II 

110TH CONGRESS 

2D SESSION S. 3412 

To achieve access to comprehensive primary health care services for all Americans and to improve primary care delivery through an expansion of 

the community health center and National Health Service Corps programs. 

IN THE SENATE OF THE UNITED STATES 

JULY 31, 2008 

Mr. SANDERS (for himself, Mr. OBAMA, Mrs. CLINTON, Mr. KENNEDY, Mr. 

BROWN, Ms. MIKULSKI, Mr. CASEY, Mrs. BOXER, Mr. DURBIN, Mr. 

INOUYE, Mr. HARKIN, Mr. KERRY, Mr. CARDIN, and Mr. LEAHY) introduced the following bill; which was read twice and referred to the Committee on Health, Education, Labor, and Pensions 

A BILL 

To achieve access to comprehensive primary health care services for all Americans and to improve primary care delivery through an expansion of the community health center 

and National Health Service Corps programs. 

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 ‘‘Access for All America 

5 Act’’. 


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1 SEC. 2. FINDINGS. 

2 Congress makes the following findings: 

3 (1) Providing health coverage for all Americans 

4 will be incomplete if access to services is not im5 proved. 

6 (2) Currently, almost 60,000,000 Americans, 

7 both insured and uninsured, have inadequate access 

8 to primary care due to a shortage of such physicians 

9 and other like providers in their community. 

10 (3) Several demonstrations are underway at the 

11 Federal and State levels to link patients to a pri12 mary care ‘‘medical home’’ as a means of assuring 

13 access, controlling costs, and improving quality. 

14 (4) Yet, there already exists a proven medical 

15 home model that accomplishes these goals and has 

16 done so over the past 40 years while serving over 

17 17,000,000 Americans. 

18 (5) Community health centers, also known as 

19 Federally Qualified Health Centers (FQHCs), have 

20 been found to more than pay for themselves by pro21 viding coordinated, comprehensive medical, dental, 

22 behavioral health, and prescription drug services 

23 that reduces unnecessary emergency room visits, am24 bulatory-sensitive hospitalizations, and avoidable 

25 specialty care. 


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1 (6) The result is that the American Academy of 

2 Family Practitioners’ Robert Graham Center found 

3 that medical expenses for health center patients are 

4 41 percent lower compared to patients seen else5 where, an average savings of $1,810 per person per 

6 year. 

7 (7) The Lewin Group found that providing ac8 cess to a medical home for every American would 

9 produce health care savings of $60,700,000,000 per 

10 year, more than 7 times the subsidy needed to sus11 tain the 1,100 current health centers and to create 

12 3,700 new health centers to accomplish full access. 

13 (8) Hand-in-hand with the expansion of the 

14 community health center program, a renewed invest15 ment in the National Health Service Corps is essen16 tial to reverse the decline in the supply of primary 

17 care physicians and dentists. 

18 (9) Both the expansion of the community health 

19 center program and the investment in the National 

20 Health Service Corps can be accomplished for less 

21 than 1 percent of total health care spending today. 

22 (10) Finally, to encourage the broader adoption 

23 of the cost-effective community health center model 

24 of care beyond underserved areas and populations 

25 and to encourage the pursuit and practice of priVerDate Aug 31 2005 00:57 Aug 05, 2008 Jkt 069200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\S3412.IS S3412

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1 mary care as a career, all willing primary care prac2 titioners should be provided with incentives and sup3 port to organize as community health center prac4 tices. 

5 SEC. 3. FEDERALLY QUALIFIED HEALTH CENTER (FQHC) 

6 OPERATING SUPPORT. 

7 (a) IN GENERAL.—The Secretary of health and 

8 Human Services (referred to in this Act as the ‘‘Sec9 retary)’’, acting through the Administrator of the Health 

10 Resources and Services Administration, shall award 

11 grants to eligible entities to carry out activities under op12 erating plans submitted under section 5. 

13 (b) ELIGIBILITY.—To be eligible to receive a grant 

14 under subsection (a), an entity shall— 

15 (1) be a public or nonprofit private entity that 

16 in fiscal year 2009, was certified by the Secretary as 

17 a federally qualified health center (including a re18 cipient of a grant under section 330 of the Public 

19 Health Service Act (42 U.S.C. 254b), or an Urban 

20 Indian Clinic or Indian Tribal Health Clinic); 

21 (2) comply with the general requirements of 

22 section 4; and 

23 (3) submit to the Secretary an application at 

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1 formation as the Secretary may require, including an 

2 operating plan in accordance with section 5. 

3 (c) CONVERSION OF EXISTING PRIMARY CARE PRAC4 TICES TO FQHC STATUS.— 

5 (1) IN GENERAL.—A medical practice that is 

6 organized solely for the purpose of providing pri7 mary care (family medicine, general internal medi8 cine, pediatrics, or general obstetric and gyneco9 logical services that are furnished by physicians and, 

10 where appropriate, physician assistants, nurse prac11 titioners, and nurse midwives) shall be eligible for 

12 designation as a federally qualified health center 

13 under section 1861(aa)(4)(B) of the Social Security 

14 Act (42 U.S.C. 1395x(aa)(4)(B)) if such practice— 

15 (A) is organized as a nonprofit private en16 tity; and 

17 (B) meets the requirements of section 4. 

18 (2) LOCATION.—An entity described in para19 graph (1) shall not be required to be located in a 

20 medically underserved area. 

21 (3) LIMITATION.—An entity that is designated 

22 as a federally qualified health center under para23 graph (1) shall not be eligible for grants under this 

24 Act unless such entity complies with the require25 ments of this Act, including serving areas that are 


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1 designated as medically underserved areas or popu2 lations. 

3 SEC. 4. GENERAL REQUIREMENTS. 

4 (a) SERVICE AREA.—To be eligible to receive a grant 

5 under section 3, an entity shall agree to provide services 

6 to designated medically underserved populations within 

7 the service area of the entity. 

8 (b) REQUIRED SERVICES.— 

9 (1) IN GENERAL.—To be eligible to receive a 

10 grant under section 3, an entity shall provide (di11 rectly or through contracts or cooperative agree12 ments) all of the required services described in para13 graph (2). 

14 (2) REQUIRED SERVICES.—Required services 

15 described in this paragraph shall include— 

16 (A) basic health services (services of health 

17 professionals, diagnostic lab and radiology serv18 ices, preventive health services, emergency 

19 health services, dental services, and pharma20 ceutical services); 

21 (B) referrals to providers of medical and 

22 other health-related services; 

23 (C) patient case management services (as 

24 defined for purposes of the Medicaid program 


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1 under title XIX of the Social Security Act (42 

2 U.S.C. 1396 et seq.); and 

3 (D) required enabling services (which may 

4 include transportation, community and patient 

5 outreach, patient education, and translation 

6 services). 

7 (3) ADDITIONAL SERVICES.— 

8 (A) IN GENERAL.—An entity that receives 

9 a grant under section 3 may provide any addi10 tional services that are approved by the Sec11 retary for inclusion in the operating plan of the 

12 entity under section 5. 

13 (B) TYPE OF SERVICES.—Additional serv14 ices under this paragraph may include any item 

15 or service covered under the Medicare, Med16 icaid, or SCHIP programs (under titles XVIII, 

17 XIX, or XXI of the Social Security Act), except 

18 for inpatient hospital or psychiatric services, ex19 tended or intermediate care or nursing facility 

20 services, residential mental health services, envi21 ronmental health services, and other enabling 

22 services not otherwise required in this sub23 section. 

24 (c) AVAILABILITY OF SERVICES.— 


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1 (1) IN GENERAL.—To be eligible to receive a 

2 grant under section 3, an entity shall agree to make 

3 its services available and accessible (subject only to 

4 capacity limitations) to all individuals residing in the 

5 service area of the entity in a manner that assures 

6 continuity, except that this subsection shall not 

7 apply to entities that serve only migrant or seasonal 

8 farmworkers, homeless individuals, or Indians. 

9 (2) ACCESSIBILITY.—To be eligible to receive a 

10 grant under section 3, an entity shall agree to carry 

11 out activities designed to make services and care ac12 cessible to all homeless persons, residents of public 

13 housing, and individuals with HIV, tuberculosis or 

14 other communicable disease who are located within 

15 the entity’s service area. 

16 (d) GOVERNING BOARDS.—To be eligible to receive 

17 a grant under section 3, an entity shall have a governing 

18 board— 

19 (1) a majority of whose members are receiving 

20 services through the entity, except that such require21 ments shall not apply to an entity that is operated 

22 by an Indian tribe or tribal organization; 

23 (2) that meets at least quarterly; 

24 (3) that establishes general policies for the op25 erations of the entity; 


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1 (4) that selects the director of the entity; and 

2 (5) that approves the entity’s operating plan 

3 and application for funds under section 3. 

4 (e) QUALITY ASSURANCE PROGRAM AND SYSTEM.— 

5 To be eligible to receive a grant under section 3, an entity 

6 shall agree to maintain an ongoing quality assurance pro7 gram and systems to protect the confidentiality of patient 

8 records. 

9 (f) REFERRAL RELATIONSHIP.—To be eligible to re10 ceive a grant under section 3, an entity shall agree to 

11 maintain an ongoing referral relationship with one or more 

12 hospitals. 

13 (g) ACCOUNTING.—To be eligible to receive a grant 

14 under section 3, an entity shall agree to comply with all 

15 Federal accounting procedures related to the funding re16 ceived by such entity under this Act. 

17 (h) FEE AND DISCOUNT SCHEDULES, PARTICIPA18 TION IN PROGRAMS.—To be eligible to receive a grant 

19 under section 3, an entity shall agree to— 

20 (1) establish a fee schedule that is consistent 

21 with locally prevailing rates for similar services; 

22 (2) establish a schedule of discounts for patient 

23 payments that is based on their ability to pay; 

24 (3) participate as a provider of services in the 

25 Medicare and Medicaid program under title XVIII 


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1 and XIX of the Social Security Act, and under any 

2 other Federal or State health insurance program; 

3 and 

4 (4) attempt to bill and collect payments for 

5 services provided through the entity from patients 

6 (with discounts) and from all third-party payers 

7 (without discounts). 

8 (i) NONDENIAL OF SERVICES.—To be eligible to re9 ceive a grant under section 3, an entity shall agree to not 

10 deny its services to any individual for failure to pay. 

11 (j) CULTURAL CONTEXT.—To be eligible to receive 

12 a grant under section 3, an entity shall agree to provide 

13 its services in the most appropriate cultural context for 

14 its patients. 

15 (k) REPORT.—To be eligible to receive a grant under 

16 section 3, an entity shall agree to submit in a timely man17 ner all reports required under this Act concerning the ac18 tivities of the entity under this grant, including reports 

19 on expenditures, utilization patterns, availability and ac20 ceptability of services, and its use of excess program in21 come. 

22 (l) CONTINUITY OF CARE.—To be eligible to receive 

23 a grant under section 3, an entity shall agree to continue 

24 to provide services to any medically underserved popu25 lations in its service area, and continue meeting all other 


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1 requirements of this section during the period of the 

2 grant. 

3 SEC. 5. OPERATING PLANS. 

4 (a) IN GENERAL.—To be eligible to receive a grant 

5 under section 3, an entity shall submit, together with its 

6 application under section 3(b)(3), a proposed operating 

7 plan that meets the requirements of this section for the 

8 fiscal year involved. 

9 (b) REQUIREMENTS.—The proposed operating plan 

10 under subsection (a) shall— 

11 (1) include a complete operating budget for the 

12 entity, including budgeting for the costs of— 

13 (A) providing or arranging for all required 

14 services and any additional services the entity 

15 has received approval to provide; 

16 (B) recruiting, training, and compensating 

17 all employees of the entity; 

18 (C) administering the entity (including the 

19 cost of meeting all requirements, and the cost 

20 of participating in one or more health plans); 

21 and 

22 (D) carrying out any off-site activities in23 volved in providing or arranging for the re24 quired and additional services in its operating 

25 plan; 


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1 (2) describe the purposes for which the entity 

2 intends to expend amounts received under the grant; 

3 (3) include a projection of the total amount 

4 that the entity expects to receive during the fiscal 

5 year as payments for the services it provides; and 

6 (4) in the case of an entity that is a public enti7 ty that does not have governing boards that fully 

8 comply with section 4(d), include an agreement to 

9 provide non-Federal matching funds in an amount 

10 equal to at least 50 percent of the operating budget 

11 of the entity. 

12 (c) ADDITIONAL BUDGETARY INFORMATION.—In ad13 dition to the information required in the proposed oper14 ating plan under subsection (b)(1), an entity may provide 

15 its proposed expenditures for— 

16 (1) providing new additional services for which 

17 the entity is seeking approval; 

18 (2) expanding the capacity of the entity to serve 

19 new patients; 

20 (3) developing and operating school-based clin21 ics, mobile clinics, satellite clinics, or off-site loca22 tions; 

23 (4) capital costs (including facilities and equip24 ment), subject to this Act; and 

25 (5) any other allowable costs. 


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1 (d) MODIFICATIONS TO PLAN.—The Secretary may 

2 approve modification to the operating plan or budget of 

3 an entity during a fiscal year if requested by the entity, 

4 and shall approve any such requested modifications that 

5 do not involve an increase in grant funds or that do not 

6 compromise the availability or accessibility of services pro7 vided through the entity. 

8 SEC. 6. AMOUNT OF GRANTS. 

9 (a) NEGOTIATIONS.— 

10 (1) IN GENERAL.—Prior to approving the appli11 cation of an eligible entity under section 3(b)(3), the 

12 Secretary shall enter into negotiations with such en13 tity with respect to the operating plan and budget 

14 contained in the application for the fiscal year in15 volved. 

16 (2) REQUIREMENTS.—In conducting negotia17 tions under paragraph (1), the Secretary shall— 

18 (A) develop and utilize criteria for deter19 mining whether the requested expenditures of 

20 an entity may be included in a entity’s plan and 

21 budget, and whether any limitations will apply 

22 to such expenditures; 

23 (B) permit all proposed expenditures that 

24 are allowable under part 413 of title 42, Code 

25 of Federal Regulations (relating to determinaVerDate Aug 31 2005 23:59 Aug 04, 2008 Jkt 069200 PO 00000 Frm 00013 Fmt 6652 Sfmt 6201 E:\BILLS\S3412.IS S3412

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1 tion of allowable costs for purposes of federally 

2 qualified health center reimbursement under 

3 Medicare and Medicaid under titles XVIII and 

4 XIX of the Social Security Act), except that no 

5 caps may be placed on any allowable expendi6 tures; and 

7 (C) provide a written explanation of any 

8 determinations concerning whether a requested 

9 expenditure— 

10 (i) is or is not allowable; 

11 (ii) is limited in any way; and 

12 (iii) is denied and, if the denied ex13 pense is for a requested additional service, 

14 whether the Secretary believes that the 

15 services is or is not needed by the center’s 

16 patients. 

17 (3) CRITERIA.—The criteria developed under 

18 paragraph (2)(A) shall ensure that the entity to 

19 which such criteria are applied will be reasonably 

20 and efficiently administered, taking into account the 

21 cost of recruiting and providing competitive com22 pensation to staff (including health professionals), 

23 the higher costs of operating entities in rural or 

24 urban areas, the higher cost of serving a population 

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1 ditions, and the higher cost of participating in health 

2 professions training programs. 

3 (b) ALLOWABLE CAPITAL COSTS.— 

4 (1) IN GENERAL.—For purposes of subsection 

5 (a)(2)(B), allowable capital costs shall include the 

6 costs of repaying loans, as well as loan guarantees 

7 or interest subsidies, for the acquisition, expansion, 

8 modernization, or construction (but only if construc9 tion is the only available mechanism) of buildings or 

10 for the purchase of equipment. 

11 (2) FEDERAL INTEREST.—The Federal Govern12 ment shall maintain an interest in any facility or 

13 equipment that is purchased, expanded, modernized, 

14 or constructed with Federal funds (in whole or in 

15 part) under this Act. Such Federal interest may be 

16 subordinated or waived if such subordination or 

17 waiver will further the objectives of this Act. 

18 (c) AMOUNT.—The amount of grant awarded to an 

19 entity under this Act shall, subject to section 7, be equal 

20 to the amount by which the approved allowable costs of 

21 the entity (as determined by the Secretary based on the 

22 application and plan submitted by the entity) exceed the 

23 approved projection of payments that the entity expects 

24 to receive during the fiscal year as payments for the serv25 ices provided by the entity during such year. 


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1 (d) NON-GRANT FUNDS.—Except as otherwise pro2 vided in this Act, the Secretary shall not restrict the ex3 penditure by an entity of non-grant funds as provided for 

4 in the operating plan and budget of the entity, so long 

5 as such funds are expended for purposes that are con6 sistent with this Act. 

7 (e) RECONCILIATION.—If, at the end of a fiscal year, 

8 the sum of the amount of the grant awarded to an entity 

9 under this Act for the fiscal year and the actual non-grant 

10 income of the entity exceeds the entity’s costs in carrying 

11 out the approved operating plan for the year, the entity 

12 may retain such excess amount so long as the entity 

13 agrees to use such excess amount to— 

14 (1) expand and improve services; 

15 (2) increase the number of individuals served by 

16 the entity; 

17 (3) purchase equipment; 

18 (4) acquire, expand, modernize, or construct fa19 cilities; 

20 (5) improve the administration of the entity; 

21 (6) establish financial reserves; 

22 (7) carry out health professions training pro23 grams; or 

24 (8) develop approvable health center-controlled 

25 networks. 


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1 SEC. 7. AUTHORIZATION OF APPROPRIATIONS; ALLOCA2 TION OF FUNDS. 

3 (a) AUTHORIZATION OF APPROPRIATIONS.—There is 

4 authorized to be appropriated to carry out this Act such 

5 sums as may be necessary for each of fiscal years 2009 

6 through 2015. 

7 (b) NATURE OF GRANT.—With respect to the pur8 poses for which a grant under section 3(a) is authorized 

9 to be expended, modifications in such purposes enacted 

10 after the date of the enactment of this Act shall not affect 

11 the amount of appropriations authorized under subsection 

12 (a) for any fiscal year. 

13 (c) ALLOCATIONS FOR UNANTICIPATED NEEDS.— 

14 (1) IN GENERAL.—Of the amount appropriated 

15 for each fiscal year under subsection (a), the Sec16 retary shall reserve 2 percent of such amount for 

17 awarding grants to any grantees under this Act 

18 that, in the determination of the Secretary, has a 

19 need for such a grant to assist the grantee in re20 sponding to unanticipated needs for required serv21 ices or additional services that have arisen in the 

22 service area of the grantee, or in responding to other 

23 unanticipated circumstances that have arisen in the 

24 provision by the grantee of required services or addi25 tional services. 


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1 (2) ALLOCATION OF UNOBLIGATED

2 AMOUNTS.—With respect to amounts that are re3 served under paragraph (1) for a fiscal year and 

4 that are unobligated as of September 30 of such fis5 cal year (referred to in this paragraph as the ‘‘unob6 ligated balance’’), the Secretary shall pay to each 

7 grantee under this Act, from such unobligated bal8 ance, an amount equal to the product of such bal9 ance and the percentage constituted by the ratio of 

10 the amount of the grant for the fiscal year for such 

11 grantee under this Act to the sum of the total 

12 amount of grants under this Act for the year. The 

13 amount paid to such grantee under the preceding 

14 sentence shall be considered by the Secretary to be 

15 part of the grant made for such fiscal year to the 

16 grantee under section 3. 

17 SEC. 8. NATIONAL HEALTH SERVICE CORPS. 

18 Section 338H(a) of the Public Health Service Act (42 

19 U.S.C. 254q(a)) is amended to read as follows: 

20 ‘‘(a) AUTHORIZATION OF APPROPRIATIONS.—For the 

21 purposes of carrying out this subpart, there are authorized 

22 to be appropriated such sums as may be necessary for 

23 each of fiscal years 2009 through 2015.’’. 

Æ 


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