II 

110TH CONGRESS 

2D SESSION S. 3413 

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, and Mr. 

INOUYE) 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’’. 

6 SEC. 2. FINDINGS. 

7 Congress makes the following findings: 


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1 (1) Providing health coverage for all Americans 

2 will be incomplete if access to services is not im3 proved. 

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

5 both insured and uninsured, have inadequate access 

6 to primary care due to a shortage of such physicians 

7 and other like providers in their community. 

8 (3) Several demonstrations are underway at the 

9 Federal and State levels to link patients to a pri10 mary care ‘‘medical home’’ as a means of assuring 

11 access, controlling costs, and improving quality. 

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

13 home model that accomplishes these goals and has 

14 done so over the past 40 years while serving over 

15 17,000,000 Americans. 

16 (5) Community health centers, also known as 

17 Federally Qualified Health Centers (FQHCs), have 

18 been found to more than pay for themselves by pro19 viding coordinated, comprehensive medical, dental, 

20 behavioral health, and prescription drug services 

21 that reduces unnecessary emergency room visits, am22 bulatory-sensitive hospitalizations, and avoidable 

23 specialty care. 

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

25 Family Practitioners’ Robert Graham Center found 


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1 that medical expenses for health center patients are 

2 41 percent lower compared to patients seen else3 where, an average savings of $1,810 per person per 

4 year. 

5 (7) The Lewin Group found that providing ac6 cess to a medical home for every American would 

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

8 year, more than 7 times the subsidy needed to sus9 tain the 1,100 current health centers and to create 

10 3,700 new health centers to accomplish full access. 

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

12 community health center program, a renewed invest13 ment in the National Health Service Corps is essen14 tial to reverse the decline in the supply of primary 

15 care physicians and dentists. 

16 (9) Both the expansion of the community health 

17 center program and the investment in the National 

18 Health Service Corps can be accomplished for less 

19 than 1 percent of total health care spending today. 

20 (10) Finally, to encourage the broader adoption 

21 of the cost-effective community health center model 

22 of care beyond underserved areas and populations 

23 and to encourage the pursuit and practice of pri24 mary care as a career, all willing primary care prac25 titioners should be provided with incentives and supVerDate Aug 31 2005 00:57 Aug 05, 2008 Jkt 069200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\S3413.IS S3413

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1 port to organize as community health center prac2 tices. 

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

4 OPERATING SUPPORT. 

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

6 Human Services (referred to in this Act as the ‘‘Sec7 retary)’’, acting through the Administrator of the Health 

8 Resources and Services Administration, shall award 

9 grants to eligible entities to carry out activities under op10 erating plans submitted under section 5. 

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

12 under subsection (a), an entity shall— 

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

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

15 a federally qualified health center (including a re16 cipient of a grant under section 330 of the Public 

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

18 Indian Clinic or Indian Tribal Health Clinic); 

19 (2) comply with the general requirements of 

20 section 4; and 

21 (3) submit to the Secretary an application at 

22 such time, in such manner, and containing such in23 formation as the Secretary may require, including an 

24 operating plan in accordance with section 5. 


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1 (c) CONVERSION OF EXISTING PRIMARY CARE PRAC2 TICES TO FQHC STATUS.— 

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

4 organized solely for the purpose of providing pri5 mary care (family medicine, general internal medi6 cine, pediatrics, or general obstetric and gyneco7 logical services that are furnished by physicians and, 

8 where appropriate, physician assistants, nurse prac9 titioners, and nurse midwives) shall be eligible for 

10 designation as a federally qualified health center 

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

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

13 (A) is organized as a nonprofit private en14 tity; and 

15 (B) meets the requirements of section 4. 

16 (2) LOCATION.—An entity described in para17 graph (1) shall not be required to be located in a 

18 medically underserved area. 

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

20 as a federally qualified health center under para21 graph (1) shall not be eligible for grants under this 

22 Act unless such entity complies with the require23 ments of this Act, including serving areas that are 

24 designated as medically underserved areas or popu25 lations. 


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1 SEC. 4. GENERAL REQUIREMENTS. 

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

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

4 to designated medically underserved populations within 

5 the service area of the entity. 

6 (b) REQUIRED SERVICES.— 

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

8 grant under section 3, an entity shall provide (di9 rectly or through contracts or cooperative agree10 ments) all of the required services described in para11 graph (2). 

12 (2) REQUIRED SERVICES.—Required services 

13 described in this paragraph shall include— 

14 (A) basic health services (services of health 

15 professionals, diagnostic lab and radiology serv16 ices, preventive health services, emergency 

17 health services, dental services, and pharma18 ceutical services); 

19 (B) referrals to providers of medical and 

20 other health-related services; 

21 (C) patient case management services (as 

22 defined for purposes of the Medicaid program 

23 under title XIX of the Social Security Act (42 

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

25 (D) required enabling services (which may 

26 include transportation, community and patient 


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1 outreach, patient education, and translation 

2 services). 

3 (3) ADDITIONAL SERVICES.— 

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

5 a grant under section 3 may provide any addi6 tional services that are approved by the Sec7 retary for inclusion in the operating plan of the 

8 entity under section 5. 

9 (B) TYPE OF SERVICES.—Additional serv10 ices under this paragraph may include any item 

11 or service covered under the Medicare, Med12 icaid, or SCHIP programs (under titles XVIII, 

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

14 for inpatient hospital or psychiatric services, ex15 tended or intermediate care or nursing facility 

16 services, residential mental health services, envi17 ronmental health services, and other enabling 

18 services not otherwise required in this sub19 section. 

20 (c) AVAILABILITY OF SERVICES.— 

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

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

23 its services available and accessible (subject only to 

24 capacity limitations) to all individuals residing in the 

25 service area of the entity in a manner that assures 


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1 continuity, except that this subsection shall not 

2 apply to entities that serve only migrant or seasonal 

3 farmworkers, homeless individuals, or Indians. 

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

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

6 out activities designed to make services and care ac7 cessible to all homeless persons, residents of public 

8 housing, and individuals with HIV, tuberculosis or 

9 other communicable disease who are located within 

10 the entity’s service area. 

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

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

13 board— 

14 (1) a majority of whose members are receiving 

15 services through the entity, except that such require16 ments shall not apply to an entity that is operated 

17 by an Indian tribe or tribal organization; 

18 (2) that meets at least quarterly; 

19 (3) that establishes general policies for the op20 erations of the entity; 

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

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

23 and application for funds under section 3. 

24 (e) QUALITY ASSURANCE PROGRAM AND SYSTEM.— 

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


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1 shall agree to maintain an ongoing quality assurance pro2 gram and systems to protect the confidentiality of patient 

3 records. 

4 (f) REFERRAL RELATIONSHIP.—To be eligible to re5 ceive a grant under section 3, an entity shall agree to 

6 maintain an ongoing referral relationship with one or more 

7 hospitals. 

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

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

10 Federal accounting procedures related to the funding re11 ceived by such entity under this Act. 

12 (h) FEE AND DISCOUNT SCHEDULES, PARTICIPA13 TION IN PROGRAMS.—To be eligible to receive a grant 

14 under section 3, an entity shall agree to— 

15 (1) establish a fee schedule that is consistent 

16 with locally prevailing rates for similar services; 

17 (2) establish a schedule of discounts for patient 

18 payments that is based on their ability to pay; 

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

20 Medicare and Medicaid program under title XVIII 

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

22 other Federal or State health insurance program; 

23 and 

24 (4) attempt to bill and collect payments for 

25 services provided through the entity from patients 


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

2 (without discounts). 

3 (i) NONDENIAL OF SERVICES.—To be eligible to re4 ceive a grant under section 3, an entity shall agree to not 

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

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

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

8 its services in the most appropriate cultural context for 

9 its patients. 

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

11 section 3, an entity shall agree to submit in a timely man12 ner all reports required under this Act concerning the ac13 tivities of the entity under this grant, including reports 

14 on expenditures, utilization patterns, availability and ac15 ceptability of services, and its use of excess program in16 come. 

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

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

19 to provide services to any medically underserved popu20 lations in its service area, and continue meeting all other 

21 requirements of this section during the period of the 

22 grant. 

23 SEC. 5. OPERATING PLANS. 

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

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


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

2 plan that meets the requirements of this section for the 

3 fiscal year involved. 

4 (b) REQUIREMENTS.—The proposed operating plan 

5 under subsection (a) shall— 

6 (1) include a complete operating budget for the 

7 entity, including budgeting for the costs of— 

8 (A) providing or arranging for all required 

9 services and any additional services the entity 

10 has received approval to provide; 

11 (B) recruiting, training, and compensating 

12 all employees of the entity; 

13 (C) administering the entity (including the 

14 cost of meeting all requirements, and the cost 

15 of participating in one or more health plans); 

16 and 

17 (D) carrying out any off-site activities in18 volved in providing or arranging for the re19 quired and additional services in its operating 

20 plan; 

21 (2) describe the purposes for which the entity 

22 intends to expend amounts received under the grant; 

23 (3) include a projection of the total amount 

24 that the entity expects to receive during the fiscal 

25 year as payments for the services it provides; and 


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1 (4) in the case of an entity that is a public enti2 ty that does not have governing boards that fully 

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

4 provide non-Federal matching funds in an amount 

5 equal to at least 50 percent of the operating budget 

6 of the entity. 

7 (c) ADDITIONAL BUDGETARY INFORMATION.—In ad8 dition to the information required in the proposed oper9 ating plan under subsection (b)(1), an entity may provide 

10 its proposed expenditures for— 

11 (1) providing new additional services for which 

12 the entity is seeking approval; 

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

14 new patients; 

15 (3) developing and operating school-based clin16 ics, mobile clinics, satellite clinics, or off-site loca17 tions; 

18 (4) capital costs (including facilities and equip19 ment), subject to this Act; and 

20 (5) any other allowable costs. 

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

22 approve modification to the operating plan or budget of 

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

24 and shall approve any such requested modifications that 

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


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1 compromise the availability or accessibility of services pro2 vided through the entity. 

3 SEC. 6. AMOUNT OF GRANTS. 

4 (a) NEGOTIATIONS.— 

5 (1) IN GENERAL.—Prior to approving the appli6 cation of an eligible entity under section 3(b)(3), the 

7 Secretary shall enter into negotiations with such en8 tity with respect to the operating plan and budget 

9 contained in the application for the fiscal year in10 volved. 

11 (2) REQUIREMENTS.—In conducting negotia12 tions under paragraph (1), the Secretary shall— 

13 (A) develop and utilize criteria for deter14 mining whether the requested expenditures of 

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

16 budget, and whether any limitations will apply 

17 to such expenditures; 

18 (B) permit all proposed expenditures that 

19 are allowable under part 413 of title 42, Code 

20 of Federal Regulations (relating to determina21 tion of allowable costs for purposes of federally 

22 qualified health center reimbursement under 

23 Medicare and Medicaid under titles XVIII and 

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


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1 caps may be placed on any allowable expendi2 tures; and 

3 (C) provide a written explanation of any 

4 determinations concerning whether a requested 

5 expenditure— 

6 (i) is or is not allowable; 

7 (ii) is limited in any way; and 

8 (iii) is denied and, if the denied ex9 pense is for a requested additional service, 

10 whether the Secretary believes that the 

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

12 patients. 

13 (3) CRITERIA.—The criteria developed under 

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

15 which such criteria are applied will be reasonably 

16 and efficiently administered, taking into account the 

17 cost of recruiting and providing competitive com18 pensation to staff (including health professionals), 

19 the higher costs of operating entities in rural or 

20 urban areas, the higher cost of serving a population 

21 with greater health risks or more severe health con22 ditions, and the higher cost of participating in health 

23 professions training programs. 

24 (b) ALLOWABLE CAPITAL COSTS.— 


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

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

3 costs of repaying loans, as well as loan guarantees 

4 or interest subsidies, for the acquisition, expansion, 

5 modernization, or construction (but only if construc6 tion is the only available mechanism) of buildings or 

7 for the purchase of equipment. 

8 (2) FEDERAL INTEREST.—The Federal Govern9 ment shall maintain an interest in any facility or 

10 equipment that is purchased, expanded, modernized, 

11 or constructed with Federal funds (in whole or in 

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

13 subordinated or waived if such subordination or 

14 waiver will further the objectives of this Act. 

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

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

17 to the amount by which the approved allowable costs of 

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

19 application and plan submitted by the entity) exceed the 

20 approved projection of payments that the entity expects 

21 to receive during the fiscal year as payments for the serv22 ices provided by the entity during such year. 

23 (d) NON-GRANT FUNDS.—Except as otherwise pro24 vided in this Act, the Secretary shall not restrict the ex25 penditure by an entity of non-grant funds as provided for 


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

2 as such funds are expended for purposes that are con3 sistent with this Act. 

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

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

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

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

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

9 may retain such excess amount so long as the entity 

10 agrees to use such excess amount to— 

11 (1) expand and improve services; 

12 (2) increase the number of individuals served by 

13 the entity; 

14 (3) purchase equipment; 

15 (4) acquire, expand, modernize, or construct fa16 cilities; 

17 (5) improve the administration of the entity; 

18 (6) establish financial reserves; 

19 (7) carry out health professions training pro20 grams; or 

21 (8) develop approvable health center-controlled 

22 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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