such quantities of qualified adult vac25 cines as may be necessary for the administraVerDate Aug 31 2005 00:44 Jan 19, 2008 Jkt 069200 PO 00000 Frm 00005 Fmt 6652 Sfmt 6201 E:\BILLS\H4993.IH H4993

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1 tion of such vaccines to all vaccine-eligible 

2 adults in the State on or after October 1, 2009. 

3 ‘‘(B) PROGRAM CRITERIA.—The Secretary, 

4 in accordance with provisions that apply pursu5 ant to paragraph (2), shall establish criteria for 

6 State programs under paragraph (1). 

7 ‘‘(C) STATE APPLICATION.—A State may 

8 participate in the program under paragraph (1) 

9 only if the State submits to the Secretary an 

10 application for such participation. The Sec11 retary shall approve any such application 

12 that— 

13 ‘‘(i) is submitted in such form and 

14 such manner as the Secretary may require; 

15 and 

16 ‘‘(ii) demonstrates that the State is in 

17 compliance with criteria under subpara18 graph (B) and the requirement of subpara19 graph (D). 

20 ‘‘(D) REQUIREMENT OF STATE MAINTE21 NANCE OF IMMUNIZATION LAWS.—In the case 

22 of a State that had in effect as of July 1, 2008, 

23 a law that requires some or all health insurance 

24 policies or plans to provide some coverage with 

25 respect to an adult vaccine, the Secretary may 


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1 not approve the State’s application under sub2 paragraph (C) unless the State certifies to the 

3 Secretary that the State has not modified or re4 pealed such law in a manner that reduces the 

5 amount of coverage so required. 

6 ‘‘(5) ADDITIONAL DEFINITIONS.—For purposes 

7 of this subsection: 

8 ‘‘(A) The term ‘adult’ means an individual 

9 who is not a child as defined in section 1928 of 

10 the Social Security Act. 

11 ‘‘(B) The term ‘adult vaccine’ means a fed12 erally recommended vaccine for adults. 

13 ‘‘(C)(i) The term ‘insured’, with respect to 

14 an adult, means that the adult is enrolled 

15 under, and entitled to benefits under, a health 

16 insurance policy or plan, including a group 

17 health plan, a prepaid health plan, or an em18 ployee welfare benefit plan under the Employee 

19 Retirement Income Security Act of 1974. 

20 ‘‘(ii) An adult is not insured with respect 

21 to a qualified adult vaccine if the adult is enti22 tled to benefits under such a health insurance 

23 policy or plan, but such benefits are not avail24 able with respect to the cost of such vaccine. 


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1 ‘‘(D) The term ‘qualified adult vaccine’ 

2 means an adult vaccine with respect to which a 

3 contract is in effect pursuant to provisions that 

4 apply pursuant to paragraph (2). 

5 ‘‘(6) PAYMENT FOR VACCINE ADMINISTRA6 TION.— 

7 ‘‘(A) IN GENERAL.—The amount of pay8 ment for vaccine administration under the pro9 gram under this section shall be the same as 

10 the amount established under the physician fee 

11 schedule under section 1848 of the Social Secu12 rity Act for payment for administration of a 

13 vaccine under part B of title XVIII of such Act. 

14 ‘‘(B) ADMINISTRATIVE CONTRACTS.—The 

15 Secretary shall enter into such contracts or 

16 agreements with qualified carriers or inter17 mediaries as may be necessary for the proc18 essing of claims for payment for vaccine admin19 istration under this section. 

20 ‘‘(7) DIRECT SPENDING.—The requirement 

21 under paragraph (1) that the Secretary carry out a 

22 program constitutes budget authority in advance of 

23 appropriations Acts, and represents the obligation of 

24 the Federal Government to make outlays to provide 

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1 cordance with this subsection, including with respect 

2 to program-registered providers and with respect to 

3 the purchase and delivery of qualified adult vaccines 

4 on behalf of States and with respect to the payment 

5 for vaccine administration. 

6 ‘‘(b) EMERGENCY RESPONSE PLAN REGARDING

7 SHORTAGES.— 

8 ‘‘(1) DEVELOPMENT OF PLAN.—The Secretary 

9 shall develop and maintain a plan for the response 

10 of the Secretary to potential shortages in supplies of 

11 vaccines that would constitute public health emer12 gencies. The plan shall include provisions with re13 spect to— 

14 ‘‘(A) communication among the relevant 

15 entities; 

16 ‘‘(B) distribution of available supplies of 

17 the vaccine involved; 

18 ‘‘(C) the designation of populations to be 

19 given priority for immunizations; 

20 ‘‘(D) interactions with State and local gov21 ernments; 

22 ‘‘(E) the use of the vaccine stockpile; and 

23 ‘‘(F) special considerations for specific vac24 cines. 


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1 ‘‘(2) COMPLETION OF PLAN.—The initial plan 

2 under paragraph (1) shall be completed not later 

3 than 12 months after the date of the enactment of 

4 the Vaccines for the Uninsured Act of 2008. 

5 ‘‘(3) STUDY ON REALLOCATION OF VACCINE.— 

6 Not later than 1 year after the date of the enact7 ment of the Vaccines for the Uninsured Act of 2008, 

8 the Secretary shall complete a study and submit a 

9 report to the Congress on successful models and al10 ternatives for tracking and facilitating, in consulta11 tion with State and local health officials, reallocation 

12 of vaccine at the local level in times of shortage or 

13 emergency. 

14 ‘‘(c) EDUCATION PROGRAM REGARDING ADULT IM15 MUNIZATIONS.— 

16 ‘‘(1) IN GENERAL.—The Secretary shall develop 

17 and implement a program to promote, among the 

18 adult population, immunizations with federally rec19 ommended vaccines. 

20 ‘‘(2) CONTENT OF PROGRAM.—The program 

21 developed under paragraph (1) shall include the use 

22 of a mass media campaign. 

23 ‘‘(3) AUTHORIZATION OF APPROPRIATIONS.— 

24 For the purpose of carrying out this subsection, 

25 there are authorized to be appropriated such sums 


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1 as may be necessary for each of the fiscal years 

2 2009 through 2013. 

3 ‘‘(d) GENERAL DEFINITIONS.—For purposes of this 

4 section: 

5 ‘‘(1) The term ‘approved vaccine’ means a vac6 cine for which a biologics license under section 351 

7 is in effect. 

8 ‘‘(2) The term ‘federally recommended vaccine’, 

9 with respect to an adult, means an approved vaccine 

10 that— 

11 ‘‘(A) is recommended by the Advisory 

12 Committee on Immunization Practices (an advi13 sory committee established by the Secretary, 

14 acting through the Director of the Centers for 

15 Disease Control and Prevention) with respect to 

16 adults generally; or 

17 ‘‘(B) is recommended by such Advisory 

18 Committee with respect to any group of adults 

19 because of their health condition, their employ20 ment status, or any other factor.’’. 

21 (b) APPLICATION OF PEDIATRIC VACCINE MAINTE22 NANCE OF EFFORT PROVISIONS TO ADULT VACCINES.— 

23 (1) UNDER ERISA.— 


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1 (A) IN GENERAL.—Section 609(d) of Em2 ployee Retirement Income Security Act of 1974 

3 (29 U.S.C. 1169(d)) is amended— 

4 (i) in the heading, by inserting ‘‘OR

5 ADULT’’ after ‘‘PEDIATRIC’’; and 

6 (ii) by adding at the end the fol7 lowing: ‘‘A group health plan may not re8 duce its coverage of the costs of adult vac9 cines (as defined under section 

10 317A(a)(5)(B) of the Public Health Serv11 ice Act) below the coverage provided by the 

12 plan as of July 1, 2008.’’. 

13 (B) MONITORING BY IG.—The Inspector 

14 General of the Department of Labor shall sub15 mit an annual report to the Congress on imple16 mentation and enforcement of the requirement 

17 of section 609(d) of the Employee Retirement 

18 Income Security Act of 1974 (29 U.S.C. 

19 1169(d)), as amended by subparagraph (A), 

20 that a group health plan not reduce its coverage 

21 of the costs of adult vaccines below the coverage 

22 provided by the plan as of July 1, 2008. 

23 (2) UNDER IRC.— 

24 (A) IN GENERAL.—Section 4980B(f)(1) of 

25 the Internal Revenue Code of 1986 is amended 


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1 by inserting after ‘‘1993,’’ the following: ‘‘the 

2 coverage of the costs of adult vaccines (as de3 fined in section 317A(a)(5)(B) of the Public 

4 Health Service Act) is not reduced below the 

5 coverage provided by the plan as of July 1, 

6 2008,’’. 

7 (B) MONITORING BY IG.—The Inspector 

8 General of the Department of the Treasury 

9 shall submit an annual report to the Congress 

10 on implementation and enforcement of the re11 quirement of section 4980B(f)(1) of the Inter12 nal Revenue Code of 1986, as amended by sub13 paragraph (A), that a group health plan not re14 duce its coverage of the costs of adult vaccines 

15 below the coverage provided by the plan as of 

16 July 1, 2008. 

17 (3) UNDER PHSA.— 

18 (A) IN GENERAL.—Section 13631(d) of 

19 the Omnibus Budget Reconciliation Act of 1993 

20 (Public Law 103–66; relating to title XXII of 

21 the Public Health Service Act) is amended— 

22 (i) in the heading, by inserting ‘‘OR

23 ADULT’’ after ‘‘PEDIATRIC’’; and 

24 (ii) in paragraph (1), by adding at the 

25 end the following: ‘‘Such requirement also 


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1 includes, with respect to a group health 

2 plan for plan years beginning after the 

3 date of the enactment of this sentence, the 

4 requirement that the group health plan not 

5 reduce its coverage of the costs of adult 

6 vaccines (as defined in section 

7 317A(a)(5)(B) of the Public Health Serv8 ice Act) below the coverage provided by the 

9 plan as of July 1, 2008.’’. 

10 (B) MONITORING BY IG.—The Inspector 

11 General of the Department of Health and 

12 Human Services shall submit an annual report 

13 to the Congress on implementation and enforce14 ment of the requirement of section 13631(d) of 

15 the Omnibus Budget Reconciliation Act of 1993 

16 (Public Law 103–66), as amended by subpara17 graph (A), that a group health plan not reduce 

18 its coverage of the costs of adult vaccines below 

19 the coverage provided by the plan as of July 1, 

20 2008. 

21 (4) EFFECTIVE DATE.—The amendments made 

22 by paragraphs (1)(A), (2)(A), and (3)(A) shall apply 

23 to group health plans for plan years beginning after 

24 the date of the enactment of this Act. 


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1 SEC. 3. AMENDMENTS TO PROGRAM OF VACCINE-RELATED 

2 GRANTS TO STATES. 

3 Section 317 of the Public Health Service Act (42 

4 U.S.C. 247b) is amended— 

5 (1) in subsection (j), by adding at the end the 

6 following: 

7 ‘‘(3)(A) For grants described in subsection (l) 

8 (relating to immunizing individuals without charge), 

9 there are authorized to be appropriated 

10 $500,000,000 for fiscal year 2009 and such sums as 

11 may be necessary for each subsequent fiscal year. 

12 ‘‘(B) Of the amount appropriated pursuant to 

13 this paragraph for each of fiscal years 2009 and 

14 2010, the Secretary shall reserve not less than 

15 $80,000,000 for the purpose of providing immuniza16 tions for adults who have not, prior to fiscal year 

17 2009, been served by immunization programs car18 ried out with grants made pursuant to this section.’’; 

19 and 

20 (2) by adding at the end the following: 

21 ‘‘(l)(1) In making grants under subsection (a), the 

22 Secretary may make grants for preventive health service 

23 programs to provide immunizations without charge. 

24 ‘‘(2) Subject to paragraphs (3) through (5), grants 

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1 graphs (1) and (2) of subsection (j) for immunization pro2 grams. The preceding sentence may not be construed as 

3 terminating the authority of the Secretary to modify such 

4 criteria. 

5 ‘‘(3) Grants made pursuant to this subsection may 

6 be expended to improve the ability of a State health au7 thority, a political subdivision of a State, or another public 

8 entity to improve an immunization program, including 

9 through the following: 

10 ‘‘(A) Conducting assessments to determine the 

11 number of adults in the area involved who need im12 munizations and the barriers to providing immuniza13 tions to such adults. 

14 ‘‘(B) Developing and implementing strategies to 

15 increase the rate of immunizations in populations in 

16 which a significant number of individuals have not 

17 received immunizations with the federally rec18 ommended vaccines (as defined in section 317A(d)) 

19 for the populations. 

20 ‘‘(C) Educating care givers, health care profes21 sionals, and the public about the need to be immu22 nized. 

23 ‘‘(D) Consulting with health care providers with 

24 respect to ensuring proper and timely immunizations 

25 for their patients. 


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1 ‘‘(E) Investigating and responding to outbreaks 

2 of vaccine-preventable diseases. 

3 ‘‘(F) Developing and modifying plans to re4 spond to potential shortages in supplies of vaccines. 

5 ‘‘(G) Preparing reports under paragraph (5) 

6 and any additional reports that are submitted to the 

7 Secretary pursuant to this paragraph. 

8 ‘‘(4) A condition for the receipt of a grant by a State, 

9 a political subdivision of a State, or another public entity 

10 made pursuant to this paragraph for a fiscal year is that 

11 the State, political subdivision, or public entity have (or 

12 agree to develop, in the case of a grant for fiscal year 

13 2008) a State plan that— 

14 ‘‘(A) ensures the distribution and administra15 tion of vaccines in the event that the Secretary de16 clares a shortage of approved vaccines as a public 

17 health emergency; and 

18 ‘‘(B) includes plans for communication and co19 ordination between— 

20 ‘‘(i) State and local public health depart21 ments; 

22 ‘‘(ii) community health centers; 

23 ‘‘(iii) hospitals; 

24 ‘‘(iv) private physicians licensed within the 

25 State; and 


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1 ‘‘(v) to the extent practicable, vaccine man2 ufacturers and suppliers. 

3 ‘‘(5) A condition for the receipt of a grant made pur4 suant to this paragraph for a fiscal year is that the appli5 cant involved agree to submit to the Secretary a report 

6 that specifies for such year the quantity of each type of 

7 vaccine purchased with the grant and the per-dose cost 

8 of the vaccine’’. 

9 SEC. 4. PROHIBITION ON MEDICAID COST-SHARING FOR 

10 VACCINES RECOMMENDED BY ADVISORY 

11 COMMITTEE ON IMMUNIZATION PRACTICES. 

12 (a) IN GENERAL.—Section 1916 of the Social Secu13 rity Act (42 U.S.C. 1396o) is amended— 

14 (1) in subsection (a), by striking ‘‘and (i)’’ and 

15 inserting ‘‘, (i), and (j)’’; and 

16 (2) by adding at the end the following new sub17 section: 

18 ‘‘(j) The State plan shall require that no provider 

19 participating under the State plan may impose a copay20 ment, cost sharing charge, or similar charge for admin21 istering to an adult individual who is eligible for medical 

22 assistance under such plan a federally recommended vac23 cine (as defined in section 317A(d) of the Public Health 

24 Service Act).’’. 


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1 (b) CONFORMING AMENDMENT.—Section 

2 1916A(a)(1) of such Act (42 U.S.C. 1396o–1(a)(1)) is 

3 amended by inserting ‘‘(other than subsection (j))’’ after 

4 ‘‘Notwithstanding sections 1916’’. 

5 (c) EFFECTIVE DATE.—The amendment made by 

6 subsection (a) shall take effect on the date of the enact7 ment of this Act. 

8 SEC. 5. MEDICARE AND MEDICAID PROGRAMS; STANDARDS 

9 TO MEASURE USAGE AND COVERAGE OF 

10 ADULT IMMUNIZATIONS. 

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

12 Human Services, acting through the Administrator of the 

13 Centers for Medicare & Medicaid Services, shall establish 

14 standards for the measurement of use by beneficiaries 

15 under the Medicare and Medicaid programs of routinely 

16 recommended adult immunizations. 

17 (b) STUDY FOR USE OF STANDARDS AS A QUALITY

18 MEASURE.—The Secretary of Health and Human Serv19 ices, acting through the Administrator of the Centers for 

20 Medicare & Medicaid Services, shall conduct a study to 

21 determine the feasibility and advisability of including adult 

22 immunization by Medicare and Medicaid beneficiaries, as 

23 a performance measure under quality initiatives conducted 

24 by the Secretary under the Medicare and Medicaid pro25 grams. 


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1 (c) MEASUREMENT OF USAGE BY HEALTH CARE

2 WORKERS.—The Secretary of Health and Human Serv3 ices, acting through the Administrator of the Centers for 

4 Medicare & Medicaid Services, shall establish standards 

5 for the measurement of use by health care workers, as 

6 defined by the Secretary for purposes of this section, 

7 working in a provider of services (as defined in section 

8 1861(u) of the Social Security Act (42 U.S.C. 1395x(u)) 

9 of adult immunizations for influenza. 

10 (d) ASSESSMENT OF BEST PRACTICES TO IMPROVE

11 COVERAGE OF ADULT IMMUNIZATIONS.—The Secretary 

12 of Health and Human Services, acting through the Agency 

13 for Healthcare Research and Quality, shall conduct a 

14 study of the best practices of health insurers and managed 

15 care organizations to encourage the use of adult immuni16 zations by enrollees of such insurers and organizations. 

17 SEC. 6. STUDY ON ADULT IMMUNIZATION FOR INFLUENZA 

18 FOR HEALTH CARE WORKERS AS A QUALITY 

19 INDICATOR FOR PURPOSES OF ACCREDITA20 TION. 

21 (a) STUDY.—The Secretary of Health and Human 

22 Services shall conduct a study to determine the feasibility 

23 and advisability of including as a requirement of accredita24 tion of a provider of services (as defined in section 1861(u) 

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1 ance with recommended adult immunizations, including 

2 influenza, for all health care workers employed by the pro3 vider of services. Any such requirement should include a 

4 provision for informed refusal by the health care worker 

5 of the immunization and appropriate documentation of 

6 usage and refusal of such immunizations. 

7 (b) REPORT.—Not later than one year after the date 

8 of the enactment of this Act, the Secretary shall submit 

9 to Congress a report on the study conducted under sub10 section (a), and shall include in that report a description 

11 of the difficulties of implementing such a requirement as 

12 well as recommendations for the resolution of those dif13 ficulties. 

14 SEC. 7. FEHBP COVERAGE OF QUALIFIED IMMUNIZATION 

15 SERVICES. 

16 (a) IN GENERAL.—Section 8902 of title 5, United 

17 States Code, is amended by adding at the end the fol18 lowing: 

19 ‘‘(p)(1) A contract may not be made or a plan ap20 proved which does not (A) offer qualified immunization 

21 services to eligible enrollees, and (B) provide for the waiv22 er of any deductible that might otherwise apply with re23 spect to any such services provided to any such enrollee. 

24 ‘‘(2) For purposes of this subsection— 


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1 ‘‘(A) the term ‘qualified immunization services’ 

2 means the provision and administration of all feder3 ally recommended vaccines (as defined in section 

4 317A(d) of the Public Health Service Act); and 

5 ‘‘(B) the term ‘eligible enrollee’, as used with 

6 respect to a health benefits plan, means an indi7 vidual enrolled in such plan under this chapter who 

8 is 18 years of age or older.’’. 

9 (b) EFFECTIVE DATE.—The amendment made by 

10 this section shall apply to services provided under any con11 tract entered into or renewed for any contract year begin12 ning later than 9 months after the date of the enactment 

13 of this Act. 

Æ 


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